MedPAQ EDBA Poster Feb 2014

Critical Infrastructure Supports EM Improvement Across the Health System!
Moss Mendelson, MD, Michael Genco, MD, Thomas Wagner, MD!
Emergency Physicians of Tidewater & Sentara Healthcare, Norfolk, Virginia
Background
Objective
To describe a collaborative approach to ED core competency improvement in a
multi-hospital, multi-physician group health system and to highlight early
results.
Innovation Description
Leadership: High level institutional administrative support was integral to the
CEC’s success. Early on, the group’s leadership developed a shared vision of
the priorities for optimizing the care delivered in the system’s EDs.
Alignment: EPT’s senior leadership along with Sentara’s executive sponsors
agreed to create a climate of trust, allowing the physicians, the ED staff and the
hospital’s administrative teams to develop shared improvement goals and
incentives for all ED stakeholders.
Culture: The CEC committed to the following principles: fix your own house
first; promote transparency and accountability to break down silos; embrace a
data/dashboard driven process; and maintain improvement momentum. The
group developed into a platform for EM solutions to system initiatives, for
patient safety education and story sharing, for integration projects between the
ED and other hospital clinical areas, and for clinical informatics improvements.
Accountability: The CEC created dashboards for throughput, patient
satisfaction, clinical goals, and patient safety metrics. The dashboards were
circulated widely and publicly, up and down the health care system. Each
month, physician and nursing leadership shared patient safety stories from their
institutions with the group, allowing other departments to learn from these
events.
Process Improvement: The CEC included dedicated liaisons from information
technology, process improvement (reinventing), and clinical effectiveness. A
group of EM leaders participated in PI educational opportunities and helped to
share these methods throughout the leadership group. Several novel solutions
addressing ED core competency issues were shared across the system through
the CEC after being validated in single site pilots.
Dashboard Development
Severe Sepsis/Septic Shock Bundle Compliance
PATIENT FLOW
SEPSIS
Productivity Index %
# of Precursor/Near
Miss
# of Serious Safety
Events
% of Severe Sepsis/
Shock Pts w/ Bundle
% of Severe Sepsis
Pts w/ Lactate
Admission Rate %
% Boarder Hours of
Total Bed Hours
ESI Level 4&5
% ≤ 75 mins
CLINICAL
CONSENSUS !
SAFETY
Boarders
LOS
Quick Reg to Provider
% ≤ 30 mins
AMA %
LWBS%
Overall % Score
Had input to ED care
MDs & RNs worked
together
Explanation of Care
Completeness of
Care
Daily Average Volume
(Budget)
Access
Admit
% ≤ 270 mins
PATIENT EXPERIENCE
ESI Level 2&3
% ≤ 180 mins
VOLUME
Daily Avg Volume
(Actual)
Growing the value of the care delivered in the Emergency Department (ED)
requires infrastructure. Within the walls of our EDs and hospitals, and across
our system’s facilities, a silo mentality was limiting the clinical effectiveness of
Emergency Medicine (EM). Emergency Physicians of Tidewater (EPT) and
Sentara Healthcare (SHC) partnered to create a system-wide leadership working
group with a performance improvement charter. The workgroup, called the
Clinical Effectiveness Council (CEC), was co-chaired by an emergency
physician and a hospital president, developed and implemented an improvement
and standardization agenda addressing the core competencies of the groups’s 5
hospital-based and 2 freestanding EDs. The group has since expanded across
the system to include 10 hospital-based EDs, 5 Freestanding EDs, and 5
independent physician groups.
Results
ACOUNTABILITY
The CEC developed a high level dashboard focusing on key
metrics of ED Core Competencies. More granular “subdashboards” were developed to support more detailed ana;ysis if
necessary. The dashboard was populated for all EDs and shared
widely throughout the health system.
BENCHMARKS
The availability of benchmarks, such as EDBA throughput data
was helpful in establishing longterm goals and setting priorities.
Communication of the current state was limited prior to the
working group. With the dashboard, all stakeholders, from
the ED staff and physicians to the C-Suite of the system,
could quickly see how the EDs were doing in comparison to
one another in key core competency metrics.
LWBS
Seven ED Practice
below 2% rate.
Maintained LWBS rates
within best practice
during a period of
significant growth in
volume.
PAT I E N T
CENTERED
Throughput steps that
did not add value to the
patient were a focus for
improvement or
elimination.
Volume
Best Practice
3%
360000
340000
2%
75%
74%
74%
2011
2012
60%
49%
45%
30%
15%
24%
2010
The CEC became the platform where the clinical priorities of the system were
translated to emergency medicine practice. The CEC developed consensus on a
“floor” of care for patients with Severe Sepsis or Septic Shock. Resources to develop
EMR tools, produce data, and communicate to frontline staff were integrated into the
CEC. In EPT’s 7 EDs, 200% improvement in bundle compliance was noted over the
first 2 years. Sepsis mortality declined for SHC over the same time frame.
PROCE SS IMPROVEMENT
S TA N DA R D I Z AT I O N
A lean project resulted in a 38% reduction
in door to door median minutes for ESI 4&5
patients at an academic, level 1 trauma
center with65K patient visits per year.
Sharing of the best practices and the PI
method followed for the pilot, led to
system-wide adoption. Staff and Physician
incentives were aligned around the goal.
SuperTrack
1%
300000
90
280000
60
260000
240000
2010
2011
EM
CEC
106
66
30
0
1
2
3
4
83
72
70
79
HB Min
5
6
7
8
9
Q4 2011
Q1-4 2012
2012
The CEC’s initial focus on throughput allowed significant
volume growth to be accommodated without producing a hit
to patient flow or left without being seen (LWBS) rates. All
participants in the group were expected to come to the table
with suggestions about how their domain could affect door
to door times.
HB Min
Best Practice
120
1.2% 1.2% 1.2%
2009
90%
Baseline
320000
1.4%
0%
Bundle Compliance
Low Acuity Flow Median Minutes Door to Door
Left Without Being Seen Rates
MARKET
Blood cultures
before antibiotics
Right antibiotics < 3
hrs
If MAP < 65 (lactate
> 4), appropriate
fluid bolus < 2 hrs
If MAP < 65 post
fluids, vasopressors <
3 hrs
MAP 65+ < 4 hrs
Admitting team
consulted < 3 hrs
Goal
76
74
75
68
72
FS Min
1
2
3
4
87
88
76
98
2013 Full Year Data: 9 hospital-based
(HB) EDs, 4 freestanding (FS) EDs
A multi-stakeholder team was convened to design and implement a lean pilot for low
acuity throughput. Both the PI process and the end-product were endorsed as the
model for EDs throughout the system. The success of the pilot was generally
replicated in 2013 full year data for the 9 hospital-based and 4 freestanding EDs that
were already live or implemented the model at the start of the year.
Lessons Learned
A well resourced working group allowed us to break down silos within the ED, the hospital and the health system, which
subsequently enabled a rapid pace of meaningful change in our EDs. The leadership workgroup defined its culture carefully and
deliberately from the onset. Strong, ongoing support from the system’s C-suite was critical to success. Physician, Nursing and
System Leadership developed a common vision of the value enhancements they wanted to bring to ED care. The team committed
to staying patient centered and accountable. Development of a physician culture that endorsed the workgroup’s vision and
acknowledged the important role that each individual physician plays on shift remains a key priority.