How One Urban Emergency Department Is Making Care Better

New York-Presbyterian Hospital’s “Making Care Better” program provides a structure in which it could enhance organizational culture.  Elements support collaboration, communication, patient engagement and care management.

ABSTRACT: Gaps in communication can lead to diminished patient experiences and decreased staff engagement. That’s particularly true in fast-paced clinical environments. Interdisciplinary team collaboration is essential to achieving communication gains. New York-Presbyterian/Weill Cornell Medical Center’s innovative program is a comprehensive approach to improving patient care and staff engagement at a large academic medical center emergency department. It has achieved promising results, as satisfaction scores, staff engagement and throughput metrics have reached new highs.

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Interdisciplinary team-building promotes both a higher quality of care and an enhanced patient experience. That’s an important consideration in light of a 2015 poll in which three-quarters of all emergency physicians say the number of emergency department hospital visits continues to grow despite the passage of the Affordable Care Act.1 Indeed, a report by the Centers for Disease Control and Prevention found “few changes in ER use” between 2013 and 2014, which was a full year after implementation of the ACA.1

With the increased regulatory scrutiny of operational efficiency and the patient experience, academic medical centers must devise innovative ways to ensure the provision of compassionate, efficient, high-quality medical care to patients.2

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The New York-Presbyterian/Weill Cornell Medical Center emergency department carefully chose members from all disciplines to comprise its "Making Care Better" team, with a focus on breaking down silos and encouraging collaborative efforts. | Google Maps

New York-Presbyterian Hospital launched its “Making Care Better” program to provide a structure in which it could enhance organizational culture by fostering relationships that improve communication and teamwork, and develop enhanced reliability, efficiency and patient care. The MCB elements support overarching themes of collaboration, communication, patient engagement and care management.

In the emergency department, the MCB team focuses on reviewing performance data and identifying improvement opportunities that inspire commitment and subsequently drive change. This unique program has achieved promising results.

Methods

Teamwork is essential in the workplace. The New York-Presbyterian/Weill Cornell Medical Center emergency department carefully chose members from all disciplines to comprise its Making Care Better team, with a focus on breaking down silos and encouraging collaborative efforts. Representatives include members of the ED faculty, hospitalists, emergency medicine residency, nursing, ancillary support, social work, patient services, advanced-care providers, senior leadership and others.

The department’s MCB team conducted an analysis that revealed key factors affecting patient flow, quality of care and patient satisfaction. These factors fall into several disciplines: patient experience, teamwork and communication, care re-design, ED leadership responsibilities and staff satisfaction.

Patient Experience

 There has been an increased focus on the patient experience throughout health care in recent years.3 Hospitals are expected not only to provide high-quality care, but to do so in a safe and efficient manner while ensuring a positive patient experience. In response to these expectations, the department’s MCB team piloted several patient experience initiatives:

No waiting room: We reviewed ED waiting room processes and found them to be an acute source of patient frustration. We devised a workflow in which patients are brought directly into the ED upon arrival, with registration and triage at bedside. This significantly reduces waiting time and ensures patients meet a provider earlier in their visit.

Vertical care unit: To optimize the limited space in our ED, we designed an area with lounge chairs and access to Wi-Fi and television, as well as an adjacent area for private examinations. The VCU allows a subset of ED patients who meet specific clinical criteria - typically, emergency severity index level 3 patients - to sit comfortably while awaiting results. The private exam area is fully equipped, allowing for a history and full physical exam to be performed. Since launching the VCU, we have reduced length of stay by an hour for patients treated in this area, and patient feedback has been positive.

Medical scribes: Adding them helps overcome patient dissatisfaction with the amount of physician face time. Under direct physician supervision, scribes gather information for the patient’s visit, perform documentation in the electronic medical record, and partner with the physician to deliver efficient patient care. This allows physicians to spend more time at bedside. Funding for the program was provided by the hospital and its physician organization. Its implementation also has enhanced and expanded resident teaching by our faculty members.4

ED discharge follow-up: Telephone calls provide us with invaluable direct feedback from patients, helping us identify opportunities for improvement in patient care. We use this information not only to improve our processes but also as a source of regular feedback to our clinical providers.

TABLE 1: MCB STAFF COMMUNICATION TOOLS

Daily interdisciplinary emergency department huddles

  • Huddle in each clinical area attended by all ED staff members.
  • Formulate a platform for communication between staff members to collect best practices and troubleshoot ideas.
  • Use standardized huddle checklist.

MCB “Message of the Week”

  • Distribute important departmental information in a timely and consistent manner.
  • Improve communication across disciplines.

Virtual Suggestion Box

  • Provides a platform for frontline staff to submit ideas, concerns or feedback via email.

 Teamwork and Communications

 Provider organizations with great teams are more effective in improving quality and reducing costs.5 According to the Joint Com-mission, communication failure is one of the most-frequently identified root causes of reported sentinel events.6 

Our department’s MCB team strongly emphasizes teamwork and communication to create better experiences for patients and staff. We developed communication tools to distribute important departmental information, and also included strategies to collect feedback from frontline staff. These include daily interdisciplinary ED huddles, an MCB message of the week, and a virtual suggestion box (See Table 1).

Care Redesign

In 2016, the department’s MCB team launched the low-acuity-area redesign as well as a telehealth express care service.

Low-acuity-area redesign: Unlike a traditional ED workflow, we bring patients immediately into an examination area where a health care provider performs a rapid medical evaluation (See Table 2). We also eliminated physical barriers between providers and nurses, and between providers and patients. Providers previously sat in a “doc box” physically separated from other staff and patients. Now, providers are stationed in a central location next to the nurses and ancillary staff to increase communication and teamwork. This location also allows providers to see patients as they arrive.

TABLE 2: LOW-ACUITY PATIENT WORKFLOW

1. Arrival

  • Patent greeted by RN upon entering emergency department.
  • Vital signs checked.

2. Transition

  • Patient immediately brought into low-acuity area.
  • Provider initiates care and orders appropriate tests.

3. Evaluation

  • RN assesses patient and completes full triage at bedside.
  • Care completed by providers, including the attending physician.
  • RN discharges patient.

Telehealth express care service: Patients with low-acuity complaints who meet our inclusion criteria are offered an option to see an attending physician in a private room via a webcam and monitor. The patient is seen after a medical screening exam performed at triage by a nurse practitioner or physician assistant. As of June 2017, more than 2,600 patients had used the service, with a total length of stay of approximately 35 minutes from arrival to ED discharge. This is significantly lower than the 2½ hours needed for the traditional ED pathway.7 Satisfaction surveys from these patients also have been positive, in the 99th percentile.

Department Leadership

ED leaders are obliged to secure buy-in from leadership across departments to achieve effective and sustainable change. The department’s MCB team developed a task force to address the issue of increasing numbers of admitted patients waiting in the ED for inpatient beds. We formed the Admitted Patients in the Emergency Department Task Force with three objectives: to improve communication between the ED and the medical department; to establish collaborative processes and protocols; and to develop feedback and accountability structures.

The task force is a core group, with representatives from emergency medicine and nursing, hospitalist medicine and nursing, operations, social work, care coordination, admitting and patient services. It meets monthly, and the efforts of this task force have streamlined communication and improved care for emergency patients. Initiatives such as scripting handoffs, fall reduction and admission improvements have been successfully launched through this group.

Staff Satisfaction

The department’s MCB leadership routinely connects with staff members, either during shifts or at planned events such as breakfasts, luncheons and outings.

This consistent outreach has resulted in enhanced staff engagement and real-time feedback/suggestions on MCB-proposed initiatives. Improved employee engagement, through the kaizen style of continuous improvement, can lead to better safety and outcomes, patient satisfaction and lower costs in direct and indirect ways.8 By working together, an actively engaged staff and the MCB team have created great gains in our workflows and patient satisfaction. These metrics continue to improve.

FIGURE 1: LOW-ACUITY PATIENT SATISFACTION

Compared as a percentile to other local peer hospitals. Low-acuity-area redesign took place in March 2016.

sharma 1

FIGURE 2: DOOR-TO-PROVIDER TIMES

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FIGURE 3: LOW-ACUITY PATIENT LENGTH OF STAY

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FIGURE 4: STAFF ENGAGEMENT INDEX

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Results

Making Care Better has empowered emergency department leadership and staff members to make high-impact changes in a short amount of time. Our initiatives have considerably improved operational efficiencies, staff engagement and patient satisfaction scores (See Figures 1-4).

In 2015, our MCB team was honored with the New York-Presbyterian Patient-Centered Care Corporate Team Achievement Award. In 2016, our emergency department’s low-acuity area placed above the 97th percentile for patient satisfaction compared to other New York City peer hospitals. Also in 2016, the Press Ganey Institute for Innovation highlighted our emergency department MCB leadership team as a case study for demonstrating effective collaborative teamwork to achieve high levels of performance.

As part of ongoing quality assurance, we monitor 72-hour revisit rates for our ED telehealth patients. That figure stands at 1 percent, which is lower than the reported rates (3 to 7 percent) for traditional ED settings.9,10 We haven’t had a single admission to the hospital for the telehealth patients that returned within 72 hours.

Discussion

Our MCB program has been a successful example of interdisciplinary team efforts with proven results. Our team started with a group of eight and now averages more than 20 staff members at our weekly meeting.

The team collaborates on every MCB initiative proposed. We achieved most of our ED innovations and initiatives by implementing process and workflow changes without requiring any additional staff members and minimizing costs while optimizing results. All operational initiatives are first implemented as six-month pilots while measuring goals and soliciting staff feedback before instituting permanent changes. Not all initiatives are successful on the first try, and the feedback we receive from frontline staff is invaluable to the success of the pilots.

While driving innovation is crucial, it is equally imperative to maintain standards and quality of care. The people, processes and systems for patient outcomes are the hallmark of a good program. As with any team, there are obstacles that must be overcome to achieve success; those commonly are staff buy-in, limited budgets and resources, and general resistance to change.

Additional obstacles include staff requests that are un-achievable, such as expanded real estate. Communication and follow-up regarding these kinds of requests are of the utmost importance. Employees must know their ideas and requests are heard and taken into consideration. This fosters an environment of open communication for improvement, translating into better patient care.11

Items that have generated expenses were hospital-supported social events, panels and electronics for the vertical care unit, and adding medical scribes to the department. The investment in staff events, new feedback vehicles and pilots were key to in-creasing staff satisfaction and buy-in. Data indicates that health care organizations that have high employee satisfaction scores often tend to have high patient satisfaction scores.12

We continue to strive for improved communication and enhanced work environments. To this end, our MCB team continues to work closely with our frontline staff to brainstorm and address issues in real time. While we have made great progress with our operational metrics and satisfaction scores, we realize that there is much more to be done to ensure sustainability and longstanding improvement.

We have made great strides and will continue to try to set a new standard for emergency care. Physician leaders should consider a similar multidisciplinary team approach to improving the patient experience, staff engagement and throughput metrics and to do so through innovative and collaborative means.

Rahul Sharma, MD, MBA, CPE, FACEP, is a physician in the emergency medicine division at New York-Presbyterian Hospital/Weill Cornell Medicine.

Matthew Laghezza, PA-C, is chief physician assistant at New York-Presbyterian Hospital/Weill Cornell Medicine.

Jane Torres-Lavoro, BA, is an administrative specialist in the emergency medicine division at New York-Presbyterian Hospital/Weill Cornell Medicine.

REFERENCES

  1. Gindi RM, Black LI, Cohen RA. Reasons for emergency room use among U.S. adults aged 18–64: National Health Interview Survey, 2013 and 2014. National health statistics reports; No. 90. Hyattsville, MD: National Center for Health Statistics. 2016.
  2.  O’Daniel M, Rosenstein AH. Professional Communication and Team Collaboration. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 33. ncbi.nlm.nih.gov/books/NBK2637/
  3. Understanding the Drivers of the Patient Experience. Harvard Business Review. 2013. hbr.org/2013/09/understanding-the-drivers-of-the-patient-experience.
  4. Ou E, Mulcare MR, Clark S, Sharma R. Implementation of Scribes in an Academic Emergency Department: The Resident Perspective. Journal of Graduate Medical Education. 2017 [in press]
  5. Thomas H. Lee. Teamwork: The Competitive Differentiator for the New Marketplace. HFM Magazine: December 2016
  6. Sentinel Event Statistics Data—Root Causes by Event Type (2004-15)
  7. Reddy S. Can Tech Speed Up Emergency Room Care? Wall Street Journal. 2017. wsj.com/articles/can-tech-speed-up-emergency-room-care-1490629118. Accessed June 16, 2017.
  8. Mark Graban. Lean Hospitals: Improving Quality, Patient Safety and Employee Engagement, Third Edition. 2016
  9. Cheng J, Shroff A, Khan N, Jain S. Emergency Department Return Visits Resulting in Admission. American Journal of Medical Quality. 2016;31(6):541-551. doi: 10.117/1062860615594879.
  10. Nunez S. Unscheduled returns to the emergency department: an outcome of medical errors? Quality and Safety in Health Care. 2006;15(2):102-108. Doi:10.1136/qshc.2005.016618.
  11. Leonard M. The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care. 2004;13(suppl_1):i85-i90. doi:10.1136/qhc.13.suppl_1.i85.
  12. Collins, Kevin S, RT(R)(T), CMD, MsEd; Sandra K. Collins, MBA, Richard McKinnies, RT (R)(T), MsEd, and Steven Jensen, PhD. "Employee Satisfaction and Employee Retention Catalysts to Patient Satisfaction." The Health Care Manager 27.3 (2008): 245-51.

ACKNOWLEDGEMENTS: With contributions from Brian Miluszusky, RN; Rhonda Krinsky, RN; Rosa Borensztein, NP, Alicia Glavin, NYP senior hospital leadership, and the ED Making Care Better team.

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