When Phoenix-based Banner Health purchased Payson (AZ) Regional Medical Center in the summer of 2015, there were clear signs things needed to change. One of the biggest sore spots at the 44-bed hospital was the ED, where long waits and low patient satisfaction were tempting patients to seek other care alternatives.
However, just a few months later, average wait times have been cut in half, patient satisfaction has turned in a positive direction, and volumes are up. Hospital administrators don’t point to any particular change that led to the turnaround. Rather, they credit a flurry of improvements ranging from ED staffing changes, a push for transparency, and fresh policies and procedures that are motivating personnel to collectively push for a higher level of care and service.
Match staffing to volume patterns
With his background as an emergency nurse, Mike Herring, MSN-L, MBA, RN, CENP, the new chief nursing officer at Banner Payson Regional Medical Center, focused much of his early attention on bringing the ED patient flow process into alignment with the other 28 hospitals in the Banner Health system.
“The model we brought here is bedside triage. Bring patients back immediately and try to decrease that time from when they walk in the door to when they see a physician,” he explains. “Focus on the three time periods that you can control: door to doctor time, doctor to disposition time, and disposition to actually being discharged or admitted time.”
To expedite patient flow, administrators adjusted provider schedules so that they better reflected patient volume patterns at the facility.
“They had a physician on duty 24/7, and they had a physician assistant [PA] ... who would usually come in at about 2 p.m.,” Herring notes. “Historically, EDs pick up at around 11 a.m. or 12 p.m. ... but in this community the ED actually picks up at around 9 a.m. or 10 a.m. just because we are a little short on primary care physicians [in this region].”
Consequently, the schedule for the PA was adjusted to begin at 9 a.m. or 10 a.m., depending on the day of the week.
“Now, there’s two providers on board before the rush hits, which allows patients to be seen more [expeditiously],” Herring says. “Of course, this decreases length of stay and allows you to stay ahead of the curve.”
Hospital management also took steps to beef up staffing in the ED to a level that is more in line with what Herring refers to as a safer staffing model. In particular, the hospital added ED techs during peak hours.
“This really empowers nurses to feel that they can manage and provide that safe care, which is what every nurse wants,” he says. “They were an extremely engaged group, and they still are.”
Part of this empowerment stems from the implementation of a series of standing orders that enable nurses to proceed with standard steps such as starting an IV or collecting a urine specimen when patients present with certain specific complaints.
“Applying those standing orders helps decrease that length of stay, which creates more real estate in the ED,” Herring says. “It starts the ball rolling.”
One new strategy that has been a big winner with nursing staff is end-of-shift huddles.
“Usually, the physician will pull the team together and they will review what went well and where the challenges were. It is kind of a constant performance improvement/self-evaluation [exercise],” Herring explains. “Also, the physician will take the opportunity to discuss an interesting case, just to [develop] the nursing staff from an educational standpoint.”
One of the primary dividends from these huddles is improved physician/nurse communication, Herring says.
“That is imperative, and it is huge for patient care,” he adds.
Bring scribes on board
Implementing so many changes can prove daunting to existing staff. However, the fact that the hospital brought in a new emergency provider group from TeamHealth, a physician staffing organization that was already familiar with the Banner model, certainly kept the transition manageable.
One technique TeamHealth brought to bear on the ED turnaround is the use of scribes, explains Joel Betz, MD, the new medical director of the ED.
“The reason we use them is to get the doctor out of the computer as much as possible and back to the patient,” he explains. “Scribes help us with documentation. Instead of having your face in a computer, typing, when patients are talking to you, you can look at them and see them as patients, providing a little bit better connection on a human level.”
A scribe is typically on staff in the ED from 9 a.m. to 9 p.m., and he or she primarily works with the physician. It isn’t complete coverage, but it makes a difference in expediting patient flow, Betz says.
“As we are doing one thing, the scribe can do another, such as getting discharge paperwork done,” he explains. “There has been some research that we have done showing there is a benefit in turnaround time, productivity, and that kind of thing.”
Most scribes are nursing or medical school students, so they are usually well-versed in the most recent medical terms and standard practices, Betz explains.
“We have used them at some other facilities that are a little bit bigger. You’ve got to judge how busy the facility is and whether it is worth having them or not, but here it does seem to be a significant benefit,” he says. “I know it helps with provider satisfaction because none of us went to medical school to be computer guys. We went to medical school to be involved with people. It makes us more interactive with the patient, and it does seem to help with patient satisfaction.”
Post key metrics
While all these tactics have helped, Betz notes one of the most powerful change agents has been the practice of posting key time metrics regarding patient flow so that staff can see how the department is doing collectively, and how their own performances are contributing.
“That is important because you have to have buy-in from the nurses and everyone working together to get those times down,” he says. “If you feel like you are part of a team and there is something you can measure, that really seems to make a difference.”
Herring concurs with these sentiments, noting that there is evidence that patients who may have previously turned to other alternatives for care are now returning to the Banner Payson ED. While average daily volume to the 10-bed ED has traditionally stood at about 44, the ED often treats 50 patients in a day, he says.
“The reputation has improved. People know they can be seen in a timely fashion, and we have staff who feel they can make a difference,” Herring says. “That is where you want to be.”