ED tracks criteria, ties quality to credentialing
ED tracks criteria, ties quality to credentialing
Nurses surveyed about physicians
"We look at a variety of things as most departments do, but I think we're trying to collect some data that there aren't good benchmarks for and can have significant variability from institution to institution or at least trying to look at our [department] numbers... to compare ourselves to our colleagues here at the hospital. That's kind of the first step as we work toward more national and regional benchmarking," says Bruce McNulty, MD, chairman of the emergency department at Swedish Covenant Hospital in Chicago. As chairman, he tracks physician performance on specified criteria, establishing aggregate benchmarks and uncovering outliers.
"We're fortunate that we have and have had for a long time an electronic medical record here at Swedish so our ability to get information is fairly simple. So we're ahead of the curve in that respect. It's fairly simple for me to be able to have both numerators and denominators on total patients seen and then the rates at which my physicians are ordering things that have the potential to impact quality and utilization," he says.
McNulty tracks a variety of measures for efficiency and quality, and those data are used in turn by the hospital's credentialing committee for recredentialing.
He tracks, for instance, per physician how many patients are seen, how quickly they are taken to a bed, and their length of stay in the hospital. Admission rates, deaths in the ED and within 24 hours, X-ray reading discrepancies, and utilization of CT scans are also collected.
"Certainly one of the things you may have heard and read about is that rates of CT scans have really gone up exponentially with the ER being a leader, if you want to look at it that way, in the use of those imaging modalities. They obviously provide incredible amounts of information and are making our diagnostic skills far superior to what they were 10 years ago. The down side is radiation exposure is far exceeding what our physicians did 10 or 15 years ago and the potential risks that go along with that," he says. So it is both a measure of utilization and patient safety, and the department has been able to create benchmarks to use to identify possible outliers.
McNulty says he wanted to be careful in collecting data on imaging tests so as not to belittle their importance or to discourage physicians from using them when necessary. "[W]hen I decided I was going to start looking at utilization rates, my concern was I don't want to by doing that create a situation where I might be encouraging physicians to not do appropriate testing or not admit patients appropriately because they're concerned that their rates may be higher than their colleagues.
"So at the same time I looked at both gross rates of return to the ERs within 48 hours and then we also specifically pull those cases and look at them individually to see what patients who we sent out come back and why and how many of those can we attribute to the fact that we maybe should have admitted them at the first visit or we decided not to do a CAT scan of abdominal pain for instance and we messed up and they came back a day later. I'm doing my best to correlate those 48-hour returns with those rates to see if we have anyone who is potentially an underutilizer and by doing that is potentially affecting patient quality. So that's the kind of two-sided look at utilization," he says.
Nurse feedback shared with physicians
McNulty also tracks less measurable, less tangible things. Annually, the nursing staff, including ED technicians and secretaries, complete a confidential, anonymous survey assessing the ED's physicians. "A lot" of the questions, he says, are on the "touch-feely" side, such as: Are you a nice person to work with? Do I feel comfortable working with you? Do I feel like you see patients quickly and efficiently? Are you easy to find? The survey also includes a free text area in which nurses can comment. (See box, below, for sample questions.)
Sample nurse survey questions Staff can answer strongly agree, mostly agree, agree, mostly disagree, strongly disagree, N/A.
Source: Swedish Covenant Hospital |
He combines the survey results with the tracked data to create the year-end review with all physicians. Physicians see both their individual scores and the aggregate scores for the department. Data are sent out monthly so McNulty can identify opportunities that may need attention before or outside of the annual physician reviews. For instance, he says, it could be a "brand new physician out of residency who is going to have a higher admission rate because they're not as experienced and not as confident and they're going to have higher CT rates for the same reasons and it's a matter of understanding the reasons why that might be and then watching for improvement." The department meets monthly to discuss any quality improvement issues as well.
He says it's been a "powerful motivator for change for physicians." They don't want to be outliers. They want to be liked by the nursing staff. Sometimes the physicians are surprised by the results of the nursing staff survey but McNulty sees it as motivation for improvement. A practicing ED physician for 21 years, he says he's certainly seen individual cases where the data have had an impact. "Probably the most powerful one," he says, "is admission rates. I've had a few physicians who clearly were above their peer level in terms of admission rates and realized that probably their criteria for admission was a little soft, for lack of a better term. And that the rest of us would try to arrange outpatient or observation admissions or be a little more creative. Second is X-ray discrepancies. I've had physicians coming out of residency who didn't have a ton of experience doing this and based on getting that feedback they've become outstanding X-ray interpreters and they've done that by learning from their own mistakes."
"We look at a variety of things as most departments do, but I think we're trying to collect some data that there aren't good benchmarks for and can have significant variability from institution to institution or at least trying to look at our [department] numbers... to compare ourselves to our colleagues here at the hospital.Subscribe Now for Access
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