When data were scarce, ED managers formed group

Alliance aims for benchmarking database

"How can we provide better care for less money?" a group of emergency department managers asked themselves. They read the literature, they attended conferences, and they found lots of theories, but no answers.

Frustration prompted them to unite and form the Emergency Department Benchmarking Alliance, a group of hospitals primarily located in the Midwest dedicated to helping each other find practical solutions to tough questions.

"There was no other venue for larger emergency departments to discuss operational issues," says alliance member James Augustine, MD, FACEP, CEO of Premier Health Services in Dayton, OH, and chairman of the department of emergency medicine at Miami Valley Hospital in Dayton.

Scientific studies are available, but managers couldn’t find data on norms in current practice.

"We have a very poor understanding in this country of what individuals are doing who practice medicine," says Gregory L. Henry, MD, FACEP, current president of American College for Emergency Physicians (ACEP) in Dallas. "We have individuals who will tell you what you should do, but none of that tells you what is actually being done."

The group’s members include representatives from Toledo (OH) Hospital; Miami Valley Hospital; Hennepin County Medical Center in Minneapolis; Methodist Hospital in Indianapolis; St. Rita’s Medical Center in Lima, OH; St. Joseph’s Hospital in Ann Arbor, MI; Bethesda Medical Group in Cincinnati; Fairfax Hospital in Falls Church, VA; and Riverside Methodist Hospital in Columbus, OH. Others are also planning on joining.

One or more ED leadership representatives from each facility, including physicians and nurses, attend quarterly meetings at various sites.

"These are the hospital emergency departments which have really done well through the changing times of the last 20 years," says Augustine. "They need to be ahead of the industry."

The alliance plans to meet this month in Fort Meyers, FL, to discuss its projects.

Healthcare Benchmarks will report on the results of this meeting in its April issue.

When the alliance formed almost a year ago, its first step was to identify the various players’ strengths and common needs.

"Being recognized, good hospitals, we shared our strong points with each other: What are we doing that’s good?" says Samuel Kiehl, MD, FACEP, director of the emergency department at Riverside Methodist. "We wanted to identify people who are doing a good job already. Then, of you good guys, what are you best at?"

The problem was that each group was looking only at its own activities, says Henry. "But we had no external way of knowing we were doing a good job," he adds. "We needed to meet with what we considered to be the best of the breed and compare our data with theirs."

At each meeting, a number of issues are explored by the benchmarkers. "For example, how many nurses should you have per shift for so many people, how many techs?" says Henry. "How are other intelligent people doing these things, and what do they consider to be excellent?"

Data are compiled and pooled for discussion at the next meeting. Averages, medians, highs, and lows are noted to provide benchmark data.

"It’s not right or wrong that we’re looking at, but if you have to talk to administration about an issue, you can say here’s what 10 other major groups in the Midwest are doing," says Henry. "You can say 10% of headache patients get CT scans, and we’re at 42%, so there is something wrong here."

Experts are sometimes brought in to address certain issues, including an attorney who spoke about the managed care landscape in California.

"There are also times when we think we can move outside our industry and apply it to our own industry," says Kiehl. "Marriott and Disney do a really good job with client satisfaction, so we’re looking at having them come talk to us."

The health care industry and the hospitality and service industries can learn a lot from each other, says Augustine. "You can come into the emergency department any time day or night, and there will be a team that handles a crisis, then another team reassembles to deal with the next crisis," he says. "It’s very fluid, and there’s a lot to be learned there by other industries."

The idea is to look at everybody’s input and try to come up with something better. "Our objective is to identify best practices and then improve on them," says Kiehl.

Information helps EDs zero-in on solutions

One of the most rewarding aspects of the group is participating in a truly free exchange of information. "Nothing is proprietary," says Bruce Janiak, MD, FACEP, director of emergency center at Toledo Hospital and a former president of ACEP.

"That makes it extremely valuable," he says, "But it’s also why you’re not going to get three hospitals from one city as members, because it’s more difficult for them to share that information. If you’re not in a geographically competitive situation, it makes it easier."

It was important to find members who weren’t afraid to exchange that kind of information. "Whenever there is a pecuniary interest, one tends to be tight-lipped," says Henry. "We had to meet with people willing to share."

Some ground rules have emerged as the group has worked together to find common solutions, including:

• A tacit agreement of confidentiality. An informal confidentiality agreement is honored by all members of the group. "We never reference anybody else’s data that was brought to the table," says Henry. "We don’t expect our members to be broadcasting this data or using it in a commercial manner. These are people I’d let hold my checkbook and know they’d treat it honorably."

• Members pulling their own weight. Members are required to do their homework. "We are getting a tremendous amount of work out of each of our members, and in fact that’s one of the criteria, you must go to meetings and put in the work," says Janiak. "Each of these projects is potentially a lifetime of work. The list of topics is really endless."

The benchmarkers want active participants, not bystanders. "The last thing we want is someone to come in and sit with their mouth closed, but that’s never happened," says Janiak. "First-timers leave in awe. Even if we don’t have all the answers, they always leave with a lot to think about."

• Always bringing something to the table. Another requirement is having something to offer. "These are pretty much a bunch of stars," says Henry. "There is a substantial commitment in time and effort, and we don’t want people who are not players. The last thing we want is for someone to take the data and go home with it."

Every member brings specific areas of knowledge to the table, including reimbursement issues, informatics, and practice management. "There are very few EDs this group couldn’t look at and make twice as efficient," says Henry.

Topics discussed are wide-ranging

Issues the group has examined include the following:

• Patient discharge. "The members feel that we haven’t paid enough attention to the details of the discharge process, which have become even more complex in this managed care world we live in," says Janiak. The group launched a project to define the components of the process and then determine best practices.

• Personnel costs. A cost analysis project will look at large hospitals and determine the actual costs of delivering emergency health care per patient, in terms of personnel alone. "That project is nearing completion, but it’s such a complicated issue, you never get all the answers you want." says Janiak. The advantage is that the group has self-comparative data. "In an attempt to compare apples to apples, we use our individual costs," he says.

• Productivity. "We are going to be rating physicians on a productivity/utilization index, to determine what constitutes an efficient physician," says Henry.

• Measuring patient satisfaction. The group assessed companies who do surveys to measure patient satisfaction. "We’ve done an analysis of these companies and their value, and have made a determination that we, the benchmarkers, could develop a patient satisfaction evaluation tool that is better than any company’s," says Janiak.

• Gathering of information. Various computer programs are being examined for effectiveness. "It’s a little more difficult because there are some proprietary issues involved, so it will probably be more of an analysis than a product," says Janiak.

• Clinical issues. This entails sharing protocols and looking at various chief complaints. "We ask questions about how we work up certain disease entities — is seven days of antibiotic better than three? What is the rule?" poses Janiak.

• Operational issues. The perspective is that every aspect of the ED has room for improvement. "We ask, How long should registration take? How long should triage take? Are we asking too many questions?’" says Janiak. "A lot of what we do early on in a visit is not useful. We are looking at reduced throughput times."

Members trade efficiency tips

The members have already derived hard benefits from the group’s work. "I have used the cost data from the group to justify staffing at my own institution," says Janiak. "My administration accepted the data and did what I wanted to do based on it."

Miami Valley Hospital has a discharge planning nurse, and other members are looking to duplicate that in their own EDs. Fairfax Hospital’s patient satisfaction course was also slated for a presentation.

In competitive times, participating in a benchmarking group is somewhat of a necessity, says Henry. "With the approach of managed care, it’s not just something that’s pleasant, it’s essential to survival." For instance, the group can bring real data on actual costs per case to the table when negotiating capitation schemes, he says.

Part of what makes the group unique is a willingness to examine difficult questions, says Henry. "If you really want to improve, if you want to know how to cut costs or evaluate staffing, you’re going to have to ask hard questions, a lot of which you may not want to know the answers to," he says. For example, data has shown that an efficient ED requires fewer doctors and nurses, and more mid-level practitioners.

The benefits from the group are immeasurable, Henry says. "We think we’re on to something here," he says. "I’d recommend it to anyone who is willing to ask tough questions and critically analyze what they are doing."