Don’t accept ED’s claim it’s too busy to benchmark

Tap into staff’s need to improve

Walk into an emergency department (ED) on a busy weekend and the scene is likely to look like something straight out of a television drama.

With so many crises going on, how could a hospital’s administration expect ED staff to gather data for benchmarking projects? But according to consultant Sharon Lau, of Medical Management Planning in Los Angeles, most emergency departments have a lot of room for improvement.

"It is an area of the hospital that seems to change least, but it is a place where the system can really get clogged," she says. "Most ED staff will tell you they don’t have time because they are busy seeing patients. But how can you improve if you don’t try to see where you stand?"

One reason why some EDs don’t benchmark is they feel out on their own, as if they aren’t really a part of the hospital. "They feel the hospital systems won’t support their efforts, and in many cases that has been true," she explains. But that reason doesn’t ring true to Lau, who says most EDs have computers that allow ED administrators to pull a lot of data straight off the systems. Some pull the data, but don’t trend or compare it, which Lau says is as big a mistake as not pulling any information at all.

Or if they want to benchmark, ED staff worry that the ensuing performance improvement initiatives will take too much of their time. "But you can network over e-mail and do some small projects that won’t take more than a couple hours a month," she says.

The ED is an area where there are a lot of data at hand to be tracked and trended with amazingly little effort, says Lau. "If I say, Do a random sample of 100 patients over three months,’ that’s only one patient a day. Measure how long from the time the patient walks in to seeing a physician. And you don’t even have to do the logging yourself. Hand the patients the cards, and let them do it. Those 300 patients are a perfectly appropriate sample."

Once you have the sample, you can figure out your weaknesses, she adds. And you must if you want to survive in the future. "If you have an average 96-minute wait time, but the hospital next door does it in 12, why would patients come to you? This is important stuff in the current environment."

The key to succeeding is having a physician champion such as Ted Walkley, MD, FACEP, medical director and chief of pediatric emergency services at Mary Bridge Children’s Hospital in Tacoma, WA.

Walkley describes himself as a "data geek" who has used his love of computers and numbers to effect some astounding changes at the 70-bed level two trauma center’s ED. With data on every patient who has presented at the department since 1996, he has a mine of information. "But we really didn’t use those data as part of how we did business until recently. You can design all the clinical pathways you want. But if you can’t measure the difference they make, why bother? These data let us show how a pathway reduces costs, length of stay, and ED admissions. They get physicians interested in doing better, in tweaking things."

For facilities without the benefit of an ED geek of their own, Walkley says presenting physicians with data that show they need to improve and giving them a say in how to make the necessary amendments can help overcome lingering fears ED staff have about benchmarking programs.

Unleash the competitor in every doctor

Even better than getting physicians to try to best their own numbers is trying to harness the competitive nature of physicians to outperform their counterparts at other hospitals, Walkley says.

Mary Bridge is part of a children’s hospital benchmarking group that has allowed Walkley to do just that. "You can have these data, and people think that they are doing the best that they can. But if you show them how they compare to others, they wonder what they can correct. Even if [your facility] is No. 1 in a particular process, you don’t want others to catch you."

One problem that benchmarking revealed at Mary Bridge was with patients who left the ED without being seen. "We had a lot of patients leaving, and knew we had a problem," he says. "But we were staffed as much as possible; we were all working hard, and no one accepted blame."

The numbers were telling. In some months, the number of patients leaving reached 20 patients per 1,000, up from a normal number of five. And the hospital ranked next to last in its benchmarking group. "One thing that blew us away was that there were much bigger hospitals that had a higher volume than we did but were doing better in this area."

Doctor-patient ratio was the answer

When Walkley took the numbers back to physicians and nurses, they agreed that something had to be done. He started analyzing data by physician, by shift, and by staff. "One interesting thing we found is that when the number of new patients per hour exceeded between three and four per doc on duty, the-left-without-being-seen figure skyrocketed. It was not related to levels of nursing staff. That surprised everyone."

As a result, the hospital changed its staffing model to have more overlapping physician coverage. The department tracks the rate monthly and looks at external benchmarks every quarter. Within a year, the data improved significantly. "We went from the worst to one of the best within a year, down to about four per 1,000 patients by the end of 1998," he says.

The number rose in January 1999, but patient volume was higher, and that was expected, Walkley explains. "And it always stayed less than the previous year." To keep the number down, Walkley gives every ED physician a quarterly graph with his or her rate, how the doctor ranks compared to peers, and how the physician would rank against the external benchmarking group if he or she was a hospital. "That’s very powerful," he says. "It’s one thing for me to say to a doctor that he is worse than his peers, but it’s completely different to tell him he is worse than an entire hospital."

And Walkley has never had to do more than present the physicians with their own data. "I hand them the numbers, and I don’t tell them what to do. It’s completely self-starting."

Further evidence of how well the benchmarking has worked came this January. "Volume was 20% above last January and the left-without-being-seen [figure] was less than four per 1,000. That’s more typical of the rate in a slow month, and this was our highest volume month in four years," Walkley says.

Currently, the hospital is looking at return visits and return visits with admissions. Other data collected include all patient demographics, the date and time the patient came and left, physician charges, who saw the patient, facility and ancillary charges, and ICD coding. The data come monthly to Walkley.

Another member of the children’s hospital benchmarking group is Children’s National Medical Center in Washington, DC. According to John Harding, MBA, program manager for emergency services, his facility is gathering data now on labor hours per visit to use for budgeting, to justify staff levels, and to determine whether the staff mix is appropriate. The hospital is also collecting data on wait times, admission order to bed times, unplanned returns, and unplanned returns with admission within 48 hours.

"We chose the latter because it provides us with the potential for a significant process improvement project," he explains. "We can figure out if it is just disease progression or if it’s a system problem. We can figure out if this is because we missed something. And it’s offered us the chance for peer review."

You can’t hate what you can’t see

Harding says he has made benchmarking work in the ED by keeping it invisible to the ED staff. "They don’t want to fill out something else. And before we ask them to, we make sure we put it into a quality improvement context."

Harding admits that staff members are resistant to any change. "But we have created a really good interdisciplinary team, with admissions, lab, radiology, registrars, docs, and nurses," he says. "Now that we are using the data, they think may-be there are ways to improve. Maybe we can change the system to do better. They are questioning things. Even though the feeling is we do great with customer service and patient care, the data are making people sit up and think about where we can improve."

Despite having to work through some computer glitches with his information systems staff, he says he believes that benchmarking in the ED is a great opportunity. "It gives you the numbers you need to prove your case for staffing to administration," Harding says. "But you should keep it simple. Find a couple of indicators that people can relate to and support. Returns is an easy sell because, although it is labor intensive, it’s the right thing to do for patient care."

"People talk about [motivating] docs like it’s trying to herd cats," says Walkley, "But we are still scientists at heart. We have a competitive streak, and we respond to data. I don’t think anyone out there doesn’t want to do the right thing or improve. Benchmarking gives us the feedback we need. It starts discussions on processes, and even if our rank doesn’t change in something, we have accomplished something just by looking at what we do."

[For more information, contact:

• Sharon Lau, Consultant, Medical Management Planning, Los Angeles. Telephone: (323) 644-0056.

• Ted Walkley, MD, FACEP, Medical Director and Chief of Pediatric Emergency Services, Mary Bridge Children’s Hospital, Tacoma, WA. Telephone: (253) 403-1420.

• John Harding, MBA, Program Manager for Emergency Services, Children’s National Medical Center, Washington, DC. Telephone: (202) 884-5996.]