Benchmark results spur action in hospital ED

Staff addresses Left without being seen’ issues

Sometimes benchmarking can do much more than show you where your facility stands compared to other facilities; sometimes it can help you see a problem that you assumed did not exist.

That’s exactly what happened several years ago at Mary Bridge Children’s Hospital & Health Center in Tacoma, WA. As part of the BENCH (Bench Marking Network for Children’s Hospitals) project, Mary Bridge had been participating with a group of 25 to 30 similar facilities. One of the areas BENCH examined was the number of patients who left the emergency department (ED) without being seen. It was an area in which the staff at Mary Bridge thought they were doing relatively well.

"We always had a busy children’s ED, although after going through managed care our volume had dropped," notes Ted Walkley, MD, FAAP, FACEP, medical director of Mary Bridge. "We were having a resurgence of volume in the department and began noticing our left without being seen’ going up, but we felt that was because we were seeing more patients."

Looking at the rate

Still, Walkley and other members of the administration wondered whether they indeed had a problem in this area. "We had been participating in BENCH for about year, so the first thing we did was begin looking at the rate," he recalls. "Like all statistics collected at a hospital, we had raw numbers. But we found our rate was increasing faster than our volume."

Being part of a benchmark project had changed the mentality "from absolute numbers to rate-based," Walkley explains. "Then, we thought there had to be somebody worse than us, so we looked at the rates for a two-quarter period."

In one of the quarters, Mary Bridge ranked dead last. In the other, it was next to last. But for Walkley, the news was not all bad. "Benchmarking gave us the ability to compare, to look at demographics, to compare volumes," he says. "It essentially gave us the tool that not only told us that we were getting worse, but that somebody else was doing a better job than we were."

So the turnaround effort began in part with conversations with representatives from hospitals that were outperforming Mary Bridge. But that was just the beginning. "We did a lot of very detailed analyses — when did patients leave, why, what doctors were treating them, and on what shift," Walkley says. Both a customer service survey and group analysis were conducted. "Many causes, but no root" were found, he says.

It was determined that the problem was not owned by a specific individual or group of individuals; it was everyone’s problem. The large problem was then broken into parts, so that some fixable parts could be identified.

By and large, they found the problem was staffing-related, says Walkley, and more physician-related than nurse-related, he says.

Changes in MD staffing included:

  • elimination of 12-hour weekend shifts;
  • change in shift times in coordination with nursing;
  • increase in MD coverage from 24 to 30 and then 32 hours per day by overlapping shifts;
  • more judicious use of backup;
  • individual feedback;
  • additional physicians.

"We created a feedback loop so that each month staff could look at the number of patients who left without being seen, at what time, and so on," says Walkley. "Each quarter they could see how they did against other hospitals."

This was an additional incentive to change, he says, because physicians are highly competitive. "The ability to create a ranking and feed it back to them gave them information not only on relative change, but on absolute change," he adds. "By the next quarter, we got to the middle of the rankings. After the third quarter, we were number one, and have consistently ranked as the best of the children’s hospitals."

As important as creating change is, "the fundamental issue is sustaining it," says Walkley, who notes that the volume challenge at Mary Bridge is ongoing. In the recent past, the department typically saw between 1,800 and 2,000 patients in a winter month. "This year, it was 3,000, and we know we won’t be No. 1 for the first quarter, but we maintained that ranking for three full years despite having grown 15% a year in terms of volume. Part of the reason is because, as we grow, our feedback loop changes; we now have almost four years of information."

Each month Walkley can show physicians how they are doing, what the rate was the previous month, and when people came in. "When the number [of left without being seen’] got small enough, we could even give physicians information on each person who left and when, so the physician could ask what was going on when that particular patient left," he notes.