Emergency Department Performance: BEHIND THE NUMBERS

Todd Lang, MD, MBA

Medical Director of Emergency Services Baptist Memorial Hospital-Memphis

Observations

“Every system is perfectly designed to get the results it gets.”

—Dr. Paul Batalden

“It’s not luck.” —Eliyahu Goldratt

“’Try Harder’ is not a tool for performance improvement.”

—Dr. Todd Lang

1. Paint a picture of a dynamic and organic organism that operates according to the goals set for it

2. Demonstrate Little’s Law for servers

3. Discuss some common ED metrics and their consequences

4. Set a simple path forward

Agenda

• Light• Cheap• Durable

•$8899

Healthcare: We want it all, yesterday, every time, and “all” grows every day.

Mountain bike parts: pick two

Inverted U-shaped curve: Patient experience and speed of care

Total Length of Stay

Ove

rall

Sat

isfa

ctio

n

“It took forever!!”Perfect Stay

“The

y di

dn’t

liste

n”

• D2D vs. LOS• LWBS vs. LOS• Clinical care vs. patient satisfaction• Doctor work vs. nurse• Nurse vs. tech/paramedic• ED work vs. ICU or Hospitalist work• Perception: Listened to me vs. pushed me out the

door• Speed and patient satisfaction• Hospital payroll vs. contract group payroll

Tensions

ED Care Team

Pat S

at

Sepsis, AMI, Stroke

Pain Control

D2D

LOS

Core Measures

Readm

ission

The ED Care Team

Moral distress occurs when one knows the ethically correct action to

take but feels powerless to take that action.

Do we cause this with our leadership and expectations?

Moral distress

• Server capacity x cycle time = Work In Process• Arrivals per hour x LOS = Patients in the ED

• Apply it to the whole ED or Unit• Apply to each pod or doctor or nurse• Go to Wikipedia!

Little’s Law: Match demand and capacity.

• LOS = 4 hours• Doc sees 2 pts/hr (on average)• 2 x 4 = 8, but if can see 3/hr then 3 x 4 = 12• Need 8 beds to be busy IF AT AVERAGE

• Doc work ends at admit order (not true for nurse)• Some patients are easier, and some days there

are holds, so need a few extra beds• So, need 12 - 14 beds per doc to account for this• But, 16 is unmanageable in most situations

Sample doc calculation Using Little’s Law

Can nurses do the work expected of them?4 HR LOS Nursing Shiftsadmit 4.5hr admit 4hr DC 3.5hr DC 2hr

4.5 4 3.5 2Shift TimeBed 1 Bed 2 Bed 3 Bed 4

0:00 15 dirty 15 50:30 5 15 dirty 151:00 15 5 15 dirty1:30 5 15 5 152:00 5 5 15 52:30 5 5 5 53:00 5 15 5 153:30 5 5 5 dirty4:00 30 15 15 154:30 dirty dirty dirty 55:00 15 15 15 55:30 5 5 5 156:00 15 15 15 dirty6:30 5 5 5 157:00 5 5 5 57:30 5 15 5 58:00 5 5 15 158:30 5 30 dirty dirty9:00 30 dirty 15 159:30 dirty 15 5 5

10:00 15 5 15 510:30 5 15 5 1511:00 15 5 5 dirty11:30 5 5 5 15

sum: 830Available 720Work: 115%

sum: 830Available 720Work: 115%

sum: 635Available 720Work: 88%

sum: 635Available 720Work: 88%

80% Utilization

96% Utilization

It’s math—not luck!

Queuing for a server: Avg wait time in hours

• Follow the value!• Map the stream and remove the waste• Give staff time to engage patients• Leverage fungible staff substitutions:

– Lab/X-ray subs for ED staff!– Paramedic substitutes for RN– RN subs for Doctor– Hospitalist subs for ED doctor

Shift the curve:

• Know the cost of a walkout• Know the value of a bed-hour• Do the math on LOS changes and staffing• What is the value of shorter LOS in nursing

cost?• What is the value of increased physician

productivity?

Average patient collections

• Triage• Doctor• RN• Pharmacy• CT or X-ray

• Read The Goal to understand bottlenecks.

The roving bottleneck server

• Demand:capacity matching• By day of week and hour• Differential scheduling by day?• Nurse and doc must match!• How about housekeeping and transport and

CT servers?

Arrival curves

• By day• By doctor• By arrival nurse• By shift worked• No excuses

What do you get if you overdo D2D?

D2D: Slice and dice it!

• By doctor• By nurse• By area• By shift• By disease state or resource utilized

What if you overdo LOS?

LOS

• By doctor• By shift• By day of week

Is it low because of lack of patients?

Patients per hour

• By doctor• By disease and by doctor• CHF• Chest pain• Abdominal pain

Why does it vary so much?

Admission rate

• Lab• CT • Morphine equivalents• Total pharmacy cost per patient• Admit• Obs• Total cost

Use the info to coach and ask the right questions! Let the high performers teach the rest.

Utilization by doctor or by disease or both!

• By CT groups: – brain/C-spine– Chest/belly w/IV only

• X-ray:– Portable chest– Others

• Study vs. reading on each of above• By hour of day

Radiology

• A significant fraction of your patients are waiting for a CT result

• CT rate often is in the neighborhood of admit rate

• Cannot dispo until CT is done and read• This key server requires management• The radiologists probably won’t volunteer to

perform better (see demand:capacity chart).

The ED alone can rarely manage this process.

CT, in particular

• Med pick and delivery times• Frequency of med send and what drugs• Frequency of stockouts in ED

Time for pharmacy

• Measure best care, not just the core measures• “consensus committee” or some other way to

decide what good care looks like• Wildly different than CMS deciding for you

• Easy examples: – imaging rules for head and neck – completion of NIHSS for stroke– time to pain meds for fractures– sepsis care

Beyond Core Measures

• What does this incentivize?• Why is it so fundamentally at odds with

“doctorhood”?• How does it fit with our national pill problem?• Do the people around you actually understand

percentiles and how that works?• Does the hospital understand common cause

variation?

The biggest miss: pay for satisfaction

• Call back time?• ED physician satisfaction (particularly if paid)• Time to definitive care• Supply use for surgical cases• Measuring and reporting it is almost as good

as putting it in the contract, but without the contention.

On Call: measure it if you bought it!

• Managing readmissions is at odds with ED flow• Is it easier to readmit than other options?

– Social work?– Inpatient doctor consult?– Ethics consult?– Palliative care?– Talk to the NH doctor?

• All take time and have limited resources!

• Providing resources will move the needle

Readmissions vs. flow

• Conditional formatting works• (S)He who controls the dashboard file has

considerable control!• Much like control of the meeting agenda!

Dashboard: goals and colors

ED Balanced ScorecardCATEGORY MEASURE Source

Volume Contract HoursTotal Admit Rate

CLINICAL Total CTs% patients getting CTTotal PE StudiesPE Studies/PtTotal Head CTsHead CTs/patientAbdominal X ray Use %Lumbar Spine Radiograph Use %Cost Per Case 2014Narcotic PrescribingRegular Use of TNCSMDEmergency Medicine Core Group SkillsBlood UseType and Screen TotalRate/PtType and CrossRate/Pt

DocumentationCritical Care Rate (% of charts)Total Undoc services for 2013 $Rate of Undoc: $/pt vol

Quality progress notes w/ MDM?Visits/hr SoloRVU/Pt RVU/Hr SoloOvertime rate

Effi ciency Typing WPM- www.typingtest.comDoor-to-doctor Year% over 4 hoursUnder 1 Hour VisitsMedian LOSAMA RateRaw Score Patient sat last 12 mLast Hour Performance/Shift Change

Works to End of ShiftTele Monitor Use on admitsRate of ICU Admission

Citizenship Conference AttendanceWhite Coat Worn at Work (A, U, S, R, N)Chart Review ParticipationMeeting Attendance: Patient Complaints-subjectiveCommittee, special projects, other workRadar Factor--positive or negativeNursing Relationships

Behave professionally?Arrive on time and ready to work?

• Data• Focus each doc on 1-3 items• Rank performance compared to internal and

external benchmarks of high performers.• Use color conditional formatting

Scorecard goals

32

“Physicians are quick to challenge performance data and to identify methodological problems with them. But the fact is that they are mesmerized by data

and cannot look away.”- Dr. Thomas Lee: Turning Doctors Into Leaders,

Harvard Business Review, April 2010.