How EDs Can Limit Chronic Visits by the Homeless

A few weeks ago I wrote about how homelessness is one of two top causes of ED overcrowding. Today, let’s take a deeper dive into what experts think may help.

A recent study published last year in Psychiatry Services, a journal of the American Psychiatric Association, followed a cohort of more than 700 homeless individuals over a three-month period, tracking their use of the ED. Over the course of the study, 30% of participants visited the ED one or two times, while 12% visited three or more times, which researchers deemed “high use.”

What researchers determined was that the reasons behind chronic ED use by the homeless were complicated.

Surprisingly, researchers concluded that housing status didn’t play a large of a role in chronic ED use. Homelessness wasn’t a cause in itself. Also, outside services did little to stem visits. However, the situation isn't totally hopeless. They found a possible solution lies in the cooperation of vested interests.

They contend that more coordination between outside services, housing organizations and healthcare providers “may better address the complex medical, housing, and psychosocial needs of chronically homeless individuals.”

“Increased ED utilization was associated with both general medical and psychiatric morbidity and greater use of non-ED services,” researchers wrote. “Thus ED use was related to high need and acuity and was not ameliorated by use of other services.”

So what does better coordination look like? Two recent news stories highlight how EDs and hospitals can better coordinate care with outside organizations to decrease ED use by homeless individuals. While these initiatives appear to be working, it’s still too early to gauge whether they’ll be sustainable in the long-term. But what they do show is how cooperation between outside organizations and healthcare providers can lead to better outcomes for homeless patients.

Finding respite in old motels

“It’s impossible for homeless people to recover from a health crisis when they just go back out onto the street after being discharged from the hospital. They end up returning repeatedly to emergency rooms and hospitals, which are very expensive.”

This story out of Buena Park, CA is a wonderful example of how coordinated care for homeless patients can better serve these individuals and positively impact a hospital’s bottom line.

The Illumination Foundation, a homeless services non-profit, has converted an old motel into a place of refuge for recently discharged patients. A triage center has been set up in the lobby and the rooms have been transformed into recovery facilities, with funding assistance provided by area hospitals and health insurers. Patients stay between two to three weeks and are able to obtain the social services necessary to help move them into more permanent housing. A nurse is even on staff.

And the program, still in its early stages, appears to be cost-effective—to the tune of $2,000 less per day than a hospital stay, which saves hospitals and insurers money. Patients, too, are experiencing positive results.    

“Housing first style” housing

“The hospital is paying to get them out of the emergency room and into housing.”

In Chicago, the University of Illinois Hospital has partnered with the Center for Housing Health to provide homeless patients an apartment and a case manager in order to curb chronic ED use. And it seems to be working.

Case managers help coordinate care by scheduling follow-up appointments, which lessen the odds of a return visit to the ED; and the apartments — which cost the hospital a third of what a hospital stay would — lessen the burden of homelessness on the patient and the healthcare system. And that’s not all. So far, with 15 patients in the pilot program, the initiative has helped lower healthcare costs for these patients by 75 percent, while having a positive impact on their health.

What these two programs highlight is how high-quality care doesn’t have to come at the expense of a hospital’s bottom line. What’s evident, is that investments in long-term solutions for the homeless and coordination of care pay off. Hospitals are able to increase the quality of care for all its patients — not just its chronic users who suffer from homelessness or mental and substance abuse issues — and cut costs.   

Is your hospital or ED working with an outside organization, or has a cutting-edge initiative it’s employing to counter the chronic use of the ED by the homeless? I’d love to hear about it. Feel free to comment below or drop me a line.

SOURCES:

Psychiatry Services: “Factors Affecting Emergency Department Use by a Chronically Homeless Population”

Kaiser Health News: “Old Motels Get New Life Helping Homeless Heal”

Texas Public Radio: “A Hospital Offers Frequent ER Patients An Out — Free Housing”

4 Signs of Staffing Issues In Your Emergency Department

Proper staffing is an important component of emergency department efficiency. EDs that aren’t appropriately staffed may find it difficult to provide the high-quality and timely care patients seek and deserve.

Determining when and how to utilize your staff for maximum efficiency and cost effectiveness can prove challenging. Patient volume fluctuates and the effects can be difficult to predict even when taking historical data and real-time analytics into account. Additionally, the strengths and weaknesses of your staff must be considered when scheduling, as should the possibility of outside events beyond your control. When it comes to staffing, preparation is everything.

But how can ED leaders conclude whether or not their ED is properly staffed in the first place?

When working with EDs, I look at four indicators first to assess if staffing issues are present. These signs can be very telling when it comes to staffing and scheduling, and whether your team is being utilized in the most efficient and cost-effective manner.

1. Patient throughput time

The first place to look to determine whether or not your ED is properly staffed is your patient throughput times. If they are above the national or state averages or are steadily rising from month to month, staffing issues may be the reason why.

Throughput times may increase for a variety of reasons, so it’s important to analyze other factors to determine which ones may be contributing to the rise. An increase could be related to an inefficient patient flow process; poor communication among staff and other departments; or a combination of factors that should be addressed with a tailored action plan. 

2. Leaving without out being seen (LWBS) rate 

Just like high patient throughput times, increased LWBS rates are a key indicator that your ED isn’t properly staff. Patients will leave if their concerns aren’t addressed in a timely manner. How your ED is staffed — specifically at triage — plays a crucial role in making sure all patients are seen. 

3. Patient satisfaction

If patient satisfaction scores are lower than expected, your schedule may be the reason why. While patient satisfaction scores aren’t the most telling of indicators when it comes to staffing issues your ED may be facing, they are important to consider. Communication and pain management are key drivers of patient satisfaction. However, staffing may be an underlying cause behind these and other issues leaving your patients unsatisfied. If the staff is in a pinch for time, it can take longer for them to get patients the pain management solutions they need in a timely manner. And, a harried staff can make clear, empathetic communication challenging. 

4. Staff morale

ED staff members are under a considerable amount of stress even when an ED is appropriately staffed. If you notice that your turnover rate is on the rise or that there is a general sense of dissatisfaction among your staff, take a look at your schedule. Morale is closely related to the three indicators discussed above — patient satisfaction especially. If patients aren’t satisfied, your staff won’t be either. A solution may lie in a few tweaks to the staff schedule.

The most effective way to properly staff an ED is by first analyzing the strengths and weaknesses of your staff members and creating the schedule accordingly. Although, the natural inclination for many ED leaders facing issues related to staffing is to increase the number of staff on duty and on-call during a given shift. However, this strategy can be expensive and it doesn’t always address underlying issues like playing the right staff in the right positions. 

If you believe your ED isn’t properly staffed, Donovan & Partners can assess the reasons why and create an action plan that maximizes efficiency while keeping your bottom line in mind. Contact Donovan & Partners today at cmd@constancedonovan.com or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

SOURCE:
Collins, Martha: “Staffing an ED Appropriately and Efficiently.”

2 Top Reasons EDs Are Overcrowded

Overcrowding is the most pressing issue facing emergency departments (EDs) today. When an ED is at — or over — capacity, quality of care, patient safety and staff morale all begin to suffer.

There are many reasons why EDs experience overcrowding. While this blog focuses on two of the biggest culprits, it’s important to understand that a variety of factors, both internally within the ED and externally in the community, contribute to this growing problem.

Here are two of the most common issues contributing to overcrowding in the ED, and a few suggestions to help EDs tackle the problem head on.

1. Homelessness

A 2002 study conducted by the American Public Health Administration found that more than 40 percent of the homeless respondents it surveyed had visited an ED at least once over the course of a year. (Nearly eight percent visited on three or more separate occasions.) Fast forward 10 years and not much has changed. This study from 2013 found that single homeless women visited the ED 13 times more often than women in the general population. For single homeless men, the rate was nine times higher than the general population.

While homeless individuals make up a small fraction of the overall population in the U.S., the frequency of ED use by the homeless takes it toll when it comes to crowding.

What can EDs do? First, they must ensure that they have a strong patient flowprocess in place. Optimized patient flow is the first step to eliminating overcrowding, regardless of the cause.

Second, it’s important to build relationships with organizations within the community that can offer assistance to homeless patients once they’re discharged. Make sure you have a list of shelters, mental health and substance abuse professionals, food pantries and other related organizations at the ready. Often, the most effective treatment is to empower patients with information on where they can seek assistance.   

2. Substance Abuse, Mental Health and Psychiatric Boarding

Much like homelessness, patients battling mental health and substance abuse issues find themselves in the ED more often than the general population. In 2007,1 in 8 ED visits were made by adults with a mental health or substance abuse problem. The role of the ED is to perform emergency medicine, not provide long-term treatment for those patients suffering from these chronic problems. But in reality, EDs are on the frontline when it comes to treating the effects.

To help patients with mental health or substance abuse problems — and stem their repeated visits to the ED — EDs should serve as a guide to outside resources and organizations that can offer long-term assistance. Just as with homeless patients — many who may be suffering from mental health and substance abuse-related medical issues — the ED best serves as an intermediary.

The boarding, or holding for treatment, of psychiatric patients is another issue contributing to the crowding of EDs. According to Dr. Scott Zeller, chief of Psychiatric Emergency Services for the Alameda Health System in Oakland, California, ED staff spend twice as much time trying to find in-patient beds for psychiatric patients than they do other patients.

Dr. Zeller says, “Often these patients are kept with a sitter, or in ‘holding rooms’ or hallways on a gurney, some languishing for hours in physical restraints, often with no concurrent active treatment.”

As a solution, he recommends regional dedicated emergency psychiatric facilities that are EMTALA compliant. Patients could go to these centers on their own to seek care, be taken by ambulance when mental health is a concern or transferred there from hospitals that don’t offer psychiatric care once medically stabilized. They could be treated right away rather than spend hours waiting in an ED bed.

Zeller’s suggestion is that the problem should be treated at the source — when patients first present, rather than at the destination — once admitted to the hospital after hours of waiting, boarded in an ED. He sites that a great majority of psychiatric emergencies can be stabilized in less than 24 hours. In his model study, patient boarding times decreased significantly — by more than eight hours, an 80 percent improvement.

How to Solve Overcrowding in Your ED
These two factors which contribute to ED overcrowding have distinct characteristics that call for customized solutions. There’s not a single, universal course of action EDs can take to address overcrowding. Only by stepping back and taking into account all the factors at play, can EDs begin to tailor a specific plan of action.

If your ED is facing issues related to overcrowding, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, along with external issues facing your community, and then help you implement the best solutions to alleviate crowding. Contact us today at cmd@constancedonovan.com or 651-260-9918. For more information on the services we offer, visit our website.

SOURCES:
American Public Health Association: “Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study.”

Science Daily: “Homeless people more frequent users of ED, other health services.”

Medscape Medical News: “Mental Disorders, Substance Abuse Linked to Increased Emergency Department Visits.”

Zeller, Scott: “Psychiatric Patient Boarding Problems in the Emergency Department.”

Wait Times: How Does Your ED stack up?

Many patients might look at the emergency department (ED) like they would their neighborhood deli — first come, first serve. Luckily, for critically ill patients, this isn’t the case. The patients who need immediate treatment are going to receive it no matter how many patients are waiting.

Explaining this logic to a patient with a broken finger or a parent with a child experiencing cold symptoms may not be easy. The ED is the last place they want to be, and to them, their pain, or child’s pain, is a priority. Patients sometimes aren’t the best judge of their symptoms, and finding a way to get care outside of the ED can prove difficult depending on the day of the week, time of day and where they live.

The stats seem to reflect that. For example, from 2009 to 2010 more than 25 percent of all ED visits by children were for cold symptoms. For adults 12 percent of visits were deemed non-urgent, for cold symptoms and the like.

But it’s not just more non-urgent patients seeking care that are adding to wait times. With increasing numbers of patients visiting the ED for nonurgent conditions, wait times are bound to spike.

Year after year, average emergency department wait times have increased across the nation because visits are too. More people are seeking treatment at EDs — for urgent and nonurgent conditions — while the number of EDs is decreasing. According to the CDC the number of patient visits to EDs increased 32 percent over a 10-year period from 1999 to 2009. And at the same time many EDs closed their doors due to financial constraints.

So how does your ED’s average wait time compare?

One Measure: Broken Bones

The wait time for treatment of a broken bone is an important measure when it comes to hospital wait times. Of course, there’s different types of breaks and the severity of each will vary, but on average in 2014, a patient had to wait 54 minutes before receiving pain medications upon arrival in the ED.

For a national average, 54 minutes is long and depending on where a patient lives and which hospital they choose for treatment, the wait could have been much longer.

Take Washington, D.C. for example. Emergency departments in urban areas typically have longer wait times. In D.C., patients suffering from a broken bone had to wait an average of 69 minutes before receiving pain meds. This is only 15 minutes more than the national average, but with eight hospitals in the area the wait times varied drastically. If a patient sought treatment for a broken bone in D.C., they may have waited as little as 50 minutes for pain meds, or as long as 150 minutes depending on which ED they chose.

Difference in Wait Times Correlated to Patient Demographics

So who is facing longer wait times besides the no-critical patient? It seems adults go last and the old and the young are put first. According to the Centers for Disease Control and Prevention, Older patients, age 65 and older had the lowest mean ED wait time from 2008-2010 at 48 minutes. Children’s was 51 minutes And, adults 18 to 64 tended to have to wait the longest at 58 minutes.

Researchers found a difference when it comes to gender. Females experienced longer waits than males — four minutes more than men (57 minutes and 53 minutes, respectively).

There were even interesting stats around race. Non-Hispanic black patients experienced the longest wait times (68 minutes), while Hispanic patients waited 60 minutes, and non-Hispanic white patients waited 50 minutes.

What Will the Future Hold When it Comes to Wait Times?

On average they’ll increase, but there’s no reason your ED can’t be an outlier. First, you need to know where you stack up, which you can do by checking outProPublica’s ER Wait Watcher.

If you find that your patients are waiting longer than those at a nearby hospital, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, and then help you implement the best solutions to cut wait times. Contact us today at cmd@constancedonovan.com or 651-260-9918.

Sources:
ProPublica: “ER Wait Watcher, Which Emergency Room Will See You Fastest?”

Centers for Disease Control and Prevention: “Wait Time for Treatment in Hospital Emergency Departments: 2009.”

Centers for Disease Control and Prevention: “Health, United States, 2012, With Special Feature on Emergency Care.”

American College of Emergency Physicians: “Emergency Department Wait Times, Crowding and Access Fact Sheet.”

5 Ways to Prevent Improvement Burnout

It’s been five years since the Affordable Care Act (ACA) was signed into law.

It was 15 years ago that the Institute of Medicine published its landmark “To Err Is Human” report.

Earlier this month, the Institute for Healthcare Improvement (IHI) held its 27th Annual National Forum on Quality Improvement in Health Care.

In other words, the current drive to improve the quality, accessibility, and cost-efficiency of healthcare in the United States has been underway for nearly three decades. In recent years — notably since passage of the ACA — we’ve seen the velocity and volume of those efforts pick up. That’s cause for excitement and optimism. But we also need to be careful to prevent burnout among our staffs—in both their day-to-day operations and their change efforts.

That’s especially true for those who work in the emergency department, where the stakes — and the passion for helping people — run high.

The theme for this year’s IHI National Forum was “Recharge.” It’s a concept I encourage you to keep in mind at this time of year, as you pause to reflect on how your organization performed against its 2015 improvement goals and begin planning for 2016. There is no more essential element to the success of your improvement initiatives than an energized, engaged, and motivated team.

I also want to share with you some ways to help recharge your department’s efforts and avoid what others in the healthcare field have called “improvement fatigue.”

1. Celebrate progress. This one is obvious, but so important that I’ve placed it first. It’s easy to put off recognition until you have the time or opportunity to make if formal. Or to wait until you’ve met the big, overarching goal. Don’t. Recognize even small increments of improvement. If your team is facing disruption or uncertainty due to operational changes, let them know in real-time how much you appreciate their patience. How you do it doesn’t much matter — often a simple written message will do — as long as you make it meaningful.
2. Reconnect with the reason you’re improving. Keep patients and their loved ones central to your efforts. They’re the reason your team members chose their professions and report for work each day. It’s easy to get caught up in eye-glazing quality measurement numbers, but they only tell part of the story. There’s another, human story behind each of those numbers. Try to include at least one patient story every time you report on progress.
3. Renew efforts to engage your staff. They’re the ones who suffer the frustrations of inefficiency or puzzle at the illogic of processes that don’t work well. Look for ways to capture their observations and identify small changes that can have significant impact. Encourage them to be solution-oriented, to replace the question “Why do we always ____?” with “What if we could _____?”
4. Triage your improvement efforts. Prioritize your resources toward those initiatives where the need is greatest, the timeline the most urgent, and the potential for a good outcome highest. Then make sure the team members you task with implementing those efforts understand what’s at stake. It’s easier for them to be motivated when they can clearly see the need for and potential impact of what they’re doing.
5. Inject a little levity. The work of the emergency department is serious business. But there’s still room to take a lighter touch with quality improvement efforts. It may even increase your team’s engagement. Think of how many times you yawned through airplane safety demonstrations until the airlines started producing videos that use humor. If you’re planning a meeting or activity related to improvement efforts, consider finding ways to incorporate humor or even game-like elements to add some fun to the proceedings.

What are some ways you’ve found to prevent improvement burnout and keep your team engaged? Contact me to share your ideas or to get more information on leading successful quality improvement efforts in the emergency department.

A 12-Point Plan to Re-Engineer the Discharge Process in Your Emergency Department

Last week I talked about some of the reasons why you should improve your emergency department discharge process. It’s one hospital quality measure that can affect your patient satisfaction scores and HCAHPS scores. Making sure your process is in order won’t just improve quality of care and patient outcomes -- it can also help you earn “top-box” HCAHPS status. As a result, you can earn higher Medicaid and Medicare reimbursements in this era of value based care.

Proven Process Improvement Borrowed From Outside Industry

Luckily, the government has funded a toolkit to help hospitals implement best practices in regards to discharge. The Re-Engineered Discharge toolkit, or RED for short, took seven years to create. When it comes to finding new and better ways to operate, I’ve touted the benefits of looking outside of the healthcare space to business or other industries for methodologies like Six Sigma before. It turns out the government did just that in creating the RED toolkit.

From the Agency for Healthcare Research and Quality (AHRQ): “Preliminary work included intensive study of the discharge process, borrowing methodologies from engineering to define the RED, such as process mapping, failure mode effect analysis, probabilistic risk assessment, root cause analysis, and qualitative analysis.”

The result requires hospitals to act with discharge in mind throughout the patient flow process including conducting follow-up after the patient leaves your facility. The RED has been mentioned to be of particular value for hospitals serving diverse populations

Lower Costs and Improve Outcomes
The AHRQ says the benefits of using the kit are clear -- among them it improves outcomes and return on investment. It can:

• Decrease 30-day readmission by 25 percent.

• Decrease ED use from 24 percent to 16 percent.

• Reduce costs by $412 per patient.

As a bonus it is “accepted as NQF Safe Practice and endorsed by Institute for Healthcare Improvement, The Leapfrog Group for Patient Safety, and CMS.”

Published Positive Results
But is it feasible to implement? A study published online this May from the Journal for Healthcare Quality looked at 10 hospitals before and after they implemented RED and the results were positive. “Eight out of 10 hospitals reported improvement in 30-day readmission rates after RED implementation,” found the authors.

They also found that while a supportive hospital culture is essential and “engaged leadership and multidisciplinary implementation teams were keys to success” -- hospitals could be flexible in their implementation strategy.

Researchers found that common challenges included: obtaining timely follow-up appointments, transmitting discharge summaries to outpatient clinicians, and leveraging information technology.

Your 12-Point Discharge Improvement Plan
The AHRQ says the “RED consists of a set of 12 mutually reinforcing actions to ensure a smooth and effective transition at discharge.” I like to think of it almost as a checklist. Take a look and see what you think. From the AHRQ:

Components of the RED

1. Ascertain need for and obtain language assistance.

2. Make appointments for followup care (e.g., medical appointments, postdischarge tests/labs).

3. Plan for the followup of results from tests or labs that are pending at discharge.

4. Organize postdischarge outpatient services and medical equipment.

5. Identify the correct medicines and a plan for the patient to obtain them.

6. Reconcile the discharge plan with national guidelines.

7. Teach a written discharge plan the patient can understand.

8. Educate the patient about his or her diagnosis and medicines.

9. Review with the patient what to do if a problem arises.

10. Assess the degree of the patient's understanding of the discharge plan.

1. Expedite transmission of the discharge summary to clinicians accepting care of the patient.

2. Provide telephone reinforcement of the discharge plan.

Ready to make some of these changes? Head on over to the online toolkit. They have printable PDFs that your team and patients can fill out. Or for expert help facilitating a re-engineering of your discharge or any other process within your emergency department, contact me. My healthcare consulting agency, Donovan and Partners, can do an assessment of your emergency department. It can help you hone in on opportunities across multiple processes that can help boost your patient satisfaction and HCAHPS scores.

SOURCES:
AHRQ: “Re-Engineered Discharge (RED) Toolkit.”
HCAHPS: “HCAHPS Tables on HCAHPS Online.”
The Journal for Healthcare Quality, “How Hospitals Reengineer Their Discharge Processes to Reduce Readmissions.” Mitchell, SE. Online May 13, 2015.

One Sad Reason Behind the Movement to Revamp Discharge Procedures

Rory Staunton was an active 12-year-old. He was sent to the emergency room for what doctors thought was a stomach bug after he got a cut on his arm chasing down a loose basketball. After he was given fluids and seemed to show improvement, he was released. Sadly, he died three days later from undetected sepsis shock. In hindsight, people have questioned if better information sharing could have raised a red flag with medical staff. Could his life have been spared?

To tell the story is not to shame the hospital where this happened. A doctor quoted in a 2013 New York Times article covering the story said: “I think it could have happened almost anywhere.”

After Rory’s death, when people looked into the case, they found a few places where better communication may have helped. They include information handoff from primary care physician to ED and back again along with making sure critical lab results get into the hands of doctors.

I’m sharing Rory’s story with you to resharpen the focus we bring with us to work each day. We know we’re in the lifesaving business but sometimes it is easy to just go about our daily routines or be OK doing things the way we do because they have always been done that way. With the pressures we face we often don’t pause to take stock and say “Is there a better way?” It also a good reminder of the reason behind some regulations and procedures. With constant changes to rules, regulations and procedures for emergency departments it can be overwhelming, maybe sometimes they even feel arbitrary or a lot of trouble to undertake for no good reason. Rory’s story is proof that they aren’t.

State-Level Regulations

In New York State, Rory’s Law was passed in the wake of his death to try and prevent future cases like his. The new regulations call for improved communication to ensure vital health information like lab and test results are relayed to children’s parents and their primary health care providers. On the national level, Agency for Healthcare Research and Quality and Boston University Medical Center (BUMC) have released a toolkit to help you re-engineer your emergency department’s discharge process.

For some ideas on how you can measure how well your emergency department’s discharge process stacks up, I’ve pulled information directly from the Re-Engineered Discharge Toolkit to help you. It’s a free government resource you can leverage yourself. The payoff can be big.

Lower Readmission and Medical Error Rates

In addition to improved patient safety and outcomes, achieving lower readmission rates can be another benefit of re-engineering your process. See these facts from that NY Times article I mentioned earlier:

“‘Every year, between 600,000 and one million patients in the United States are sent home from emergency rooms only to return within 72 hours because of medical errors,’ according to Dr. Michael Weinstock, an associate professor in the emergency department at Ohio State University. During a career of 30 to 35 years, the average emergency doctor ‘will send home 17 patients who will die an avoidable death within seven days.’”

How to Make Evidence-Based Change

In its toolkit, AHRQ acknowledges the challenges and benefits of taking a closer look at discharge procedures. The process is complex and requires syncing communication among “inpatient care team, primary care team, community services, the patient, and the patient's caregivers. There are many opportunities for improved discharge processes at U.S. hospitals that, if accomplished, could lead to reduced rehospitalization of patients, which is currently at a rate of almost 1 in 5 for patients covered by Medicare.”

Here’s information directly from AHRQ's toolkit to get you started in the re-evaluating and reengineering your process. The excerpt below highlights four possible trouble spots to examine:

• Delayed Transfer of Discharge Summary: There is frequently a delay between the time a patient is released from the hospital and when the primary care doctor receives the discharge summary. This delay means the doctor is not immediately aware of which tests and procedures were done during the patient's hospital stay or what conditions still need attention.
• Unknown Test Results: Test results are not always complete by the time the patient leaves the hospital. This means the test results will not be included in the report the patient's primary care doctor receives.
• Lack of Follow-up: Patients themselves often do not fully understand the nature of their health problems or realize they need to make appointments for tests or procedures after leaving the hospital. They may be unable to make appointments due to lack of access to transportation or availability of appropriate doctors/specialists. Research has found that more than one-third of the patients who left the hospital in need of more care (e.g., lab tests or a referral to a specialist) failed to get that care.
• Medicine Reconciliation and Adverse Events: Confusion about which medicines to take can also lead to problems after a patient leaves the hospital. When patients are admitted to the hospital, many stop taking their regular medicines and start taking new ones. Once they leave the hospital, there is often confusion regarding which of the prehospitalization medicines should be continued. This may result in the patient failing to take needed medicine, taking duplicate medicine, or experiencing adverse drug events or natural remedy interactions.

The result of hospitals' failure to ensure an effective transition has included adverse events, high readmission rates, and high ED visit rates. Forces are, however, converging to push hospitals toward improving their discharge processes and reducing readmission rates.

For personalized help revamping your emergency department’s discharge processes to improve patient outcomes and safety and stay ahead of the HCAHPS regulations, contact me. I’m happy to help and create a customized action plan for your emergency department.

SOURCES:
AHRQ: “Re-Engineered Discharge (RED) Toolkit.”

Boston University: “MED Prof Earns Drucker Award.”

New York Department of Health: “Rory’s Regulations.”

New York State: “Governor Cuomo Announces New York State to Lead the Nation in Fighting Sepsis the #1 Killer in Hospitals and Make Major Improvements in Pediatric Care Through "Rory's Regulations.

NY Times: “Death of a Boy Prompts New Medical Efforts Nationwide.”

Tips to Set the Scene for Open Patient Communication

We’ve all heard the saying, “There is no such thing as a stupid question.” But how good of a job is your emergency department nursing and medical staff at making patients truly feel that way? Your patient satisfaction and HCAHPs scores are riding on it.

Healthcare has become consumer driven. Patient satisfaction surveys ask patients if nurses and doctors care about them, if they were given the information they needed to get well, and whether they are likely to recommend your hospital to someone else. Reimbursement is dependent on the effectiveness of our communication and the effectiveness of our treatment.

Here are some tips to help your team in their communication with patients.

1) Make Eye Contact. To engage the patients and families try being mindful to look them in the eye and listen with a caring and warm attitude.  Recognize this first step is the most important in establishing a rapport and this rapport will most likely set flow for the patient’s entire experience.  

2) Use Your Senses. You want to develop a communication style that is adaptive to the situation and patient you’re working with. Look, listen and feel to understand what is being said and not being said. Empathy and acknowledging the patient’s well-being and comfort demonstrate respect.

3) Anticipate. When you listen to understand your patients and their families it helps you anticipate concerns they may have. This can be very comforting. Anticipating involves knowing customarily what, when, why care is a certain way (process) and then thinking about questions the patient might have about the process but be too intimidated to ask. Try making thoughtful remarks such as “Many patients what to know when the doctor will see you”. Then acknowledge that the doctor has several patients and follow-up with information on how quickly the doctor will see them.

4) Try a Different Delivery Style. Think about creating a relationship where patients feel comfortable talking to us. You can create this type of relationship if you understand how to initiate conversations using techniques called “appreciative inquiry or welcoming questions.” These open channels of communication between patients and caregivers. That’s so important because patients have information that is crucial to helping them get better.

Appreciative inquiry involves framing questions in a way that helps you gather relevant information, foster a give and take in communication, and encourage positive action as a result

Rather than just communicating in short questions or commands, it involves asking an open ended question around the topic you want to address. Then you can guide to conversation to impart important information.

This might be a communication tactic which is different than the informative caregiver mode of communication that you’re used to. It’s no secret nurses and doctors are busy caregivers, we often need to make “a long story short” -- get to the point quickly and with technical accuracy. But while that is perfectly OK and actually important in communication between one shift of nurses to the next or between nurses and doctors or PAs, this hospital-speak is sometimes lost on patients.

In addition to being confusing, it often doesn’t create relationships with patients and family that inspire open and effective communication. Patients can become intimidated and are reluctant to ask questions because their nurse or doctor has such urgency.

How to Use Appreciative Inquiry
Here’s an example you might use when talking to a patient before discharge:

“We have a lot of patients that come to the ED for migraines. Have you sought out help for them from the emergency department before?”

This sets the scene in an empathetic way. You appreciate their problem -- the migraine. You set them at ease by letting them know they are not alone in seeking help for their type of problem and don’t feel scolded for it.

If they answer “Yes, twice before,” you can share information that will direct them toward taking positive action going forward. For example, you could then say: “We know about this clinic where you can get help managing your migraines.”

5) Be patient. Keep in mind that when you try this type of approach you may get more questions from patients. For example, a question about how long they can expect their recovery to take might be something you automatically know. But with patients you can’t take for granted that this is common knowledge. Patients and family don’t know what they don’t know, and need guidance to help them ask the right questions and establish expectations.

Remember, there are no stupid questions. Questions are a good thing. It means the patient is tuned in. Asking questions can help them better understand what role they need to take in recovering. Having an ongoing conversation can help you provide the best care.

Being composed, acknowledging, listening to understand, being responsive, knowing, and caring has the potential to engage and create a rapport with the patient and their family which impacts their overall experience. Interestingly, these approaches to communication can increase understanding, focus and efficiency too.

If you’re interested in talking more about communication techniques or making appreciative inquiry something you practice in your ED, drop me a message. I’m happy to talk more about it with you.

Create a Culture of Carefulness and Communication

Last week I mentioned two ways you can boost your patient satisfaction scores. Here's one doctor's perspective on how upping her communication game helps her provide quality care to the patients he sees. It's a good read.

Communication is another area that you can focus on to boost scores. Solid communication among emergency department staff is so important. It influences patients' care and perception of that care.

As she talks about, establishing solid communication at shift changes is key. She also offers his personal tips and tricks for how to do it. Additionally, I love the shout-outs to the nursing staff. Do you have any things that have helped you create a "culture of carefulness and communication" in your emergency department?

This blog has got me thinking. In my next post we'll take a deeper dive into polishing up communication in the emergency department.

How to Decode and Fix Low Patient Satisfaction Scores

Patients have an uncanny ability to pick up on underlying areas that need improvement in your hospital. Do you know how to translate what they’re saying? Learning how to interpret patient satisfaction results is becoming even more crucial because of upcoming changes to Centers for Medicare & Medicaid Services (CMS) scoring.

Starting next year, your hospital’s overall reimbursement score will be impacted by how well your emergency department does on patient satisfaction surveys. It could cost your hospital a percent of your Medicaid reimbursement.

Here is how to translate some patient satisfaction results into changes for good.

Low score on: Attentiveness of nursing staff

Take a look at: Your staffing ratios and scheduling and rounding procedures

Nurses that don’t have time to spend with patients and satisfaction scores reflect that. Patients report less empathetic nurses when the nurses are harried and pressed for time.

In California, safe staffing laws have stated the appropriate staffing ratio in emergency departments is four patients to every nurse. The closer you are to that ideal the more time nurses have to talk with patients and provide quality care. Not only do patient satisfaction scores rise but outcomes can too.

If you feel you can’t afford new hires, take a look at how you’re doing scheduling. Maybe you can rebalance how staffed up your emergency department is so you’re making the most of the staff you do have and are balancing your staff to workload ratio appropriately.

Another way to boost scores in this arena: take a look at rounding. Are patients being checked on every hour by staff? When you provide scripting for allied health professionals when they complete rounds it makes it easier for the staff and ensures that patients are being listened to and their basic needs are being cared for.

Low score on: Delays in care

Take a look at: Operational efficiencies

How is patient triage upon arrival? Does your staff have processes in place to rapidly assess whether a patient is suffering from a heart attack or sore throat and get them the proper care? Develop processes to provide the right service with the right provider at the right cost. This approach requires developing clear procedures for routing patients efficiently and effectively to the appropriate treatment area and for diagnostics, e.g. x-rays.  Putting specific processes in place creates efficiencies and cuts down on the possibility of a patient languishing in one area and long throughput times.

For more insights into what your patient satisfaction scores are trying to tell you, reach out to me. I am happy to help your emergency department with an assessment that uncovers opportunities for improvement and outlines recommended actions.

Pay Attention to Safety and Caring and Patient Satisfaction Scores Will Rise

Four Areas to Target Including One Surprise

Patient satisfaction can seem like an ephemeral thing. Is there anything tangible you can focus on to boost it?

Several studies have indicated that yes, yes there is. It is all about getting back to the basics. It appears that by focusing on things that improve safety and caring, patient satisfaction scores will rise as well.

A review published in the British Medical Journal in 2013 looked at 55 studies that measured care and patient satisfaction in several types of healthcare settings. The idea for the review came about in an effort to answer the question: should patient satisfaction even be used as a measure to rate hospitals?

The review found that, higher patient satisfaction scores were often linked to higher safety and clinical efficiency scores.

“Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations,” said the authors.

If patient satisfaction scores were high, the same hospital was likely to have high patient safety and patient experience scores as well.

Results from a Patient Safety and Quality Care survey of studies in 2008 speculated that this might be because the same things that help prevent serious complications, patient identification errors, infections, medication errors and falls also happen to improve patient satisfaction.

What Steps Can Your Emergency Department Take to Improve Safety, Caring and Satisfaction?

There are many things you can do and I am happy to talk to you about a unique plan for your hospital but for the purpose of this post, we’ll take a look at four biggies.

1) Take a look at communications. Make sure you have procedures in place to make communication of patient information easy. Areas to look at? Transfer of information between caregivers, shifts and different departments within your hospital. Looking at your procedures for intake and discharge can be especially effective.

Nursing leaders, you can reinforce the importance of communication in your rounding and bedside reporting to oncoming nursing staff. Modelling this behavior yourself -- leading by example -- can help ensure the whole nursing staff adopts this approach.

2) Make sure staffing coverage meets the demand for patient care.AHRQ’s Patient Safety Network has concluded what most of us know -- nurses are critical in ensuring patient safety. So let’s help set them up for success. Staff that aren’t pressed for time and stressed running from one emergency to the next has the time to provide quality care. Appropriate coverage also minimizes mistakes.

So how can you make this a reality? Experienced nursing leadership knows the wisdom of a data-driven staffing and scheduling approach. You can use healthcare analytics to understand demand and your functional capacity to solve your staffing challenges.

3) Encourage an environment of trust and non-judgmental for reporting errors. Staff is less likely to report errors or perform well when there is a “blame game” type of atmosphere. Patient safety and satisfaction suffer. Fostering the right culture can help remedy this.

A “just culture” -- one that strikes the right balance between openness and accountability -- improves safety without being arbitrarily punitive. The Leapfrog Group, a circle of large employers focused on improving health care safety, has recognized the importance of a fair and just culture in improving safety.

There is a methodology and algorithm you can apply to help you implement this type of culture and spell out guidelines for appropriate actions when errors are made.

4) Limit noises to promote healing and focus. This one may come as a bit of a surprise. Patient satisfaction surveys tell us patients are not as happy in loud environments. Studies have found that noise hinders healing, causes sleep deprivation, and increases pain.

So upon a second look -- it also makes sense that chaotic unscripted emergency department noise can compromise safety. Researchers have found that louder healthcare environments produce more medical mistakes. It makes it hard to concentrate, may desensitize staff to important alarms, and interferes with the effective communication between caregivers. The Joint Commission made a National Patient Safety Goal on managing clinical alarms systems in 2014. They recognized that if they are not properly managed, they can compromise patient safety.

To take control of noise you need to understand it. Every interaction, every piece of equipment, every medical alarm, every emergency page, and every phone creates noise. Even patients, visitors and others add to it.  

To solve this multi-faceted problem, engage everyone in pinpointing sources of noise and taking personal responsibility to limit it. Sometimes changes to the physical environment can help too.

So Why Does Improving Safety Yield Other Benefits?

None of the study authors pinpointed the whys behind the link between good safety scores and high patient satisfaction. Perhaps emergency departments that rate well on patient satisfaction measures are also paying more attention to safety rules too.

Or maybe it is because people go to emergency departments to get better. When adverse events are kept to a minimum and safety is a priority, people are more likely to improve and heal. It’s natural that those patients will be more satisfied.

What I do know for sure is that when you invest in improving processes and communication to improve safety and care it can yield a double-win!

If you need help examining safety protocols or your patient satisfaction survey results and finding ways to improve, I can help. Contact me. I’d love to talk over your emergency department’s unique situation with you.

SOURCES:

Patient Safety and Quality Healthcare: “Safety and Satisfaction: Where are the Connections?”

BMJ Open: “A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.”

AHRQ PSNet: “Nursing and Patient Safety.”

Hospitals and Health Network: “Runaway Noise in the Hospital.”

New England Journal of Medicine: “Balancing "no blame" with accountability in patient safety.” Wachter RM, 2009.

The Joint Commission: “The Joint Commission Announces 2014 National Patient Safety Goal.”

Patient Navigators: Worth Their Weight in Gold

For those of us that work in health care, the ins and outs of how the process works, referrals, follow-ups, prescription instructions, insurance – it’s part of our everyday language. But for the average American, dropping them in the health care system can feel as foreign as plopping them down on another planet.

The rules are different, the language is different, the path is unfamiliar and winding, and there is money as well as their health on the line. It can be downright scary and intimidating. The stress of these challenges can make getting well hard to do. Enter the patient navigator.

What is a patient navigator?
Today, Patient Navigators are on the leading edge of the changing tide of health care. They function differently depending on the situation -- sometimes they provide patient education, other times they operate as a coach and a patient advocate.  

Not investing in hiring nurse navigators for your emergency department may wind up costing you. Why? The beauty of patient navigators is they can help on multiple fronts:

1) They reinforce the patient's discharge instructions and help schedule follow up appointments which helps deliver better patient outcomes. They hook patients up with the right services which helps deliver better patient outcomes.

2) Patients are more likely to follow their instructions, get well, and report higher satisfaction scores. Not only is this what we all wish for our patients but thanks to patient satisfaction surveys and outcome measurement systems, these are crucial areas hospitals are measured on and funding is tied to performance.

3) Because patients are receiving better care, it cuts down on repeat visits and re-admissions – which adds to costs and can be even more expensive in the face of funding penalties

How exactly do they do this?
Patient navigators help patients connect the dots to get the care they need. They are a single point of contact for a patient. They can connect patients with different doctors, primary care specialists and therapy providers. They can track down answers to medication or insurance questions. They make calls to remind patients about appointments and arrange for transportation. It’s their job to follow-up with the patient early and often. For a patient navigator that works with emergency department patients, an initial part of their job would be to contact the patient and make sure they understand and are following their self-care instructions at home. They also work to get them to primary care physicians.

They are especially helpful in working with underserved populations. One study published in the Journal of Healthcare Management defined these as people who are low income, uninsured, publicly insured, or recent U.S. immigrants.

The study examined one Texas hospital’s use of navigators. It found some interesting results. Among folks who less frequently used the emergency department for primary care services, navigators helped decreased their odds of returning to the emergency department. Among patients who returned to the emergency department for primary care, the pre/post mean visits declined significantly over a 12-month pre/post-observation period. The authors also found that by lowering primary care emergency department visits it saved enough money to cover the cost of hiring and training the navigators.

So where do patient navigators come from?
Patient navigation is a relatively new field. Sometimes you may have heard them called nurse navigator, patient advocate, healthcare advocate or consultant, or medical advocate. Patient navigators aren’t providing patient care. They are enabling it to happen.

The story goes that in the ‘80s and early ‘90s Dr. Harold Freeman developed the concept in Harlem after survival rates for women with breast cancer at his hospital were low --  39 percent 5-year survival rate. The expected rate: about percent.

He recognized that it is challenging to get well. A lot of different things have to come together. Additionally, the challenges can be greater if you’re poorer. Time away from work, transportation, and childcare all have a cost. After implementing patient navigators, he was able to raise survival rates to 70%.

The field really began growing in recent years in part because of changes brewing ahead of the Affordable Care Act and the move towards accountable health care and Medicaid penalties.

You should know that because it is a relatively new occupation there is no accrediting body or licensing process. But the industry is moving towards that over the long term. Earlier this month, the National Association of Healthcare Advocacy Consultants just posted best practices.

Right now, if someone wants to become a patient navigator there are training programs, certifications, and even master's degrees that produce some of these practitioners. Some hospitals have had success using peer training programs.

How much does it cost to hire patient navigators?
Accenture and a hospital foundation spent $254,500 to fund six patient navigators for a year-long pilot program. The Bureau of Labor and Statistics classifies navigators as Health Educators and Community Health Workers. They list the median income for 2012 as $41,830 a year. With a nursing degree or other medical training they command more.

If you are interested in hiring, there may be some grants available from government agencies. Big Pharma and other Foundations are also pitching in at some hospitals.

What’s the ROI?
According to Managed Healthcare Executive, the returns on investment are considerable. They reported that the year-long Accenture pilot project in Pennsylvania resulted in a 43 percent reduction in excessive emergency department visits. This was across three hospitals. They helped about 4,000 patients.

It also netted other benefits. “… one system had a 60 percent reduction in 30-day readmissions, as part of a broad set of activities…” according to Managed Healthcare Executive.

That project used non-medical navigators that they trained from the community. This kept costs low.

Another hospital Managed Healthcare Executive reported on, Mercy Health in Cincinnati, Ohio, is expanding its navigator program after its pilot program brought a return of $5 for every $1 spent. The system’s one-year pilot decreased emergency visits by about one third. They brought hospital admissions among the high-risk pool down by one-half. Readmissions were cut by one-third.

Who’s hiring patient navigators?
Even though it is a relatively new field, hospitals are starting to catch on to the real benefits that patient navigators can hire.

While they were first utilized mainly to work with cancer patients and chronic disease like diabetes, hospitals are finding ways to leverage their help in more acute situations.

The American College of Cardiology announced in the fall of 2014 that they were launching a patient navigator program at 35 hospitals across the country. Their goal: reduce unnecessary patient readmissions.

The announcement of the program cited “the stresses of the initial hospitalization, to patient fragility at time of discharge, a lack of understanding of discharge instructions, and the inability to carry out discharge instructions” as reasons that drive patient back for readmission. Patient navigators can help in all these areas.

More Details Please
If you have specific questions about how patient navigators can help your hospital, contact me. I’m happy to talk with you about how your emergency department can work more efficiently and get better results.

SOURCES:
Patient Navigator Training Collaborative
Patient Navigator: “Patient Navigators – Who We Are and What We Do,” “Ethical Standards and Best Practices – Final Version Published,” “Training Programs for Patient Navigators.”
National Association of Healthcare Advocacy Consultants – Present at the Creation
Agency for Healthcare Research and Quality: “Connecting Underserved Patients to Primary Care After Emergency Department Visits.”
Accenture: “Jameson Health System Launches Patient Navigation Program with Highmark Foundation and Accenture.”
Mena Report: “Pittsburgh Hospitals Reduce Emergency Healthcare Executive: “Navigators reduce no-shows.”
American College of Cardiology: “American College of Cardiology Patient Navigator Program Completes Hospital Selection.”
Journal of Healthcare Management: “Reducing preventable emergency department utilization and costs by using community health workers as patient navigators.”
CNN: “Helping Patients Navigate the Healthcare System.”

EMTALA Compliance: Pain, Plan and a Pass

One of my clients recently faced Emergency Medical Treatment and Labor Act (EMTALA) violations – pinged not once, but twice within four weeks.

With no time to wallow, we moved into action on a correction plan. A week after receiving CMS’s last notification letter, we submitted the hospital’s plan of correction, which included the following:

• Redefining quality patient safety practice standards/policies
• Improving emergency care delivery system processes
• Providing physician and nursing staff education
• Implementing compliance monitoring processes

As with any good game plan, we stuck to it like glue. Three weeks after the plan of correction was submitted, CMS re-surveyed the Hospital, which passed with flying colors.

Throughout my many years in clinical consulting, I’ve learned a few things – one being that any plan needs a solid structure and toolkit with which to execute. My arsenal starts with Verge Solutions. This web-based compliance tool served as our means for ongoing professional practice evaluations, and with it we were able to link to the regulatory standards, ensure real-time compliance reporting and customize the interface for any community hospital.

If you are interested in avoiding receiving CMS deficiency letters and needing to write corrective action plans, let’s talk about doing a survey readiness assessment for your hospital’s emergency department.

If you would like to learn more about Verge Solutions, you can check out their website or connect with them on LinkedIn.