Do Return ED Visits Signal Lower Quality of Care?

When a patient makes a return visit to the emergency department, you may draw the conclusion that quality of care the first time wasn’t great. But a study recently published in the Journal of the American Medical Association offers data that may contend otherwise.

The study’s authors acknowledge that return visits to the ED “are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.” So they set out to find whether or not these return visits, which led to in-patient admission, were evidence of a lower quality of care from the ED that initially treated the patient. The pervading question being, that if a patient is ultimately admitted to the hospital, shouldn’t it occur during their first visit to the ED, and not the second or third?

Researchers looked at in-hospital mortality, intensive care unit admission, length of stay, and inpatient costs to determine whether a patient returning to the ED was a reliable measure of quality of care within that ED. The results were surprising.

“Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay,” researchers concluded. “These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.”

Let’s look closely at the numbers. Patients discharged from an ED and subsequently admitted to the hospital upon a return visit experienced:

  • An in-hospital mortality rate of 1.85 percent vs. 2.48 percent for those patients admitted during their initial visit to the ED.
  • An ICU admission rate nearly six percent less (23.3 percent vs 29 percent).
  • The cost of care for these patients was also less ($10,169 vs. $10,799), even though their length of stay was slightly higher (5.16 days vs. 4.97 days).

And for those patients admitted to the hospital within 14 and 30 days of their ED visit? Similar outcomes were experienced.

But what about those patients readmitted to the hospital after hospital discharge and a return visit to the ED?

“In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit,” researchers found.

What do you think? Are return visits to the ED an adequate measure of quality of care? Please comment below or feel free to drop me a line.

The Journal of the American Medical Association: “In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department”

How Patient Obesity Affects Emergency Departments

Obese Patient

The Centers for Disease Control and Management describes obesity in three words: Common. Serious. And costly.

Nearly 80 million adults in the United States are obese and the list of adverse health effects related to obesity are long — think heart disease, stroke and type 2 diabetes, to name a few.

And the cost? According to the CDC, the healthcare costs associated with obesity was nearly $147 billion in 2008.

In emergency departments across the U.S. patient obesity presents an array of challenges for doctors, nurses and staff who manage care. Physical exams are more challenging as rolling the patient is more difficult, and examining the patient’s whole body can be difficult.

A study published in Emergency Medicine Australasia concurs, noting that when treating obese, and morbidly obese patients, measuring blood pressure, inserting IVs, positioning patients and performing other medical procedures are all increasingly hard.

“BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture,” the report concludes.

EDs, doctors, nurses and staff have countered these challenges with common sense solutions. EDs turn to things such as lifting equipment; larger blood pressure cuffs and beds; and increased staff to help with mobilization and positioning. While these extra initiatives come with a price tag, they all are necessary to provide the quality of care patients who are obese deserve when visiting the ED.

However, surprisingly, whether patients are obese or not may not have a serious impact on average length of stay. In a 2005 study published in Academic Emergency Medicine, researchers were surprised to find that obese patients and non-obese patients presenting to the ED with abdominal pain had similar experiences:

  • Length of stay for obese patients was 457 minutes, while non-obese patients LOS measure higher at 486 minutes.
  • 3.2 laboratory studies were conducted for obese patients versus 2.9 for non-obese patients.
  • Rates of consultation were four percent less for obese patients
  • Admission rates were six percent lower for obese patients.

Does this surprise you? What strategies has your ED implement to better treat patients who are obese? Please comment below or feel free to drop me a line

Centers for Disease Control and Prevention: “Adult Obesity Facts.”

Emergency Medicine Australasia: “Obesity significantly increases the difficulty of patient management in the emergency department.”

Academic Emergency Medicine: “Obese patients with abdominal pain presenting to the emergency department do not require more time or resources for evaluation than nonobese patients.”

Why Higher HCAHPS Scores Don’t Always Mean Improved Quality of Care

Filling in questionnaire.
Man filling in a medical questionnaire.

The most satisfied patients aren’t always the ones receiving the highest quality of care. It may seem counterintuitive, but recent studies and news articles suggest that a patient’s level of satisfaction doesn’t strictly correlate with the quality of care they receive.  

Since the inception of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which measures patient satisfaction and influences Medicare reimbursements to hospitals, healthcare providers have placed extra emphasis on their patients’ happiness. Some hospitals have gone as far as implementing valet service, hiring door greeters and even adopting loyalty programs, all in an effort to please their patients. While a nice touch, these added “amenities” offer little when it comes to actual quality of care. 

Hospitals will soon begin to measure satisfaction among patients within their emergency department with the Emergency Department Patient Experiences with Care (EDPEC) Survey. And just as with their inpatient population, hospitals will face financial repercussions if their ED patients are left unsatisfied. 

When it comes to this new survey, emergency departments will find the greatest cause for concern in regards to their patients’ perception of pain management. Specifically, these three questions:

• During this emergency room visit, did the doctors and nurses try to help reduce your pain?
• During this emergency room visit, did you get medicine for pain?
• Before giving you pain medicine, did the doctors and nurses describe possible side effects in a way you could understand?

If the inpatient experience is any indicator, patients suffering from acute and chronic pain may be disappointed to find that the pain medication they believe they urgently need will be prescribed sparingly or withheld altogether. 

With the growing opioid crisis in the country, many EDs are instituting strict guidelines when it comes to prescribing these narcotic pain medications. They’re turning to alternative therapies, such as acupuncture and even laughing gas, which have proven effective and have less dangerous side effects—think addiction, overdose and death. 

Even with alternatives some patients are set on receiving pain medication, regardless of the consequences. And if they don’t receive them, or are prescribed a limited quantity, the likelihood they’ll express their dissatisfaction in the EDPEC survey will be great. 

In many cases related to the management of pain, quality of care will come at the expense of patient satisfaction. When it comes down to it, the patient’s perception of the quality of care they receive isn’t as important as the reality of the care they receive. However, Medicare reimbursements may be in jeopardy as a result. 

I believe this short quote from The Atlantic sums up the dilemma hospital and ED leaders face:

"Patients can be very satisfied and be dead an hour later."

What do you think? What strategies have you implemented to increase patient satisfaction? Are you confident these strategies aren’t undermining the quality of care your ED provides? I’d love to hear your experience. Feel free to comment, send a message or email me directly at

The Atlantic: “The Problem With Satisfied Patients.”

AMA Journal of Ethics: “Patient Satisfaction Reporting and Its Implications for Patient Care.”

What Is The Emergency Medical Treatment and Active Labor Act (EMTALA)? Why Is It Important?


EMTALA is the federal law that ensures people can access emergency care, whether or not they can pay. When someone goes to the emergency room with a medical emergency they must be seen, receive a medical screening exam and be stabilized if the hospital has the ability to do so. Generally, people interpret it to mean: a hospital can’t turn a patient away without the benefit of a medical screening examination.

Of course nothing is simple and EMTALA carries its own controversy along with it. People tend to fall into one of two camps: Either EMTALA is one of the great things about living in America -- it ensures that people who need emergency care receive it. It’s a safety net.

Or, others believe that EMTALA drives up the cost of healthcare and adds to financial difficulties hospitals experience. That’s because when EMTALA was written into law, funding was not written into the federal budget to pay for it. 

How does EMTALA affect to emergency departments?

Some pinpoint EMTALA as a cause for emergency department overcrowding. Politics and opinions aside, as an emergency department, you must be ready to evaluate and stabilize basically any and all who come your way. To do that you need to make sure the following are in place and buttoned up:

  • intake and triage processes
  • patient flow protocols
  • staffing and scheduling procedures

Failing to provide medical screening examination and stabilize patients can cost you in penalties and lawsuits.

Why does EMTALA matter to doctors and hospital administrators?

You need to know what the law requires. When patients show up at your door, every effort must be made to complete a medical screening exam and initially stabilize the patient within the abilities of your hospital. Know that if your hospital cannot fully stabilize a patient, you must transfer them to another facility with the capabilities to do so. You must also transfer the patient, if they request to be transferred.

The nuances of EMTALA are not always easy and it can get tricky. How can you be sure you’re complying with EMTALA? You may wonder what counts as an “emergency medical condition”? What should your medical examinations involve to make sure you are providing a screening that will comply as an “emergency medical screening” under the law?

For these questions, it is best to go by the book. Luckily, the Center for Medicaid and Medicare Services have these online resources so you can look up the law.

You need to know what counts as an emergency. For a brief explanation of what counts as an emergency condition, the American College of Emergency Physicians summarizes it this way:

“An emergency medical condition is defined as ‘a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.’”

You need to be prepared to cover the costs. And since seeing patients who seek care but cannot pay does cost money, physicians and hospitals are left absorbing that cost. According to the American College of Emergency Physicians: “Emergency physicians provide the most charity care of all physicians (AMA 2003).”

 Because of this, the group advocates for ways to get emergency doctors compensated for EMTALA patients and federal guidance on how to comply with the law.

 The cost of treating patients who cannot pay is passed down to hospitals and may ultimately be passed down to other patients at the hospital.

Who gets fined for EMTALA violations?

Physicians can be fined up to $50,000 per violation and lose their ability to receive Medicare reimbursements. Depending on its size, the hospital can also be fined up to $50,000, or more, depending on the number of violations. A hospital can also lose its Medicare funding, a significant source of revenue in most hospitals. A hospital can also sue another hospital that passes along a patient that isn’t stabilized.

How can Donovan and Partners help with challenges associated with EMTALA? 

While Donovan and Partners is not an EMTALA compliance specialist, we can help you take a look at your emergency department’s protocols and procedures to make sure you are capable of handling some of the situations that EMTALA can create and ensure that everyone gets quality care. We can help you examine and improve your:

  • emergency department’s intake and triage process
  • patient flow protocols
  • staffing and scheduling procedures

We’ll help you implement best practices so you’re prepared and in good position to handle any strains EMTALA may cause. In addition, we can also help with CMS response and action plan development in the event you are cited. Contact us today at or 651-260-9918.


Centers for Medicare and Medicaid Services: “Emergency Medical Treatment & Labor Act (EMTALA)”

American College of Emergency Physicians: “EMTALA”

What Is HCAHPS? Why Is It Important?


Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) usually refers to a survey created by the federal government. It is designed to measure how well hospitals are performing in the eyes of its patients. Generally speaking, it measures patient satisfaction. It’s pronounced “H-caps.”

This year marks the 10th anniversary of public reporting of HCAHPS scores. To celebrate, let’s answer some common questions about it with help from the Centers for Medicare and Medicaid Services’ (CMS) website as our source.

Why Do HCAHPS Scores Matter?

How patients rate hospitals can impact the hospital’s bottom line. Of the things hospitals are measured on, they can face financial incentives or penalties (up to 2 percentage points of their annual payment update) based on whether they report results and how they score in 10 areas. Also, in the new era of hospital Value-Based Purchasing, how hospitals do on the survey accounts for how well they perform in the patient experience of care domain.

What Are Hospitals Measured on?

According to CMS:
■ Nurse Communication (Question 1, Q2, Q3)
■ Doctor Communication (Q5, Q6, Q7)
■ Responsiveness of Hospital Staff (Q4, Q11)
■ Pain Management (Q13, Q14)
■ Communication About Medicines (Q16, Q17)
■ Discharge Information (Q19, Q20)
■ Cleanliness of Hospital Environment (Q8)
■ Quietness of Hospital Environment (Q9)
■ Overall Rating of Hospital (Q21)
■ Willingness to Recommend Hospital (Q22)

How Does the HCAHPS Survey Take Place?

Patients are surveyed by mail or phone. Hospitals can conduct the surveys themselves or hire an outside group to do it for them. The information is collected monthly and reported quarterly. 

How Can I Find Out How Well My Hospital Scores?

You can look up the HCAHPS scores of your local hospital and compare its performance to how hospitals are performing across your state and the country on the Hospital Compare website: 

How HCAHPS Holds Hospitals Accountable

The HCAHPS survey value lies in that it is a standardized measurement tool that makes it easy to compare one hospital to another and because the results are publically available. This type of transparency holds hospitals accountable.

To create the survey CMS partnered with the Agency for Healthcare Research and Quality (AHRQ).

According to them, there were three main goals for creating it were to:

1) “Produce comparable data on patients' perspectives of care that allows objective and meaningful comparisons among hospitals on topics that are important to consumers”

2) “Create incentives for hospitals to improve quality of care” because the results are available publicly

3) “Increase transparency and increase public accountability” because of public reporting

New for 2016

Medicare and Medicaid reimbursements have been influenced about how hospitals score on HCAHPS as a whole for inpatients. This year hospitals will also be held accountable for how well their emergency departments are performing. These scores will begin to affect reimbursements.

If you’d like more information on HCAHPS or talk about ways to help boost your Emergency Department’s scores, contact Donovan & Partners today. We bring to bear more than 20 years of experience in helping emergency departments assess opportunities and set up efficient and cost-effective processes to deliver quality care.

Centers for Medicare and Medicaid Services: “HCAHPS: Patients' Perspectives of Care Survey,”

“The HCAHPS Survey - Frequently Asked Questions.”

In the Emergency Department and on the Field: Teamwork + Talking = Win!

Ever watch the coaches’ post-game interviews after a big game? You often hear the winning coaches give solid communication a big piece of the credit. They say things like, “They did a few things that we didn’t anticipate, so it was a good adjustment on the sideline with the staff and the players. We had good communication there.” -- Iowa University Coach Kirk Ferentz

In the Emergency Department and on the Field Teamwork Talking Win.jpg

And from coaches on the other end of the scoreboard, poor communication can get the blame.

“Yeah, you know I think there is a lot to figure out. I think a lot of that falls back on communication. Sometimes we are communicating well, sometimes we’re not. Different spots in the game and it is really not even week-to-week, it is really drive-to-drive, series-to-series. You know it is really good then it falls down and obviously some of it is holding us back.” -- Buffalo Bills’ Coach Rex Ryan

Both of these quotes are from last month. It’s interesting how team communication on the football field plays a role in success just as it does in the emergency department. Take out the references to sidelines and drives and I am struck by the similarities.

In the emergency room there are always unanticipated things that crop up -- it’s part of the job. Your healthcare providers need a plan for how to communicate those changes to adjust treatment plans.

And while you might have solid communication for the most part, slippage can cause you to fall down. It can cause medical errors putting patient safety at risk. It can also hold your organization back from earning the most it can in the growing pay-for-performance healthcare environment. 

This Thanksgiving here are three communication techniques I am thankful for that can help. I’ve seen them work in many emergency departments to help them maximize communication between doctors and nurses. Bonus, you don’t need an expensive new technology to implement them.

1. Try SBAR at the Get-Go -- This is an acronym that can help nurses remember crucial facts to pass along to doctors or physician's assistants after they do the initial workup of a patient. You’ll want to convey the Situation, the patient’s Background, an Assessment of what you saw and learned, and a Recommendation for action.

Wait? Nurses recommend an action to the doctor? Yes. This type of information can be crucial to a patient’s care. It’s all in how you do it. Let’s put the entire technique in perspective with an example.

A patient comes in after a fall and complaining of hip pain. He’s in his 60s and has diabetes. As his nurse, you help him change into a gown before the doctor comes into examine him, you come to learn his left toe hurts. You check it out and see that it is red and swollen. This isn’t the issue he came in complaining of but it is something that is causing him trouble. It could be from the fall or perhaps even gout. You make a mental note. “It’s probably worth the doctor checking out.” Then, when you give the doctor her briefing, mention it. Here’s how it breaks down: 
Situation -- The patient is complaining of hip pain.
Background – He came in after falling. He also has diabetes.
Assessment – In addition to hip pain he has a red inflamed big toe on his left foot.
Recommendation – You might want to check out his toe while examining him. 

This is a crucial information handoff point in the patient care continuum. But don’t let your in-person talks between doctors and nurses end there.

2. Communicate Face-to-Face Often -- Ah, remember the days of this? I’m only half joking but even in our nonprofessional lives it seems people are shying away from good old fashioned eye contact and human connection.  We have all gotten so busy and have benefited so much from technology tools that many of us now communicate mostly electronically. We’ve come to neglect tried-and-true means of human connection. Nearly a decade ago there was some pushback against this trend in the corporate world. In an effort cut its employees’ dependence on nonverbal communication over the phone or in-person exchanges, a few companies instituted e-mail-free Fridays.

"As a medium, [email]'s inherently ambiguous," said behavioral science professor Nicholas Epley of the University of Chicago Graduate School of Business in an ABC news article on instituting email-free Fridays. "There's not as much information conveyed. The pitch of your voice, the speed with which you say something, the emotional tone that's carried in your voice isn't there."

Sound familiar? The same can be said for relying too heavily on nonverbal communication tools in the emergency department. There are similar reasons to buck this trend of relying on only written communication.

Encouraging face-to-face communication can help build relationships between your staff. And it can be more efficient. Going to find the doctor or nurse you’re working with to tell them something may take time but it can save time as well. You can convey things in the moment and it presents an opportunity for a give and take, and the ability to ask questions and dive deeper to collect all the information in one communication session versus several electronic volleys. So the next time you have an important update on a patient, take five minutes to seek out the team member you’re collaborating with to give them a status update face-to-face.

3. Readback to Confirm the Message Is Received -- While you’re looking each other in the eye, try this one out as well. Most nurses do practice this but sometimes in my consulting work I find it is helpful to go back to some of these basics or foundation elements that are crucial to good communication. Reading back what a physician or physician's assistant says for confirmation can save your team from making mistakes and can even save lives. Was that 2 ccs or 25 ccs? In the nonmedical world, this technique can be called mimicking or rephrasing and is a key element of active listening. It helps signal that the nurse is listening and comprehending. It also provides an opportunity for the physician to reaffirm their order.

This is one little check and balance to add to your team’s arsenal whether it is about medications or discharge instructions. Doctors can try this as well to confirm that they have heard and understand the information nurses have relayed. It even works at shift change. It closes the loop. As the one on the receiving end of communication: Knowing the message you got is the one that the sender intended is a beautiful thing. And as the one doing the reporting of information: Knowing the message you sent was received is reassuring.

These are just three communication techniques you can try to improve communication among your emergency department team. It can be amazing how formulating a game plan for everyone to follow can really help team performance.

 If you’d like help with improving communication in your emergency department, contact me. I’d be honored to help by doing a personalized assessment of opportunities and formulate a customized action plan to put you all on the right path.

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.

How to Decode and Fix Low Patient Satisfaction Scores.jpg

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?

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

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.


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

Patient Navigators Worth Their Weight in Gold.jpg

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.

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.”