Is Your Emergency Department Operating At Maximum Efficiency?
One bright sunny day you head off to college with the idea of becoming a doctor. As you progress through school, you make the decision to go to medical school. Medical school progresses and you decide you want to become an Emergency Physician. You complete your medical school and seek to find a residency program for your Emergency Medicine training. You pay your dues with long hours and grueling schedules to become a highly skilled well-trained Emergency Physician and you are now ready to practice your trade with full vigor. As your career progresses you are highly motivated and well respected within your hospital and community. The Hospital Administrator or group administrator summons you for a meeting. You are presented with the opportunity to become the Medical Director of the Emergency Department. Since you are highly motivated, you jump at the opportunity.
Your ship has finally come in, or so you thought. It is at this point that the administrators inform you of the perceived problems within the emergency department and the direction they would like you to lead the department. All these years you thought you and your colleagues were providing outstanding care to your patients; therefore, the vast majority of the patients and administration is very happy. As one of the ESPN football pre-game hosts would say “Not so fast my friend”.
While you were aware that managed care and Medicare cutbacks had forced your group to reduce physician hours even in the midst of increasing patient volumes, your group felt forced to make these changes to maintain physician income. The effects of staffing changes seemed to be minimal. Patient turnaround time went from three hours to three hours thirty minutes. Patient satisfaction scores went from 70% nationally to 55%. The physicians were simply working harder to maintain their income. Does this scenario sound familiar?
Evaluate How Your Physician Group Does Business
As Emergency Physicians, the vast majority of your training focuses on clinical skills rather than the business-side of your practice. As I have written in previous articles the business-side of your practice is often as important or more important than the incredible clinical skills each of you possess. Previous articles have focused on business partner; however, I would like to provide suggestions on how to maximize your efficiency and thus your budget. As most practicing physicians would admit, their emergency department does not operate with maximum efficiency. When speaking with various hospitals and physician groups regarding their efficiency woes, most tend to think the answers to the problems revolve around correcting staffing shortages in the nursing, lab, x-ray, or physician areas. Often times, each group vigorously defends their own turf and the result is finger pointing and the blame game. This begs the next question of “Where are the problems and how do we measure them”?
In today's world, many of the Emergency Department problems such as patient turnaround time, patient satisfaction, and left without seen volumes are believed to be directly related to the performance of the Emergency Physicians. You will notice that I said believed to be because in depth review often shows that the entire system (nursing, lab, x-ray, admitting, etc.) needs an overhaul. These results will be shocking to all parties because a good evaluation will measure where delays occur and provide suggestions on how to remove current roadblocks. While this evaluation may be somewhat expensive on the front-end, I firmly believe many Emergency Department will greatly benefit from this experience. The end result is usually greater efficiency and improved departmental operations.
Set Goals, Evaluate, and Break Down Barriers
To maximize your emergency department efficiency, all departments within the hospital that interact with the Emergency Department must be on the same page and focused on the same goal. Emergency Department Physicians and Nurses are only as good as their support systems. In today's environment, teamwork within the hospital departments seems to be a lost art at many institutions. Many hospital departments are caught up in the workings of their own department and give little or no thought to the importance of the operational efficiency of the Emergency Department. Why is operational efficiency of the Emergency Department important to other hospital departments? The answer is very simple. The Emergency Department is the front door to the hospital and supplies at least fifty percent of most hospital admissions.
To break down the barriers, I would suggest creating goals for critical times within the department that affect patient care and satisfaction. First and foremost are goals for patient turnaround for both admitted and discharged patients, of which I suggest tracking separately. Components of the entire turnaround time are very important to determine and track where delays occur within your department. Critical component times such as patient presentation to triage time, triage time to emergency department room, emergency department room to nurse evaluation time, triage to initial physician assessment time, lab/x-ray order to completion time, and time from admission to transportation to the inpatient unit. Once you track these individual times, you will be amazed at the number of roadblocks your current system has in place.
To create these goals, you will need to work with hospital administration, nursing, ancillary staff, and the directors of the various departments. Let each of these people know that your goal is to create efficiencies that will result in better patient care and increased patient satisfaction. As with any goals, you will need to measure and track the results of your efforts. Tracking will alert you to real roadblocks and identify areas that need continued efforts. While the tracking and measuring seems like a time-consuming and cumbersome process, many emergency departments have benefited far beyond the time or financial cost to implement such systems. Several software programs are currently on the market to assist you with this effort. Additionally, you may want to seek the assistance and guidance of a consulting group to facilitate this process. Remember, if you are not evaluating and looking for areas of improvement, your competitors are taking advantage of this opportunity. With the number of hospital closing over the last few years, it is foolish to think that your hospital and emergency department is beyond reproach.
Evaluate Your Staffing Models
As the practice of Emergency Medicine changes, so to will the need to evaluate your staffing models. Since most emergency department volumes have increased annually, physician groups are faced with the problem of how to manage this volume without increasing patient turnaround time and decreasing patient satisfaction. Some physician groups have a demographic mix or hospital stipend that affords the luxury of simply increasing physician hours; however, many other hospitals have adjusted staffing models to include mid-level practitioners and/or part-time coverage from primary care specialties. Physician extenders are utilized in fast-track/urgent care settings and in the main emergency department. Since most emergency departments have greater than fifty percent lower acuity patients (99281-99283), physician extender hours are increasing due to their significant cost savings. Several high volume emergency departments I have worked with have filled physician turnover by creating more physician extender hours. To operate efficiently, evaluate your current staffing model and determine if physician extenders will increase your productivity and reduce your payroll costs. Many groups I have worked with have provided raises or maintained current physician salary levels by changing their long time staffing models.
Evaluate Your Charting System
As the practice of emergency medicine has changed, so to have the methods utilized to document the patient encounter. Ten years ago, most emergency physicians provided chart documentation via dictation or hand-written notes. With the increased documentation requirements, scrutiny of billing, coding, and documentation practices, and rising cost of transcriptionists, emergency physicians were forced to reevaluate their documentation. In today's environment, most emergency physicians are utilizing dictation or charting systems to document patient encounters. Template systems, of which there are many in the market, were developed to meet documentation guidelines, increase the speed of charting by eliminating transcription, and reduce cost. Many hospitals refuse to pay for dictation; therefore, physicians must chose a template or hand-written documentation. Since time charting is an integral piece of the patient turnaround time, I would suggest that all groups evaluate your current method of charting and determine if this best fits the goals your have set for your emergency department.
Efficiency = Profitability
The need for operational efficiency in the Emergency Department is greater today than in past years. Emergency Physicians are faced with increasing patient volumes, decreasing reimbursement, nursing shortages, ancillary service shortages, and pressures to increase patient satisfaction. To make certain that your contract is solid for a long time to come, set goals, measure performance, and more importantly work very closely with other departments and administration to improve department efficiency. Patients do have a choice where to obtain services. If your group provides outstanding clinical services in a very time and cost efficient manner, word will spread quickly and you might be very surprised at the economic results.
Sources: Jay Kaplan, M.D., FACEP, Medical Director, Studer Group