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HCM Emergency Department Scoring Points with Patients
Wednesday, August 31, 2011 • Posted August 31, 2011

Hospitals have long labored to increase their patient satisfaction scores. And, as hospitals go, the emergency department is one of the toughest areas in which to achieve high rankings.Cara Deike, RN, interim director of Hill Country Memorial’s emergency department (ED), reports that her emergency team is currently in the top one percent of the 1,738 emergency departments across the nation participating in an improvement tracking program run by Press Ganey, a recognized leader in health care performance improvement. The company currently works with more than 10,000 health care organizations nationwide, including half of all U.S hospitals, to improve clinical and business outcomes.“So far for this third quarter, we’re at the 99th percentile,” Ms. Deike said. That means that for the third quarter, the local ED’s patient satisfaction rankings are higher than 99 percent of all the U.S. hospitals in its Press Ganey peer group.“For an emergency department, that is an amazing result, because we get sick people, injured people, unhappy people. Nobody wants to be in the emergency room. So we used to be really thrilled when we hit even the 90th percentile. There was this mindset that as an emergency room, we could never achieve the really high results just because of the nature of our work.”She said the HCM emergency team decided that would not be their mindset. Earlier this year, they started earnestly working on what they perceived were the department’s main challenges: waiting time, keeping patients and family members informed about what’s happening and reducing the number of patients who leave without being seen.Triage time was the first target they tackled. “Triage is the initial greeting of the patient where we begin the sorting process, determining the order and priority of a patient’s treatment based on the severity of his or her condition, and even the determination of the patient’s destination,” Ms. Deike said.Triage can be a bottleneck that causes delays, particularly when multiple patients arrive for care at the same time or in rapid succession.“In the past, the registration clerk would call and tell us we had a triage to do. Then the triage nurse would be in the triage room assessing a patient, and another patient would arrive, then maybe a third patient. So they were all in the waiting room while the first triage was finishing up,” Ms. Deike said. “Beyond the flow problem, what we also found was that the first patient might have had a sore throat and a cough for three weeks, but the third patient might have been having chest pain. Meanwhile, other patients would present, compounding the wait time. Obviously, we needed to take a hard look at the system we were following.”The team did just that, making a couple of rapid decisions: when the emergency department traffic grew heavy, more than one nurse would triage patients and not necessarily in the triage room. In another innovation, they adopted a “split flow” or fast-track process where patients are sorted to designated areas for specific patient conditions.“We can electronically monitor patients from all of our rooms, but we keep those with emergent needs closer to the nursing station where we can better observe them directly,” she said. Non-emergent patients—those who need a prescription medication or their throats swabbed—are placed in designated rooms or in the department’s internal waiting room away from the high activity areas of emergent care. “They can be in a quiet, comfortable place while we keep the patient flow moving. We very, very rarely have patients waiting out front in the public waiting room. That’s pretty incredible in itself, and patients appreciate it.”These simple changes had an almost immediate effect, she said. “The quick sorting of our patients and the fast decisions on where they needed to go really helped the patient flow. Instead of trying to get this long history from every patient, we would look at their breathing, their color and their level of consciousness. Our first priority now was to get them to the appropriate room as quickly as possible where, essentially, we could complete the triage without causing a bottleneck.”Another area where the team has shown sharp improvement is in patient communication. “We have made a lot of effort to keep our patients and their family members informed,” she said. “If they’re just waiting, they need to know why and what they’re waiting for, be it lab test results or x-rays or whatever,” Ms. Deike said. “We tell them what to expect next, when the doctor will be in to explain results and what will happen then. Even though we’re fortunate enough to be in the 99th percentile of patient satisfaction, we still work hard on keeping everybody informed. We know there’s always room for improvement, and we want to get to that next level, whatever it may be. Just keep that communication going.”To maintain its high rankings, the department routinely tracks progress in several specific areas, including how many patients leave without being seen. “Basically, those who leave get tired of waiting and go some other place,” Ms. Deike said.The department sees about a thousand patients a month, and a comparison of the last three quarters clearly shows improvement: during the fourth quarter of 2010, 54 of 3,269 ED patients left without seeing a doctor; during the first quarter of 2011, 63 of 3,269 ED patients left without seeing a doctor; but during the second quarter of 2011—after the new processes had been in place three months—only 11 of 3,329 ED patients left without seeing a doctor.And the trend is holding steady so far during the first two months of the third quarter of 2011: only seven of 1,714 ED patients had left without receiving care.Hospital administrators keep close track on the department’s progress, and they’re more than pleased with the direction ED employees have established. “Phenomenal” was the comment from the hospital’s chief strategy officer, Debbye Wallace, after she had reviewed this year’s quarterly performance to date. “The ED team continues to drive patient satisfaction higher and higher each month,” she said. “We are very proud of all their hard work which is obviously making a difference to our patients. The team has now placed our ED at the 99th percentile in patient satisfaction in the nation. That’s the top one percent, which is remarkable and very gratifying.”She said sustained improvement is the overarching goal, and as the numbers in other categories improve, so do patient satisfaction results. In the first quarter of 2011, ED patientsatisfaction stood at the 93rd percentile. The second quarter showed an improvement to the 97th percentile. So far in the third quarter, the results are at the 99th percentile. “It shows that our high results are not a fluke but a solid upward progression, and that is our goal,” Ms. Wallace said.While such numbers and quality facilities are important, the human touch also is a critical element. Though the local ED is filled with cutting edge technology, its staff recognizes that keeping patients comfortable and as happy as possible sometimes depends on low-tech solutions. One recent ED patient, a 93-year-old man, grew chilly as he lay in bed awaiting lab results. Barbara Eilers, RN, appeared at his bedside not only with a blanket, but one fresh from a tall blanket warmer in a nearby corridor. As she put it over him, she said, “This is where you go ‘Ohhhhh, that feels good!’” The patient, sporting a wide grin, obediently repeated the sentence as he snuggled down into the welcome warmth. For good measure, Ms. Eilers placed a second blanket over the first to help keep in the heat.“Sometimes, we are extremely busy in here,” Ms. Deike said. “With more than a thousand patients a month, we constantly train ourselves to be alert not only to our patients’ emergent conditions but to their need to be comfortable and well informed.”Another change that has made a big difference in the department’s success involves the nurse management team.“Dr. Williams (Michael R. Williams, M.D., Hill Country Memorial’s chief executive officer) wants our ED nursing director and supervisors down here in the department rather than off in an office somewhere. And that’s a great thing, because just placing me down here lets me step right in when they need me to help out. Most of the time when that happens, it’s just for a few minutes, helping them get over the hump and keeping the patient flow moving. It may be triaging patients, calming fears or getting that blanket. It’s a wonderful idea that is making a big difference in our results.”Quality and satisfaction are deeply rooted in the fabric of this emergency department. According to Marvin Rusche, RN supervisor in the ED, quality patient care and patient satisfaction go hand in hand. “We strive to treat our patients as we would our own family members,” he said. “So at the end of the shift, we can feel confident that we’ve done all we can to provide our patients with a quality-driven experience.”Such attention to detail is showing up in patient review comments, many from out-of-town patients. “It was absolutely a good idea to come to this hospital,” reports the husband of an ED patient. Another writes, “There was no waiting. I was seen as soon as I arrived.” That’s a common theme in the flow of feedback from patients. “I live in San Antonio and stopped in Fredericksburg because I wasn’t feeling well,” a woman relates. “I was in a lot of pain. A nurse saw me immediately. I was alone, and she made me feel like she was my family. Thank you very much.”What’s the bottom line behind such success? Ms. Deike, who has watched the process from the trenches, has this answer: “It takes communication within a cohesive team and the passion from all of us to deliver remarkable care,” she said. “The whole team needs to have buy-in, because it takes everybody.”

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