Updating EHR templates to match staff workflows aids ED performance
The emergency department at St. Mary Medical Center in Apple Valley, California, was operating well over capacity, facing recurring gaps in department leadership, all while facing a systemwide upgrade to its electronic health record system.
Some patients were experiencing prolonged lengths of stay and the department had a high rate of patients leaving the hospital without being seen by a provider. While these issues were not unique to St. Mary Medical Center, the organization wanted to find a way to better serve its patients and support its employees.
It knew that to do so effectively, it would have to engage with external experts, said Marilyn Drone, RN, executive vice president, COO and chief nursing officer at St. Mary Medical Center.
So, in 2015, the medical center reached out to Philips Blue Jay Consulting for their advice on overall emergency department performance improvement – including work with the EHR – and interim leadership.
The 212-bed community hospital asked Philips to provide interim emergency department leadership and lead a process improvement program to reduce left-without-being-seen volume and increase patient throughput capacity.
Philips brought in an interim emergency department manager and an emergency department director who immediately embedded themselves within the medical center's team. These individuals focused on day-to-day operations and staff management and quickly became leaders of the emergency services team.
Next, a performance improvement consultant completed a comprehensive review of key operational metrics, EHR documentation and more, and created a custom performance improvement plan. The consultant worked with the hospital team to update the EHR templates to match staff workflows, minimize workarounds and support increased patient flow.
St. Mary Medical Center also added a third Philips consultant focused exclusively on change management, leading and instructing teams on how to improve key performance indicators. These Philips consultants became part of the hospital team.
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MEETING THE CHALLENGE
"To assess our situation, consultants gathered system and patient data and conducted interviews with our administrators, departmental leaders and staff, covering topics such as intake, triage, processes and education," Drone explained. "They also spent considerable time observing patient workflow, departmental processes and communications."
Consultants then conducted a performance assessment including a thorough analysis of data collected on volume, arrival patterns, staffing patterns, emergency severity index level distribution, department billing, disposition breakdown and length of stay – some of the key performance metrics the hospital wanted to focus on.
"The consultants worked with our nurses and clinical staff who were closely aligned with our IT team to develop and implement a daily dashboard," Drone said. "The dashboard populated the necessary data and provided a snapshot of the emergency department operational performance. A daily PDF report was created to enable the team to quickly see what was working well and where further changes may be necessary."
After the assessment, hospital staff and consultants agreed on several opportunities for improvement, including:
- Revising the front-end processes to include the intake and triage; re-educating the staff on the emergency severity index five-level triage system;
- Restructuring leadership and clarifying roles to increase accountability for standards of practice and quality of patient care;
- Establishing processes to ensure workflow optimization and capacity issues;
- Redesigning EHR documentation templates to better match processes and staff workflows; and Articulating a shared vision and mission for leadership.
"Following the assessment, we assembled a performance improvement work team," Drone said. "Led by Philips, this group consisted of hospital physicians, administrative leaders and emergency department ancillary staff. The objective was to create an action plan focused on decreasing the walkout rate as well as the length of stay of the department."
The work team completed a deep-dive review into each area identified in the assessment and leveraged the data analysis and stakeholder input gathered earlier, she added. They developed recommendations for process change, with priority given to the change initiatives that could make the greatest impact, she explained.
St. Mary Medical Center, with the help of the consultants, was able to reduce emergency department discharge patient length of stay by 34.4 percent, reduce the left-without-being-seen rate by 85.3 percent, and reduce the arrival-to-provider time by 66.2 percent.
"Implemented changes included front-end processes, emergency severity index five-level triage training, improved patient communication, and other process standards," Drone said. "As a result, we were able to reduce left without being seen from 7.5 percent to 1.1 percent and emergency department discharge length of stay from 361 minutes to 237 minutes."
A critical driver of the hard results was the development of a "Middle-Trac" process, Drone said.
"Derivative of a split-flow process where patients are triaged quickly into parallel care streams, Middle-Trac focuses on patients in the middle, emergency severity index Level 3 – those who do not require immediate lifesaving treatment," she explained. "The Middle-Trac patient flow keeps these patients vertical and moving through the department while not occupying valuable treatment spaces until a disposition decision is made."
Like an assembly-line, the Middle-Trac process works cohesively occupying 14 treatment spaces, she added. When a patient arrives at the emergency department, a triage nurse classifies the patient into one of three categories: immediate bed needed; fast track appropriate; and remaining Middle-Trac patient population, she said. A carefully detailed process flow maximizes continuity of care, manages essential resources, and minimizes provider hand-offs, she said.
ADVICE FOR OTHERS
"For me, the most important thing to consider is how will these consultants work with our key stakeholders?" Drone advised. "Do they have the real-world, clinical experience this role and engagement demands? Can they relate to the challenges we are facing? Do they have a strong track record of success?"
Just like hiring any other team member, hospital staff interviewed each consultant before they joined the project; it was vital to ensure they had the high level of expertise the hospital needed and would be a good fit with the rest of the team, she concluded.