ED Benchmarks and Best Practices

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ED Benchmarks and Best Practices

Jeanne McGrayneVHA’s Consulting Services

Jeanne McGrayne/VHA

V H ATogether we’re greater than TM

VHAVHA Inc. is a cooperative that serves 2,200 of nation's leading community-owned health care organizations and their affiliated physicians, providing services to help them improve financial and clinical performance. VHA provides products, programs and services to 1,400 not-for-profit hospitals, to help them improve operational efficiency and clinical effectiveness. Based in Irving, Texas, with 18 local offices across the U.S., VHA was named one of the “100 Best Companies to Work For” by Fortune in January 2003, for the fourth year in a row. As a cooperative, VHA distributes income annually to members based on their participation.

Jeanne McGrayne/VHA


VHA’s ED Consulting Services

Emergency Department Operational AssessmentData Analysis/BenchmarksSimulationFacility DesignFinancial AssessmentImplementation Assistance

Jeanne McGrayne/VHA


What is the difference between benchmarks and benchmarking?

Benchmarks are the actual measurements used to gauge the performance of a function, operation, or business relative to others.

Jeanne McGrayne/VHA



Benchmarking is the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers.It is learning how to adapt Better and Best Practices learned through the benchmarking process that promotes breakthroughs in process improvements and builds healthier communities.

Jeanne McGrayne/VHA



The objective of benchmarking is to identify Better and Best Practices so that an organization can set higher goals and improve performance. Comparing benchmarks can do this.

Jeanne McGrayne/VHA


Seven Step Benchmarking Model

Identify what to benchmarkDetermine what to measureIdentify who to benchmark against?

Criteria vs. CharacteristicsCollect dataAnalyze data and determine performance gapSet goals and develop an action planMonitor the process

Jeanne McGrayne/VHA


Key ED Processes

• Patient Access

• Door to Test/Treatment

• Test to Disposition

• Disposition to Discharge/Admission

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Key Supporting Operations

• Staffing

• Facility

• Customer Service

• Technology

• Leadership

Jeanne McGrayne/VHA


Benchmarks and Measures

CDC Trends in Hospital Emergency Department Utilization: United States 1992-2001; June 2003

VHA ED Process Data

HBSI ACTION 1st Quarter, 2003

VHA On-Line ED Participant Data Data

Jeanne McGrayne/VHA


Access Between 1992 and 2001, ED utilization increased by 20% from 89.8 million to 107.5 millionVisit rate increased by 8% from 35.7 visits/100 persons in 1992 to 38.4 visits/100 persons in 2001

Annual Volume of ED Visits: NHAMCS, 1992-2001

80859095

100105110

1992 1993-1994

1995-1996

1997-1998

1999 2000 2001

Jeanne McGrayne/VHA


Regional ED Volume % Distribution and

Visits per 100 persons per year

West17.5 %

33.0

Midwest25.1 %

40.1

South39.3 %

43.8

Northeast18.2%37.6

Data Source: National Ambulatory Medical Care Survey: 2000

Jeanne McGrayne/VHA


Annual ED Volume

0%5%

10%

15%

20%

% o

f Hos

pita

ls

Rep

rese

nted

Lessthan

20,000

20,001-30,000

30,001-40,000

40,001-50,000

50,001-60,000

60,001-70,000

70,001-80,000

80,001-90,000

90,001or more

Staying the Same9%

Decreasing5%

Increasing86%

Source - VHA On-Line Survey

Jeanne McGrayne/VHA


Reasons for Increased Demand

Less restrictive management of ED visits and reimbursement by HMO’sGreater enforcement and compliance with EMTALAIncreased demand from the uninsuredLimited access to Primary Care ProviderInpatient bed capacity/staffing limitationsLack of multi-lingual care providers at all levels

Jeanne McGrayne/VHA


Age and Payer Mix

CDC ED Payer Mix (2001)

Medicaid17%

Medicare15%

Other9%

Self Pay15%

Workers Comp3%

Commercial/HMO40%

Age Distribution of ED Patients

Under 15

21%

15-2416%

25-4430%

45-6418%

65-746%

75+9%

Jeanne McGrayne/VHA


Access

Jeanne McGrayne/VHA


Access

• Immediacy with which patient should be seen:

• Emergent: 15 min

• Urgent 15-60 min

• Semi-Urgent 1-2 hours

• Non-Urgent 2-24 hoursVHA Comparative Average Acuity

Urgent42%

Emergent7%

Non-Urgent

51%

Jeanne McGrayne/VHA


Trend in ED Visit Rates for Visits Triaged as Emergent

5658606264666870727476

1997 1998 1999 2000

Number of EmergentVisits per 1000Patients


Jeanne McGrayne/VHA


Leaving Without Being Seen %

2.15%

0%

8%

2%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

Average Minimum Maximum Median

Jeanne McGrayne/VHA


Reason for Visit (top 18)

0100020003000

400050006000

7000

Number of Visits in Thousands

Abdo

min

al P

ain

Ches

t Pai

nFe

ver

Head

ache

SOB

Back

Pai

nCo

ugh

Non

spec

ific

Pain

Lace

ratio

nSo

re T

hroa

tVo

miti

ngAc

cide

ntDy

spne

aEa

rach

eSk

in R

ash

MVA

Low

Back

Pain

Inju

ry


Jeanne McGrayne/VHA


0:04 0:

10

0:05 0:

240:13

0:06

0:28

0:38

0:01 0:02 0:03

0:080:05 0:04

0:07

0:27

0:00

0:07

0:14

0:21

0:28

0:36

Avg Max Avg Min Avg Median Avg

Avg 0:05 0:04 0:10 0:24Max Avg 0:13 0:06 0:28 0:38Min Avg 0:01 0:02 0:03 0:08Median Avg 0:05 0:04 0:07 0:27

Time from Arrival to Triage Triage Time Triage to

Registration Triage to a Room

Triage and Registration

VHA ED Database

Jeanne McGrayne/VHA


Access Best Practices

Nurse managed health triage lineUrgent Care facilitiesExtended office hoursWalk-in medical clinic adjacent EDPatient EducationFaith based clinics in neighborhoodsStreet clinics for the homelessCase/Care management

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0:24

0:54

0:32

1:05

1:31

0:50

0:12 0:14

0:240:31

0:20

0:54

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40

1:55


Avg 0:32 0:24 0:54Max Avg 0:50 1:05 1:31Min Avg 0:12 0:14 0:24Median Avg 0:31 0:20 0:54

Arrival to Room In Room to First MD Visit

Arrival to First MD Visit

Door to Doctor

VHA ED Database

Jeanne McGrayne/VHA


Visible, Involved Triage NurseAbility to generate account number at or before triageAssessment Separate from TriageTriage driven room placementRegistration at BedsideNursing Room AssignmentsPhysician Room AssignmentsTracking System

Door to Test or Treatment Best Practices

Jeanne McGrayne/VHA


Triage

75% Perform Bedside Registration

31% use Mobile Computers

13% use Bedside Computers

69% Staff Collect Data in Room

Escorted to room

58% by Triage Nurse

60% by ED Tech

35% by Charge Nurse

Jeanne McGrayne/VHA


What Impacts Patient Flow?

Case Management/Care Coordination

Test Utilization

Ancillary Turnaround Times

ED Staffing/Teamwork

Consultant Availability

Technology/Communication

Information Flow

Incentives

Jeanne McGrayne/VHA


Don’t Bother Fixing the Front End if you Don’t Fix the Back End!

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Patient Flow Best Practices

Active Use and Support of Protocols

Nurse/Physician Teams

Collaborative Practice

Point of Care Order Entry

Visual Cueing System

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Visual Cueing

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ED Technology

55.84%

44%

4%

34%

19%

10%

1%0%

10%

20%

30%

40%

50%

60%

% o

f ED

's

% With an EDInformation

System

% PatientTracking

% Staff Tracking % D/CInstructions

% PhysicianDocumentation

% NurseDocumentation

% Auto Coding


Jeanne McGrayne/VHA


ED Documentation

62%

51%

30%

0%

10%

20%

30%

40%

50%

60%

70%

Dictation Template Handwritten


Jeanne McGrayne/VHA


0%

10%

20%

30%

40%

50%

Percent Utilization

% of all ED Patients Requiring Test/Procedure

VHA 2003 32% 37% 15% 7% 2% 19% 8% 2% 16%2001 CDC Data 29% 40% 14% 6% 2% 18% 8% 10% 12%

Lab Xray EKG CT US IV Monitor Sutures%

Admitted

Utilization Percentages

Source: VHA ED Database

Jeanne McGrayne/VHA


0%

1%

2%

3%

4%

5%

6%

7%

Percent Utilization

CDC and VHA Data

Percent of CT per 100visits per year

2% 3% 3% 4% 5% 5% 6% 7%

19921993-1994

1995-1996

1997-1998

1999 20002001 VHA

2002 VHA

CT Utilization

Jeanne McGrayne/VHA


X-Ray Turnaround Time

0:110:

20 0:20

0:19

0:470:55

1:34

0:35

0:45

0:33

0:110:08

0:230:18 0:18 0:16

0:08

0:46

0:01

0:10

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40


Avg 0:20 0:19 0:20 0:11 0:47Max Avg 0:33 0:35 0:45 0:55 1:34Min Avg 0:11 0:08 0:10 0:01 0:23Median Avg 0:18 0:18 0:16 0:08 0:46

MD VISIT TO ORDER

ORDER TO TRANSPORT

TRANSPORT TO RETURN

RETURN FROM X-RAY TO RESULTS

ORDER TO RETURN


Jeanne McGrayne/VHA


CT Turnaround Time

0:330:

39

0:30

0:54

1:47

2:40 4:022:28

0:53

1:13

0:12 0:14

0:380:390:46

0:30 0:30

1:35

0:00

0:12

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40

1:55

2:09

2:24



MD VISIT TO ORDER

ORDER TO TRANSPORT

TRANSPORT TO RETURN


ORDER TO RETURN


Jeanne McGrayne/VHA


Ultrasound Turnaround Time

0:17

1:07

0:340:

39

1:31

1:25

2:38

1:16

1:02

2:15

0:240:15

1:05

0:53

0:380:33

0:13

1:26

0:000:10

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40

1:55

2:09

2:24



MD VISIT TO ORDER

ORDER TO TRANSPORT

TRANSPORT TO RETURN


ORDER TO RETURN


Jeanne McGrayne/VHA


CBC

0:50

0:19

0:36

0:16

1:37

0:34

0:52

0:31

0:120:09

0:180:15

0:38

0:44

0:28

0:18

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

0:57

1:04

1:12



MD VISIT TO ORDER

ORDER TO COLLECTION

COLLECTION TO RESULT READY

LAB ORDER TO RESULTS

RETURNED


Jeanne McGrayne/VHA


Chemistry

1:00

0:19

0:46

0:18

1:41

0:39

0:59

0:29

0:13

0:04

0:16 0:17

0:48

0:59

0:44

0:38

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

0:57

1:04

1:12



MD VISIT TO ORDER

ORDER TO COLLECTION



RETURNED


Jeanne McGrayne/VHA


Serum Pregnancy

0:47

0:13

0:38

0:11

1:05

0:21

1:00

0:16

0:11

0:01

0:13 0:12

0:35

0:50

0:28

0:17

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

0:57



MD VISIT TO ORDER

ORDER TO COLLECTION



RETURNED


Jeanne McGrayne/VHA


Urinalysis

0:58

0:29

0:45

0:25

1:58

0:51

1:23

0:55

0:12

0:01

0:220:28

0:42

0:55

0:280:23

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40



MD VISIT TO ORDER

ORDER TO COLLECTION



RETURNED


Jeanne McGrayne/VHA


Troponin

1:08

0:26

0:56

0:14

1:54

0:36

1:21

0:41

0:120:05

0:26

0:13

0:56

1:09

0:47

0:35

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40



MD VISIT TO ORDER

ORDER TO COLLECTION



RETURNED


Jeanne McGrayne/VHA


Ancillary Best PracticesDirect stick draw if IV > 20 gaugePneumatic TubePoint of Care TestingDedicated Phlebotomist if > 50,000 visitsStat Lab if > 70,000 visitsDedicated Room and Staff24/7 Service – cross trainingPACSED MD Preliminary InterpretationGastrographin Contrast

RadiologyRadiology

Medical RecordsMedical Records

Criteria for Early Access Automated RecordED Based MR Staff

LaboratoryLaboratory

Jeanne McGrayne/VHA


Point of Care Testing

79%88%

61%

76%

35%

51%

19%

32%

13%

25%

13%22% 21%

30%

0%10%20%30%40%50%60%70%80%90%

Glucose Urine Dip Urine Preg ISTAT RapidStrep

Troponin Blood Gas

20022003


Jeanne McGrayne/VHA


MD Assessment to Disposition

0:18 0:

200:38

1:11

1:53

1:09

0:33

0:250:19

0:13 0:11

0:430:36

0:17 0:19

1:11

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40

1:55


Avg 0:38 0:18 0:20 1:11

Max Avg 1:09 0:25 0:33 1:53Min Avg 0:19 0:13 0:11 0:43

Median Avg 0:36 0:17 0:19 1:11

Consultant Called to Present

MD Visit to First Lab Order

MD Visit to First Xray Order

First MD Visit to Disposition


Jeanne McGrayne/VHA


Percent of ED Patients Admitted

12%

15%

18%

0%2%4%6%8%

10%12%14%16%18%20%

25th %tile 50th %tile 75th %tile

ALL HOSPS

Data Source: Solucient ACTION Database, 3rd Quarter 2002

Percent of Hospital Admissions that Arrive through the ED

Average - 49%

Minimum -11%

Maximum - 85%


Jeanne McGrayne/VHA


Admission Effect on Cost/Visit

Direct Cost per Visit

Direct Cost = Salary Cost + Supply Cost + all other

$0.00

$20.00

$40.00

$60.00

$80.00

$100.00

25th %tile $47.97 $59.56 $70.05 50th %tile $57.71 $69.18 $86.48 75th %tile $75.99 $78.81 $95.19

0-10% ED Adm

11-20% ED Adm

21-30% ED Adm


Jeanne McGrayne/VHA


Disposition to Discharge/Admit

0:58

0:28

0:16

1:26

2:00

0:40 0:42

1:34

0:050:14 0:14

0:42

0:16

0:58

0:27

1:33

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40

1:55

2:09



Disposition to Discharge

Disposition to Bed Ready

Bed Ready to Unit

Disposition to Admit


Jeanne McGrayne/VHA


Disposition to Discharge/Admission

2:21 2:

39

4:23

7:23

4:133:52

2:49

1:38 1:44

4:06

2:17 2:27

0:00

1:12

2:24

3:36

4:48

6:00


Avg 4:23 2:21 2:39Max Avg 7:23 3:52 4:13Min Avg 2:49 1:38 1:44Median Avg 4:06 2:17 2:27

Arrival to Admit Arrival to Discharge

Arrival to Discharge/ Admit


Jeanne McGrayne/VHA


DischargesVideo Discharge InstructionsDischarge Area to Increase CapacityDischarge Instruction SystemAuto Fax to Primary Care or Referral MDFinancial Counseling

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Admissions

No Refusal PolicyFax ReportED assigns bedBegin Admission process earlyED Staff TransportsCritical Paths/ Protocols

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Admissions

Express Admission UnitAdmission TeamBed ‘czar’“Be a Bed Ahead”Housekeeping triageTelemetry/OximetryAccountabilityCharge Transfer

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0.00

1.00

2.00

3.00

4.00

Patients per StaffedPhysician Hour

1.32 2.27 2.24 3.50

Minimum Average Median Maximum

Average Number of Patients Per Staffed Physician Hour

Source: VHA On-Line Survey69% Use Physicians Assistants42% Use Nurse Practitioners29% Have Staff On-call

Jeanne McGrayne/VHA


Patients per MD/PA/NP Worked Hour by Volume

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Pts. per Staffed Hour 1.75 2.08 2.38 2.07 2.44 2.60 2.11 2.91

Less than

20,001-30,000

30,001-40,000

40,001-50,000

50,001-60,000

60,001-70,000

70,001-80,000

80,000 Plus

VHA On-Line Survey

Jeanne McGrayne/VHA


ED Physician Relationship

Small local contracted

group38%

Independent Contractor

29%

Employed by Hospital

24% National ED Contract Mgmt Co.

9%

Source: VHA On-Line Survey

Jeanne McGrayne/VHA


ED Physician Practice

30%

55%

17%

32%

51%

73%

22%

47%

0%

10%

20%

30%

40%

50%

60%

70%

80%

% Write AdmittingOrders

% OutsourceCoding/Billing

% Bill for XRayInterpretation

% Bill for EKGInterpretation

Source: VHA On-Line Survey

Jeanne McGrayne/VHA


Nurse/Tech/Clerical Staffing

0

1

2

3

25th %tile 2.08 1.84 2.17 2.36 2.5550th %tile 2.45 2.17 2.49 2.55 2.9175th %tile 2.8 2.42 2.7 2.82 2.97

All Hospitals

ED Pt Vol 0-20K

ED Pt Vol 21K-40K

ED Pt Vol 41K-60K

ED Pt Vol 61K+

Worked Hours per Visit

Data Source: Solucient ACTION Database, 1st Quarter 2003

Jeanne McGrayne/VHA




0

1

2

3

4

25th %tile 2.48 2.08 2.0550th %tile 3.14 2.45 2.2575th %tile 3.53 2.80 2.81

Level 1 Level 2 Level 3


Jeanne McGrayne/VHA




0

0.51

1.5

22.5

3

25th %tile 1.86 2.17 2.3950th %tile 2.19 2.49 2.8275th %tile 2.39 2.67 2.96

0-10% ED Adm

11-20% ED Adm

21-30% ED Adm


Jeanne McGrayne/VHA


ED Staff Worked Hours/Visitby Region

Southwest2.72

Mid-America2.52

Gulf States2.23

West Coast2.24

Mountain States2.49

Oklahoma/Arkansas2.20

Upper Midwest2.60 Michigan

2.48

Empire State2.56

East Coast2.52

Central2.38

Central Atlantic2.31

Pennsylvania2.24

Southeast2.72

Georgia2.68


Jeanne McGrayne/VHA


ED Labor Cost/Visitby Region

Southwest

$64.05

Mid-America

$52.52

Gulf States

$54.58

West Coast

$80.59

Mountain States

$56.61

Oklahoma/Arkansas

$49.06

Upper Midwest

$69.75Michigan

$57.57

Empire State

$55.72

East Coast

$78.04

Central

$55.56Central Atlantic

$51.31

Pennsylvania$51.98

Southeast

$57.34

Georgia

$57.69

Data Source: Solucient ACTION Database, 2nd Quarter 2002

Jeanne McGrayne/VHA


ED Staff Skill Mix

0%

20%

40%

60%

80%

2000 Staff Skill Mix 71% 17% 12%2001 Staff Skill Mix 63% 23% 14%2002 Staff Skill Mix 65% 22% 13%

Registered Nurse

ED Tech/NA

Unit Secretary

Jeanne McGrayne/VHA


Technology

Wireless data entry and access = Paperless!Low frequency cell phones

Telematics – remote access to real time videoSmart cards; scanners for ID and insurance documentsDigitized radiography Bedside ultrasoundNon-Invasive physiologic monitoringPOC testing

Jeanne McGrayne/VHA


Technology

Registration/Discharge kiosks On-Line medical informationBiometric monitoring (“wristwatch” monitor)Stretchers and floor tiles to measure weightUltrasound monitors to record respiratory rateAmbient air samples to assess exhaled breathThermographic sensors for heart rate and tempScanning lasers to assess pupil size, shape and reaction to light

Jeanne McGrayne/VHA


Facility Size and Admission %

BEDSBased on % of admissions15% admissions 2,000 patients per ED bed10% admissions 2,250 patients per ED bed20% admissions 1,750 patients per ED bed25% admissions 1,500 patients per ED bed

Jeanne McGrayne/VHA


Facility

Build Process Before WallsStrategic PlanningInvolvement of EveryoneTriage VisibilityDischarge areaDesign Supportive of Team EnvironmentCDU/Observation /Express AdmitPsychiatric ED

51% Recently Renovated33% Planning or in Process51% Recently Renovated33% Planning or in Process

Jeanne McGrayne/VHA


Customer Service

Be ProactiveSecurityScriptsChecklistFollow-up Phone callsCommunicate Time ExpectationsCommunicate Plan of Care

Jeanne McGrayne/VHA


Leadership

Medical Director active in Medical StaffArticulate Goals Communicate Outcomes Allocate ResponsibilityAssign AuthorityAccountability/Courage

Jeanne McGrayne/VHA


The benchmarking process is a journey…

We learn during and from the process. We must not be so caught up in the numbers that we forget the journey.

We are reaching toward excellence, improving quality as well as financial results. True improvement and excellence are part of the journey and a process by-product.

Benchmarking is more of an art than a science. We begin with paint by number and end with a masterpiece.

Jeanne McGrayne/VHA


Internet References

http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm

http://www.hospitalconnect.com/aha/hret/emergency.html

http://www.acep.org

http://navymedicine.med.navy.mil/BBP/BBP/faq_bbp.asp

http://www.riskinstitute.org/ptrdocs/Benchmarking_Guidelines.pdf

http://www.bshsi.com/tews/docs/TEWS.FutureInED.pdf

VHA On-Line Survey - http://www.vhatools.com/ed

Jeanne McGrayne/VHA


Questions?

Jeanne McGrayneVHA’s Consulting Services

(910) [email protected]

ED Benchmarks and Best Practices

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