IMPERATIVE: Core Measures Compliance
CASE STUDY: Jefferson Memorial Hospital
ST. LOUIS, MISSOURI... Jefferson Memorial Hospital is non-profit community hospital, located within an hour of St. Louis. It is the sole community provider of healthcare services for Jefferson County and other surrounding communities. With the intent of improving patient access, throughput and satisfaction, the hospital board backed by the community, invested millions of dollars into redesigning its Emergency Department. In June of 2006, the new department opened. The Emergency Department had been designed without a waiting area, — a feature that leadership assumed would lower patient length of stay and eliminate wait times. It boasted 24 private, patient rooms built around a central clinical nursing core. Patient transportation, visitation, and other activities occurred via a perimeter hallway. As a labor streamlining measure, the department installed the latest technology.
By December of 2006, hospital leadership learned that patient throughput times had not improved — throughput times had actually increased to 4.61 hours, productivity was at 4.5 hours per patient, and patient satisfaction scores were low at the 2nd percentile. Staff morale was declining proportionately. Compounding the situation, the hospital had been advertising "no waiting" for the Emergency Department. In January of 2007, hospital administration brought Jerome Ladous on board as Vice President of Operations to "fix" the Emergency Department.
By May of 2007, Ladous decided he needed to be in the department 24/7 or enlist outside help to facilitate change of this size. After reviewing three consulting firms, Compirion Healthcare Solutions, a hospital consulting firm out of Elm Grove, Wisconsin, was engaged to aid in the improvement. According to Ladous, Compirion was chosen for their willingness to be at risk and to work under hospital direction as part of the team"Compirion was chosen for their willingness to be at risk and to work under hospital direction as part of the team."
Emergency Department Director Shelley Layton added, "Compirion made a great presentation. What clinched it was the money-back guarantee that they would meet agreed upon goals."
Compirion was engaged for 6 months to help the hospital staff develop tools and processes in order to effect permanent change. Compirion sent a team of three to work with the senior administration in defining goals and in determining the hospital teams that would address key areas. Core teams were RN/MD Charge Team, Core Measures, Patient Satisfaction, Bed Control and Triage/Registration. Goals included: improve patient throughput time from over 4 hours down to 3 hours, improve productivity, raise Press Ganey patient satisfaction scores to the 75th percentile and improve core measures scores.
Compirion's philosophy states that for the project to be truly successful the entire hospital needs to take ownership of it. In accordance with that, Compirion's team began by getting the entire staff on board including the physicians. Then the Compirion team went to work in the department, side-by-side with hospital personnel and physicians, observing the key processes and procedures of the ER care continuum. The RN/MD Charge Team worked to optimize patient flow throughout the entire department. During the process, they began recognizing internal changes that needed to be made in order to reach the goal.
E. D. Director Layton pointed out, "Up until this point, Jefferson had never had Charge Nurses who rounded hourly and supervised. All the RNs had been seeing patients. The Charge Nurse role is a managerial one so those appointed to the position stopped seeing patients. They arranged for the rooms and for resources so that everything needed to treat the patient was waiting for the RN. The Charge Nurses became the 'push' that kept things moving throughout the department."
The Compirion team built tools to aid in the daily, real-time management of patients and resourcesThe Compirion team built tools to aid in the daily, real-time management of patients and resources. Tools included a Charge Nurse daily checklist, rounding monitor, a metrics dashboard, daily dot-and-plots, a patient snapshot from triage and a shift management report. A constant process of piloting, implementing and evaluating became part of the daily regimen. At the beginning of the improvement, LOS was at 4 hours, 12 minutes. At the end of the 6-month process, LOS was at 3 hours and billable patient volume had risen 6%. Productivity went from 3.5 worked hours per patient to 2.9 for a 17% improvement.
At the same time, the Core Measures Team set specific goals for treatment of cardio patients: aspirin on arrival for 100% of patients with chest pain, door to PCI within 90 minutes (according to Medicare reimbursement guidelines), and door to EKG within 10 minutes. For pneumonia patients, 100% were to receive a blood culture prior to antibiotic, and an antibiotic within 4 hours of diagnosis. Some of the challenges involved educating core staff members and agency/travel nurses who were not aware of Core Measures and protocols. Compirion worked closely with hospital staff to appoint a Heart Watch Team, develop a Heart Watch packet that contained orders/protocols for patient care, and a timing sheet. They also developed an AMI tackle box containing key drugs along with many other changes and additions focusing on AMI patients. In total, several dozen changes were developed and fully implemented. At the end of the improvement engagement, aspirin on arrival, primary PCI within 90 minutes, blood culture prior to antibiotic and antibiotic within 4 hours of diagnoses were all at the desired 100%.
The Patient Satisfaction Team was put in charge of determining current patient satisfaction Press Ganey scores for both the ER and Inpatients. Prior to the improvement, Jefferson Memorial Hospital did not have a patient satisfaction team in place. Before proceeding, the staff had to be educated regarding Press Ganey and the importance of patient satisfaction. What I liked about Compirion was that they didn't bring a 'book of solutions' they were part of the solutionThe team's first step toward improvement was identifying baseline percentile Press-Ganey rankings, which turned out to be lower than the 20th percentile, and setting goals for increasing scores. Next, they identified issues and causes for low scores. Based on findings, they developed and implemented real-time satisfaction surveys with patients at the time of discharge. A standard script was written for answering patients' questions. A real-time service recovery system was also implemented. The data was summarized weekly and the results and progress were shared with the team, critical steps to keeping the momentum. Because teamwork in the department was poor to nil, employee of the month nominations were instituted and thank you letters were sent to employees named in Press-Ganey scores. At the end of the 6-month engagement, Press-Ganey scores were in the 74th percentile.
Before the improvement, there were unexplained waits in the lobby averaging 23 minutes. Initial door to treatment time was 59 minutes, and door to EKG time was at 35 minutes. Decreasing door to treatment time became the primary objective of the Triage/Registration Team. First they changed the physical layout of the Triage area to enhance patient flow and added a treatment room near triage to begin protocols in the event that room was not available in the main Emergency Department. A Quick Registration process was established. Nine additional standardized triage protocols were instituted based on ESI guidelines. A Water cooler and a clock were placed in the lobby for patients, their families and friends. Within weeks, wait times began to drop. Door to treatment time decreased to 37.5 minutes and door to EKG dropped to 15 minutes.
Work conducted on the inpatient flow also improved throughput. The time to admit and transfer a patient from Emergency Department to a floor went from 2.5 hours to under 50 minutes.
According to V. P. Operations, Ladous, "What I liked about Compirion was that they didn't bring a 'book of solutions' they were part of the solution. They used the resources of the hospital, specifically the front line managers, to come up with customized answers to fit Jefferson's needs. I also liked that Compirion's people believe that to create change you need to create dynamic tension. In Jefferson's case, this dynamic tension consisted of once-a-week Core Team meetings of accountability with the hospital CEO."
E.D. Director, Layton added, "From my perspective, accountability was the biggest piece Compirion brought to the table and was worth every penny!From my perspective, accountability was the biggest piece Compirion brought to the table and was worth every penny! Every week the steering committee had to listen to issues in the department, help determine what was needed and who would be responsible for making it happen."
"I never worked with a consulting group before but I think this was a great project," Layton concluded. "The Compirion team deserves huge kudos. They did a wonderful job and became part of the E.D. family in the process."
To insure lasting results of the improvement, the entire service line continues to meet weekly to go over the data report card and make adjustments. As part of their Sustainable Results Program, the Compirion team returns twice during the year at no charge to the hospital to review and make any adjustments.
