Quality Rounds
Keri Gardner

Chris Pepon

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Accelerting the Improvement Journey

Quality Rounds
Get Better! Quality

Defining a Clear Path to Improvement

Have you ever tried to quantify quality? To pick a common image that represents quality to anyone who looks at it? Yes, an A+ rating represents quality, as does an upward trend on a graphical representation. But how about the full picture, the end- to-end of quality? Defining this is a daunting task.

Let's now think about quality in the eyes of patients-what does that look like? Some will tell you it's clean floors, or warm food. Finance people might say it means being financially stable in all the right areas. Still others might ask the basic question: do patients walk out better than when they came in?

The First Step

Regardless of where we are in this pursuit of quality, better metrics, and improved outcomes, the important first question is: Do you want to Get Better!?

The simple desire to Get Better! is the first step in the journey. Taking pause to evaluate the situation, your department, patients, co-workers, and organization. Overwhelming? Impossible? We have the direction and tools to get us there. While the technical software programs may be what we discuss and stand behind, it's the want for improvement that will drive us.

What's Next?

After establishing the desire to Get Better! we then move to the symptoms of the problem. What's the diagnosis? How will we treat it? It's this conversation that will help to set us apart from all the rest. We must identify the issues together and face the diagnosis with a treatment that is agreed upon
and collectively followed.

When you think about the medical model in relation to process improvement, the correlation becomes so apparent. How often do we stop taking the antibiotics, and then wonder why our throughput metrics have reverted to what they were, or gotten worse than before we even started? Knowing the answers and the treatment is one thing; applying this knowledge is another.

Let's start asking those difficult questions and keep our improvement journey moving forward. Let's Get Better!

Get Better! Communication

Mastering the Art of the Huddle

I recently had a phone call with Nick Hanno, ED nurse manager at Lewis County Medical Center in Lowville, NY. The purpose of the call was to discuss the general status of the department and to review metrics. This is a fairly common call that I make; in this case, the conversation was to help prepare for a site visit. We discussed several projects he was working on and spoke about PI team implementation.

As the conversation came to an end, I asked what, if anything, would be the one issue I could fix or help with. After some hesitation, Nick admitted that the one thing he struggled with-more so than issues like door-to-provider time-was communication. Nick began detailing his struggle communicating with both doctors and nurses. He said it didn't really appear to matter whether it was day or night staff; there wasn't one solution that seemed to work better for either group.

This was a problem I had faced as an ED director as well. In fact, I found it to be one of the most time-consuming and


difficult things to manage. Technology brought so many tools to help with communication-emails, texting, posting to the time clock, and so on. But none of these methods came without significant monitoring and upkeep, and none worked reliably all the time.

That is, until I implemented Huddles.

Build Teamwork and Unity in Under Five Minutes

I had worked at a couple of facilities that had tried variations of Huddles and had some success with them. I didn't embrace them myself until I read a Fast Company magazine article and decided I needed to look into them a bit more.

As I researched, I learned that Huddles had originally started with John Rockefeller, the American business magnate, and now have grown to organizations of every size. I spent the next year trying various forms of Huddles in the organization I was with at the time. One of the greatest finds I made during my initial exploration was stumbling onto a Huddle that the cafeteria director conducted on a daily basis.

Peter Merritt worked for Morrison Food group, and they had perfected the Huddle by developing a daily agenda 30 days in advance. This agenda covered safety items, a three-question quiz on food preparation, daily happenings, and customer satisfaction-all in less than five minutes. I brought over 60 key people through his Huddle before kicking it off organizationally.

Over the next year, I had helped to launch the Huddle in all clinical areas, either independently on a unit or by bringing a member of the organization through to lead a Huddle once a week-or both. Huddles provided a great form of communication, bringing everyone together for a quick agenda-driven meeting. There was never a question as to who got the message and what was communicated.

Best Practices for a Successful Huddle
  1. Keep it short, preferably less than five minutes.
  2. If practiced in an area with shifts, hold them for each shift, delivering the same message.
  3. Have an agenda and stick to it.
  4. Try to celebrate something or someone to keep it positive.
  5. Invite a guest to share an update or to answer questions about an area the team has little access to.
  6. If discussion goes to operations, continue it after the Huddle. This forum is not suited to one-on-one discussion or lengthy information/operational conversations.
  7. Schedule a time for the Huddles and make it a routine.
  8. Don't let anyone skip out-it's the most important five minutes of the day!
If you haven't yet discovered the wonder of the Huddle, now is the perfect time to start. It might just be the most powerful tool you implement in your ED all year.

Get Better! Leadership

Insights From an Airport Conversation

Whether you're an aspiring leader just starting out or a seasoned veteran, we all struggle with the same obstacles. The emergency department isn't unique in seeing varying strengths in leadership. However, we in the ED do deal with some of the strongest personalities in the business and some extremely challenging customers, not to mention some very stressful events.

I recently sat next to a gentleman in the airport on a return flight from Texas. As we exchanged quick intros-where do you live, what do you do, etc.-we quickly realized we worked in a similar arena: process improvement that included the constant review of metrics. There were a few differences, like the fact that he was retired and had been the co-founder of a financial consulting firm that had recently sold for more money than most people win in the Powerball. His career had been spent catering to some of the largest banking corporations in the world. I had the opportunity to spend time chatting with him, see pictures of his grandchildren, and learn about his lifelong passion, horses.

As this man and I talked, I learned many things about his company and what challenges he had faced in the industry over the years. I learned of the ups and downs, and the changes that technology had brought both his firm and the clients he served. There were many parallels with his business and the work I'd done in hospitals. It was not surprising, but it made me realize that healthcare is not always different from other businesses. We all struggle with change, we all struggle with technology, and we all struggle with leadership.

Here are the top five things my airport friend learned over his career, boiled down to a condensed, French-fries-and-glass-of-wine version.

1. Management is essential. "I've gone into companies that spent 30 million dollars on a software solution and had no tangible improvement. It doesn't matter how big you are or what you buy to fix something, it'll only work if you manage it."

2. Always start with the metrics. "Look at each part, break it up into the process, and fix it. So often, people take metrics that represent five or even ten process components and wonder why things don't improve when they fix only one or two of them."

3. Pick one thing and stick with it. "Banking, horses, it's all the same. We may be talking trainers or consultants. Most of the time, we fail when we try too many different approaches, or when we take advice from several people and try bits and pieces that we like from each. It doesn't usually even matter if an approach is the best-just stick with one, and stay the course."

4. Peer pressure is everything when it comes to motivation. Show someone metrics of five other banks, and if they aren't in the top two, or not in the group at all, they will respond-if they're looking to improve, that is." What if they are ok with mediocrity? "For me, that part was easy. I was there because they were having problems and wanted to Get Better!. It usually meant a significant loss of money."

5. The top five performers typically beat all others by at least 20%. "I found over the years that if an organization is committed to doing a great job, they apply the same principles to all areas. Once you find a method that works, deploy it in all areas of your organization."

If quality metrics and outcomes had a common denominator, it would be the leadership provided. Leadership in the emergency department is what makes or breaks it. So how do we Get Better! leadership? This is truly the million-dollar question. The pointers above-derived from a long and successful career in business performance improvement-seem like a great place to start.

Get Better! Metrics

Improving Arrival-to-Provider Time

Each quarter, our review of metrics will include defining the measures we look at on a daily basis and suggesting methods that have been used to improve these areas. NES uses benchmark data for each of the performance measures in ActionCue. The areas that don't have national benchmark data (e.g. "ED returns admitted") were reviewed internally and then assigned a value that is meaningful to the organization and to emergency medicine based on case reviews and relative articles.

Arrival-to-provider time is one of the metrics that can have the greatest positive impact on throughput times. Although each ED will have its own solutions to perfect this process, there are key areas of possible improvement. We have had success at NES by deploying many of the techniques discussed; this is evident by our organizational dashboard which displays the average door-to-doctor time by month for all the EDs managed by NES.
ED Arrival to ED Provider Time

What Defines Arrival-to-Provider Time?

The "door to doc" time is measured from when the patient walks though the door of the ER until their first meaningful contact with a provider. Traditionally, mapping of ED processes looked at Patient entrance-Registration-Placement for waiting-Triage-Room assignment-Initial provider contact. But this flow was not patient-centered. Why have a patient do anything but enter a room after arrival if a room is open? This enables the other processes to happen simultaneously and throughput times to plummet.

It's interesting to listen to the wide variety of responses that providers and nursing staff give when asked, "What processes can be changed so that the provider is one of the first people that greets a patient who comes into the ED?" NES recommends building your PI team around questions like this to define the goal, then letting the team decided how best to get to the goal.

Best Practices to Consider

Here are a few best practices to keep in mind when striving for improvements to your arrival-to-provider process:
  1. "Pull to full"-bedding arriving patients immediately into open ED beds
  2. Team triage (physician, nurse)
  3. Bedside registration
  4. Utilization of nursing protocols to initiate care in common complaints
  5. Surge protocol
  6. Transfer of admitted patients to inpatient beds within 60 minutes
  7. Predictive volume/staffing models

These recommendations are simply the start to a process that will result in getting patients to rooms faster and met by providers more quickly. The effort involved in putting these pieces into place will require the commitment of your entire team but will benefit everyone!

Get Better! Patient Satisfaction

Patients Are Talking. Are You Listening?

For ED doctors and nurses, the emergency department is not just our workplace, but a place where we lay out our heart and souls, share in tears with our patients, and suffer scorn from the unhappy. For some administrators, especially non-clinical ones, the emergency department is a chaotic and disturbingly complaint-ridden department that is unlike any other hospital service.

Many patients who enter the ED carry with them the baggage of years of scary stories and long wait times. I think Brian Regan encapsulates the ED experience better than anyone else in his stand-up comedy act seen on YouTube. His initial comment on emergency departments not having valet service-and needing to drag yourself into the ED as you die-is a great window into what some of our patients think and reminds us of some of their expectations.

Where Do We Go From Here?

How will we Get Better! in this area, when the cards are so clearly stacked against us? The answers are beginning to be understood and implemented, and range from solid "people" skills like consistently using friendly introductions, to expectation management about wait times, to the emphasis on timely care and improved turn around times. Unexpectedly, help is on the way with the Emergency Department Consumer Assessment of Healthcare Providers and Systems (EDCAHPS), which focuses on collecting data that will allow for direct comparison of emergency departments. This survey, which is required to be sent out by a third party vendor on behalf of the hospital, asks patients to formally rate the service they've received in the emergency department and will ultimately help to improve standards and expectations. The government's focus on this survey will help unite the ED staff and the hospital administrators to support patient-centered care in the ED.

Getting set up to Succeed

The starting point for all of the sites managed by NES is partnering with Qualitick, the company that provides Client IQ patient survey tablets to our sites. The tablets have a
simple, 5-question survey that touches on key areas of patient satisfaction and uploads them via wi-fi to a webbased software program. This proactive approach will help us to better understand the areas that patients are most satisfied with and the areas that show the greatest opportunity. While we've all used other data sources that can take two to four months to receive, Client IQ surveys deliver immediate feedback-even seconds after completion-to our smartphones and tablets, if desired.

What do we do with the information received through Client IQ?

We've used it to Get Better! across the board. The surveys allow us to celebrate our successes and recognize the individuals who do a great job with customer service. Equally as important, these surveys allow us to pinpoint those areas and individuals in need of improvement.

Getting Started

How do you begin in delivering a better patient experience? Here are the three things we recommend as a starting point:

1. Expectation management. Many patients don't know much about Emergency Departments and no one knows the current state of your ED like you and your nurses. Manage your patients' expectations immediately by letting them know kindly what to expect.

2. Client IQ tablets. As discussed above, these are the cornerstone of enhancing the patient experience. They are your link to your patients and the opinions they have about your department and staff.

3. Routine rounding: The industry standard is hourly rounding. This is often inadequate in the emergency department, where stays for routine visits can and should be only one to two hours from start to finish. In the ED, being meaningful is essential. What communication and information will you be prepared to deliver each time you go into the patient's room?

4. Performance Improvement (PI) team. Organize your ED staff into a PI team that can brainstorm on solutions to problems utilizing the whole ED team. This allows for consistent conversation, decreases rumors and gripes, and allows home-grown approaches to achieving best practice results!

Today, the patient experience is the most pivotal factor in getting people to walk through the ED door. Listening to patients' feedback-and acting upon it-is the key to keeping satisfaction metrics on an upward trajectory.


Get Better! Care

Visiting NES emergency department sites from Ketchikan, Alaska to Brooklyn, NY I am awed by a country as vast in distance as it is in providers, care systems, illnesses and injury patterns. Each location is so different that it seems impossible to define one "standard of care", and yet more and more we hear this term-and certainly plaintiffs claim that it exists in malpractice courts across the country.

As we manage the claims that come in, I am often surprised by what I hear and I imagine you will be too. An orthopedic expert for the defense claimed that the standard of care in the ED should be the same standard of care as if the patient had gone to an orthopedist's office. One Emergency Physician was slapped with an EMTALA violation for "failure to stabilize" a patient with a head bleed and an INR of 1.4-who did just fine on transfer and had no worsening of symptoms or signs.

We no longer can afford to practice based on what we remember or what we used to do. It is imperative that we use current references, that we seek validated guidelines to support our clinical decisions, and that we use our consultants appropriately. Recently I called our cardiologist to back me up because I thought the ST elevations were inconsistent with the need for fibrinolysis, and he said that he didn't have a way of looking at the ECG. Not acceptable! It turns out that he did receive images on his smartphone and so I messaged the ECG (with Protected Health Information removed). It is an admirable goal to achieve the same standard of care in rural Louisiana as in a major academic center-and to do it in the incredibly short time frame of an ED visit that we have to do it in-but it will require significant work. In this newsletter we will highlight not just best practices of ED performance, but will discuss some high risk issues in emergency medicine that you can take to your department wherever you are in this vast and incredible country of ours.

TPA for stroke

Let's start with one of the most controversial therapeutic options in Emergency Medicine: giving TPA for stroke. Not that many years ago, when a patient had a presumed ischemic stroke, we administered an aspirin and admitted the patient. Now, treating an ischemic stroke requires neurologic consultation, offering a risky medicine with a questionable success rate, and a lengthy conversation with the family and documentation on the chart about the subtleties of treatment.
Not going through these steps has caused many physicians to spend years in malpractice cases. Therefore, there is a suggested series of steps to follow. Figure 1 has the Institute for Clinical Systems Improvement guidelines for stroke treatment, which has been incorporated into the National guideline Clearinghouse at guideline.gov. ACEP and AAEM also have policy statements on stroke identification and treatment.

A Case in Point

The pastor of the local Lutheran church has come in after his wife noticed that he suddenly started having trouble speaking while they were watching TV. He is struggling to respond to questions, and his only response seems to be "it's out there". He walked with her to the car and is gesturing normally with his hands.

You have developed a stroke protocol with your nursing staff, so they place the patient in an empty room upon arrival and send the tech to room 3 where you are seeing a teenager with an earache to alert you to the possible stroke. You excuse yourself and go to the patient's bedside immediately, noting that he is undressing without any difficulty to get into a gown. You ask the RN to draw blood and establish an IV while you examine him and you ask the tech to get a first set of vital signs. A quick exam reveals only an expressive aphasia, and by the time you are done the RN has completed the IV placement. You return to your computer and order the labs and head CT and initiate your Code Stroke protocol so the patient can go to CT immediately. When he returns, you review the CT, which looks normal to you and you reexamine him to see if his deficit has changed. It has not. Now you do a complete examination and a thorough neuro exam. History is obtained from the patient's wife, and time of onset is 20 minutes prior to arrival. It is now 30 minutes from arrival. You are still in the TPA window.

BP is noted to be 180/95. You ask the tech to get an EKg, and that a call be place to the neurologist at the closest center with an inpatient neurology service. While that is happening, you talk to the patient's wife since he does not seem to be able to comprehend. You take in the TPA for stroke handout from the AAEM site to share a pictoral display of the risks and benefits of TPA. You also take in the list of contraindications to TPA and review each one with the wife, but there are none. The patient's wife listens to you through tear filled eyes while you discuss the statistics, then says, what would you do if it were your spouse?


Get Better! Care

Stroke Code Algorithm

Case Study - Alice Hyde

CEO Doug Divello asks: can we attain best practices ED care, sustained process improvement, and top-class metrics?

When the NES Get Better! team analyzed the Alice Hyde Emergency Department, they identified that the answer lay in a committed site medical director with strong leadership skills.

The first step was looking for the right site medical director who would enjoy living and working in Malone, NY. Malone is a rural community but boasts an acclaimed 36-hole golf course and is 1 hour away from both Lake Placid and Montreal. This was just the right fit for Dr. Keri Gardner, who is an avid outdoorsperson but wanted to live within an easy drive of an NHL franchise. Her husband, an avid golfer and hockey player, was delighted to make the move.

Dr. Gardner brought strong leadership and detailed oversight to AHMC while working closely with the ED staff and nurse manager. Departmental processes were brainstormed at Process Improvement Team meetings and the right solutions were identified through rapid cycles of measurement and changes. Working closely with hospital leadership, the ED staff hard-wired:

•  "Pull to Full" bedside triage and registration implemented
•  Staff huddles
•  Patient rounding
•  Bedside handoffs
•  Hospital-wide surge plan

And the data shows how with NES Health the ED did Get Better!

•  ED arrival-to-discharge time improved from 166 to 134 minutes.
•  ED arrival-to-provider times improved from 66 to 8 minutes.
•  Overall throughput times improved from 190 to 114 minutes.
•  LWBS percentages improved from 2.7 to 1.1%.
•  96% of patients surveyed "would recommend" the ED.
•  Increase in visits by 12% in 2014 compared with 2013.

Alice Hyde Medical Center


Keri Gardner

Quality Rounds