NSG 626 Lutheran Medical Center HealthCare Case Study

NSG 626 Lutheran Medical Center HealthCare Case Study

NSG 626 Lutheran Medical Center HealthCare Case Study

NSG 626- Systems Thinking For Quality Case Study-Leadership Lutheran Medical Center is a 400-bed, inner-city, community teaching hospital located in Southwest Brooklyn in New York City. It is one of only two Level 1 trauma centers (the most critical) in the borough of Brooklyn. There are three major competing hospitals within five miles of the hospital and this competition continually challenges the hospital’s efforts to grow and gain market share. Lutheran’s community is made up mainly of immigrants and blue-collar wage earners. The payer mix is 75% Medicare and Medicaid. Recent efforts, therefore, have focused on reaching out to the neighboring community of Bay Ridge, where the population is dense, better insured, and facing the closure of its only hospital (one of the aforementioned three hospitals). With low New York State reimbursement rates, the high cost of New York healthcare (wages, malpractice, benefits, etc.), the hospital must keep 90% of its beds filled in order to break even. Lutheran is already known as a low-cost provider, so growth is its only real option. Most hospital administrators know that having a hospital routinely filled at over 85% creates many challenges. Safety, quality of care, and patient satisfaction must be emphasized more than at hospitals at lower, more comfortable occupancy rates. In response to its primary objective, (i.e. growth and maintenance of high census while still improving quality of care, safety, and patient satisfaction levels), the hospital embarked upon an effort to dramatically improve its emergency department (ED). Generally known to be the “front door” to the community, over 70% of Lutheran’s admissions come from the ED. Lutheran’s thinking about the ED is that if it works beautifully, patient satisfaction will go up, first impressions will be positive, quality of care and patient safety will be improved, and more and more residents of the community, and beyond, will choose the hospital for care. The hospital did three main things to address the goal of becoming the ED of choice in Brooklyn: 1. Replaced the leadership of the ED. 2. Expanded the ED’s space by 60% and modernized it. 3. Redesigned all ED systems and processes. The specific measurable goals for this redesign project were to: 1. Increase the percentage of patients reporting being “satisfied” or “very satisfied” from 52% to 70%; 2. Increase visits from 147 per day to 175 per day; 3. Have a provider see every patient within 30 minutes of arrival in the ED; 4. Have fewer than 2 percent of patients return to the ED for a second visit within 48 hours of their first visit, and; 5. Hire 100% ED-trained physicians in the ED. The project began in 2002 and was completed in 2006. The first step was to replace the leadership. The leaders, at that time, were reluctant to change and were not familiar with national best practice models in emergency department care. Also, 80% of the physicians were non-ED-trained. Replacing the chairman and the vice president of nursing for the ED took one year to accomplish. Turning over the staff to have 100% ED-trained took three and a half years. Next, in 2005, the hospital formed an ED Process Redesign Task Force. Previous leadership had attempted a redesign in 2002, but it failed. A major lesson learned was that redesign and “overhaul” are impossible without the right leadership in place. This effort was led by the hospital chief operating officer (COO) and the new chairman of the ED. The other members of the team included the chief nursing officer (CNO), the vice president of nursing for the ED, the nurse manager for the ED, the ED educator, and the VP of operations for the ED. There were seven main results of the process redesign: 1. A care team model for the ED was created, allowing small groupings of patients to be treated by a team that included MD, RN, and an aide. 2. A position called ED patient navigator was created. This person was available to communicate with referring physicians about their patients and serve as a case manager for ED patients. 3. The role of the ED nursing care coordinator/charge nurse was redefined to be the daily “director” of movement, operations, and oversight of the entire ED. 4. The traditional nursing triage model was replaced with a combined triage/fast-track model. Physician assistants (PAs) replaced nurses at triage and triaged, treated, and released (when appropriate), or triaged and moved patients to the main ED when appropriate. 5. All the ED staff were given portable internal zone phones to increase communications and reduce the noise level. 6. Paper charts were replaced with a fully automated medical record and tracking system. 7. Bedside registration was implemented. So patients go directly from triage to an ED bed without stopping to be registered. Within 18 months of introducing the process redesign team, the following occurred: • Patient visits went from 147 per day to 172 per day • The average door-to-provider (MD or PA) time went from 90 minutes to 30 minutes. • 100 % of the MDs were ED-trained • Two percent of patients needed to return to the ED within 48 hours of their initial visit. • ED patient satisfaction went from 52% to 66% (still 4 percentage points short of the goal) Clearly the team was disappointed by the lack of progress in patient satisfaction, but they were not confused by it. The reason was that as patient volume increased, the number of available hospital beds remained fixed, and so patients waited longer as more time was needed to move patients from the ED to a hospital inpatient bed. Because the hospital must remain at over 90% occupancy to break even, adding beds would have created operating losses for the institution- an option the team did not have available. The new challenge is to improve patient satisfaction given the increasing wait times for hospital beds. As Vice President of Operations for the Emergency Department what would you do to move toward this patient satisfaction goal? Consider at a minimum: 1. Analysis of the process using quality improvement tools 2. Determination of potential quality lapses using a potential flowchart (you can create the process for ED patient movement and then flowchart it) 3. Identification of measures for these quality points 4. Designing interventions 5. Collecting data from appropriate data sources 6. Reporting results (Who would receive the results?) 7. Revising interventions for continuous improvement efforts (What would you consider next if this did not work? What are the next considerations if the patient satisfaction does improve?)

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