Buy-in, incentives move patients faster

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UCSF project wins Permanente Journal ­Service Quality Award

Despite sustained attention from hospital leaders, wait times in the University of California, San Francisco (UCSF) ED were considerably longer than desired. Knowing that longer wait times means poor patient satisfaction and a higher risk of poor health outcomes, a team of resident physicians set out to find innovative strategies to decrease wait time.

What they found can probably be applied to many quality improvement projects: education, buy-in, and incentives work.

Most importantly, remembering that people run the show, not systems, processes, or data, is critical to success.

“Don’t count out the human aspect,” advises Gene Quinn, MD, MS. Quinn and 10 of his fellow residents participated in the health systems and leadership track of their residency. The track—a two-year program developed by Arpana ­Vidyarthi, MD, and currently run by Read Pierce, MD, both faculty in UCSF’s Department of Medicine—­allows selected residents to spend part of their training preparing for leadership careers in health systems improvement. ”A large portion of that [track] is quality improvement and patient safety training,” says Quinn. The group ­focused on decreasing ED door-to-floor time, or the time from stepping into the ED to hospital admission, as part of the Quality & Safety Innovation Challenge (QSIC). Launched in 2010 by the UCSF Department of ­Medicine, QSIC invites trainees, staff, and faculty to work as teams over the course of six to nine months to design and implement innovative solutions aimed at improving patient care. The project won a Permanente Journal Service Quality Award.

“You’re really having to rally a lot of different subcultures and groups with their own ideas and values and their own ways of doing things. You are trying to get them all excited about one specific thing and work together,” says Quinn. “It’s extremely difficult but ­really ­important for sustainability. You have to get people behind the ­project to make any sort of meaningful change.”

Assessing the problem
The group used Lean methods, process mapping, Failure Modes and Effects Analysis, and stakeholder ­interviews to pilot strategies that changed the work flow and culture of the admissions process.

Process mapping was a huge undertaking, as there are a number of steps involved in admitting a patient who presents to the ED, including:

  • Initial registration
  • Triage
  • Placing the patient in an ED bed
  • Consulting with the ED physician
  • Ordering lab tests
  • Admission decision

Deciding whether to admit a patient is a process in itself. The ED physician must call an admitting ­service, which in a large hospital can be one of a number of ­departments, including internal medicine, ­multiple subspecialty surgery services (e.g. neurosurgery, ­vascular surgery, etc.), and psychiatric. The ­appropriate level of care must then be decided. Providers must ­also consider whether the patient needs telemetry, additional monitoring, or is ill enough to justify admission to the ICU.

Admission orders are then written, but of course a bed must first be available and ready for the patient, which involves environmental services staff.

"That’s quite a lot of things that actually have to ­happen,” says Quinn. “ED wait times were a major ­quality improvement focus for the hospital.”

“When we started the project, our ED door-to-floor time was much higher than our goal and above the average for a number of peer institutions,” he admits. “It has a lot of different effects on us; obviously, it’s not good for patient safety—there’s some evidence to suggest you’re more likely to have a complication the longer you wait down in the emergency room before being admitted.”

There was another issue, too: The emergency medicine residency program participants knew that long wait times could affect their training goals and, ultimately, the accreditation of their program.

The group of residents took a multitiered approach to curbing wait times, including interviews with all levels and types of staff from multiple departments.

“We spoke with the pediatrics department, admitting services, the emergency room, as well as a lot of people in administration who have been trying to work on the issue previously,” says Quinn. “We didn’t just speak with doctors; we spoke with nurses who are actually doing a lot of this work, the front desk, with triage, emergency room clerks, and with environmental services who clean the rooms. Out of that, we had a lot of insights.”

Education and buy-in
After conducting extensive research, the team broke down what needed to be done into three categories:

Work flow. Looking critically at work flow had been done before, says Quinn. But this time, the focus was on how the process worked, and whether it worked well. The team asked how to make orders easier to write, how to get laboratory tests sent earlier to facilitate timely results and begin the decision-making process earlier. Essentially, the team focused on ensuring that top priority was given to the work directly involved in making an admission decision.

“If the patient needs advanced tests that may take a while but don’t actually affect that original decision that the patient goes up to the hospital, then perhaps it can be done once the decision has been made to admit so that the work to get a patient a bed can be started,” says Quinn. The team also focused on avoiding bottlenecks for needs such as telemetry.

Culture. “When we talk about culture, it really has to do with the people,” says Quinn. He notes that some departments have a long history of butting heads, which has to be recognized. “For example, admitting services and ED services certainly have a long history ­together; they have very different cultures that can ­create barriers to working together efficiently.”

The team worked to make the admitting process more collaborative and less adversarial. “As long as we foster a culture of collaboration, it’s better for patient safety and door-to-floor times as well,” says Quinn.

Incentives. Quinn notes that incentives are often broadly defined to include disincentives, but focusing on positive reinforcement rather than punishment is a more sustainable model. The term “incentive” usually invokes thoughts of money; however, sometimes a good reason is all the incentive you need.

“Most of the providers that were actually doing this didn’t understand why ED door-to-floor time was important; all they knew was that they were told by administration that the time needs to go down,” he says. “If you’re told that, you’ll work to make the time go down for a little while, but you’ll miss what the time represents, which is increased patient safety and making sure there are fewer poor outcomes.”

Understanding the culture is critical to incentives. The fact that providers care about their patients and the outcomes of their efforts acts as its own incentive, and presenting it as such was a simple (and cost-effective) matter of education.

Providers also care about patient satisfaction knowing patients often have the choice to go to other hospitals, so the team made sure providers understood door-to-floor time is also tied to patient satisfaction.

Data sharing was another incentive that was tightly tied to ­education. Providers were given reports on their ­individual door-to-floor times.

“Without any feedback, it sort of becomes this nebulous concept where you’re not really sure if you’re doing any good,” says Quinn. “Most people think they’re probably doing well but have no idea what their time is.”

A good example of this powerful tool was how the process improvement actually added a step. Previously, before the team was involved, a one-page order set was added to the process of ED door to floor. The idea was to have this quick order set to get the information needed for admission; later, the provider fills out a five-page order set. But although the one-page order set was intended to speed up the process for the patient, it meant one more page of documentation for the provider. The form was underutilized until providers began receiving feedback on performance and started to understand that those who used the one-page set had lower times.

“So even though there’s no incentive for decreased work, there is an incentive because of the buy-in and feedback on performance,” notes Quinn.

Recurrent feedback on times has proven to be an effective incentive for providers, says Quinn, noting that it also keeps them accountable and gives them ownership of the initiative.

“When people feel as if they have a seat at the table, then they are more likely to be interested in the project,” he says.

Quinn says some components of ED door-to-floor time have decreased. He notes that education and buy-in are critical for sustainable change.

“Once you take away incentives, you have to have some sort of internal drive that people believe in,” says Quinn.