A historic gathering quietly took place in Atlanta in February. Nineteen influential members of the emergency medicine community with specific interests and expertise in performance improvement came together at the Performance Measures and Benchmarking Summit to craft a document that standardizes the vocabulary and terminology used in quality improvement.
There are compelling reasons that emergency practitioners should standardize the language, terminology, and implementation of performance measures and benchmarking practices, not the least of which is regulatory burden. The Joint Commission on Accreditation of Healthcare Organizations is now pursuing clinical quality improvement data in the form of core measures. Any facility that does not have an infrastructure to track these data risks its accreditation. The measures are likely to be under double scrutiny as the Centers for Medicare & Medicaid Services launch its Pay for Performance (P4P) initiative, which will reward hospitals that perform best along those same parameters. (A Comprehensive Review of Development and Testing for National Implementation of Hospital Core Measures. www.jcaho.org/pms, March 2005; Amer Med News, Sept. 5, 2005.)
The Joint Commission also just levied additional regulatory burdens in the form of the so-called “flow standards.” (Meeting the JCAHO Patient Flow Standard, Urgent Matters Regional Conference, Oct. 27, 2005.) If an ED wants to maintain its credentials and be reimbursed maximally, data tracking and following quality measures will be imperatives. It is essential that further regulatory requirements use parameters that come from within the specialty and that emergency medicine experts who understand the nuances of data collection and analysis lead these endeavors.
ED operations management, with principles readily adaptable from other service industries, is a developing area within emergency medicine, and EDs will be searching for techniques to improve ED patient flow and processes. (Acad Emerg Med 2003;10:806.) To determine whether ED process innovations are effective, standardized markers for efficiency and quality will be required.
The fundamentals of quality improvement research are more similar to business models than those used for human research, but these principles are not widely accepted in traditional medical research. To advance the growing body of knowledge relative to quality improvement, the standardization of terminology and methodology are necessary. (Qual Saf Health Care 2005;14:315.) To date, much QI work goes unpublished, and those working in emergency medicine quality improvement are failing to build a body of research pertinent to operational efficiency. This is everyone's loss. By standardizing the discipline, we can begin to aggregate knowledge and create a solid knowledge base.
While others have written about clinical quality measures (Acad Emerg Med 2002;9:1091, 1139), and indeed many of these parameters are being tracked by regulatory requirements, operational benchmarks for emergency medicine have been slower to evolve. Measuring time intervals in the ED and tracking patients who leave before being seen have become de facto markers for quality and efficiency in the literature (Meeting the JCAHO Patient Flow Standard, Urgent Matters Regional Conference, Oct. 27, 2005; Acad Emerg Med 2003;10:806; Qual Saf Health Care 2005;14:315), though no standardized definitions for these markers have been offered or accepted.
The Performance Measures and Benchmarking Summit was charged with formulating definitions for basic ED operations, drafting a consensus statement on benchmarking in emergency medicine, developing a comprehensive set of benchmarks for patient flow and operations that also could be used for operational quality, forming a simple cohort scheme for categorizing EDs for benchmarking, and disseminating and publishing the results.
Participating were emergency medicine experts with ties to the American College of Emergency Physicians, the Emergency Nurses Association, the Emergency Department Benchmarking Alliance, the Emergency Department Practice Management Association, the National ED Inventory Project, the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality, the Volunteer Hospital Association, the Society for Academic Emergency Medicine, the Urgent Matters Project/Robert Wood Johnson Foundation, and the Centers for Medicare and Medicaid Services. The results of the summit are organized into four sections: a cohort scheme for benchmarking, general definitions, time measures, and proportion measures.
The ED Cohort Scheme
The schematic (see table) of the cohort system was developed to take into account volume and acuity. Recognizing that there is a large cohort of lower volume EDs seeing fewer than 10,000 patients a year, the scheme affords stratification at the lower volume end. The acuity designation takes into account the trauma designation of the department, its admission rate, and whether it has transplant services. Certain parameters also serve as markers for high-acuity ED services: admissions higher than 20 percent of ED volume, presence of transplant services, and designation as a Level I or II trauma center, using American College of Surgeons Committee on Trauma criteria.
To use the cohort scheme, first assign the ED's annual volume to one of the four volume categories, and then apply the acuity function to designate high or low acuity. EDs also should identify other departments in the same geographic area for benchmarking purposes. Benchmark cohorts likely will be built first at the state level, then regionally.
The Performance Measures and Benchmarking Summit agreed on a host of definitions that can be used to define the elements of benchmarking:
An emergency department is a 24-hour location serving an unscheduled patient population with anticipated needs for emergency medical care. This definition is provided by the Centers for Medicare and Medicaid Services. A psychiatric ED is represented to the community as one that serves the unscheduled needs of patients with mental health conditions. Arrival time is the time that a patient is first recognized and recorded by the emergency department system as requesting services in the department. MD/LIP Contact is the time of first contact in minutes by the physician or licensed independent practitioner (LIP) with the patient to initiate the medical screening exam.
The decision to admit is the time at which the physician or LIP makes a decision to admit the patient. Time of bed request may be used as a proxy. Conversion time is the time at which disposition is made for a patient to be admitted to the hospital as an inpatient or observation patient or when a patient is designated for observation within the ED. Discharge time is the time of a discharged patient's physical departure from an ED treatment area. Physician disposition time is the time from physician notification (generally an emergency physician, but may be a staff physician responsible for ED patients) that all results are available until disposition time, and left ED is the time at which an admitted or transferred patient physically leaves the ED treatment area.
ED length of stay is the patient time in the ED using these markers: for admitted patients, arrival time to conversion time; for discharged patients, arrival time to discharge time; and for transferred patients, arrival time to transfer conversion time. Active acuity level utilizes the Emergency Severity Index (ESI) for analyzing patients in the ED. Boarding is holding for extended periods in the ED patients who have been admitted by a physician with admitting privileges. This includes certain elements of the admission process and ongoing patient care provided by ED staff members.
A boarded patient is an admitted patient for whom the time interval between decision to admit and physical departure of the patient from the ED treatment area (decision-to-left-ED time) exceeds 120 minutes. Daily boarding hours is the sum of minutes of all boarded patients (see above) in a 24-hour period. Divide total minutes by 60 to determine hours of care provided by ED.
The ED boarding load is a snapshot of the boarded patient load being cared for in an ED and an indirect marker for complexity/severity of patients being held in the ED. It is calculated as the total number of admitted patients, observation patients, and transferred patients divided by the total ED patient care spaces. It can be calculated at any time, and can be reported as a daily maximum value for a period of time.
Radiology turnaround time is the time from placing an order for a radiographic test until the results are returned. Laboratory turnaround time is the time from placing an order for laboratory testing until the results are returned. Decision to transfer is the time at which the physician or licensed independent practitioner makes the decision to transfer the patient to another facility; time of transfer request may be used as a proxy. Transfer accepted is the time at which the patient is accepted for transfer by the receiving facility.
The age cutoff for pediatric patients when using performance measures to describe and monitor this population needs to be tied to the resources required to manage them. The group recommends, however, that key performance indicators be specific for the pediatric population in two age ranges: from birth to age 2 and age 2 to age 18.
A pediatric emergency department is one designed to serve the needs of a pediatric patient group. It should be defined as an ED that sees a patient population under age 18 for more than 80 percent of its total volume. This designation also should be applied to portions of a multifunction ED that serve this targeted population.
Next month: Performance and time measures for discharged, admitted, and transferred patients, measures for patients who left before they should have, complaints, diversion, and patient flow.