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The Balanced Scorecard

Welch, Shari J. MD

doi: 10.1097/01.EEM.0000340950.69012.8d
Quality Matters

In the early 1990s there was a belief that emergency physicians had to see at least 2.1 patients an hour to keep their skills up. These beliefs were supported by publications from our professional society, and before long became accepted as productivity benchmarks. (“Physician Staffing of the Emergency Department,” in Managing the Emergency Department: A Team Approach. Irving, TX: ACEP Publications; 1992.)

Other leaders suggested 2.5 patients per hour as a reasonable goal for the front lines. (Managing to Get it Right: The ACEP's User's Guide to Emergency Department Management. Irving, TX: ACEP Publications; 1998.) Such numbers are still touted by groups trying to push the limits of their productivity, but much has changed in the past 15 years. It may be time we took a second look at these numbers, and got realistic about our goals.

Many of the changes we have witnessed in emergency medicine since then place constraints on productivity goals. First, the sheer burden of documentation has increased linearly. (Building the Clockwork ED. Washington, D.C.: The Advisory Board; 2000.) In 1990 the majority of departments were still using paper charting, less than a page for even the most complex patients and often following the simple SOAP note format (subjective, objective, assessment, and plan). Fast forward to the new millennium, and increasingly charts are template documents, transcribed and dictated charts, or a hybrid of the two. Increasingly physician charting is becoming part of an overall electronic health record which in many cases completely disregards workflow, and is detrimental to expedient care. Complex patients now require the documentation of a 10-item systems review, an eight-item physical exam, hospital course and medical decision-making sections, and separate documentation of procedures, critical care, and observation. Many transcribed reports are three typewritten pages or more! This documentation burden takes time, and is increasing.

The complexity of care delivered in the acute care setting increases with increasing age. We are just beginning to see baby boomers being added to the geriatric cohort, and it's the fastest growing group to be using emergency services. ED visits were up 26 percent for the 65-and-over age group in the latest Centers for Disease Control and Prevention report. (National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. National Health Statistics Reports; No 7. Hyattsville, MD: National Center for Health Statistics. 2008.) The anticipated increasing complexity of patients will mean more work for the ED staff. Many departments feel compelled to add observation areas or clinical decision units for evaluating patients with increased complexity and who use more resources.

When physicians touted a goal of seeing 2.1 to 2.5 patients an hour, there were no national databases or quality and performance measures like there are today. Back then, door-to-antibiotics or door-to-balloon times were not posted on a national database. Many more clinical entities such as sepsis, acute stroke, and shock are on the clock with critical actions required in the ED, tracked as time measures and for compliance with guidelines.

Two decades ago, emergency physicians may have had a passing familiarity with patient satisfaction surveys, but for years we were still taking issue with their validity. (Ann Emerg Med 2001; 38[5]:527.) Today, physicians are likely to be held accountable for personal, group, and departmental scores. This is not necessarily a bad thing, but it takes time to ensure a positive patient encounter, and nothing does more to tank satisfaction scores than a physician perceived as being rushed.



The point is that the workload of the emergency physician has insidiously changed in a number of dramatic and tangible ways, and this has not been factored into most productivity schemes. Many elements of an emergency practice are important to patients, families, and hospital administrators aside from the sheer number of bodies that can be moved through the system. A physician can see many patients per hour, while generating plenty of patient complaints, low satisfaction scores, and sentinel events. Increasingly, you will hear leadership in health systems management talking about a balanced scorecard. This will typically take into account not only efficiency as a performance measure but also safety, financial goals, patient satisfaction, and operational defects. The same sort of strategy can be applied to physicians in the ED. Several measurable parameters could be included in a balanced scorecard for emergency departments and used to reward performance:

  • ▪ Patients per hour.
  • ▪ Length of stay.
  • ▪ Left without being seen and AMA rates.
  • ▪ Patient complaints and compliments
  • ▪ Staff and medical staff surveys.
  • ▪ Documentation compliance and downcoded charts.
  • ▪ Patients satisfaction surveys.
  • ▪ Sentinel events.
  • ▪ Unscheduled returns and missed diagnoses.
  • ▪ Core measures performance.
  • ▪ Unique contributions to the group or organization.

The balanced scorecard approach to physician performance takes into account myriad elements that are important to all of our stakeholders in the emergency department. As opposed to the limited and one-dimensional measure of patients per hour, it creates a more comprehensive picture of each practitioner and his contributions to the group, the organization, and patients' care. John Lyman, MD, the regional medical officer for Premier Health Care Services, reports that their group has been using a balanced scorecard successfully for many years. They include community involvement as an element on their scorecard. Randy Pilgrim, MD, the chief medical officer for the Schumacher Group, which staffs more than 100 locations, reports excellent results across a range of ED sites using a balanced scorecard. He said physicians and medical directors often appreciate a broad and flexible approach, which reflects a comprehensive ED practice environment. The trend seems to be growing.

Back to the issue of patients per hour: Jeanne McGrayne, the senior director and managing principal of Premier Healthcare Informatics, which has one of the largest ED operations databases, notes the trending down of this number. They are currently seeing an average of 1.8 patients per hour.

© 2009 Lippincott Williams & Wilkins, Inc.