The ER: The frontline of efficiency?
Photo | Emily Micucci
Dr. Jeffrey Hopkins stands among bed at the emergency department at Milford Regional Medical Center
Health care organizations of all kinds are striving for efficiency under the looming transition to managed-care systems.
Instead of being paid for each service, providers will instead be paid to deliver care for a set number of patients annually. Naturally, this is leading providers to reconsider how they manage those patients from the moment they walk through the door.
For hospitals, that process begins in the emergency room. And indeed, MetroWest-area hospitals are retooling ER operations in myriad ways, in part to achieve greater efficiency.
A new approach to staffing …
For the last two years, Steve Roach, CEO of Marlborough Hospital, has worked toward this goal. Roach, who describes himself as an “extremely data-driven” administrator, came into his new job with ideas on how to improve patient flow in the emergency room. Roach said that not all hospital administrators are so focused on the numbers. And while this type of approach to hospital management is becoming more dominant, he said it hasn't always been so pronounced.
“If they're not looking at the numbers, they're not focusing on being lean,” Roach said.
In his previous role as CEO of Nashoba Valley Medical Center, in Ayer, Roach set a patient wait time cap of 30 minutes, the industry standard Roach brought to Marlborough, where door-to-doctor time previously averaged about 75 minutes.
Cutting down wait times in Marlborough has taken longer than planned, but using a new staffing model has helped the hospital get there. Roach explained that shifting nursing staff to match peak patient-volume times (about 9 a.m. until 11 p.m.) has improved flow, and adding nurse practitioners and physician assistants to the ER provider team has helped further.
According to Roach, there are many ways health care providers can make staffing more efficient today, but it's sometimes met with resistance. In Marlborough Hospital's case, it hasn't always been easy to get the nurses' union on board with the new approach, but Roach believes it's an important way to operate a leaner hospital and to make patients happier, which is important, because patient satisfaction now impacts reimbursement from Medicare and Medicaid, as well as some commercial insurers.
“… Patient needs and wants are a lot of times (as simple as) just getting to the bathroom, and that doesn't require a nurse,” Roach said.
By the end of this month, Roach hopes to have a special unit up and running for ER patients who are to be admitted as a way to free up ER resources for other patients, and to increase satisfaction among patients who will be staying at the hospital.
… and mental health
Sorting patients in the ER according to their medical needs is an approach that MetroWest Medical Center, with campuses in Framingham and Natick, has also taken. MetroWest, owned by Texas-based Tenet Healthcare, accomplished this through a significant expansion of its behavioral health unit late last year, while adding a separate area for patients who arrive in the ER with mental health emergencies.
Those types of ER visits are common, said Richard Curcuru, executive director of behavioral health for Tenet's New England operations. And while a lack of beds across Massachusetts is a significant barrier for mental health patients who need treatment, it can also crowd the ER with patients in crisis.
Curcuru recalled the situation when he began his current role two years ago. There wasn't enough room at the three behavioral health units between Tenet's three Massachusetts hospital campuses, which also includes Saint Vincent Hospital in Worcester.
“We couldn't move patients through the (emergency department) quickly enough,” Curcuru said.
With Curcuru leading the effort, Tenet decided to invest in a new behavioral health unit at MetroWest's Leonard Morse campus in Natick. The hospital unveiled the new, 14-bed adult psychiatric unit in a formerly vacant wing last fall. And this month, Curcuru said construction of Phase 2 of the project, which will add another 28 beds, is slated to begin. That is expected to be complete in July, and will expand mental health services for patients who arrive at all three of Tenet's emergency rooms in Massachusetts, since MetroWest Medical Center handles placement for mental health patients who are seen at all locations.
The project has already had a pronounced effect, according to Curcuru.
“It absolutely has improved flow. The availability of 14 additional beds has been huge for the organization,” Curcuru said.
The goal is to have patients evaluated and placed in an appropriate unit within 24 hours. But the new unit has also prompted more patients to seek help at MetroWest Medical Center, and that means ER volumes are up for mental health patients. And despite an increase in beds, the unit is at capacity, according to Curcuru, though the creation of a separate treatment area for mental health patients in the ER has helped streamline their care.
Meanwhile, at Milford Regional Medical Center, a $54-million project to renovate and expand the community's hospital's emergency room has been underway for months and is slated for completion late this summer. The hospital is also adding a 24-bed unit to increase capacity beyond the ER, and is converting some formerly shared rooms to private rooms. Edward Kelly, president and CEO of Milford Regional, said in an April 2014 interview that this is more efficient because it's easier for staff to treat patients when they're in a room alone.
Is the competition providing relief?
When it comes to streamlining the ER, hospitals may also be getting help from some of their competitors: urgent care centers. So says Bing Yeo, owner of the local urgent care franchise Doctors Express.
After opening locations in Natick and Marlborough, Yeo said the reaction from area hospitals has been largely warm. That's because Doctors Express and other urgent care centers, which are rapidly expanding in Massachusetts and beyond, are providing another way to treat patients without life-threatening conditions who might otherwise come to the ER.
“The ER should truly be for emergencies … but if you're just having rashes or a problem with your eyes — I mean, you know you're not dying from it — a place like this is much more cost effective and efficient,” Yeo said.
Pat Noga, vice president of clinical affairs at the Massachusetts Hospital Association (MHA), stopped short of agreeing that hospitals prefer patients with less urgent care needs should seek help from urgent care clinics and other providers. But she thinks patients with non life-threatening urgent care needs are becoming more inclined to seek care at the most appropriate venue, not necessarily the ER.
“We always believe in the right care, at the right time and the right place,” Noga said.
Noga, who has worked in hospital administration, also agreed that the switch to a global payment system in health care, in which providers contract with insurers to manage care for a population of patients for a set fee, provides a greater incentive for hospitals to become more efficient and manage patient flow more effectively in the ER and elsewhere. This has resulted in many Bay State hospitals changing their approach to managing observation patients — those who are monitored for potential admission — so that they're moved from the ER as quickly as possible.
“You're looking at the operations of the entire hospital when you're looking at what is happening in your ER,” Noga said.
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