Time and expenses associated with the implementation of strategies to reduce emergency department crowding.

INTRODUCTION: The Emergency Nurses Association and other groups have encouraged the adoption of patient flow improvement strategies to reduce ED crowding, but little is known about time and expenses associated with implementation. The purpose of this study was to estimate the time spent and expenses incurred as 6 Urgent Matters hospitals planned and implemented strategies to improve patient flow and reduce crowding. METHODS: We conducted key informant interviews with members of the hospitals' patient flow improvement teams at 2 points in time: immediately after strategy implementation and approximately 6 months later. A total of 129 interviews were conducted using a semistructured interview protocol. Interviews were recorded, transcribed, and coded for analysis. RESULTS: Eight strategies were implemented. The time spent planning and implementing the strategies ranged from 40 to 1,017 hours per strategy. The strategies were largely led by nurses, and collectively, nurses spent more time planning and implementing strategies than others. The most time-consuming strategies were those that involved extensive staff training, large implementation teams, or complex process changes. Only 3 strategies involved sizable expenditures, ranging from $32,850 to $490,000. Construction and the addition of new personnel represented the most costly expenditures. DISCUSSION: The time and expenses involved in the adoption of patient flow improvement strategies are highly variable. Nurses play an important role in leading and implementing these efforts. Hospital, ED, and nurse leaders should set realistic expectations for the time and expenses needed to support patient flow improvement.

Barriers to collecting patient race, ethnicity, and primary language data in physician practices: an exploratory study.

BACKGROUND: Experts recommend that physician practices collect and use patient race, ethnicity, and primary language data to document and address health care disparities and improve health care quality for diverse populations. Little is known about demographic data collection in small practice settings. OBJECTIVE: To conduct an exploratory study to examine demographic data collection in physician practices to reduce disparities and provide qualitative descriptions of facilitators and barriers to data collection. DESIGN: Semistructured telephone interviews. SETTING: Medical practices with 5 or fewer physicians. PARTICIPANTS: Practice managers, nurse managers, and physicians from 20 practices nationwide. RESULTS: Of the 20 practices interviewed, 9 reported collecting demographic data. Only 1 practice feature facilitated demographic data collection: use of an electronic medical record (EMR) system (7 of 10 practices with an EMR collected data). Participation in pay-for-performance programs, cultural competency training, and measuring clinical quality did not facilitate data collection. One practice linked demographic and quality data. A few used the data to track language service needs. The main perceived barriers to demographic data collection included concerns about privacy, the legality of collecting the information, possible resistance from patients and staff, difficulty recording the data, and uncertainty about whether the data would be useful. CONCLUSIONS: Few small practices use data to track or address disparities in health care. Most perceived barriers to data collection can be surmounted. There is hope for improved collection and use of data through the spread of information technology with comprehensive national health reform.

Changes in patient flow among five hospitals participating in a learning collaborative.

This was an evaluation of the efforts of five hospitals that participated in a collaborative aimed at improving patient flow and reducing emergency department (ED) crowding. Interviews with hospital implementation team members were conducted at two separate times, and multivariate linear regression models and bivariate logistic models were constructed to assess changes in ED length of stay (LOS) and left without being seen (LWBS). By the end of the collaborative, four of the five hospitals had at least one fully implemented improvement strategy. Those hospitals experienced modest improvements in patient flow: a hospital that implemented front-end improvements and devoted additional resources to fast track had a 51-min reduction in ED LOS, another that implemented only front-end improvements had a 9-min reduction in LOS, a third hospital that improved communication between the ED and inpatient units to facilitate admissions decreased LWBS from 0.6% to 0.4%, and a fourth hospital reduced LOS by 59 min for mid-acuity patients by establishing a new care process for them. Results suggest that relatively small changes may lead to improvements in measures of patient flow that are modest, at best.

Facilitators and barriers to the implementation of patient flow improvement strategies.

Patient flow improvement strategies have been effective in reducing emergency department (ED) crowding, but little guidance is available on the implementation process. By using a qualitative research design, our objective was to identify common facilitators and barriers to the implementation of patient flow improvement strategies and successful approaches for mitigating barriers. Six hospitals participated in an 18-month Urgent Matters learning network launched in October 2008. The hospitals selected strategies to improve patient flow that could be implemented within 3 months with measurable impact. Across 6 hospitals, 8 strategies were implemented. We conducted 2 rounds of key informant interviews with improvement teams, for a total of 129 interviews. Interviews were recorded, transcribed, and coded by using a grounded theory approach to identify common themes. Factors facilitating implementation included participation in the learning network and strategic selection of team members. Common challenges included staff resistance and entrenched organizational culture. Some of the challenges were mitigated through approaches such as staff education and department leaders' constant reinforcement. Our findings indicate that several facilitators and barriers are common to the implementation of different strategies. Leveraging facilitators and developing a strategy to address common barriers may leave hospital and ED leaders better prepared to implement patient flow improvement strategies.

Medicare's payment policy for hospital-acquired conditions: perspectives of administrators from safety net hospitals.

In 2008, Medicare implemented a policy limiting reimbursement to hospitals for treating avoidable hospital-acquired conditions (HACs). Although the policy will expand nationally to Medicaid programs in 2011, little is known about the impact on safety net hospitals. The authors conducted interviews with 60 chief quality officers and 55 chief financial officers from safety net hospitals to explore the impact of Medicare's HACs policy during its first year. Despite the predicted small financial impact, the authors found that the policy gained the attention of hospital leaders and many governing boards. Although the policy reportedly provided additional motivation to reduce HACs, few hospitals implemented new care practices and instead focused on documenting conditions that are present for patients on admission. The findings also illustrate the need for Centers for Medicare & Medicaid Services to provide more guidance to the industry when this type of policy is introduced.