Here is a sampling of breakthrough patient flow practices being adopted by progressive organizations in the emergency department (ED) and beyond. To view the infographic, click on the jpg images below. To learn more details about the specific practices highlighted, scroll down.
If you have trouble reading these jpg files, download a PDF of the infographic.
Help patients find the least busy ED. Middlesex Hospital posts wait times for its three EDs that patients can access via smartphones and computers.
In September of 2009, the central Connecticut hospital began posting the wait times of each ED (the hospital's ED and two satellite EDs) on its web site, according to a January/February 2011 case study in Urgent Matters E-Newsletter. Wait times are updated every five minutes. About a year into the effort, 3,000 people per week were accessing the wait times. More important, wait time across the three EDs began to level out. Pilot frequent user programs. Spectrum Health identified patients who use the ED 10+ times a year-and launched a clinic just for them.
Spectrum's new multispecialty center is a response to an issue identified by emergency and addiction medicine specialist R. Corey Waller, MD, MS, in 2008, according to a Spectrum press release. During that year, about 950 patients were identified as visiting Butterworth and Blodgett hospital EDs greater than 10 times. These patients were responsible for more than 20,000 total visits and $40 to $50 million in costs.
The central goal of the Center is to identify, accurately diagnose, and develop a care plan for each patient. When treatment is stable and the patient has successfully followed up with a primary care physician, the patient will be transferred into a primary care office. It is estimated that the program could save commercial insurers plus Medicare and Medicaid more than $15 million in Spectrum Health ED reimbursements during the first year of operation.Collaborate to eliminate diversions. After targeting zero diversions, Syracuse hospitals cut total hours on diversion by ~75 percent.
"Diversion can be eliminated only when it's the focus of the entire hospital, not just the ER," said John McCabe, MD, CEO at Syracuse, N.Y.'s Upstate University Hospital in a May 2010 article in The Post-Standard.
Hospitals in California and Massachusetts are also reporting reduced diversions after regional or statewide decisions to eliminate ambulance diversions, according to a November 2010 article in Emergency Medicine News.
In addition, the California ED Diversion Project documented diversion declines of about 20 percent after collaborative efforts in California metropolitan areas that involved hospitals, local emergency medical services, and other stakeholders, according to a March 2011 study.
Eliminate the waiting room. At Penn State Hershey Medical Center (PSU-HMC), patients are triaged in an ED greeting area, which only contains a few chairs.
After a brief registration at Penn State Hershey Medical Center, the patient is triaged by a nurse, ED technician, and a physician/physician assistant, according to a January/February 2011 article in the Urgent Matters E-Newsletter. The provider conducts a medical evaluation and, as necessary, orders tests or sends the patient to an ED room for complex resuscitative care. While critical patients are sent immediately to a room, many patients can be treated and discharged without using a room. The left-without-being-seen rate fell from 5.7 percent to 0.4 percent, while volumes increased from 42,000 to 62,000.
Swedish Medical Center in Issaquah, Wash. has also eliminated its ED waiting room, per an October 2011 article in Becker's Hospital Review. When an ED patient arrives, a greeter notifies the clinical team and brings the patient into a treatment room. Patient satisfaction is greater than 95 percent. Pull till full. When an ED room is open, Christiana Care Health System uses direct bedding, bypassing triage and placing patients in open beds.
The intervention was a major cultural shift for staff, says Heather Farley, MD, assistant chair, department of emergency medicine, in a September/October 2011 article in the Urgent Matters E-Newsletter. "Triage nurses realized that their workload was lessened, but core nurses were uncomfortable getting patients who had not had full assessments. Physicians were confronted with full chart racks showing how much work was yet to be done-which is not necessarily a bad thing." Tell patients what to expect. Orlando Regional Medical Center increased patient satisfaction with a waiting room video on what occurs during an ED visit.
Patient satisfaction was about 12 percent higher in patients who watched the video, according to a July 2008 study. The authors conclude: "Preparing patients for their ED experience by describing the ED process of care through a waiting room video can improve ED patient satisfaction and the knowledge of outpatient clinic resources in an ambulatory population." Start the patient's care. Thanks to standing orders for common complaints, University of Kansas Hospital nurses can arrange EKG and other tests while patient is in the waiting room.
The ED staff worked with physicians to create standing orders for the 10 most common patient complaints, such as abdominal pain and extremity injuries, according to a 2009 article in The Business of Caring. These standing orders allow nurses to start a patient's care-for example, sending the patient for an X-ray or EKG and drawing blood-while the patient is in the waiting room. A small lab draw station was created near the waiting room to provide privacy.
"The time that the patient was sitting there and doing nothing is now value-added time," says Selig. "This has reduced our left-without-being-seen rate because the patients perceive that they're getting their treatment started."
Bonus point: Physicians appreciate having more information about the patient's condition when they arrive in the exam room because it allows their work to proceed more efficiently.
Triage as a team. Inova Fairfax Hospital's triage team includes an ED physician, nurse, scribe, emergency technician, and a registrar.
The five member team works together on the ED patient's evaluation and treatment. "The scribe records everything the physician says and the technical assistant completes multiple tasks, such as order-entry. A registrar expedites care by registering patients into the Inova Fairfax Hospital computer system," according to a March/April 2011 case study in Urgent Matters E-Newsletter.
Patient throughput time for patients seen by the triage teams decreased by 64 percent. In addition, patient and staff satisfaction increased, and left-without-being-seen rates decreased.Segment patients by severity level. A triage nurse at Good Samaritan assesses the patient and triages them into three groups: emergent (higher acuity), urgent (complex, lower-acuity), and nonurgent (low-acuity).
The ED at Good Samaritan Hospital in Suffern, N.Y., has 19 bays: 14 in the main ED and five for minor procedures. Patients who bring themselves to the ED are now met by a greeter/registrar and sign in at a quick registration kiosk. A triage nurse then assesses the patient and triages them into three groups:
Read the full October 2011 Leadership article: Going with the Flow: Three Strategies Help Improve Patient Throughput.Establish specialized units. St. Joseph's Regional Medical Center has a geriatric ED, and Bellevue Hospital Center established a step-down chest pain center.
Establishing units for specific types of patients or expanding observation or step-down units can help free up critical ED beds and ensure patients get needed care. New York City's Bellevue Hospital Center established a six-bed chest pain center in 2010, according to an April 2011 report by the National Public Health and Hospital Institute. ED staff can now send chest pain patients-who do not appear to have a heart attack but should require monitoring-to a step-down area.
St. Joseph Medical Center in Paterson, New York, has reduced hospital readmissions of geriatric patients by opening a geriatric ED. When they arrive at St. Joseph's ED, patients ages 65 or older are transferred to a separate 14-bed geriatric unit, unless they require immediate emergency assistance, according to a March/April 2011 article in Urgent Matters E-Newsletter.
A third example: Grady Health System established a seven-bed Care Management Unit in the ED for patients with diagnoses of asthma, chest pain, congestive heart failure, or hyperglycemia, according to a January/February 2011 case study.
Assign dedicated teams to each track. At Thomas Jefferson University Hospital, separate ED teams manage emergent, urgent, and nonurgent patients.
Each of the ED teams includes nurses, physicians, techs, and physician assistants, according to a June/July 2011 case study in the Urgent Matters E-Newsletter. "Teams are thinking critically about how they use their resources. For example, they are assessing whether it is necessary to continue taking vital signs on a patient every two hours if the patients are completely stable and in the process of getting admitted to another department where patients' vital signs will be monitored every four hours." Redesign each track. Using Lean methods, teams at Christiana Care Health System streamlined all three tracks, reducing length of stay.
The team assigned to tackle the nonurgent (or fast) ED track, reduced length of stay for these patients by 51 percent, according to a September/October 2011 case study in Urgent Matters E-Newsletter. Separate teams also used lean methods to reduce length of stay for emergent and urgent patients, by 36 percent and 20 percent respectively.
Christiana Care Health System used three common approaches to improve efficiency on each ED track:
Provide point-of-care testing in ED. Massachusetts General Hospital created a satellite lab in the ED that offers a limited menu of rapid tests.
The ED lab kiosk is managed and staffed by the hospital's central core laboratory, according to a September/October 2011 case study in the Urgent Matters E-Newsletter. A 2003 study found that the ED lab decreased test turnaround time by 87 percent, which correlated with a reduction in overall ED length of stay.
Centralize bed management. The RN-staffed patient placement center at the University of Mississippi Medical Center coordinates all admissions.
Akin to an air traffic control center, this unit combines all of the bed control functions, admitting nurse functions, and front-end utilization review nurse activities, as described in a June 2010 hfm case study. This level of centralization enables the patient placement center to maintain accountability over bed control, place patients in accordance with best-practice algorithms, and even cluster patients by attending physician to enable physicians to complete their rounds more efficiently.
Good Samaritan Hospital, in Suffern, N.Y., also has an RN staffed patient flow center, according to a October 2011 case study in the Leadership enewsletter. Directed by Kitty Welsh, RN, the Logistics Center manages bed availability, patient transport, patient discharges, and housekeeping from one centralized area. An electronic bed board is a major component of this central command center. Implemented in early 2011, the web-based bed board gives nursing and admissions staff a real-time snapshot of the status of beds across Good Samaritan. By looking at the bed board-which is viewable from any computer with Internet access and via a large monitor in the ED-staff can instantly obtain key bed information. As room information is updated, the changes are displayed in the "bed status" window.
Schedule early discharges to free up beds. Kaiser Foundation Hospital aims for 11 a.m. discharges.
After discovering that most admissions/discharges were occurring on the night shift, Kaiser Foundation Hospital set the goal of having 40 percent of discharges happen before 11 a.m., according to a case study from the California ED Diversion Project. "Discharge rounds now take place at 11:30 am, to begin the process of the following day's discharges. During these rounds, they identify which patients are likely to be discharged the following day, so that they can make sure that all necessary work is completed ahead of time, and a time can be scheduled for these patients to be discharged the following morning." Adopt a boarder. When Stony Brook University Medical Center's ED reaches capacity, patients awaiting admission are given beds in acute care hallways.
In the first year after the protocol was implemented, ED patient satisfaction increased from the bottom percentile to the 80th percentile, while inpatient satisfaction held steady, according to a case study in the March 2007 issue of The Business of Caring. The new approach has also impacted length of stay. A study conducted at Stony Brook found that the average length of stay is 0.8 days shorter when patients are moved to an inpatient hallway, compared with an ED hallway. A 2002 study by the Health Care Advisory Board found that reducing LOS by one day is equivalent to adding 49 new beds in a typical 300-bed hospital.
Establish a discharge lounge. Bellevue Hospital Center's discharge center is open part-time five days week, currently processing 1,000 patients.
"This gives ED staff an avenue for freeing up beds and sending patients to a more private area for step-down clinical care, as well as dispensation of discharge instructions, according to an April 2011 report by the National Public Health and Hospital Institute. The discharge coordinator also has full access to the team of 29 certified, in-house interpreters."Partner with health centers. A Maryland health center works with a local hospital to link eligible patients to a primary care provider at the center.
Baltimore Medical System community health workers are at the ED from 8 a.m. to 11 p.m. weekdays and some weekend hours, according to a May 2011 U.S. Government Accountability Office report. Community health workers meet with eligible patients after triage by ED staff to discuss the benefits and services available at the health center. Community health workers schedule follow-up appointments for patients who would like to receive care at the health center. At their first health center appointments, patients are connected to primary care providers who, in coordination with case managers, oversee the patients' future needs.Navigate to primary care. ED navigators at Presbyterian Hospital set up appointments with primary care physicians for nonurgent patients.
In July, the 453-bed hospital started the program aimed at reducing ED traffic by deferring such nonemergency cases like earaches and minor wounds to the hospital's primary care physicians, according to an October 2010 case study in HFMA's Healthcare Cost Containment newsletter. Currently, the hospital's ED gets about 180 visits a day; the goal is to reduce the number of ED visits by 10 to 15 percent, says Mark Stern, MD, medical director, Medical Management and Endcare Coordination, Presbyterian Healthcare Services, a network of eight hospitals in New Mexico.
All patients are first triaged by a nurse to determine the required level of care. Cases like earaches, sore throats, and lower-acuity upper respiratory infections in patients older than two years old are sent to a clinician, such as a nurse practitioner, who performs a screening and obtains a medical history. Cases that are nonemergent or nonurgent are sent to customer service representatives, called navigators, who then schedule an appointment for the patient to see a primary care physician within 12 to 24 hours; uninsured patients are connected to other care resources within the community.
In addition to the tactics outlined above, many hospitals and health systems are reporting success with the following tactics.
KeyBank: Offering Expertise in Tax-Exempt Financing to Give Health Systems Flexible Options for Growth
In this business profile, Amy Gross, senior vice president of Key Government Finance, discusses the benefits of private placement transactions to support large-scale financing projects.
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
Xtend Healthcare: Enabling Efficient Business Office Workflow
In this business profile, Doug Polasky, executive vice president at Xtend Healthcare, explains the importance of having sound workflow processes in a consolidated business office to ensure optimal performance and reduce costs.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
TriMedx: Elevating and Streamlining Clinical Engineering
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
McKesson: Leveraging Predictive Analytics to Rein in Operating Costs
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Accretive Health: Partners with Providers to Excel in a Rapidly Transforming Revenue Cycle Environment
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Conifer Health Solutions: Helping Providers and Employers Build a Foundation for Better Health
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
Ontario Systems: Optimizing Accounts Receivable in a Rapidly Changing Environment
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Optum: Enabling Transformative Change
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Somnia: Bending the Healthcare Cost Curve Toward Improved Anesthesia Value
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
PMMC: Navigating Revenue Cycle Management Challenges as Value Based Purchasing Emerges
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Burgess: Simplify the Business of Healthcare
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.