Patient Safety & Quality in Emergency Medicine
Easy Ways to Start a Quality Improvement Program at your Emergency Department
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Things to Do next Monday
That which should be easy often presents unexpected hurdles.
That which should be difficult suddenly becomes possible.
Outline of steps to take for Director / Co-director of the Emergency Department / Faculty interested in Quality Improvement
A. Immediate Steps to take (weeks to months)
1.
Schedule introductory / informational meetings with all heads of departments at your hospital to provide recognition, information, description of EM program a.
Clinical – Cardiology, Neurology, Surgery / Trauma, ICU/CCU, etc b.
Board of Directors c.
Non-clinical – laboratory, security, custodial, clerical, financial d.
Medical school, nursing school, paramedics
2.
Arrange regular meetings with main groups associated with EM to discuss cases / problems / quality / announcements a.
Weekly i.
Faculty ii.
Residents / EM faculty iii.
Nursing b.
Bi-weekly i.
Clerical ii.
Security iii.
Chiefs / heads of departments most associated with EM iv.
Financial offices / reimbursement / economic c.
Monthly i.
Board of directors ii.
Laboratory d.
Bi-annually i.
All department heads associated with EM ii.
All department heads associated with EM resident training rotations
3.
Start case file / incident file for instructional / exemplary cases a.
Delays in consultation, bad outcomes, missed diagnosis, quality assurance b.
Appropriate / good outcomes must be recognized / rewarded c.
Follow up with individuals in writing, professionally, non-accusatory
4.
Start to lead by example
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Dutch Administration & Management Fellowship
May-June 2010

a.
Promptness b.
Professionalism c.
Availability d.
Accountability e.
Responsibility
SAMPLE SHORT EASY PROJECTS FOR IMMEDIATE TERM:

Arrange coffee or lunch with major hospital figures, including the lab director, chief of radiology, chief of internal medicine, chief of surgery, etc.

Set up a regular meeting with the laboratory to review regular difficulties and start on a project that will provide mutual benefit such as speeding up a given test or reducing hemolysis or improving the system for critical results.

Determine basic volume figures and resolve into graphs. Share with senior administration.

Obtain a soda and juice machine for the department – for both staff and patients. (A very popular item.)

Review the department library to include essential ED texts. (A good starting list can be found at the ACEP bookstore.)

Establish a regular lunch meeting with your nurse manager.
B. Medium Steps to take (3-6-12 months)
1.
Attend regular meetings as described above a.
Prompt b.
Regular c.
Agenda d.
Follow-up / action points / accountability e.
Positive and negative agenda
2.
Determine and join multiple hospital committees a.
Finance, research, medical ethics, institutional review board, b.
Medical school, education, international c.
Planning, Healthy Netherlands 2015, etc d.
Avoid controversial committees like credentialing at first
3.
Institute a (bi-) monthly SEH Morbidity and Mortality meeting a.
Cases involving multiple departments with aberrant / poor outcomes for discussion by multiple departments / individuals involved i.
Specialized as needed
1.
Trauma / Cardiology / pediatric ii.
Emphasize teaching purposes not blaming
4.
Form / join community outreach programs a.
Local Red Cross, EMS, disaster response b.
Elementary and secondary schools, high schools c.
Local / professional sporting events
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d.
Community health fairs, blood drives, etc e.
Local, national press / media i.
Medische Centrum , radio, newspaper, TV ii.
Hospital newsletters / publications
5.
Institute Grand Rounds / Topics in Emergency Medicine lecture series a.
4-6 hour mini-conferences with multiple departmental faculty with lectures, case presentations and panel discussions i.
Cardiac Emergencies
1.
Invite cardiology, internal medicine, ICU, CCU ii.
Psychiatric Emergencies
1.
“The Agitated, Intoxicated Patient in the SEH”
2.
Invite pharmacists, psychiatry, security, nursing iii.
Obstetric / Gynecological Emergencies
1.
OB / GYN, pediatrics, neonatal, NICU, nursing iv.
Et cetera
6.
Identify and meet with key individuals outside of medical field a.
Non-medical hospital administrators b.
Local and national Ministry of Health c.
Private companies i.
Insurance, vendors, pharmaceuticals ii.
International development consultants
SAMPLE SHORT EASY PROJECTS FOR MEDIUM TERM:

Form an ED QI committee for review of cases. This can consist of 1-2 people initially. Include random cases.

Find a medical student or assistant to make follow-up calls and trial some basic administrative research approaches.

Determine your basic financial figures, eg charges / patient, cost / patient, ED profits per patient, in-patient profit / ED patient.

Coordinate your staff meetings by teleconference. (This may help improve attendance.)

Buy a digital camera for the department to record stories (but keep note of patient privacy).

Share a patient compliment widely.

Share a patient complaint, and your response, widely.

Send a note of thanks to a supportive individual in your hospital.

Write a department orientation for residents and faculty.

Have a rounds on feedback & set up a formal feedback process.

Invite a local politician for an ED tour (and make sure to include your administration in this).
 Make a list of your department’s top three challenges and top three goals for the next year. Share it with senior administration.

Embroidered lab coats for ED physicians—in red: o Example – T. Mulligan MD

Emergency Medicine Specialist

Your Hospital Name
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Dutch Administration & Management Fellowship
May-June 2010

C. Long-term Steps to take (12-18-24 months)
1.
Faculty training programs a.
Administration & Management Fellowship program b.
Local, national and international exchange programs c.
Instructor courses in ACLS, ATLS, APLS, Disaster d.
MBA, MPH, Economics, Law for key individuals
2.
Faculty retention programs a.
Fellowships in Sub-specialty areas of EM (6-12 months) i.
Administration ii.
Research iii.
Public health iv.
Health policy / health economics / health legislation
3.
SEH-artsen training programs a.
Establish, improve, expand b.
Collaborate, cooperate with local / national / international programs
4.
Local, regional and national training conferences and programs a.
Trauma, ultrasound, airway, toxicology, disaster, etc b.
By and for EP’s AND all other specialties
5.
Develop and maintain protected time for development work outside of clinical / medical arena a.
Primary development i.
Education, academics ii.
Faculty, AIOS and student programs iii.
Programs for nursing, paramedics, clerical b.
Secondary development i.
Administration & Management ii.
Economic education, collaborations, programs c.
Tertiary development i.
Legislative ii.
Public Health iii.
Health Policy
6.
Develop and maintain national and international professional and political ties a.
EP professional societies i.
NVSHA, EuSEM, ACEP, SAEM, IFEM, etc b.
Dutch Society of Medical Specialists c.
Dutch National Public Health Associations d.
Ministry of Health e.
Private industry and business
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Dutch Administration & Management Fellowship
May-June 2010

SAMPLE SHORT EASY PROJECTS FOR LONG TERM:

Along with your nurse manager, develop patient safety and quality rounds. Invite senior leadership to attend. Remember to include maintenance, environmental services, transport, etc.

Review medications available in the ED and revise to include frequently used or critical items that are not there.

As the National Health organization to revise their report on emergency care annually or every other year.

Make a list of the physicians you most commonly contact along with their admission and consultation preferences and post it in the department.

Start your own database of stories and cases.

Start an Morbidity & Mortality Case Review in emergency medicine for your department, and invite other departments

Give a mini-conference for medicine or surgery: what is emergency medicine, how it is changing, and what we do for patients.

Establish a sign-out process or protocol.

Start daily board rounds for 10” either in the morning or afternoon. Invite as many of the physicians, nurses, residents, and students in the department as possible. Discuss an interesting case.
 Find someone else’s hints and tips that you can then forward o University of Maryland’s “tip of the day” o Amal Mattu’s cardiology updates o EMedHome’s Emergency Medicine Question of the Day.

Begin follow-up rounds in your hospital. Go to the floors and check in with patients.
Ask, for example, whether everything went well in the ED. Alternatively, go to the physician lunch room, or wherever physicians’ gather, and check in with your colleagues.

Establish an ED research committee to review studies and get your people involved in studies. See the guidelines from the Canadian Association of Emergency Medicine and the Arizona chapter of ACEP.

Make a list of two or three ways you can assist each department. Share it with individuals in those departments over the next few months.

Call media relations and offer yourself or your partners as speakers for emergency medicine associated concerns.
 Designate someone in the ED on “Shift Scheduling Specialist”

Distribute information / an interactive on sleep hygiene / fatigue / adaptation strategies.

Have a book / binder in the ED for protocol mix of major conditions so that there is departmental consistency (TIA, DVT, PE, CHF, pneumothorax, etc)

Establish, maintain and follow(!) interpretation protocol for ED

Encourage labeling of cognitive & affective errors at M&M

Develop emergency medicine courses for EM physicians: airway management course, trauma for EP’s, ultrasound, ECG workshop, procedures (tube thoracostomy, open thoracotomy, central lines / cortis lines, splinting/casting, etc)

Clinical leaders should do media communications courses
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Dutch Administration & Management Fellowship
May-June 2010


Let the various hospital media departments and various media organizations that you are available to provide “emergency specialist” opinions
3 rd
Dutch Administration & Management Fellowship
May-June 2010