Sixty days after new contractors took over at both Palomar Health hospitals, the hospital board got a progress report, analysis and performance improvement plan from the new executive team.
The decision to bring Emergent Medical Associates (EMA) and Benchmark Hospitalists & Intensivists “in house” at Palomar Medical Center Escondido and Palomar Medical Center Poway, and replace Vituity that had performed those services for four decades was and remains highly controversial. So the “Palomar 2021 State of the State” analysis and improvement plan presented Monday night will likely be closely scrutinized by supporters and critics alike.
Before the report, directors took a few minutes to congratulate CEO Diane Hansen for her recent designation as CEO of the Year by the Association of California Healthcare Districts.
“It’s time we had some good news,” said Hospital Board President Linda Greer. She noted that there are 79 hospital districts in California, and “Our district is the number one largest in the state. We are doing a phenomenal job.” She added, “This is the first time this award has been given.”
CEO Hansen gave credit to “the board members and our incredible team. I work with people who are so driven to achieve our mission.”
The board president, who is also an RN of many decades’ experience, added, “The personal Diane Hansen I know walks the floors and corridors of our hospital and doesn’t run away from people who come to ask her questions. This is the kind of person that I know who is the current CEO and president. She is leading an organization that is proud to have her as a leader.”
Dr. Mark Bell, president and founder of EMA benchmark noted that EMA and Benchmark Hospitalists and Intensivist are two faces of the same company.
Their three months integrating into the hospital system, “has been somewhat of a struggle because of COVID but with the help of a lot of people we are making great strides,” he said. He added that the nursing department, “have been great leaders for us to cover a large number of shifts.” The transition will continue over the next several months. “We want it to be as high quality as it can be. We are trying to listen to all stakeholders, to integrate ourselves into the fabric of the departments we serve and build relationships.”
Bell said EMA is very data-driven. “What gets measured, gets managed. We are concentrating on driving quality service and efficiencies by gathering good data.” They have identified “various operations that will help us achieve best practices that will drive quality and service.”
Priorities during the transition, he said, are:
- Listen, key stakeholder interviews, understand existing processes, and integrate into the fabric of the departments we serve
- Build relationships, teams, and culture,
- Medical Staff, Nursing, Ancillary Services, Administration, and Board
- Establish best practices and action plans to drive change
Dr. Scott Brewster, chief medical officer of EMA spoke about the emergency department. “We have been very happy with the transition of the emergency department. It has been going very, very well.”
Although a number of emergency room physicians left, “The core group of emergency room physicians have stayed and have been integral to the transition,” he said.
Dr. Brewster introduced Emergency Department Physician Leadership, topped by Jordan Cohen, Medical Director of Escondido, Bruce Friedberg, associate medical director of Escondido and Medical Director of Poway and Molly Brady, associate medical director of Poway.
“We really believe this group will take the emergency department to the next level,” said Brewster. One of their first actions was to create the Emergency Department Operations Committee, a multidisciplinary group that will focus on ED nursing, ED physicians, quality, education, patient experience, ancillary services and administration. It meets twice a week.
They monitor total ED (emergency department) patients, average ED patients per day, total admissions, total ambulance runs, etc. so they can compare them to the day before, last week, a year ago and figures for how long it takes a patient to go from his door to this provider.
Through constant monitoring of such data on a DART display, said Brewster, “we are getting efficiency data on a daily basis,” and added, “we are off to the races.”
They are monitoring data from both hospitals from before they took over until now. “We are seeing key metrics in the EM (emergency room) department improve,” said Brewster.
One such metric is “door-to-provider” i.e. time the patient arrives at the hospital to his first interaction with a health care provider. Before the transition, it was 46 minutes; now it is 35 minutes, a 24% decline. But there are bottlenecks.
Currently, 60 to 70% of patients are being met in the waiting room, said Brewster, which leads to extended lengths of stay (LOS) for patients, “poor patient experience, caregiver burnout, which adds to chaos.”
The “best practice” solution scheduled to start on Tuesday, October 12, will “unwind front care” and lead to immediate bedding of the sickest patients and a quick care program for the 60% who are the less sick patients.
The sickest patients have been spending excessive time in the waiting room. “We are doing a process redesign to where we better recognize the sickest patients and prioritize them for a bed,” said Brewster.
The current length of stay at the emergency room is 5-6 hours, which should, said Brewster, be closer to 3.3 hours. “We see people leaving without treatment because they don’t want to wait that long. Sixty percent of patients could be seen within two hours,” he said.
Related to this issue is the “capacity crisis at both sites,” said Brewster, which is related to the nationwide—and local— nursing shortage, which causes unstaffed beds, excessive time admitting patients which negatively impacts the ED capacity and increases hospital stays. “We have a nursing shortage,” he said, which means effectively fewer beds.
The solution, said Brewster, is “to aggressively hire nurses,” create a hospital “surge plan: and create alternative patient care areas.” They have reached 70% of their hiring goal and “we expect to be up to 90 percent soon.”
Dr. Scott Enderby, Benchmark CMO, introduced Ali Fadhil, hospitalists medical director, Baroon Rai, intensivists medical director and Dr. Fang Wu, hospitalists associate medical director. Rai was recruited by Fadhil and Wu.
As with the Emergency Department Operations Committee, the hospitalists and intensivists set up a leadership committee, the Hospitalist and Intensivist Operations Committee, whose goal is to “create patient-centered quality improvement initiatives through engagement with multidisciplinary teams focusing on nursing, case management, CDI specialists, quality, patient experience, hospital administration, education/training, pharmacy and clinical performance.”
Their observations from pre-transition concluded: “Chaotic patient assignments for physicians prevents routine rounds with CM and nursing” which caused communication challenges and delayed discharges. The solution Benchmark is “Geographic assignment of doctors aligned with CM (case management) and nursing.”
“We are a data-driven organization” said Enderby, so they are encouraging physicians to use a “provider app” to list their own information, “so we get real time feedback on what patient volumes are, and if they see a trend they can bring in extra help in real time.”
Before the transition, said Enderby, “doctors have patients who are assigned all through the hospital. Throughout the day they were being called downstairs to admit patients while they were doing rounds.” This created gridlock, eroded staff morale and increased wait time.
The best practice solution was to put a designated doctor in the ER room to help patients move through the process. “We are going to create geographic assignment of the doctors so they don’t have patients all over the hospital, they will be assigned the same floor,” he said.
There will be triad teams, with doctors and bedside nurses sharing information. They will also revamp the morning case management rounds so personnel assigned to a patient will have meetings about each patient daily.
The discharge process “is impacted by there not being case rounds in the morning, so there is no way to identify those with early discharge,” said Enderby. This causes additional time before doctors write discharge orders and patients are discharged later than they need to be.
Another problem is emergency department transfers between the Escondido and Poway campuses. They are creating a “streamlined process to allow for transfers to be more streamlined,” said Enderby.
Following a report on the intensivists, Dr. Bell concluded that the “transition has included listening, understanding, holding ourselves to a standard of determining what the best processes.” He added, “Now we have to hold ourselves accountable to execute them.”
The higher priority initiatives, such as developing a standardized, scripted daily morning case management meeting, and designating admitting doctors and geographically assigning rounding providers, they hope to achieve in the next quarter.
At the same time, he said, “We want to expand our market share among the 15 hospitals in the county. Our goal is to become the best.”
Board President Greer pronounced herself “thrilled” by the “rounding changes.” “I can’t imagine a better pairing then having those people down there. I’m just very happy with what I’m hearing,” she declared.
Dr. Bell added, “Once we have our data platform set up, we will be able to see our high points and low points so we can call in extra help when we need out.” This data, he said, “allows us to take any outliers that happened from the day before and create performance improvement from them.”
Director Jeff Griffith commented, “The director side of me is really happy, and the paramedic side of me is happy we are reducing the wait time for our first responders. I know a lot of fire chiefs are going to be really happy about this.”
Bell plans to return to the board with data showing improvements in all areas in four months.
At the end of the meeting Dr. Richard Engel announced his resignation. He said he has a conflict of interest because his physician group is entering a new relationship with Palomar Health.