Showing posts with label Administrative. Show all posts
Showing posts with label Administrative. Show all posts

How does emergency medicine stack up relative to other medical specialties when it comes to malpractice risk?

According to a recent article in the NEJM, "Malpractice Risk According to Physician Specialty" we're in the middle of the pack as measured by number of malpractice claims (annually, 8% of ER physicians have a malpractice claim), claims with payment (1.6%), and  amount of malpractice payments ($75,000 [median], $180,000 [mean]).  The specialties sued most often are neurosurgery and thoracic-cardiovascular surgery; and the least are psychiatry and pediatrics. 


Source

Jena, A. et al.  "Malpractice Risk According to Physician Specialty"  NEJM.  18 Aug 2011 (free, no subscription required)

7 Steps to Patient Satisfaction Success

  1. Improve the system.  Wonderful "people skills" are short-lived unless underlying systems support them.  Employees get very frustrated apologizing for the same inconveniences day after day.  Make the patient care environment friendly (magazines, clear signage, etc). 
  2. Hire right.  Get those with the customer service gene not simply the technical skills.  Ask the interviewee, "What is the worst thing I'm going to hear about you?"  Ask the interviewee's supervisor, "When other's see this person's name on the schedule, how does your staff react?"
  3. Orient right. Show staff that patient satisfaction leads to an easier and more satisfying job.  It is not simply more work.  Make commitment to service excellence clear but keep rule book thin and let staff create that service.  (ie. Let patients know what to expect.  Anticipate patient needs - view use of the call bell as a failure.  Resolve problems within 48 hours.)
  4. Reward champions visibly and meaningfully.
  5. Re-orient stragglers.  Give concise and timely feedback.  "When you do x, it results in y; try z instead."  Tie the negative impact of B-team behavior to its impact on the team and its vision and mission. Given that the team vision and mission are mutually developed and agreed on, relating B-team actions to those team goals can be helpful and keeps any discussion from becoming personal. 
  6. Fire those who can't be re-oriented
  7. Repeat steps 1 - 6.  In service excellence, there is no finish line.
Just as customers expect an airlines to get them from point A to B, patients expect excellent clinical care.  Emergency departments are distinguished by their service excellence.

Source

Leebov, W. et al.  Patient Satisfaction: A Guide to Practice Enhancement.  1989

Mayer, T. and Cates, R.  Leadership for Great Customer Service: Satisfied Patients, Satisfied Employees.  2004.


A few pearls of wisdom for impoving your ED

  1. Reduce variation that does not add value 
  2. Be a "thin-rulebook company."  Establish department values and principles and empower employees to provide service accordingly.  Make no decisions at a higher level that can be made at a lower level. 
  3. Collaborate with radiology to decrease the number of patients that need oral contrast.  A retrospective chart review indicated that use of oral contrast added an average of 155 minutes to a patient's length of stay. 
  4. Schedule staff so that they operate at 85% maximal capacity.  Running consistently at 100% capacity in a system with unscheduled arrivals and variable service times is not the most effective way to operate.  
  5. Exhorting the troops and acting as an example often is insufficient to motivate change as it is viewed as "more work."  Help people understand why change is good for themselves ie it makes their jobs easier and more fulfilling.  All meaningful and lasting change is intrinsically motivated, not extrinsically motivated. 
  6. Consider implementing team traige (MD, RN, tech) or triage-advanced orders to begin care in the waiting room when no ER beds are available. 
  7. Recruit and retain the best talent.  Hire owners not renters ("clock punchers").  This is where great companies start. 
  8. Adapt your leadership style to accommodate different staff if it will make the team stronger.
  9. Preempt call lights by anticipating patients' needs. 
  10. Create a results-waiting area where appropriate patients can wait for results without tying up a bed. 
  11. Cross train.  When possible train one person to do two jobs rather than two people to do two jobs.
  12. Hold a contest to determine the best ideas for decreasing delays. 

Source

Mayer, T. and Jensen, K. Hardwiring Flow: Systems and Processes for Seamless Patient Care

What is the physician fee for a level 5 ED visit compared to a CABG?

$316: level 5 ED visit

$3714: CABG

These and other health care costs can be found at Healthcare Blue Book a website which publishes the price insurance companies pay for various health care expenses. While the website is not all inclusive, it is still an interesting site to peruse as much of this pricing information is not readily available.  While I can't vouch for the accuracy of all the information, the ED rates cited seem to be on par with medicare reimbursement rates.


Source

http://healthcarebluebook.com/page_Default.aspx

"I have seen the patient and agree with the documented findings" = 15% reimbursement increase

When a patient is seen by a physician extender without the direct involvement of the supervising physician, the visit is reimbursed at 85% of the physician fee.  If, however, there is a DOCUMENTED  "face-to-face" encounter between the physician and patient (ie "I have seen the patient and agree with the documented findings") then the visit is reimbursed at 100% of the physician fee. 


Source

Mattu, A. et al.  "Understand the Documentation Requirements of Midlevel Practitioners"  Avoiding Common Errors in the Emergency Department

Which cases qualify for critical care billing in the emergency department?

Click here to check out a great critical care billing FAQ from ACEP.

Would a 24-7 365 days a year social worker be helpful?

Check out this site, benefitscheckup.org. While its definitely not as good as a live social worker, it's a good alternative resource. One can simply type in a locale, social and financial profile and the site will list the benefits (financial, medical, housing, utility, etc) available for those in tough financial straights and how to apply for said benefits. I just entered a hypothetical case, and the interview and results were quite comprehensive. A++ to the National Council on Aging for creating this resource!

Perhaps some of our ED patients will find this useful, particularly in these difficult economic times.

How much does a CT scanner cost?

The concept of a free standing ER such as these in Texas is an interesting one. The overhead costs of starting one of these practices is pretty high though, including the cost of a new CT scanner which can run from about 1.5 - 2 million dollars depending on the bells and whistles attached.

If you don't care about new though, you can grab this steal of a scanner for $17,000 on Ebay. Hurry though. Only 6 days left on the auction!

Source

CT-scan-info.com. "How much does a CT scan cost?" http://www.ct-scan-info.com/ct-scan-cost.html

MedGadget. "Brilliance 64 Slice Scanner by Phillips." http://medgadget.com/archives/2005/04/brilliance_64sl.html

Of the following items, which are not mandated by the FAA to be stocked in the medical kits on US commerical flights?

  • aspirin
  • diphenhydramine tablets
  • IV diphenhydramine
  • atropine
  • IV amiodarone
  • IV dextrose
  • IV normal saline
  • AED
  • oropharyngeal airways
  • adenosine
*

*

*

*

*

All are required except IV amiodarone and adenosine. The other medical items required by the FAA to be stocked on commercial flights include:

  • IM epinephrine (1:1000)
  • IV epinephrine (1:10000)
  • inhaled bronchodilator
  • lidocaine
  • nitroglycerine tablets
  • nonnarcotic analgesic
  • instructions for medication administration
  • sphygmomanometer
  • stethoscope
  • latex gloves
  • syringes
  • needles
  • IV catheters with tubing and connectors
  • AMBU bag
  • CPR masks
These items are the minimum and offer a pretty good repertoire of tools. No cric kit though. I guess some SC/IM benadryl for local anesthesia and a fork or pen would have to do.

Source

Prout, M. MD and Pine, J. MD. "Management of inflight medical emergencies on commercial airlines." Up to Date. Oct 2008.

A Sticky Situation: Answered

Answered ..... well, not really. It's a no win situation. Admit the patient and you might end up in court facing false imprisonment charges. Discharge the patient and you could end up there for medical malpractice after the man dies of an MI.

Aside from getting a good lawyer who shows well at the dog and pony show, a well documented evaluation of the patient's medical decision making capacity may come in handy. This assessment should consider the patient's ability to:

  • understand their medical problem

  • understand pros/cons of proposed treatment

  • understand pros/cons of refusing proposed treatment

  • understand pros/cons of alternative treatments

  • and to make a decision free of depression, delusions, and psychosis


These pointers are derived from a formal, structured assessment tool used to evaluate capacity, the Aid to Capacity Evaluation (ACE) , conceived at the University of Toronto Centre for Bioethics.

Source

Tunzi, M. MD. "Can the Patient Decide? Evaluating Patient Capacity in Practice." Am Fam Physician 2001; 64: 299-306.

A Sticky Situation: Is this guy competent to sign out AMA?

46 y/o male presents w/ complaints of exertional chest pain. History of etoh abuse. Last drink 6 hours ago. Physical exam unremarkable. Database notable for non-specific EKG; otherwise unremarkable. Etoh level 150.

After waiting 3 hours for admission, patient wants to sign out AMA. Ok or not?

  • Does the patient have adequate decision making capacity?

  • If patient is permitted to "sober" and metabolize off the etoh he might go into w/ drawal. He certainly won't have adequate decision making capacity then.

  • Hmmmm ... what to do?

Caution when giving Med Control

I feel sorry for all involved in this unfortunate circumstance.

Via CNN:


Authorities investigate emergency workers who misdiagnosed a man's heart attack for acid reflux.

Is it mandatory by law to report sexual assault?

State Rape Reporting Requirements

Depends on the state. Click on the above link to find out.

Improving patient satisfaction: an evidence based approach, Part I

Maintaining high patient satisfaction scores is important to any group interested in maintaining its ED contract. They're key to growing market share and decreasing liability. So no matter whether you're group is in the 20th or 80th percentile, most are always looking for ways to improve. What works? What doesn't? What gets you the most bang for the buck? In the series, "Improving patient satisfaction: an evidence based approach," I'll take a look at a few studies that have looked into the issue. Perhaps you'll learn a useful tidbit that you can incorporate into your practice ...

JS Williams et al demonstrated that sprucing up the physical infrastructure of the ED had little impact on patient satisfaction scores and that what really matters to patients, in terms of making them happy, is the length of stay, the shorter, the better. Here's some additional details on their study:
Methods

We conducted a retrospective review of patient satisfaction scores before and after major renovations in a large, inner-city academic emergency department. The patient satisfaction scores in this hospital are collected by an independent contractor that retrieves and analyzes approximately 30 surveys monthly from randomized patients. The ED underwent a major renovation in the areas of the department that primarily treat low and moderate acuity patients. The renovations created private rooms with flat-panel televisions, an updated entrance and parking, and a new waiting room and nursing station. Overall satisfaction of ED care, time in emergency department, quality of care, and privacy were the variables selected for review. Pre-renovation data included the third and fourth quarter prior to construction and the same quarters for the following 2 years after the completion of the remodel, resulting in 573 patient reviews. This included 196 from 2004, 191 from 2005, and 186 from 2006.

Results
There was no statistical difference in patient satisfaction scores after the renovation. Moreover, there was no difference between the rated quality of care and likelihood of recommending the emergency department to their peers. Further, the length of stay was unchanged during the time periods studied, and a majority of the respondents still indicated prompt care and long wait times were the biggest need for improvement. An unexpected finding was that even after the renovations, which included private rooms, more patients rated their privacy as fair or poor (12.13% versus 7.65%).

Hmmmm ... interesting. The results of this study seem a bit surprising to me. I thought that there would be at least some improvement in satisfaction scores with improvements in physical infrastructure. Perhaps our limited administrative budgets should be spent improving throughput rather than buying a flat screen TV to distract patients while they wait.

Source

Williams, JS, Lee, MA, Morrisey, T. "Remodeling Patient Satisfaction." Annals of Emergency Medicine: ICEM 2008 Scientific Abstract Program. v 51. April 2008.

What's the best way to retain excellent nurses and other staff?

As emergency medicine is a team sport where everyone's contribution is important, assembling the best group of nurses and office staff is key to providing quality patient care. As an ED physician, what methods do you employ in your daily practice to motivate and retain the best staff?

Yes, money works but can only go so far. So to shed some light on the issue, we can start with the results of a Public Agenda Foundation study that elucidated the characteristics of an ideal work environment by surveying employees. The top ten results were:

1. Work with people who treat them w/ respect

2. Do interesting work

3. Be recognized for doing a good job

4. Have opportunity to develop skills

5. Work for people who listen to ideas about how to improve things

6. Have opportunities to think for themselves

7. See results of their work

8. Work for efficient managers

9. Have a job that is challenging

10. Be well informed about the goings on of the office

The good news is that emergency medicine work inherently fulfills several of these characteristics of an ideal work environment such as doing interesting and challenging work. Many of the others can be inoculated into the staffs' work environment by the physician's actions.

1. Respect the staff. Gone are he days of the hell raising surgeon that would throw a tantrum every time he did get his way.

2. Recognize the staff when they do a good job. In public, if they will take well to this. Always criticize in private.

3. Staff want to develop their skills and knowledge. Teach the techs and nurses about what you're seeing on the x-ray or ECG. If your super motivated, start a teaching conference for ancillary staff q month.

4. Listen to staff when they want to vent (or give accolades) about their work environment. Make appropriate changes when possible. If not, be the mouth piece for your staff, bringing their issues (and by association yours too) to administration. While it shouldn't be so, physicians often have more political clout to help bring about change.

5. Encourage staff to think for themselves. Don't tell them the nitty gritty details of how you want the job done. Tell them what you want as the end result and allow them to get their however they see fit. This may not apply to less experienced staff but for the gray haired ... let them fly.

6. Show staff the result of their work. For instance, if the tech gets an EKG quickly on a chest pain patient that helps expidite his transfer to the cath lab, tell him that his work help save the patient's life.

7. Be efficient. Just as we don't like running around in circles. Neither does you staff. Think twice before giving orders.

8. Keep the staff abreast of department goals and progress towards achieving them.

Alright, If I can incorporate a couple of these actions into my next shift, I think my staff and I will be better off for it. Any other suggestions .... ?
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