This article is the third of a four-part series of articles focusing on emergency department improvement. The fourth and final article in the series will be ” The Multidisciplinary ED Performance Improvement Team”.

To evaluate the performance of a team, the concepts of measurement, analysis, trending, and other statistical analysis tools must be used to determine strengths, weaknesses, and opportunities for improvement. Without data, data analysis, and trending analysis, it is impossible to know how the team is performing and therefore impossible to know how to improve the team’s performance. Does your ED Team measure up? Do you use a scorecard to track performance data? Do you use collected data to identify trends and guide improvement efforts? If the answer is yes … stop reading. If the answer is no … read on.

Why use a scorecard?

The ED has many moving processes that require frequent monitoring to determine efficiency. Emergency departments are often measured and graded in terms of time, both in the clinical arena (door to drug, door to cath lab, etc.) and in the performance and satisfaction arena (time of arrival to physician, time of arrival to disposition, etc.). In the clinical arena, EDs do much better at data collection. There are several reasons for this, reimbursement may be dependant on treatment or outcomes, state or federal regulations require certain data capture and reporting, research, etc. But when it comes to data capture, analysis and trending for efficiency, some EDs fall short of needed data and data analysis capabilities.

The ED Scorecard should be used to help ED physicians, Directors, Administrators and staff recognize areas of inefficiency, make appropriate process improvement decisions and monitor changes (trends). A well-developed scorecard coupled with dedicated ED process improvement commitment gives the best opportunity for successful ED efficiency improvements.

What data to collect

Metrics applicable to the ED can be grouped into three categories, volume, cycle time, and patient satisfaction. Volume metrics include patient volume, numbers of LWTs (left without treatment), number of admissions, etc. Cycle time metrics include door to triage, triage to physician, physician to disposition. Cycle time metrics are the key indicators used in process improvement. These “process segment measures” are predictable, measurable and reliable indicators of process inefficiencies. Patient satisfaction data is also critical to evaluation of the effectiveness of improvement efforts. The following measures are common and provide an easy opportunity for comparison and benchmarking:

Volume:

• Monthly patient volume
• Monthly patients left without being treated
• Monthly admissions/discharges

Cycle times:

• Arrival to triage time
• Triage to room placement time.
• Arrival to physician time
• Physician to disposition time.
• Average time for lab/imaging study report availability

Patient Satisfaction:

• Monthly trended scores
• Verbatim comments with general themes identified

Manual vs electronic data collection

Manual data collection requires manpower to accomplish. Manual collection systems require paper tracking tools that tend to be a nuisance to the staff to complete, a headache for directors to tabulate, and provide unreliable results for performance improvement teams to make decisions. Extracting data from the ED medical record can also be challenging. Often, vital time stamps are not included as part of the record, or clinicians fail to complete the record making it hard for data miners to find key data elements.

Electronic systems seem to be a growing trend in ED improvement efforts. Although some of these systems are very intuitive, there are also not without challenges. These systems can be very costly. Depending on the facility infrastructure, the cost of IT upgrades could add substantial cost to an otherwise affordable system. Electronic systems also require system support, hardware maintenance, software management, training, etc.

Whether manual or electronic, the data must be reliable, valid and reportable in a fashion that makes sense to all ED process stakeholders, from administrators to housekeepers.

How to effectively use an ED performance scorecard

After the rigors of data element identification, data capture and analysis, it is time to report and interpret the data. Key questions to ask include:

• How should the data be displayed?
• Who should review the performance scorecard?
• How often should the performance scorecard be reviewed?

How should the data be displayed?

Presenting your scorecard in a way that is meaningful, powerful, and memorable should be considered. Graphs seem to be the preferable way, but what types of graphs? Pie charts, statistical process control charts, trend charts, etc. are all good ways to show an ED scorecard. Administrators seem to like dashboards that can provide the big picture at a glance. ED directors may prefer trend charts that are easily shared and understood by staff members, while physicians may tend to be interested in statistical analysis and prefer statistical process control charts. Displaying your performance scorecard in a visually powerful format helps to provide understanding of the root cause issues that are affecting performance.

Who should review the performance scorecard?

The scorecard should be shared with everyone in the hospital. Why? Because ED function and efficiency is dependent on the entire facility. At some level, each department should have an understanding of the ED and the efficiency issues faced by the ED. Department directors should also have a working knowledge of ED operations because decisions made in other departments often affect ED patient flow. ED process improvement should be guided by a performance improvement team that is committed, focused and supported to make improvement decisions and devise strategies to improve efficiency. The performance scorecard should be the guide to focus these efforts.

How often should the performance scorecard be reviewed?

The best answer is on a regular basis at an interval that allows time for statistically significant data sample size, data tabulation and report creation and allows time for improvements to have affected a large portion of the patient sample. Most facilities review the performance scorecard on a bimonthly or monthly basis. The key is to review the scorecard as close to “realtime” as possible so that actions and changes are related to the data under review.

The ED scorecard can be a valuable tool in ED process improvement. Using data to guide improvement efforts avoids the “shot in the dark” approach and helps focus on true inefficiencies. Scorecards provide useful feedback as improvement efforts progress and also provide an opportunity to reward staff and other stakeholders for successful improvement implementation efforts.