This document discusses approaches to improving emergency department (ED) throughput and addressing overcrowding. It provides background on the problem of ED overcrowding, including factors contributing to increased patient volumes and decreased bed capacity. Common models for improving throughput focus on separating patients by acuity, expediting diagnostics, and using technology. The document also discusses a conceptual model of ED crowding involving input, throughput, and output phases. Key approaches to improving throughput discussed are patient-specific flow models, rapid triage, providers in triage, flow expeditors, and technology. The significance of addressing overcrowding relates to accreditation standards, hospital finances, and patient satisfaction.
Defensive medicine effect on costs, quality, and access to healthcareAlexander Decker
This document discusses the practice of defensive medicine and its effects. Defensive medicine occurs when doctors order unnecessary tests or procedures in an attempt to reduce malpractice liability. The document finds that defensive medicine increases healthcare costs and can lower quality by leading doctors to avoid high-risk patients or procedures. It also discusses how defensive medicine practices like unnecessary referrals and extra diagnostic tests can limit access to care. The document examines factors that contribute to defensive medicine and its negative impacts on healthcare systems.
1) The Quality and Outcomes Framework (QOF) in the UK introduced pay for performance in primary care on a large scale, providing financial incentives for general practices to meet performance criteria in clinical care, organization, patient experience, and additional services.
2) Studies found mixed results on the impact of QOF, with some evidence that it improved processes of care for certain conditions like diabetes but unintended consequences like a focus on financial targets over patient-centered care.
3) There is concern that pay for performance could undermine intrinsic motivations if it does not align with professional values or leads to unfair exclusions of complex patients, and some experts argue for transparency and feedback over financial incentives.
2008 Pov Ill Book Challenges In Identifying Poor Oddar Meanchey Cambodiawvdamme
This document summarizes a study that assessed household eligibility for a Health Equity Fund (HEF) in Oddar Meanchey, Cambodia four years after an initial pre-identification process. The study evaluated three tools to assess HEF eligibility: 1) a scoring tool used in the original pre-identification, 2) interviewer assessments, and 3) a socioeconomic status index. The results showed high targeting errors across all three tools, suggesting that the original HEF eligibility granted through pre-identification four years prior did not accurately reflect households' current poverty status. Regular updates of pre-identification combined with post-identification are recommended to minimize targeting errors in the future.
It's National Nurses week . Acute care nurses and other healthcare staff are at high risk of injuries, particularly musculoskeletal disorders, due to intense physical demands of manually lifting and moving patients. In this white paper We discuss effective patient mobilization programs and more.
Problem And Description Of Terms For DisseratationJenniferlaw1
This document summarizes a research study on medical malpractice and errors in the hospital system. The study investigated the lack of education and understanding of tort law among healthcare workers. Medical errors cause up to 98,000 preventable deaths annually in the US. The study aims to determine if providing education on tort law concepts would improve healthcare workers' understanding of negligence and reduce errors. The null hypotheses are that there is no significant difference between errors and lack of education, and that quantitative strategies have no impact on error rates.
Physician shortages in Canada have been a topic of debate for decades. In the 1990s, there was a consensus that Canada had a physician surplus, but by the early 2000s policies shifted to increasing medical school enrolment and allowing more foreign graduates due to a perceived shortage. However, the causes of shortages are complex, with factors like physician migration to the US and preferences for specialty careers over family medicine contributing. While some argue for general increases in physician supply, others propose improving retention through addressing job satisfaction or focusing on primary care over specialties. There are differing views on how to best address physician resource issues in the Canadian healthcare system.
This document summarizes a study on data sharing practices and ethics in Vietnam. The study explored stakeholders' attitudes, experiences and expectations regarding sharing individual-level clinical research data through interviews and focus groups. Key findings included the importance placed on trust, respect and reciprocity in the local research culture. Existing Vietnamese laws and guidelines do not prohibit data sharing but do not specifically address it either. There is a need to develop culturally appropriate policies and best practices for data sharing in Vietnam to maximize benefits while respecting local needs and expectations.
Defensive medicine effect on costs, quality, and access to healthcareAlexander Decker
This document discusses the practice of defensive medicine and its effects. Defensive medicine occurs when doctors order unnecessary tests or procedures in an attempt to reduce malpractice liability. The document finds that defensive medicine increases healthcare costs and can lower quality by leading doctors to avoid high-risk patients or procedures. It also discusses how defensive medicine practices like unnecessary referrals and extra diagnostic tests can limit access to care. The document examines factors that contribute to defensive medicine and its negative impacts on healthcare systems.
1) The Quality and Outcomes Framework (QOF) in the UK introduced pay for performance in primary care on a large scale, providing financial incentives for general practices to meet performance criteria in clinical care, organization, patient experience, and additional services.
2) Studies found mixed results on the impact of QOF, with some evidence that it improved processes of care for certain conditions like diabetes but unintended consequences like a focus on financial targets over patient-centered care.
3) There is concern that pay for performance could undermine intrinsic motivations if it does not align with professional values or leads to unfair exclusions of complex patients, and some experts argue for transparency and feedback over financial incentives.
2008 Pov Ill Book Challenges In Identifying Poor Oddar Meanchey Cambodiawvdamme
This document summarizes a study that assessed household eligibility for a Health Equity Fund (HEF) in Oddar Meanchey, Cambodia four years after an initial pre-identification process. The study evaluated three tools to assess HEF eligibility: 1) a scoring tool used in the original pre-identification, 2) interviewer assessments, and 3) a socioeconomic status index. The results showed high targeting errors across all three tools, suggesting that the original HEF eligibility granted through pre-identification four years prior did not accurately reflect households' current poverty status. Regular updates of pre-identification combined with post-identification are recommended to minimize targeting errors in the future.
It's National Nurses week . Acute care nurses and other healthcare staff are at high risk of injuries, particularly musculoskeletal disorders, due to intense physical demands of manually lifting and moving patients. In this white paper We discuss effective patient mobilization programs and more.
Problem And Description Of Terms For DisseratationJenniferlaw1
This document summarizes a research study on medical malpractice and errors in the hospital system. The study investigated the lack of education and understanding of tort law among healthcare workers. Medical errors cause up to 98,000 preventable deaths annually in the US. The study aims to determine if providing education on tort law concepts would improve healthcare workers' understanding of negligence and reduce errors. The null hypotheses are that there is no significant difference between errors and lack of education, and that quantitative strategies have no impact on error rates.
Physician shortages in Canada have been a topic of debate for decades. In the 1990s, there was a consensus that Canada had a physician surplus, but by the early 2000s policies shifted to increasing medical school enrolment and allowing more foreign graduates due to a perceived shortage. However, the causes of shortages are complex, with factors like physician migration to the US and preferences for specialty careers over family medicine contributing. While some argue for general increases in physician supply, others propose improving retention through addressing job satisfaction or focusing on primary care over specialties. There are differing views on how to best address physician resource issues in the Canadian healthcare system.
This document summarizes a study on data sharing practices and ethics in Vietnam. The study explored stakeholders' attitudes, experiences and expectations regarding sharing individual-level clinical research data through interviews and focus groups. Key findings included the importance placed on trust, respect and reciprocity in the local research culture. Existing Vietnamese laws and guidelines do not prohibit data sharing but do not specifically address it either. There is a need to develop culturally appropriate policies and best practices for data sharing in Vietnam to maximize benefits while respecting local needs and expectations.
WHO PAYS MORE: Public, Private, Both or None? The Effects of Health Insuranc...Economic Research Forum
Oznur Ozdamar, Bologna University
Eleftherios Giovanis, University of Verona
ERF Workshop on The Economics of Healthcare in the ERF Region
Cairo, Egypt - May 23, 2016
www.erf.org.eg
Linking clinical workforce skill mix planning to health and health care dynamicsIme Asangansi, MD, PhD
Current health workforce planning methods are inadequate for the complexity of the task. Most approaches treat the workforce supply of individual health professions in isolation and avoid quantifying the impact of changes in skills mix, either planned or unplanned. The causes and consequences of task delegation and task substitution between or within health professions is particularly important in handling workforce shortages in developing countries and understanding and planning possible responses to both rapid catastrophic health demands and slower background trends in their social and political environment. As well as the contextual environment, interactions and delays in supplying and balancing health resources and configuring clinical services are required to address the geographic, profession-specific and quality imbalances. These supply side resources include knowledge and research, skills and attitudes of clinicians, buildings and equipment, medications and medical technologies, information and communications technologies and any other methods and models to improve the provision of clinical services. The interaction between demand
and supply could adjust for feedbacks of health services outcomes, policies and governance on population expectations, funding, political and social supports and explicitly link these to clinical workforce supply in a useful, rigorous and relevant tool. The challenge is capture the relevant essence of the dynamic complexity of health and healthcare for this purpose.
The Effect of Service Quality on Patient Loyalty (A Study on Inpatients of Re...IJAEMSJORNAL
This study aims at examining whether service quality influences customer loyalty, in this case, hospital’s inpatient. Service quality is represented in the form of five independent variables, which are tangibles, reliability, responsiveness, assurance, and empathy. This study is conducted at some regional hospitals in Jakarta, Indonesia, and the respondents are inpatients of the concerned hospitals. The data are analyzed by employing a multiple linear regression method. The research shows that the five independent variables simultaneously, significantly influence patient loyalty. Partially, almost all of the independent variables significantly influence it except the reliability variable.
Barriers to Access Quality Healthcare Services among Physically Challenged Pe...Premier Publishers
This study examined barriers to accessing quality healthcare among physically challenged persons in Gem Sub County, Siaya County, Kenya. The researchers conducted a cross-sectional study using questionnaires with 108 physically challenged individuals. The results showed that environmental accessibility of hospitals, their locations, and infrastructure leading to the hospitals greatly influenced the ability of physically challenged persons to access healthcare. All healthcare facilities were not adequately equipped to handle people with disabilities. Healthcare system-related factors like distance to facilities, awareness of services, and staff attitudes negatively influenced access to quality care for physically challenged persons in Gem Sub County. The combination of these barriers created significant obstacles for physically challenged persons to overcome in accessing needed healthcare services.
The Link between Health Condition Costs and Standard of Living Through Out-of...Economic Research Forum
Eleftherios Giovanis - University of Verona
Oznur Ozdamar - Bologna University
ERF Workshop on The Economics of Healthcare in the ERF Region
Cairo, Egypt - May 23, 2016
www.erf.org.eg
- Grady Memorial Hospital is a large non-profit hospital in Atlanta, Georgia that provides care regardless of patients' ability to pay. It employs over 5,000 people including registered nurses.
- Registered nurses play a key role by maintaining patient health and records, administering medications, monitoring for side effects, and coordinating with healthcare teams on patient care plans. Their job faces challenges like generational differences, technological changes, ethical dilemmas, and legal issues that can lead to stress and turnover.
- Grady proposes to implement a performance management system for nurses to evaluate development, decision-making, and training needs using measures of nurses' behaviors, adaptability, and teamwork abilities gathered from supervisor reports
Assessing the Effectiveness of the New Senior ED Program at SummaAhmed Furkan Ozgur
This document describes a study that assesses the effectiveness of a new Senior Emergency Department (ED) program at Summa Akron City Hospital. The study compares outcomes between a historical cohort of geriatric ED patients from 2012 and patients seen in the new Senior ED program from 2013. Key outcomes measured include length of stay, admission rates, observation rates, and discharge disposition. The results showed that the Senior ED program significantly reduced admissions, increased observations, and increased discharges home compared to usual ED care. This suggests the new program effectively managed elderly patients.
Money Your Practice May Be Throwing Awaye-MedTools
The document discusses ways physicians can improve documentation and coding to maximize reimbursement from insurance companies. It notes that many physicians under-code patient encounters, potentially losing $300 or more per day. Implementing electronic medical records or using standardized paper forms can help improve documentation and billing accuracy to recoup this lost revenue without requiring additional work. The document estimates that decreasing billing errors by 50% through better documentation could increase practice revenues by around $40,000 per year.
Identikit of the Person Seeking Care at Public Hospital in Italy in the Europ...asclepiuspdfs
The number of frail patients for whom the care of a single acute episode necessarily requires both a global approach and a close interaction with the local health services and social services is progressively growing. The issue of managing frail and complex patients at hospitals still needs to be resolved. Currently, care is fragmented in multiple specialized interventions and patients often find themselves moved from one ward to another, resulting in a perilous loss of information and continuity. The purpose of this paper is to analyze hospitalization modalities, the impact of internal medicine (IM) on the hospital activities, the relationship with emergency room (ER) and general patient characteristics, in order to explore putting the current discussion on the new role of IM in the future hospital into practice.
Factors Predicting Health Insurance SatisfactionElisa Lenssen
This study examined factors that influence graduate students' satisfaction with their health insurance plans. A survey of 253 graduate students at Ohio State University found that contextual factors, such as the ability to choose one's own doctor, and enabling factors, like knowledge of the insurance plan and various sources of financial support, were the strongest predictors of satisfaction. Students with more choice of doctors and greater understanding and funding of their plans reported higher satisfaction. The findings suggest policies should aim to decrease students' out-of-pocket costs, increase financial resources, and help students better comprehend their plan provisions in order to improve satisfaction.
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
This document discusses several enduring problems in healthcare systems including uncertainty about clinical effectiveness due to poor quality research, persistent variations in clinical practice, patient safety issues, reluctance to manage skill mix, and poor outcome measurement. It also outlines some achievements of the UK healthcare system such as the establishment of NICE to evaluate clinical and cost effectiveness, introduction of targets to reduce wait times, and beginning to benchmark safety incidents. However, it notes continuous reorganizations have not been properly evaluated and there is a need for greater focus on improving average performance and ensuring best practices are universally adopted.
Health Care Quality: The impact of hospital quality system in private and pub...AI Publications
This document summarizes a research article that examines the impact of hospital quality systems in private and public sectors on patient satisfaction in the Kurdistan region of Iraq. The study developed three hypotheses to measure this impact. A survey was administered to 993 patients across Kurdistan. The findings supported all three hypotheses, showing that developed quality management systems, complex quality systems, and a focus on quality all positively predicted higher patient satisfaction. In conclusion, the introduction of quality management systems in hospitals was found to improve patient satisfaction by enhancing service quality.
This thesis analyzes data from the Centers for Medicare and Medicaid Services (CMS) to identify which quality measurement parameters have the greatest impact on hospitals' overall performance scores and ratings. The author sorted CMS data into categories for mortality, readmissions, safety, and patient experience. Correlation coefficients were calculated between each measurement and hospitals' total performance scores. It was found that hospital-wide readmission rates, acute myocardial infarction 30-day readmission rates, and patient experience measures of doctor communication and responsiveness of hospital staff had the strongest correlations with overall performance scores. Therefore, hospitals looking to improve their ratings may want to focus most on improving these specific factors.
Global Medical Cures™ | Medicare Payments- How Much Do Chronic Conditions Mat...Global Medical Cures™
Erdem, E., Prada, S. I., Haffer, S. C.
E6
MMRR
2013: Volume 3 (2)
1) The document analyzes differences in Medicare payments by beneficiary characteristics such as gender, age, and chronic conditions using 2008 and 2010 Chronic Conditions Public Use Files.
2) It finds that beneficiaries with multiple chronic conditions account for a disproportionate share of Medicare payments, with payments increasing significantly with the number of chronic conditions. "Stroke/Transient Ischemic Attack" and "Chronic Kidney Disease" were the most costly conditions for Part A, while "Cancer" and "Chronic Kidney Disease" were most
How a 5 Hospital System Reduced Infection Rates, Saved Over $2 million and In...Innovations2Solutions
A 5-hospital health system collaborated with a healthcare services company to reduce infection rates and increase patient satisfaction. They implemented initiatives like rapid diagnostic screening, expanded handwashing campaigns, and upgraded cleaning protocols using UV disinfection. As a result, MRSA infections decreased 64% and all device-related HAIs decreased 56% from 2010-2012. Patient satisfaction scores also improved significantly, increasing 14% on HCAHPS and gaining 63 percentile points on Press Ganey. The initiatives helped the system save over $2 million annually while improving outcomes.
Decline of empathy during medical educationAhmad Ozair
This document contains 3 letters responding to an article on empathy decline among medical students.
The first letter proposes a multi-institutional longitudinal study to identify causal factors for empathy decline internationally. Empathy is important but current studies are cross-sectional.
The second letter questions the significance of small empathy declines found in medical school given that burnout is very high after graduation, negatively impacting patient care.
The third letter supports a longitudinal study and notes a large study found empathy declines in Indian medical students as well, suggesting it's a universal issue important for good patient outcomes worldwide.
The document summarizes a study on the financial burden and ability to access healthcare services of households in Thuy Van commune, Vietnam. The study found that households bear 72% of total health expenditures in Vietnam. While public health services are convenient for minor illnesses, households resort to private providers and hospitals for serious conditions, burdening the poor. Inpatient costs exceeded 1-2% of income for poor households, indicating health costs trap them in poverty. The study recommends expanding community-based insurance, regulating drug costs, and investing in primary care to improve access and affordability for the poor.
Healthcare Utilization and Self-assessed Health in Turkey: Evidence from the ...Economic Research Forum
Firat Bilgel - Okan University
Burhan Can Karahasan - Piri Reis University
ERF Workshop on The Economics of Healthcare in the ERF Region
Cairo, Egypt - May 23, 2016
www.erf.org.eg
This document provides details about Farshid Tavakoli, including his education, skills, expertise, and professional experience. He has a Master's degree in Mechatronic & Automation and founded Faraz Dena Tajhiz Co. in 2009. As the local distributor for Smith&Nephew Co. since 2009, his company achieved $1 million in product sales in 2015 and provides medical devices and orthopedic products in Isfahan, Iran. He has over 7 years of experience in marketing, sales, and servicing medical devices, and manages a team of 10 people.
WHO PAYS MORE: Public, Private, Both or None? The Effects of Health Insuranc...Economic Research Forum
Oznur Ozdamar, Bologna University
Eleftherios Giovanis, University of Verona
ERF Workshop on The Economics of Healthcare in the ERF Region
Cairo, Egypt - May 23, 2016
www.erf.org.eg
Linking clinical workforce skill mix planning to health and health care dynamicsIme Asangansi, MD, PhD
Current health workforce planning methods are inadequate for the complexity of the task. Most approaches treat the workforce supply of individual health professions in isolation and avoid quantifying the impact of changes in skills mix, either planned or unplanned. The causes and consequences of task delegation and task substitution between or within health professions is particularly important in handling workforce shortages in developing countries and understanding and planning possible responses to both rapid catastrophic health demands and slower background trends in their social and political environment. As well as the contextual environment, interactions and delays in supplying and balancing health resources and configuring clinical services are required to address the geographic, profession-specific and quality imbalances. These supply side resources include knowledge and research, skills and attitudes of clinicians, buildings and equipment, medications and medical technologies, information and communications technologies and any other methods and models to improve the provision of clinical services. The interaction between demand
and supply could adjust for feedbacks of health services outcomes, policies and governance on population expectations, funding, political and social supports and explicitly link these to clinical workforce supply in a useful, rigorous and relevant tool. The challenge is capture the relevant essence of the dynamic complexity of health and healthcare for this purpose.
The Effect of Service Quality on Patient Loyalty (A Study on Inpatients of Re...IJAEMSJORNAL
This study aims at examining whether service quality influences customer loyalty, in this case, hospital’s inpatient. Service quality is represented in the form of five independent variables, which are tangibles, reliability, responsiveness, assurance, and empathy. This study is conducted at some regional hospitals in Jakarta, Indonesia, and the respondents are inpatients of the concerned hospitals. The data are analyzed by employing a multiple linear regression method. The research shows that the five independent variables simultaneously, significantly influence patient loyalty. Partially, almost all of the independent variables significantly influence it except the reliability variable.
Barriers to Access Quality Healthcare Services among Physically Challenged Pe...Premier Publishers
This study examined barriers to accessing quality healthcare among physically challenged persons in Gem Sub County, Siaya County, Kenya. The researchers conducted a cross-sectional study using questionnaires with 108 physically challenged individuals. The results showed that environmental accessibility of hospitals, their locations, and infrastructure leading to the hospitals greatly influenced the ability of physically challenged persons to access healthcare. All healthcare facilities were not adequately equipped to handle people with disabilities. Healthcare system-related factors like distance to facilities, awareness of services, and staff attitudes negatively influenced access to quality care for physically challenged persons in Gem Sub County. The combination of these barriers created significant obstacles for physically challenged persons to overcome in accessing needed healthcare services.
The Link between Health Condition Costs and Standard of Living Through Out-of...Economic Research Forum
Eleftherios Giovanis - University of Verona
Oznur Ozdamar - Bologna University
ERF Workshop on The Economics of Healthcare in the ERF Region
Cairo, Egypt - May 23, 2016
www.erf.org.eg
- Grady Memorial Hospital is a large non-profit hospital in Atlanta, Georgia that provides care regardless of patients' ability to pay. It employs over 5,000 people including registered nurses.
- Registered nurses play a key role by maintaining patient health and records, administering medications, monitoring for side effects, and coordinating with healthcare teams on patient care plans. Their job faces challenges like generational differences, technological changes, ethical dilemmas, and legal issues that can lead to stress and turnover.
- Grady proposes to implement a performance management system for nurses to evaluate development, decision-making, and training needs using measures of nurses' behaviors, adaptability, and teamwork abilities gathered from supervisor reports
Assessing the Effectiveness of the New Senior ED Program at SummaAhmed Furkan Ozgur
This document describes a study that assesses the effectiveness of a new Senior Emergency Department (ED) program at Summa Akron City Hospital. The study compares outcomes between a historical cohort of geriatric ED patients from 2012 and patients seen in the new Senior ED program from 2013. Key outcomes measured include length of stay, admission rates, observation rates, and discharge disposition. The results showed that the Senior ED program significantly reduced admissions, increased observations, and increased discharges home compared to usual ED care. This suggests the new program effectively managed elderly patients.
Money Your Practice May Be Throwing Awaye-MedTools
The document discusses ways physicians can improve documentation and coding to maximize reimbursement from insurance companies. It notes that many physicians under-code patient encounters, potentially losing $300 or more per day. Implementing electronic medical records or using standardized paper forms can help improve documentation and billing accuracy to recoup this lost revenue without requiring additional work. The document estimates that decreasing billing errors by 50% through better documentation could increase practice revenues by around $40,000 per year.
Identikit of the Person Seeking Care at Public Hospital in Italy in the Europ...asclepiuspdfs
The number of frail patients for whom the care of a single acute episode necessarily requires both a global approach and a close interaction with the local health services and social services is progressively growing. The issue of managing frail and complex patients at hospitals still needs to be resolved. Currently, care is fragmented in multiple specialized interventions and patients often find themselves moved from one ward to another, resulting in a perilous loss of information and continuity. The purpose of this paper is to analyze hospitalization modalities, the impact of internal medicine (IM) on the hospital activities, the relationship with emergency room (ER) and general patient characteristics, in order to explore putting the current discussion on the new role of IM in the future hospital into practice.
Factors Predicting Health Insurance SatisfactionElisa Lenssen
This study examined factors that influence graduate students' satisfaction with their health insurance plans. A survey of 253 graduate students at Ohio State University found that contextual factors, such as the ability to choose one's own doctor, and enabling factors, like knowledge of the insurance plan and various sources of financial support, were the strongest predictors of satisfaction. Students with more choice of doctors and greater understanding and funding of their plans reported higher satisfaction. The findings suggest policies should aim to decrease students' out-of-pocket costs, increase financial resources, and help students better comprehend their plan provisions in order to improve satisfaction.
Automated Post-Discharge Care: An Essential Tool to Reduce ReadmissionsPhytel
Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients that are discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.
This document discusses several enduring problems in healthcare systems including uncertainty about clinical effectiveness due to poor quality research, persistent variations in clinical practice, patient safety issues, reluctance to manage skill mix, and poor outcome measurement. It also outlines some achievements of the UK healthcare system such as the establishment of NICE to evaluate clinical and cost effectiveness, introduction of targets to reduce wait times, and beginning to benchmark safety incidents. However, it notes continuous reorganizations have not been properly evaluated and there is a need for greater focus on improving average performance and ensuring best practices are universally adopted.
Health Care Quality: The impact of hospital quality system in private and pub...AI Publications
This document summarizes a research article that examines the impact of hospital quality systems in private and public sectors on patient satisfaction in the Kurdistan region of Iraq. The study developed three hypotheses to measure this impact. A survey was administered to 993 patients across Kurdistan. The findings supported all three hypotheses, showing that developed quality management systems, complex quality systems, and a focus on quality all positively predicted higher patient satisfaction. In conclusion, the introduction of quality management systems in hospitals was found to improve patient satisfaction by enhancing service quality.
This thesis analyzes data from the Centers for Medicare and Medicaid Services (CMS) to identify which quality measurement parameters have the greatest impact on hospitals' overall performance scores and ratings. The author sorted CMS data into categories for mortality, readmissions, safety, and patient experience. Correlation coefficients were calculated between each measurement and hospitals' total performance scores. It was found that hospital-wide readmission rates, acute myocardial infarction 30-day readmission rates, and patient experience measures of doctor communication and responsiveness of hospital staff had the strongest correlations with overall performance scores. Therefore, hospitals looking to improve their ratings may want to focus most on improving these specific factors.
Global Medical Cures™ | Medicare Payments- How Much Do Chronic Conditions Mat...Global Medical Cures™
Erdem, E., Prada, S. I., Haffer, S. C.
E6
MMRR
2013: Volume 3 (2)
1) The document analyzes differences in Medicare payments by beneficiary characteristics such as gender, age, and chronic conditions using 2008 and 2010 Chronic Conditions Public Use Files.
2) It finds that beneficiaries with multiple chronic conditions account for a disproportionate share of Medicare payments, with payments increasing significantly with the number of chronic conditions. "Stroke/Transient Ischemic Attack" and "Chronic Kidney Disease" were the most costly conditions for Part A, while "Cancer" and "Chronic Kidney Disease" were most
How a 5 Hospital System Reduced Infection Rates, Saved Over $2 million and In...Innovations2Solutions
A 5-hospital health system collaborated with a healthcare services company to reduce infection rates and increase patient satisfaction. They implemented initiatives like rapid diagnostic screening, expanded handwashing campaigns, and upgraded cleaning protocols using UV disinfection. As a result, MRSA infections decreased 64% and all device-related HAIs decreased 56% from 2010-2012. Patient satisfaction scores also improved significantly, increasing 14% on HCAHPS and gaining 63 percentile points on Press Ganey. The initiatives helped the system save over $2 million annually while improving outcomes.
Decline of empathy during medical educationAhmad Ozair
This document contains 3 letters responding to an article on empathy decline among medical students.
The first letter proposes a multi-institutional longitudinal study to identify causal factors for empathy decline internationally. Empathy is important but current studies are cross-sectional.
The second letter questions the significance of small empathy declines found in medical school given that burnout is very high after graduation, negatively impacting patient care.
The third letter supports a longitudinal study and notes a large study found empathy declines in Indian medical students as well, suggesting it's a universal issue important for good patient outcomes worldwide.
The document summarizes a study on the financial burden and ability to access healthcare services of households in Thuy Van commune, Vietnam. The study found that households bear 72% of total health expenditures in Vietnam. While public health services are convenient for minor illnesses, households resort to private providers and hospitals for serious conditions, burdening the poor. Inpatient costs exceeded 1-2% of income for poor households, indicating health costs trap them in poverty. The study recommends expanding community-based insurance, regulating drug costs, and investing in primary care to improve access and affordability for the poor.
Healthcare Utilization and Self-assessed Health in Turkey: Evidence from the ...Economic Research Forum
Firat Bilgel - Okan University
Burhan Can Karahasan - Piri Reis University
ERF Workshop on The Economics of Healthcare in the ERF Region
Cairo, Egypt - May 23, 2016
www.erf.org.eg
This document provides details about Farshid Tavakoli, including his education, skills, expertise, and professional experience. He has a Master's degree in Mechatronic & Automation and founded Faraz Dena Tajhiz Co. in 2009. As the local distributor for Smith&Nephew Co. since 2009, his company achieved $1 million in product sales in 2015 and provides medical devices and orthopedic products in Isfahan, Iran. He has over 7 years of experience in marketing, sales, and servicing medical devices, and manages a team of 10 people.
Natureview yogurt was founded in 1989 and has found success due to its longer shelf life and high quality taste. It currently sells primarily through supermarkets but is considering expanding into other channels. Expanding its 8oz, 32oz, and children's multipacks into supermarkets could bring both advantages like filling market needs and disadvantages like increased competition. Moving first into natural food stores with a children's multipack may allow time to prepare for supermarkets while maintaining strong relationships in natural stores. Financial projections show the various product sizes have different costs, prices and profit margins. Adjustments are recommended around pricing, costs and partnerships to improve competitiveness.
This study examined the relationship between perceived attractiveness and intelligence. The researcher hypothesized that 1) attractive individuals would be perceived as more intelligent and 2) individuals who rate themselves as attractive would also rate themselves as above average in intelligence. Participants rated the attractiveness and perceived intelligence of photos of 23 individuals. While no correlation was found between attractiveness and intelligence ratings of photos, a significant positive correlation was found between self-rated attractiveness and intelligence. So the second hypothesis was supported but not the first. Limitations included using separate samples for attractiveness and intelligence ratings and not controlling for clothing in photos.
Servicio de tarot telefónico 24 horas desde España. Videncia de calidad por videntes y astrólogos respetables y fiables. Increíbles ofertas. Compruébalo.
The implementation of a flow coordinator role in an emergency department did not improve key throughput metrics like length of stay and left without being seen rates. While the flow coordinator aimed to improve efficiency, an electronic medical record change slowed processes down for months, counteracting any benefits. Analysis found that males and patients aged 20-40 were highest risk for poor throughput outcomes. Patient satisfaction still improved despite worse metrics. Recommendations include studying different clinical roles for flow coordination and its impact on other areas like admissions and diversions.
This resume is for Jaimy Garcia, who graduated from Gage Park Academy in 2016 and has experience in sales and customer service roles at Solid Gold Jewelry and Fashion Marks. Garcia has excellent communication and interpersonal skills as well as being bilingual in English and Spanish. References are available upon request.
Uno e los puntos importantes de una empresa es la buena gestión del departamento de Recursos humanos.¿Cómo mejorar la calidad humana dentro de una empresa para un buen desempeño y gestión de calidad.?
Best Buy's business objectives are to obtain and grow market share through international growth and connected digital solutions. It aims to be the best consumer electronics retailer through a focus on customer connectivity. Some keys to Best Buy's success have been knowledgeable staff, positive customer perceptions compared to Walmart, and acquisitions. However, it faces risks from intense competition from retailers like Walmart and Amazon, as well as economic challenges. To compete, Best Buy provides high quality customer service and aims to lead through research and development.
Unit 1Emergency Department Overcrowding Due to L.docxwillcoxjanay
This study aims to evaluate factors contributing to overutilization of emergency departments for non-urgent care through a questionnaire. It will be conducted in a rural North Carolina county at the local emergency department, which sees an average of 1300 visits per month. Participants will complete an informed consent and anonymous survey assessing reasons for their emergency department visit and potential influences on their decision to seek care there rather than primary care, such as availability of appointments, transportation barriers, and convenience. The goal is to understand utilization patterns to help address overcrowding challenges faced by many hospital systems.
Whitepaper: Hospital Operations Management reduces wait states and replaces d...GE Software
No Wait States … in pursuit of the frictionless patient experience. Electronic health records have fallen short. Patients continue to wait. Costs remain high. Why focusing on operational management can help hospitals make things right … starting now.
BENCHMARK 1
Evidence-Based Practice Project: PICOT Paper
Daysha Y. Polk
NUR 550
Grand Canyon University
June 1st, 2021
Evidence-Based Practice Project: PICOT Paper
Generally, a high level of patient satisfaction for the clients in the emergency department (ED) is vital, especially at this time when the healthcare system is shifting towards patient-centered care. Prakash (2010) notes that patient satisfaction levels significantly impact on medical malpractice claims, patient retention, and clinical outcomes. That is, it affects quality healthcare’s timely, efficient, and patient-centered delivery, making it both a proxy but a very effective key indicator for measuring the hospitals and doctors’ success. Consequently, supporting the improvements of patient satisfaction levels can positively affect several healthcare organizations’ components, such as preventive possible malpractice lawsuits, securing a positive local reputation, and enhancing patient retention rates. Thus, there is an increased need to develop strategies to improve ED patient’s satisfaction with the provided care services. Increasingly, the use of real-time location systems (RTLS) by hospitals to track patients, instead of relying on the traditional, manually-entered status updates, is increasingly being viewed as a better strategy to decrease the number or rate of Left Without Being Treated (LWBT) patients, and thus, improve ED patient’s satisfaction levels and hospital’s revenue collection (Boulos & Berry, 2012). Thus, the paper will explore whether the utilization of RTLS in the hospital’s ED, compared to manually-entered status updates to tract patients, help decrease the rate of LWBT and to raise revenue collection within 6 months, for ED patients with decreasing satisfaction levels with the provided healthcare services.
A wide array of factors is responsible for the decreased rate of satisfaction levels amongst ED patients. The current delays, long waits, leaving without being treated, decreased revenue collection from the ED unit, and reduced patient satisfaction scores have negatively portrayed the hospital's reputation to the public. As a result, the daily patient visits have continued to decrease as people attribute the facility to poor emergency care services delivery. All these complications result from the use of combined data resources and manual entry status updates when tracking patient records. This manual tracking cannot meet the demand for many patients and leads to overcrowding due to and reduced patient flow in the ED. Therefore, there is a need to install an automatic patient tracking system to increase the flow.
Patient satisfaction level, especially for hospital’s emergency department (ED) is increasingly becoming a key health quality indicator. Patient satisfaction regards the degree to which patients are happy with their healthcare (Heath, 2016). Patient satisfaction levels is a care quality measure and gives healthcare providers infor ...
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, DioneWang844
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, AND PROJECT INSTRUCTIONS
Page | 1
Quality
Nearly fifteen years ago, the Institute of Medicine published the “To Err Is Human” report, which exposed the substantial impact of medical errors in the US healthcare system and called for a dramatic system change, including an improved understanding of those errors (McCarthy, Tuiskula, Driscoll, & Davis, 2017). Medical errors are considered to be failure to achieve the original goal or plan of action, and these errors may range from a patient falls to a mistake in the operating room. Not only do medical errors cause harm to the patient and jeopardize the patient’s trust, but they also cause a financial strain for the health system (“To Err is Human,” 1999). One of the contributing factors to medical errors is the lack of effective communication between doctors who are treating the same patient. This results in healthcare providers overprescribing medications for patients as well as increases the possibility of a patient having unnecessary tests or procedures performed. The report’s four-tiered approach includes:
· Focusing on creating a stronger foundation of education on patient safety
· Mandating a nationwide reporting system to encourage timely reporting of errors
· Increasing the standards of performance for healthcare providers
· Taking advantage of the security that safety systems offer (“To Err is Human,” 1999)
Creating a strong educational foundation for patient safety is most important. Healthcare personnel are much more likely to actively participate in reporting systems, encourage one another to perform at a higher level, and take advantage of safety systems when they are well educated on patient safety and the implications of medical errors. The reporting system seems to provide the least amount of impact on patient safety as they can result in losing patient trust in certain healthcare systems. The healthcare system as a whole has made progress in establishing a safe environment for patients when they are in need of care.
Challenges for Patient Safety and Steps for Improvement
Despite continuing evidence of problems in patient safety and gaps between the care that patients receive and the evidence about what they should receive, efforts to improve quality in healthcare show mostly inconsistent and patchy results.
Tap each image to know more.
Data Collection and Monitoring Systems
This always takes much more time and energy than anyone anticipates. It is worth investing heavily in data from the outset. Assess local systems, train people, and have quality assurance.
Tribalism and Lack of Staff Engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals, and use shared language.
Convince People That There's a Problem
Use hard data to secure emotional e ...
Running head U.S. HEALTHCARE EXECUTIVES 1U.S. HEALTHCARE EX.docxjenkinsmandie
Running head: U.S. HEALTHCARE EXECUTIVES
1
U.S. HEALTHCARE EXECUTIVES
7
Week 2 Assignment-Operational challenges, trends and issues for the U.S. Healthcare Executives
Student’s Name
Institutional Affiliation
Introduction
A healthcare system is an organization of funds, individuals, and institutions which provide healthcare to satisfy the health requirements of a society. Globally, healthcare systems vary depending on the specific healthcare needs of particular states. Nevertheless, the common aspects of public and private care are often similar (Drummond, Sculpher, Claxton, Stoddart & Torrance, 2015). Over the years, we have witnessed the systems evolving, and with this constant change, it is vital to analyze operational challenges, trends, and issues for the U.S. healthcare executives. In this paper, the main areas that will be discussed are operational challenges, trends, and problems experienced in the United States health care executives.
Challenges experienced in the healthcare workplace
Various problems have been experienced in the healthcare workplace relating to healthcare provision in the United States. Financial difficulties are one of the main challenges being experienced in the healthcare workplace in the United States. The vital financial problems arise due to lack of enough finances for implementation of new technologies to improve healthcare delivery process (Mayes, 2017). Most healthcare facilities lack adequate funds to implement advanced technologies that can be used to increase the quality of healthcare delivery. As a result, this has reduced healthcare quality improvement plans in the United States. Therefore, there is a need for federal governments to meek proper arrangements to fund all healthcare activities to improve services delivery in the health sector.
Besides, healthcare professionals to comply with federal requirements for electronic health records is another challenge that has been experienced in the United States healthcare workplace. For the past year, some healthcare professionals have failed to comply with federal government guidelines regarding health care delivery (Mayes, 2017). Furthermore, the increasing number of patients who cannot pay for health care services is a significant challenge that has been experienced in the United States healthcare delivery systems. These finance challenges adversely affect healthcare delivery system in the United States.
Work overload is another major challenge that has been experienced in the United States health sectors (Mayes, 2017). Observations for past years reveal that work overload at the workplace affects the performance of health care professionals in the United States. Most healthcare professionals are assigned many responsibilities at workplaces, which reduces their efficiency.
Another cause of the rising cost of healthcare is the introduction of government programs. For example, Medicare assists those without insurance, which led to an incre.
Operartions research in US Healthcare IndustryPrasant Patro
1. This document describes how operations research (OR) models can help reduce delays in healthcare. It identifies three major sources of delays: emergency department delays, delays for medical appointments, and delays for nursing care.
2. Within emergency department delays, it notes long wait times to see physicians and delays in getting inpatient beds once admitted. For medical appointments, it describes waits of several weeks on average to see primary care physicians. Delays for nursing care can compromise patient safety due to insufficient staffing levels.
3. It argues that healthcare delays remain prevalent because they have not been well measured or reported, hospitals face cost pressures to maximize occupancy, and national shortages of healthcare professionals exacerbate delays. OR models have
1) Healthcare faces significant workforce challenges due to underinvestment in HR and talent management. Hospitals are often understaffed which impacts patient care and satisfaction.
2) The study found occupancy rates average around 50% but fluctuate daily/weekly due to varying patient demand and lack of staff to cover all beds. Inadequate staffing was cited as the cause of not meeting demand nearly half the time.
3) Additional staffing could allow for more wellness programs, higher patient satisfaction scores, and greater revenue from filled beds but hospitals have difficulty finding enough qualified candidates.
4-1 Responses 1Healthcare services are always going to be .docxtroutmanboris
4-1 Responses
1
Healthcare services are always going to be needed, and prices will get higher with time; in fact, "Reimbursement just keeps growing over time, say the critics. A Washington Post analysis of records for 5,700 procedures reportedly showed that work RVUs are seven times likelier to increase than to fall" (Baltic, 2013.) The question that is needed to be asked is: What actions can be implemented in order to change and improve the current healthcare problematic? Here are some of the factors that can influence it:
1) Geographic position: The better positioned and available the hospital is, the more consumers can access to health and promote business. There are some other interesting choices that places like Oregon has implemented to help Medicare rates and allow more patient to be seen in community hospitals, which is known as a new Accountable Care Collaborative program "allowing to connect healthcare providers as well as social services and community-based assistance" (Johnson, 2013.)
2) Physician Alignment: Great physicians increase the visit numbers due to high success rates, which contributes to more financial stability and solvency for the hospital.
3) Cost structure: "Hospitals with a high-cost structure either due to high debt, high employee costs or the inability to amortize costs over larger revenues are more susceptible to bankruptcy" (Becker & Dunn, 2010.)
4) Quality of services: low-quality care increase bad reputation, which means no clients for the hospital. High mortality or nosocomial infections equal to poor care as well.
What do you think? Is it necessary to invest more in healthcare workers to increase patient satisfaction? Will that helps the quality of care? What do you think will happen with your cost structure?
Thanks
Reference
Baltic, S. (2013). PRICING MEDICARE SERVICES: Insiders reveal how it's done. Managed Healthcare Executive, 23(11), 28-40.
Becker, S., & Dunn, L. (2010, September 30). 7 Factors to Assess the Sustainability of a Hospital. Retrieved from https://www.beckershospitalreview.com/hospital-management-administration/7-factors-to-assess-the-sustainability-of-a-hospital-assessing-a-hospitals-viability-its-financial-situation-and-the-severity-of-the-threats-it-faces.html
Jonhson, S. R. (2013, September 09). Controlling costs. Modern Healthcare, 43(36), 7-12.
2
When there is more of a demand for health care services, organizations can see that there is more of a need to be cost efficient because there needs to be a balance between the cost that is made when using resources and as well as providing health care to our patients. Instead of breaking even, organizations should consider making revenue so that they can offer adequate pay for staff, allow for departmental growth with expansions and update supplies and technology to be competitive among other hospitals in the area.
As stated in our classroom textbook, Essentials of Healthcare Finance (8th Edition) written by William Cleverley a.
MSN 5650 Miami Regional University Reducing Hospital Readmission Presentation...bkbk37
This document discusses reducing hospital readmissions and improving quality of care. It identifies some key causes of hospital readmissions, such as medication errors, non-compliance by patients, and inappropriate transition from hospital to home. It notes that readmissions negatively impact quality of care and that hospitals have implemented programs to reduce readmissions. The document discusses the importance of clearly explaining medical instructions to patients and ensuring a smooth transition from hospital to home care through follow-up appointments and support.
Emergency department crowding is a major issue facing hospitals in the US. The aging population and lack of available inpatient beds has led to overcrowding in emergency departments. This overcrowding can negatively impact patient care and satisfaction. Solutions proposed in the document include treating patients in hallways if beds are unavailable, using a team approach to quickly treat and process patients, and displaying wait times online to attract patients. Information sharing between healthcare providers also needs improvement to better manage patient care.
This document summarizes the current status of research on the digital transformation of healthcare through health information technology (HIT). It finds that while HIT has potential to improve quality and reduce costs, evidence of its actual impacts is mixed. Research has focused on HIT adoption issues and its effects on performance, but results are equivocal, finding both positive, negative, and no effects. The document identifies important areas for further research, including HIT design/implementation, quantifying HIT impacts, and extending the traditional realm of HIT.
The document analyzes quality indicators for emergency departments at five hospitals in Dallas, Texas. It finds that while the hospitals serve similar populations, there is variation in quality outcomes. Texas Health Presbyterian generally had the best outcomes compared to national and statewide averages. Factors like overcrowding, staffing levels, and communication can impact quality and efficiency of emergency care provided. Improving processes and structures in emergency departments may help hospitals achieve better results.
MSN 5650 Reducing Hospital Readmission And Improving Quality.pdfbkbk37
This document discusses reducing hospital readmissions and improving quality of care. It identifies several key causes of hospital readmissions, including non-compliance with treatment plans, inappropriate transition from hospital to home, complex medical conditions, and medication errors. The document evaluates different solutions to reducing readmissions, including patient segmentation, improving care transitions, reducing errors, and ensuring adequate staffing. It determines that ensuring adequate and competent hospital staffing is the best option to improve quality of care and reduce preventable readmissions in an ethical manner.
Behavioral Intention In Revisiting Hospital Under The Effect Of Expertise, Reputation And Service Quality. Trust comes from the belief of a party’s promise or sentence is reliable and the obligation that party need to be fulfilled in vice versa for relationship purpose (Schurr and Ozanne, 1985). Based on the trust, the interaction of a buyer’s perception future and service provider (seller) is anticipated (Doney and Cannon, 1997). It creates a long-term orientation of a relationship B2C in positive ways (Ganesan, 1994). The trust’s advantages which create strong relationship in business has been researched in the literature review of Morgan and Hunt in 1994. The individual experience is considered as the trustworthy source rather than the referral from relatives or friends which is explained as the second-hand trust referral or the popular.
JOB SATISFATION AND NURSE PATIENT RATIO24Table of Contents.docxchristiandean12115
This document provides an overview of a research study that examines the relationship between nurse job satisfaction, nurse-patient ratios, and nurse fatigue. It includes an introduction that outlines the background, problem statement, purpose, significance and research questions. It also presents hypotheses and a brief literature review. The methodology chapter describes the research design, sample, instruments and data analysis plan. Results, discussion and conclusions chapters are also outlined. The document provides a framework to guide the proposed empirical study on the key factors relating to nurse fatigue.
12
Capstone Project
Olivia Timmons
Department of Nursing. St. Johns River State College
NUR 4949: Nursing Capstone
Dr. C. Z. Velasco
November 14, 2021
Capstone Project
There is a saying that states one can only learn through doing it, practically and physically. It is the explanation as to why it is very important to implement the skills acquired in theory into practice to ascertain one’s competence. This is even more crucial in the medical field as they have no choice but just to be perfect at what they are doing, the only secret is through practice. Practicums connect the two worlds of theory and classwork, thus breaking the monotony alongside connecting what was taught in class with what happens in the field. They are important as apart from sharpening the student’s skills, they also open a window of opportunity and build up connections that will come in handy for the student later on. They will feel the experience and the pressure that comes with it thus preparing themselves accordingly.
Statement of the Problem
Timing is essential in the nursing field and the Emergency Room is notorious for its long wait times. The goal of a clinical laboratory is to deliver medically useful results for patients on a timely basis. This goal can be hindered by the new paradigm of the modern laboratory – “do more with less" (Lopez, 2020). When implementing new care models for patients, the patient perspective is critical. The objective of this study was to describe and develop an understanding of the information needs of patients in the ED waiting room concerning ED wait time notification (Calder, 2021). As a patient arrives at the ER waiting area, it's critical to have lab results for the provider to evaluate. I can give you an example of a patient that waited in the waiting room for over 3 hours, no labs were completed because they were waiting for the patient to go back into a room. The patient was suffering from a heart attack and his troponins were elevated and no one knew until 3 hours later. If POC labs were done on all patients as soon as they arrived, mistakes like these can be avoided. Completed POC blood can cut the wait times in half and the laboratory also won't be backed up on resulting lab specimens.
PICOT Question
Question: Is there a significant decrease in Emergency Department patient length of stay (LOS) for those whose blood was analyzed using POC testing versus those whose blood was analyzed using laboratory testing?
· P-Population= emergency room patients
· I-Intervention or Exposure= POC testing of blood specimens
· C-Comparison= Laboratory blood specimens
· O-Outcome= Decrease patient stay in the emergency room
· T-Time = N/A
History of the Issue
The length of patient stay in the emergency department (ED) is an issue that not only increases the severity of illnesses but also reduces the quality of patient care. Serious health conditions including diabetes and hypertension can worsen while patients are ...
12
Capstone Project
Olivia Timmons
Department of Nursing. St. Johns River State College
NUR 4949: Nursing Capstone
Dr. C. Z. Velasco
November 14, 2021
Capstone Project
There is a saying that states one can only learn through doing it, practically and physically. It is the explanation as to why it is very important to implement the skills acquired in theory into practice to ascertain one’s competence. This is even more crucial in the medical field as they have no choice but just to be perfect at what they are doing, the only secret is through practice. Practicums connect the two worlds of theory and classwork, thus breaking the monotony alongside connecting what was taught in class with what happens in the field. They are important as apart from sharpening the student’s skills, they also open a window of opportunity and build up connections that will come in handy for the student later on. They will feel the experience and the pressure that comes with it thus preparing themselves accordingly.
Statement of the Problem
Timing is essential in the nursing field and the Emergency Room is notorious for its long wait times. The goal of a clinical laboratory is to deliver medically useful results for patients on a timely basis. This goal can be hindered by the new paradigm of the modern laboratory – “do more with less" (Lopez, 2020). When implementing new care models for patients, the patient perspective is critical. The objective of this study was to describe and develop an understanding of the information needs of patients in the ED waiting room concerning ED wait time notification (Calder, 2021). As a patient arrives at the ER waiting area, it's critical to have lab results for the provider to evaluate. I can give you an example of a patient that waited in the waiting room for over 3 hours, no labs were completed because they were waiting for the patient to go back into a room. The patient was suffering from a heart attack and his troponins were elevated and no one knew until 3 hours later. If POC labs were done on all patients as soon as they arrived, mistakes like these can be avoided. Completed POC blood can cut the wait times in half and the laboratory also won't be backed up on resulting lab specimens.
PICOT Question
Question: Is there a significant decrease in Emergency Department patient length of stay (LOS) for those whose blood was analyzed using POC testing versus those whose blood was analyzed using laboratory testing?
· P-Population= emergency room patients
· I-Intervention or Exposure= POC testing of blood specimens
· C-Comparison= Laboratory blood specimens
· O-Outcome= Decrease patient stay in the emergency room
· T-Time = N/A
History of the Issue
The length of patient stay in the emergency department (ED) is an issue that not only increases the severity of illnesses but also reduces the quality of patient care. Serious health conditions including diabetes and hypertension can worsen while patients are ...
1. Approaches to Improving Emergency Department Throughput
Susan Flaming
INTRODUCTION
The problem of overcrowding in emergency departments (EDs) has grown
significantly over the last two decades into a national crisis, with the number of patient visits
increasing by 26% between 1993 and 2003, according to the Institute of Medicine’s (IOM)
2006 report, Hospital Based Emergency Care: At the Breaking Point. Further fueling this
crisis is the decrease of nearly 200,000 ED beds resulting from the closing of 425 emergency
departments during the same time period (IOM, 2006). Additionally, an increased reliance on
EDs for routine health care for uninsured patients, and the challenges of accessing health care
quickly and efficiently by patients who do have insurance have contributed to higher volumes
of patient visits (Asplin et al., 2003; IOM, 2006). The disparity between the increasing
demand for ED resources and decreasing available capacity is at the heart of the crisis of
overcrowding in EDs throughout the nation.
In an effort to address the challenges of overcrowding, various care delivery models
have attempted to optimize the efficient flow of patients into, through and out of the ED, a
concept referred to in the field of emergency medicine as the “throughput process.” The
models aimed at improving throughput have traditionally focused on three methods: (1)
separating patients by acuity level into acute and non-acute treatment areas, and (3) using
technological advances to expedite diagnostics and treatment results for ED patients (Storrow
et al., 2009; Wiler et al., 2010). While these interventions have shown promise in improving
efficiency of patient flow through the ED, researchers have cited the need for more study to
determine the most effective models to improve ED throughput (Oredsson et al., 2011; Wiler
et al., 2010).
2. Background
The problem of ED overcrowding is the result of nationwide trends in the health care
environment including hospitals choosing to close EDs due to poor profitability, and an
unmanageable surge in volume due to limited access for patients in the primary care
environment that end up seeking care in EDs. In their study aimed at determining the causes
of ED closures in the United States, Hsai, Kellerman and Shen (2011) investigated all of the
EDs that closed their doors from 1990 to 2009. During the study period, 1,041 EDs shut
down and only 374 new EDs opened, for a net loss of 27% of ED bed capacity nationwide.
The most significant contribution of their study was the identification of the factors most
highly associated with ED closure, including for-profit ownership status, location in a
competitive market, safety net status, and a low profit margin (Hsai et al., 2011). As
previously mentioned, while the number of available EDs has decreased, volume of patients
seeking care has increased significantly. Of that larger volume of patients seeking care in the
ED, a disproportionately higher number of those people were either publically insured or
uninsured, creating even more of a financial burden on EDs already struggling to keep their
doors open (Hsai et al., 2011).
Adding to the strain created by fewer EDs, a rising number of ED patients, and a poor
payer mix, is the trend toward non-emergent patients seeking care in the ED (Pitts, Carrier,
Rich & Kellerman, 2010). From 2001 to 2004, Americans made 1.09 billion visits to
outpatient services to seek medical care. Of those visits, 28% were to hospital EDs, with
many of the complaints classified as “non-emergent.” The main reason for the trend toward
ED utilization for primary care issues was the lack of timely access to care, especially after
business hours and on the weekends (Pitts et al., 2010). The data paints a bleak picture for
3. EDs that remain open for business: a surging volume due to neighboring EDs closing, a
deteriorating payer mix and an increase in patients that should be receiving services in
primary care settings but lack timely access, and so utilize the ED for basic health care needs
(Asplin et al., 2003; Pitts et al., 2010).
Problem
The consequences of overcrowding and prolonged wait times in the ED are well
established in the research literature and affect not only the quality of the care patients
receive, but also satisfaction level and the overall length of stay in the hospital (Miro et al.,
1999; Richardson, 2006; Sprivulis, Da Silva, Jacobs, Frazer & Jelinek, 2006). Effects of
crowding in the ED include poorer clinical outcomes, including a correlation between high
ED volumes and higher patient mortality rate and delays in receiving time-sensitive
interventions for critical conditions like stroke, heart attack, pneumonia and prompt pain
management (Fee, 2007; Hwang et al., 2008; Kulstad & Kelley, 2009; Schull, Vermeulen,
Slaughter, Morrison & Daly, 2004). Further, the patient’s length of stay in the ED has been
shown to affect his or her entire hospital stay, as longer hospitalizations typically occur when
time in the ED exceeds 24 hours (Bernstein et. al, 2008). Not only are patient clinical
outcomes directly affected by ED overcrowding, but prolonged wait times have also been
shown to be the driving reason for dissatisfaction in patients who access emergency care
(Beaudroux & O’Hea, 2004; Pines, Decker & Hu, 2012; Vieth & Rhodes, 2008).
Aside from the impact on quality, timely care and patient satisfaction, ED
overcrowding has a distressing impact on ED staff morale. The “work environment” has been
cited as a leading cause of stress among ED employees, with workload and overcrowding
topping the list of contributing factors (Healy & Tyrrell, 2011). Additionally, the presence of
4. “burnout,” a widely used concept in organizational psychology defined as emotional
exhaustion, depersonalization and a reduced sense of personal accomplishment, is widespread
among nurses in EDs, with the highest contributing factor being a work environment
characterized by overcrowding, high demands and lack of adequate resources (O’Mahoney,
2011). While the effect of overcrowding on ED staff may seem to be a separate issue from
the patient’s experience, burnout among nurses has been shown to impact the likelihood of
their retention and subsequent impact of patient care quality and satisfaction, suggesting a
positive feedback loop between the reaction of nurses to the level of stress in the work
environment and the patients’ satisfaction with their hospital experience (Aiken, Clark,
Sloane, Sochalski & Silber, 2002). Each of these negative outcomes of ED overcrowding,
poorer quality of care, reduced patient satisfaction, and staff burnout, compound the already
challenging situation that EDs face in the United States. This reality has led the federal
government and accrediting agencies to put the burden on hospitals to address the problem
(Balik, 2011; Raso, 2013).
Significance
Reducing ED overcrowding and creating efficiencies in the throughput process have a
direct impact on the public image and financial performance of hospitals (Bayley et al., 2005;
Handel & McConnell, 2008; Tekwani, Keerem, Mistry, Sayger & Kulstad, 2012). Recent
regulations from accrediting agencies such as The Joint Commission and the federal agency
the Centers for Medicare and Medicaid Services (CMS) have focused on hospital responses to
ED overcrowding. The regulations from these two agencies have raised the standard of
performance to maintain accreditation, and have tied financial performance to the patient’s
perception of their care (cms.gov, 2012).
5. As of January 1, 2014, The Joint Commission revised the “patient flow standards”
(Leadership standard 04.03.11 and Patient Care standard 01.01.01) to include additional
requirements for hospital EDs. In addition to the existing elements related to goal setting and
data tracking of patient flow, EDs are now expected to meet the goal of holding admitted
patients in the ED for no more than 4 hours, a concept referred to in the field of emergency
medicine as “boarding” (“Approved Standards,” 2012). Additionally, EDs must have a
written plan for the boarding of psychiatric patients requiring services not offered at the
facility. As the expectations to achieve accreditation from the Joint Commission become
more stringent, EDs are forced to confront the problems of overcrowding and pursue any
available intervention to improve throughput (“Approved Standards,” 2012).
In addition to the stringent requirements for throughput performance to maintain
accreditation, recent studies have shown that ED crowding leads to significant revenue loss
for hospitals (Bayley et al., 2005; Falvo, Grove, Stachura & Zirkin, 2007; Handel &
McConnell, 2008). Overcrowding leads to reduced capacity to treat patients, causes diversion
of ambulances and increases patient elopements based on prolonged ED wait times. Lastly,
ED overcrowding contributes to revenue loss for hospitals that range from more than $200 per
patient based on a study that measured the impact of wait times greater than 3 hours (Handel
& McConnell, 2008), and up to $119,000 weekly, from another study assessing the
connection between frequency of ambulance diversion and loss of revenue opportunity (Falvo
et al., 2007).
Adding to the challenges of maintaining accreditation and limiting revenue loss is the
increased focus by the federal government on the patient’s experience during their hospital
stay. A 2 year study of patients directly discharged from the ED, found that ED
6. overcrowding, as measured by volume above the average for time of day and day of the week,
was inversely correlated with patient satisfaction scores (odds ratio [OR] 0.32, 95%
confidence interval, [CI] 0.17 to 0.59, p < 0.001), suggesting that overcrowding is associated
with the patient’s satisfaction with their care experience in the ED (Tekwani et al., 2012).
Further, changes to hospital reimbursement established by the value-based purchasing (VBP)
model currently tie 30% of potential funds from CMS to patient satisfaction scores, which
reflect the quality of the patient experience (Raso, 2013). With the financial bottom line now
impacted by health care consumers’ perception of their care, patient satisfaction has moved
from one of many priorities to a top concern for hospital executives (Balik, 2011).
Beyond the financial incentives that the federal government has provided for hospitals
to improve patient satisfaction, the health care environment has increasingly taken on a
consumer-mentality where patients have access to quality measures and patient satisfaction
scores empowering them to make choices about their care based on these publically-
accessible measures (Christianson, Ginsburg & Draper, 2008). These patient choices will be
influenced by the experience in the ED offering an opportunity for the ED to establish a
positive experience for the patient throughout his or her hospital admission. In light of the
significant financial risks facing hospitals and the impact of public reporting of satisfaction
measures, every aspect of care that influences the patient’s satisfaction must be thoroughly
examined. As such, common predictors of patient satisfaction in the ED, including quality of
interpersonal interaction with providers, perception of provider skill level, and wait times,
require focused attention to assure a positive experience for patients (McCarthy et al., 2011).
One specific intervention that could impact the wait time indicator is process flow redesign
7. and improving efficiencies in throughput which may, in turn, improve patient satisfaction
(Boudreaux & O’Hea, 2004).
Conceptual Model of ED Overcrowding
The problem of ED overcrowding and the resulting challenges to throughput are best
understood using the conceptual model of ED crowding developed by Asplin et al.
(2003). Asplin et al.’s model takes a systems approach to the throughput process, and has
gained traction in the literature as an effective tool to understand the elements that enter the
ED system, how those factors are managed through the patient flow process, and how the
elements leave the system. This model is divided into three phases describing the flow of
patients into and out of the ED: the input phase (divided into the three patient types who
utilize the ED), the throughput phase (the stages of care that occur when the patient is
physically in the ED) and the output phase (the destination of patients from the ED once their
treatment is complete).
Asplin et al.’s model breaks the input phase into three main patient types: (1)
emergency care, including the ill and injured from the community, and the seriously ill
referred from primary care sources, (2) unscheduled urgent care, created by a lack of capacity
in the ambulatory care system and patients using the ED for care that is considered more
immediate and convenient, and (3) safety net care, consisting of vulnerable populations such
as the uninsured and those with barriers to accessing care such as transportation or financial
need. The second and third groups, unscheduled urgent care and safety net care, have
contributed disproportionately to the rise in ED visits over the last two decades, and are
largely responsible for the high demand funneling into the input phase of the system (Hsai et
al., 2011; Pitts et al., 2010).
8. Theoretical Framework
FIGURE 1. The input-throughput-output conceptual model for ED crowding adapted from
Asplin et al. (2003).
The throughput phase of the model is divided into four segments: arrival at the ED,
triage and room placement, diagnostic evaluation and ED treatment, and patient disposition
(Asplin et al., 2003). The throughput phase is the point in the process where ED care is
rendered, including the initial triage process, provider assessment, treatment and diagnostic
testing.
The output phase of Asplin et al.’s (2003) model begins when the provider makes the
decision regarding the patient’s disposition to follow up care, whether it is a referral to the
ambulatory care system, transfer to another facility, or admission to the hospital. The point at
Emergency Care
• Seriously ill and
injured patients from
the community
• Referral of patients
with emergency
conditions
Unscheduled Urgent
Care
• Lack of capacity for
unscheduled care in the
ambulatory system
• Desire for immediate
care (e.g., convenience,
conflicts with job,
family duties)
Safety Net Care
• Vulnerable
populations (Medicare
beneficiaries, the
uninsured)
• Access barriers (eg,
financial,
transportation,
insurance, lack of usual
source of care)
Ambulance
Diversion
Demand for
ED care
Patient arrives
at ED
Triage and room
placement
Diagnostic
evaluation and
ED treatment
Leaves
without
treatment
complete
Patient
disposition
Ambulatory
care system
Input Throughput Output
ACUTE CARE SYSTEM
Lack of access to
follow up care
Transfer to
other
facility
(eg, skilled
nursing,
hospital
referral
Admit to
hospital
ED boarding of
inpatients
Lack of available
staffed inpatient
beds
Focus of Flow
Coordinator Role
9. which the patient leaves the ED ends the throughput phase and initiates the output phase. The
limited influence over the input and output phases of the system has led ED management and
hospital administrators to focus heavily on the throughput phase of ED care, the point over
which they have the most control (Oredsson et al., 2011).
Approaches to Improving ED Throughput
In the literature, the most commonly applied strategies to manage ED overcrowding
and improve throughput center around five different initiatives: patient-specific flow (PSF)
models, rapid triage (RT), provider in triage (PIT), the flow expeditor model, and the use of
technology (Wiler et al., 2010).
Patient-Specific Flow
For ED managers, one of the primary strategies to increase throughput times is to
design the layout of the ED to function most efficiently for different types of patients. This is
usually achieved by splitting high acuity versus low acuity patients, or by creating smaller
geographical pods staffed by teams that care for either the high or low acuity patient groups
(Baker, Shupe & Smith, 2013). The idea behind splitting patient types is to expedite
treatment of lower acuity patients that require fewer resources to treat but may
disproportionately occupy valuable ED treatment areas (Oreddson et al., 2011). Three
applications of the PSF model include the zoning system, fast track and vertical flow.
Zoning system. At a well known university hospital in New Jersey, hospital
administrators instituted a zoning system in achieve a “15/30” guarantee that they made to
patients, that they would be seen by a practitioner within 15 minutes of arrival and would
receive a medical examination within 30 minutes (Welch, Jones & Allen, 2007).
Administrators created four zones, the first three of which were staffed by a physician, two
10. nurses and a tech and the fourth zone staffed by a physician, two mid-level providers, two
nurses and a tech. The idea behind the separate zones was to increase accountability for each
care team. Rather than a single employee functioning independently within a large
department, each zone’s performance was tracked and tied to the clinical staff working in that
area. Six months after implementation of the four-zone system, the ED’s door-to-provider
time fell from an average of 21 to 16 minutes, the LWBS rate fell from 3% to 1% and patient
satisfaction scores in the ED rose from the 75th
to the 80th
percentile (Welch et al., 2007). The
zoning model has become a best-practice for EDs based on several core concepts: smaller
areas allow for more efficient work flow and communication, supplies are more accessible
when readily available in the zone and zones specific to patient population assist in accurately
tracking patient location (Welch et al., 2007).
Fast-track flow. Several additional studies present the fast-track translation of the PSF
model, which is generally defined as a separate treatment area for lower acuity patients, often
staffed by mid-level providers such as a nurse practitioner or a physician assistant (Nash,
Zachariah & Nitschmann, 2007; Rodi, Grau & Orsini, 2006; Sanchez, Smally, Grant &
Jacobs, 2006). Researchers at a public teaching hospital in Melbourne, Australia measured
the effect of a fast-track model on ED length of stay (Considine, Kropman, Kelly & Winter,
2008). During the three-month post-implementation period, non-admitted patients spent 16
fewer minutes in the ED compared to the control group. Secondary results of the study also
included a decrease of 55 minutes in length of stay for admitted patients, most of whom did
not utilize the fast-track unit, suggesting that all patients in the ED benefit from the fast-track
model (Considine et al., 2008).
11. White et al. (2010) performed a similar retrospective study comparing before and after
implementation of a fast track unit in a large, urban ED. Overall LOS and LWBS were both
decreased by half, with perhaps the most important contribution being no change in quality of
care, as measured by revisits to the ED and overall mortality rate (Sanchez et al., 2005).
Vertical flow. Similar to the zoning model is a split-flow model that “keeps vertical
patients vertical” after initial evaluation, meaning that patients who are able to walk are not
placed in a bed at any point of their visit to the ED. This model is based on the concept of a
“results pending” area, where ambulatory patients wait for test results in a common area and
not in a treatment room (Baker et al., 2013). The vertical flow model aggressively separates
patients needing urgent or emergent care and directs them to treatment areas in the ED, while
ambulatory patients are evaluated quickly, and wait for results outside of the main treatment
areas. “Vertical patient flow,” keeping ambulatory patients out of the main ED treatment area
is seen as a common, effective and relatively inexpensive strategy to reduce overcrowding
and improve efficiency (Lui, et al., 2013).
Patient specific flow models are emerging in the literature as promising interventions
to alleviate overcrowding in EDs. However, of the three types of PSF models reported in the
literature, the fast track application is the most widespread and scientifically vetted,
consistently showing a positive impact on ED length of stay, LWBS and elopements
(Considine et al., 2008; Nash et al., 2007; Rodi et al., 2006; Sanchez et al., 2006). Thus,
focusing on the fast track application may yield the best outcome for throughput metrics.
Rapid Triage
Perhaps the most widely implemented of the throughput strategies is the RT model,
which typically focuses on combining tasks that previously occurred sequentially, most often
12. registration and nurse triage. Also, in the RT model, the provider sees the patient sooner in
the process by doing a brief medical screening examination to assist in sorting high vs. low
acuity patients (Oreddson et al., 2011). This separation of patients allows for lower acuity
patients to be siphoned off to a common waiting area for expedited treatment and discharge.
Murrell, Offerman & Kauffman (2011) reported a decrease in the LWBS rate from
7.7% to 3% and the D2P time from 62 minutes to 41 minutes after the implementation of a
Rapid Triage and Treatment (RTT) model consisting of simultaneous registration, nurse triage
and designation of high acuity patients immediately to a treatment room to be seen by a
provider and low acuity patients to an internal waiting area for quick treatment and discharge.
Provider in Triage
A third approach to reduce overcrowding and improve throughput that has been
broadly applied throughout the United States is the model of stationing a provider in triage
(PIT) (Bahena & Andreoni, 2013). This model uses either a physician or a mid-level provider
in triage with the aim of combining the triage process with provider assessment and eventual
discharge, especially for low acuity patients. In a 23-bed ED in Massachusetts, the
emergency department management team studied the effect of placing a physician in triage on
D2P time, median length of stay in the ED and LWBS. In the PIT model, patients saw a
provider immediately after the quick registration process, allowing laboratory, radiology and
other interventions to be initiated immediately. Patients who required no interventions were
assessed and discharged within one interaction. Six months after implementation, the ED
experienced a decrease in their D2P time of 36 minutes; a decrease in their median LOS of 12
minutes and their LWBS fell from 1.5% to 1.3% (Imperato et al., 2012).
13. While placing a physician in triage provides the largest scope of practice to the front-
end of the throughput process, it is also an expensive model (Bahena & Andreoni, 2013).
Many EDs have instituted mid-level providers in triage that include nurse practitioners and
physician assistants who will assess, order testing, discharge lower acuity patients, and refer
the higher acuity patients to a primary ED physician. At a large and busy ED in Minnesota,
the use of PAs during high volume times decreased the median length of stay in the ED by 41
minutes and the LWBS fell from 9.7% to 1.4% compared to days without a PA in triage
(Nestler, et al., 2012).
As each of these studies show, placing a physician in triage provides the broadest
range of care options at the front-end of the throughput process because of their ability to
assess, diagnose, treat and discharge a comprehensive range of patient acuities and conditions,
but this model can prove to be expensive to sustain. A modification of this concept is the use
of mid-level providers to provide rapid assessment and initiation of orders, leaving the
remaining care and discharge of patients to other providers later in the patient’s course of stay
in the ED.
Flow Expeditor
The fourth model employed by emergency departments aiming to tackle the
challenges of overcrowding is the flow expeditor role, typically staffed by a nurse, paramedic
or technician (Feehan & Smolin, 2006). This role is modeled after the maître d’ in a
restaurant, and is responsible for attending to patients quickly upon arrival, keeping the flow
of patients moving forward, alleviating bottlenecks and ensuring that patient care tasks do not
fall through the cracks. A variety of flow expeditor models that have been measured for
14. effectiveness in improving throughput include paramedic, technician, registered nurse, nurse
practitioner and physician roles (Wiler et al., 2010).
At a university medical center in Oregon, Handel et al. (2011) studied the effect of
using a paramedic as a flow expeditor on the ED length of stay (LOS) and ambulance
diversion hours. Post-implementation, the average LOS fell from 5.4 hours to 5.0 hours,
despite a significant increase in their daily census during the testing period (Handel et al.,
2011). Furthermore, elopements fell from 6.6% to 5.7% after implementation of the
paramedic expeditor.
In a slightly modified application of the flow expeditor role, emergency department
leadership at a large hospital in Los Angeles County created a “lobby coordinator” role during
peak volume hours (Rubino & Chan, 2007). The lobby coordinator was a registered nurse
dedicated to updating patients on wait times, reassessing patient status, acting as a liaison
between waiting patients and ED staff and enhancing customer service. Four months after
implementation of the lobby coordinator, patient satisfaction increased by 24 % and the
LWBS rate fell by 23% (Rubino & Chan, 2007).
While the flow expeditor role can be found in the literature in several different forms,
its impact on throughput is yet to be firmly established. The studies focusing on the flow
expeditor are, at times, anecdotal, inconsistent and lack scientific rigor (Handel et al., 2011).
Technology
The final category of throughput interventions employed in EDs is the use of
technology. The most common technological applications aimed at reducing overcrowding
and improving throughput are point-of-care (POC) testing (Halverson & Milner, 2011),
15. bedside ED imaging capabilities (Halm, 2013) and electronic mapping of ED utilization
(Welch et al., 2007).
Point of care testing. Point of Care (POC) testing is the measurement of various
laboratory values at the point of patient care, or at the patient’s bedside (Oredsson et al.,
2011). POC testing allows caregivers access to laboratory results much more quickly than
using the traditional method of sending blood samples to the central hospital laboratory to be
placed in a queue and resulted along with many other patients’ laboratory tests. Many EDs
have used POC testing for many years, but the effect on the throughput process has only been
widely studied in the last decade (Oredsson et al., 2011).
Bedside ED imaging. Similar to the POC concept is the trend of making bedside
ultrasound available for use in the emergency department. In a case study of a pediatric
patient with a medical emergency, Halm (2013) found that length of stay in the emergency
department was decreased by three hours and the patient’s critical condition diagnosed within
one hour of arrival to the ED.
Mapping ED utilization. Software programs exist that map ED utilization with the
goal of directing resources most efficiently at the times and locations where they are most
needed (Welch et al., 2007). This mapping includes varying staffing patterns, increasing
certain roles based on patient-type specific volume, such as registration or triage personnel
and adjusting supply levels based on time of day, day of the week and season of the year.
A more facility-specific application that has shown promise applying the PTS concept
is a patient flow simulation, which tracks the actual flow of patients from arrival to the
various points of testing and treatment, and eventually to discharge or admission in a specific
ED, allowing ED managers to reallocate resources to decrease backflow and maximize the
16. most efficient ED design (Brenner et al., 2010). While technology may be one useful answer
to solve throughput challenges, there is no conclusive evidence on the best applications to
alleviate overcrowding burdens.
CONCLUSION
Throughput in the emergency department is a dynamic process with many factors
affecting how efficiently patients move through the course of their care. This multi-factorial
system is most commonly represented in the literature by Asplin et al.’s three-phase
conceptual model of ED overcrowding (2003). Many efforts have been made to address the
problem of overcrowding in the ED, with the most common interventions focusing on the
throughput stage: PSF models, the RT model, the PIT model, the flow expeditor model, and
the use of technology (Wiler et al., 2009).
17. REFERENCES
Aiken, L., Clark, S., Sloane, D., Sochalski, J. & Silber, J. (2002). Hospital nurse
staffing, patient mortality, nurse burnout and job dissatisfaction. JAMA 288(16):
1987-1993.
Approved: Standards Revisions Addressing Patient Flow Through the Emergency
Department. (2012). Joint Commission Perspectives 32(7): 1-5.
Asha, S. E., & Ajami, A. (2013). Improvement in emergency department length of stay
using an early senior medical assessment and streaming model of care: A cohort
study. Emergency Medicine Australasia, 25(5), 445-451. doi:10.1111/1742-
6723.12128
Asplin, B., Magid, D., Rhodes, K., Solberg, L., Lurie, N. & Camargo, C. (2003). A
conceptual model of emergency department crowding. Annals of Emergency
Medicine 42: 173-180.
Ay, D., Akkas, M. & Sivri, B. (2008). Patient population and factors determining length
of stay in adult ED of a Turkish university medical center. The American Journal
of Emergency Medicine 28(3), 325-330.
Bahena, D. & Andreoni, C. (2013). Provider in triage: Is this a place for nurse
practitioners? Advanced Emergency Nursing Journal 35(4), 332-343.
Bayley, M., Schwartz, J., Shofer, F., Welner, M., Sites, F., Traber, K. & Hollander, J.
(2005). The financial burden of emergency department congestion and hospital
crowding for chest pain patients awaiting admission. Annals of Emergency
Medicine 45(2): 110-117.
Baker, S., Shupe, R. & Smith, D. (2013). Driving efficient flow: Three best-practice
models. Journal of Emgergency Nursing 39(5), 481-484.
Bellow, A., Flottemesch, T. & Gordon, G. (2012). Application of the emergency
department census model. Advanced Emergency Nursing Journal 34(1), 55-64.
Bernstein, S., et al. (2008). The effect of emergency department crowding on clinically
oriented outcomes. Academic Emergency Medicine 16, 1-10.
Boucher, D & Doak, T. (2012). Lean-driven solutions slash ED wait times, LOS. ED
Management Dec 2012, 139-141.
Brenner, S., Zeng, Z., Liu, Y., Wang, J., Li, J. & Howard, P. (2010). Modeling and
analysis of the emergency department at University of Kentucky Chandler Hospital
using simulations. Journal of Emergency Nursing 36(4): 303-310.
Burchett, P. (2013). Culture change improves ED throughput. Hospital Case
18. Management Jan 2013, 8-10.
Burstrom, L, Starrin, B., Engstrom, M. & Thulesius, H. (2013). Waiting management at
the emergency department—a grounded theory study. BMC Health Services Research
2013 13: 95.
Chan, T., Killeen, J., Kelly, D. & Guss, D. (2005). Impact of rapid entry and accelerated
care at triage on reducing of emergency department patient wait times, length of stay
and rate of left without being seen. Annals of Emergency Medicine 46(6): 491-497.
Christianson, J., Ginsburg, P. & Draper, D. (2008). The transition from managed care to
consumerism: a community-level status report. Health Affairs 27, 1362-1370.
Balik, B. (2011). Leaders’ role in patient experience. Healthcare Executive, 26(4),
74-76.
Cohen, S. (2013). Perspectives on emergency department throughput. Emergency
Nursing Advocacy 39: 61-64.
Community Benefit Report and Community Benefit Plan, FY2013, St. Mary Medical
Center (2012).
Considine, J., Lucas, E., Payne, R., Kropman, M., Stergiou, H. & Chiu, H. (2012).
Analysis of three advanced practice roles in emergency nursing. Australasian
Emergency Nursing Journal 15, 219-228.
Day, T., Al-Roubaie, A., & Goldlust, E. (2013). Decreased length of stay after addition
of healthcare provider in emergency department triage: a comparison between
computer-simulated and real-world interventions. Emergency Medicine Journal 30:
134-138.
Ding, R., McCarthy, M., Li, G., Kirsch, T., Jung, J. & Kelen, G. (2006). Patients who
leave without being seen: Their characteristics and history of emergency
department use. Annals of Emergency Medicine 48(6): 686-693.
Doyle, S., Kingsnorth, J., Guzzetta, C., Jahnke, S., McKenna, J. & Brown, K. (2012).
Outcomes of implementing rapid triage in the pediatric emergency department.
Journal of Emergency Nursing 38(1), 30-35.
Falvo, T., Grove, L., Stachura, R. & Zirkin, W. (2007). The financial impact of
ambulance diversions and patient elopements. Academic Emergency Medicine 14: 58-
62.
Fee, C., et al., (2011). Consensus-based recommendations for research priorities related
to interventions to safeguard patient safety in the crowded emergency department.
Academic Emergency Medicine 18, 1283-1288.
Feehan, M. & Smolin, G. (2006). Flow techs help ED run smoothly. ED Management,
19. May 2006, 57-58.
Frequently Asked Questions: Hospital Value-Based Purchasing Program. (2012).
Retrieved September 30, 2012. http://www.cms.gov/Medicare.
Halm, B. (2013). Reducing the time in making the diagnosis and improving workflow
with point-of-care ultrasound. Pediatric Emergency Care 29(2): 218-221.
Halverson, K. & Milner, D. (2011). Implementation of point-of-care testing in the
emergency department: A study on decreased throughput times for patients being
seen for rapid Group A Strep testing. Point of Care 10(3): 116-119.
Handel, D. & McConnell, J. (2008). The financial impact of ambulance diversion of
inpatient hospital revenues and profits. Academic Emergency Medicine 16: 29-33.
Handel, D., Ma, O., Workman, J. & Fu, W. (2011). Impact of an expeditor on emergency
department patient throughput. Western Journal of Emergency Medicine 12(2), 198-
203.
Healy, S. & Tyrell, M. (2011). Stress in emergency departments: Experiences of doctors
and nurses. Emergency Nurse 19(4), 31-37.
Hsai, R., Kellerman, A. & Shen, Y-C. (2011). Factors associated with closures of
emergency departments in the United States. Journal of the American Medical
Association 305(19): 1978-1985.
Hwang, U., Richardson, L., Livote, E., Harris, B., Spencer, N., & Sean Morrison, R.
(2008). Emergency department crowding and decreased quality of pain care.
Academic Emergency Medicine, 15(12), 1248–1255.
Imperato, J., Morris, D., Binder, D., Fischer, C., Patrick, J., Sanchez, L. & Setnik, G.
(2012). Physician in triage improves emergency department throughput. Intern
Emergency Medicine 7: 457-462.
Institute of Medicine (2006). Future of emergency care in the United States health
system. (Report brief: June 2006). Retrieved from www.iom.edu.
Jang, J-Y, Shin, S-D, Lee, E-J, Park, C-B, Song, K-J & Singer, A. (2013). Use of a
Comprehensive Metabolic Panel Point-of-Care Test to Reduce Length of Stay in
the Emergency Department: A Randomized Controlled Trial. Annals of Emergency
Medicine, 61(2): 145-151.
Johnson, K. & Winkelman, C. (2011). The effect of emergency department crowding on
patient outcomes: A literature review. Advanced Emergency Nursing Journal
33(1), 39-54.
Johnson, M., Meyers, S., Wineholt, J., Pollack, M. & Kusmiesz, A. Patients who leave
20. the emergency department without being seen. Journal of Emergency Nursing
35(2), 105-108.
Kennebeck, S., Timm, N., Farrell, M., & Spooner, S. (2012). Impact of electronic health
record implementation on patient flow metrics in a pediatric emergency
department. Journal Of The American Medical Informatics Association, 19(3),
443-447.
Kilcoyne, M. & Dowling, M. (2007). Working in an overcrowded accident and
emergency department: Nurse’s narratives. Australian Journal of Advanced Nursing
25(2), 21-27.
Klein, M. & Reinhardt, G. (2012). Emergency department patient flow simulations using
spreadsheets. Simulation in Healthcare 7:40-47.
Knapman, M. & Bonner, A. (2010). Overcrowding in medium-volume emergency
departments: Effects of aged patients in emergency departments on wait times for
non-emergent triage-level patients. International Journal of Nursing Practice 16:
310-317.
Kulstad, E. B., & Kelley, K. M. (2009). Overcrowding is associated with delays in
percutaneous coronary intervention for acute myocardial infarction.
International Journal of Emergency Medicine, 2(3), 149–154.
Liu, S., Hamedani, A., Brown, D., Asplin, B. & Camargo, C. (2013). Established and
novel initiatives to reduce crowding in emergency departments. Western Journal of
Emergency Medicine 14(2): 85-89.
Long Beach Quickfax. US Census Bureau (2010). Retrieved from
www.quickfax.census.gov on October 27, 2012.
McCarthy, M., Ding, R., Zeger, S., Agada, N., Bessman, S., Chiang, W., Kelen, G.,
Scheulen, J. & Bessman, E. (2011). A randomized controlled trial of the effect of
service delivery information on patient satisfaction in an emergency department fast
track. Academic Emergency Medicine 18(7): 674-684.
Miro, O., Antonio, M. T., Jimenez, S., De Dios, A., Sanchez, M., Borras, A., & Milla, J.
(1999). Decreased health care quality associated with emergency department
overcrowding. European Journal of Emergency Medicine, 6(2), 105–107.
Moore, C. (2013). An Emergency Department Nurse-Driven Ultrasound-Guided
Peripheral Intravenous Line Program. Journal of the Association for Vascular Access
18: 45-51.
Morgan, R. (2007). Turning around the turn-arounds: improving ED throughput
processes. Journal of Emergency Nursing 33(6), 530-536.
21. Murphy, S., Barth, B., Carlton, E., Gleason, M. & Cannon, C. Does an ED flow
coordinator improve patient throughput? Journal of Emergency Nursing 40(6),
605-612.
Murrell, K., Offerman, S. & Kauffman, M. (2011). Applying Lean: Implementation of a
rapid triage and treatment system. Western Journal of Emergency Medicine 12(2),
184-191.
Nash K., Zachariah B., Nitschmann J, et al (2006). Evaluation of the fast track unit of a
university emergency department. Journal of Emergency Nursing 33:14-20.
Nestler, D., et al. (2012). Effect of a physician assistant as triage liaison provider on
patient throughput in an academic emergency department. Academic Emergency
Medicine 19(11): 1235-1241.
O’Mahoney, N. (2011). Nurse burnout and the working environment. Emergency Nurse,
19(5), 30-37.
Oredsson, S., et al. (2011). A systematic review of triage-related interventions to
improve patient flow in emergency departments. Trauma, Resuscitation & Emergency
Medicine 19:43-52.
Pennsylvania Patient Safety Advisory (2010). Managing patient access and flow in the
emergency department to improve patient safety. Pennsylvania Patient Safety
Authority 7(4), 123-134.
Pines, J., Decker, S. & Hu, T. (2012). Exogenous predictors of national performance
measures for emergency department crowding. Annals of Emergency Medicine
60(3), 293-298.
Pitts, S., Carrier, E., Rich, E. & Kellerman, A. (2010). Where Americans get acute care:
Increasingly, it’s not in their doctor’s office. Health Affairs 29(9): 1620-1629.
Poissant, L., Pereira, J., Tamblyn, R., & Kawasumi, Y. (2005). The Impact of
Electronic Health Records on Time Efficiency of Physicians and Nurses: A
Systematic Review. Journal of the American Medical Informatics Association :
JAMIA, 12(5), 505–516. doi:10.1197/jamia.M1700.
Polevoi, S., Quinn J., Kramer N. (2005). Factors associated with patients who leave
without being seen. Academic Emergency Medicine 12:232-236.
Raso, R. (2013). Value based purchasing: What’s the score? Nursing Management
44(5): 29-34.
Richardson, D. B. (2006). Increase in patient mortality at 10 days associated with
22. emergency department over- crowding. Medicine Journal of Australia, 184(5),
213–216.
Rodi, S., Grau, M. & Orsini, CM (2006). Evaluation of a fast track unit: alignment of
resources and demand results in improved satisfaction and decreased length of
stay for emergency department patients. Quality Management Health Care 15:163-
170.
Rowe B., Channan P. & Bullard M., et al. (2006). Characteristics of patients who leave
emergency departments without being seen. Academic Emergency Medicine
13:848-852.
Rubino, L. & Chan, M. (2007). Innovative approach to the aims for improvement:
Emergency department patient throughput in an impacted urban setting. Journal of
Ambulatory Care Management 30(4), 327-337.
Russ, S., Jones, I., Aronsky, D., Dittus, R. & Slovis, C. (2010). Placing physician orders
at triage: The effect on length of stay. Annals of Emergency Medicine 56(1), 27-33.
Sanchez, M., Smally, A., Grant, R. & Jacobs, L. (2005). Effects of a fast-track area on
emergency department performance. Administration of Emergency Medicine 31:
117-120.
Schull, M. J., Vermeulen, M., Slaughter, G., Morrison, L., & Daly, P. (2004). Emergency
department crowding and thrombolysis delays in acute myocardial infarction.
Annals of Emergency Medicine, 44(6), 577–585.
Sharieff, G., Burnell, L., Catonis, M., Norton, V., Tovar, J., Roberts, K., VanWyk, C.,
Saucier, J. & Russe, J. (2013). Improving emergency department time to provider,
left-without-treatement rates, and average length of stay. The Journal of
Emergency Medicine, 45(3), 426-432.
Shetty, A., Gunja, N., Byth, K., & Vukasovic, M. (2012). Senior Streaming Assessment
Further Evaluation after Triage zone: A novel model of care encompassing various
emergency department throughput measures. Emergency Medicine Australasia,
24(4), 374-382. doi:10.1111/j.1742-6723.2012.01550.x
Sprivulis, P. C., Da Silva, J. A., Jacobs, I. G., Frazer, A. R., & Jelinek, G. A. (2006). The
association between hospital overcrowding and mortality among patients admitted
via Western Australian emergency departments. Medicine Journal of Australia,
184(5), 208–212
Storrow, A., Lyon, J., Porter, M., Chou, Z., Han, J-H. & Lindsell, C. (2009). A
systematic review of emergency department point-of-care cardiac markers and
efficiency measures. Point of Care 8(3): 121-125.
23. Tekwani, K., Keerem, Y., Mistry, C., Sayger, B. & Kulstad, E. (2012). Emergency
department overcrowding is associated with reduced satisfaction scores with
patients discharged from the emergency department. Western Journal of
Emergency Medicine 14:11-15.
Thamburaj, R. & Sivitz, A. (2013). Does the use of bedside pelvic ultrasound decrease
length of stay in the emergency department? Pediatric Emergency Care 29: 67-
70.
Tsai, V., Sharieff, G., Kanegaye, J., Carlson, L. & Harley, J. (2012). Rapid medical
assessment: Improving pediatric emergency department time to provider, length
of stay, and left without being seen rates. Pediatric Emergency Care 28(4): 354-
356.
Vieth, T. L., & Rhodes, K. V. (2006). The effect of crowding on access and quality in
an academic ED. American Journal Emergency Medicine, 24(7), 787–794.
Welch, S. (2009). In the zone: Redesigning flow. Emergency Medicine News, July 2009.
Welch, S., Jones, S. & Allen, T. (2007). Mapping the 24-hour emergency department
cycle to improve patient flow. The Joint Commission Journal on Quality and
Patient Safety 33(5): 247-255.
White, B., Brown, D., Sinclair, J., Chang, Y., Caringna, S., McIntyre, J. & Biddinger, P.
(2012). Supplemented triage and rapid treatment improves performance measures
in emergency department. Administration of Emergency Medicine 42(3): 322-
328.
Wiler, J., Gentle, C., Halfpenny, J., Heins, A., Mehrotra, A., Mikhail, M. & Fite, D.
(2010). Optimizing emergency department front-end operations. Annals of Emergency
Medicine 55(2), 142-160.
Wilner, J., Handel, D., Ginde, A., Aronsky, D., Genes, N., Hackman, J., Hilton, J.,
Hwang, U., Kamali, M., Pines, J., Powell, E., Sattarian, M. & Fu, R. (2012).
Predictors of length of stay in 9 emergency departments. The American Journal
of Emergency Medicine 30, 1860-1864.