What focused physician services management looks like on the ground
The past two months have been extremely trying for many of our hospital partners. I don’t think it’s a stretch to say that working through the Delta surge has, in many parts of the country, felt like working through a war.
As I write, the U.S. is still averaging more than 2,000 deaths a day from COVID-19. Across the country, and especially in the South, where Core has many hospital partnerships, ICUs have been close to full. Hospital staff are doing what they always do in times of crisis: pulling together, working long shifts, and often risking their own health through contact with COVID-positive patients, all day, every day.
Though case rates are finally coming down nationally, some parts of the country are just now beginning their own Delta surges. So, I thought in this issue we should do three things:
- Acknowledge and thank all of our staff and partners for the incredible work they have been doing over the past few months. Thank you!
- Urge everyone who is not yet vaccinated to get vaccinated—that is the clearest and most direct way we have to end this pandemic. The story we are about to tell below took place in a community in Louisiana where only about 36 percent of people are fully vaccinated.
- Share a story here about what good, focused physician services management can do to help hospitals manage the kind of stress the Delta surge has put on the healthcare system.
So, here is how we responded to a Delta surge at our partner hospital in Monroe, Louisiana:
The Delta Surge at St. Francis Medical Center
When we announced the partnership with St. Francis Medical Center in May 2020, we built a staffing model for 125 patients a day coming through the Emergency Department. At the time, volume was actually a little lower, around 110/day. But that was about to change.
In June, it started to increase to about 150/day. As physician groups do, we re-adjusted. We had already been hiring: several APPs, and two new board-certified emergency medicine physicians for a community of just under 50,000 in Monroe, Louisiana.
A turning point came in July, when Mark Canada, Core’s Vice President of Clinical Operations, noted a spike in left without being seen (LWBS) rates related to volumes that were approaching 175/day, on their way to 200/day. In August, we set continuous records, with many days close to 250. On the busiest day, in late August, the ED volume was 264.
Thankfully, long before that, Mark had been on the ground implementing and refining a process that allowed the hospital to manage the surge. And not just that: LWBS rates fell, patient satisfaction scores rose, and at a time when nearby facilities were overwhelmed, St. Francis earned a reputation for being the place you can go to get outstanding COVID care.
But back to that early spike in left without being seen rates. In some places, such a spike might be met with a phone call to local leadership, or noted at a monthly department meeting, or even missed entirely. But Mark’s reaction was: I think I should go down there.
That, in a nutshell, is what the Core model of partnership is all about. Mark’s attentiveness to one of the core measures of a well-functioning emergency department, and his commitment to spending time on the ground to help manage the situation, are characteristic of what it means to have a physician services group built on a foundation of partnership, as we are.
I’m proud of what we did and are doing in Monroe, proud of our clinical team there, and proud of the company we are building—without this kind of management, metrics like LWBS suffer, hospitals suffer, and, as you’ll see below from Mark, patients suffer.
Ok, enough from me: enter Mark Canada:
Rapid Cycle Improvement at St. Francis Medical Center
By Mark Canada, VP of Clinical Operations
In mid-July, I started noticing an increase in the volume at St. Francis. Then, on July 20 and 21, I saw a spike in the left without being seen rate. In one day, 20 people left without getting care. We knew Delta was beginning to hit that facility and the surrounding areas. I met with Dr. Robinson and we decided it would be a good idea for me to go down to St. Francis to be onsite.
Over the next month, I made two trips from my home in St. Louis to Monroe to help design and implement what is known as a rapid-improvement cycle for improving ED flow. There’s a HealthIT article that says rapid-cycle improvement “implies” changes are made in three months or less (as opposed to the usual Lean Methodology which takes 8-12 months). What we did in coordination with nursing and leadership in Monroe, we did in a matter of weeks and days.
Implementing a Split-Flow Model
Increased volume at registration and triage seemed to be causing a bottleneck. When I met with the nursing leader, Kayla Johnson, right away we both agreed we needed to implement a split-flow model. Kayla and her team are phenomenal partners with Core and the team she put together was amazing to work with, multidisciplinary in nature, and totally focused on bringing the best care to the people of Monroe.
On Monday, August 9, we developed the initial process: if you arrived at the ED for a COVID test, or a desire to receive a monoclonal antibody, or because of COVID-related symptoms, you were seen by a triage nurse, a registration clerk, and an APP. For anything else, there was a separate registration, also with a triage nurse, registration clerk, and an APP.
The next day, Tuesday, we put the new process in place.
Plan, Do, Study, Act
Rapid-cycle improvement calls for a four-step process: plan, do, study, act. That’s what we did at St. Francis.
My role during these process improvements is often to be a partner with an outsider’s eye. It’s my job to see things people who are really working in the thick of it may miss. On Tuesday, the day we implemented the split-flow, I observed how the new registration process was working. I also met with the upstairs nurse leader in charge of the area where we were administering monoclonal antibody and spent time observing the flow from the ED to the upstairs area.
By Wednesday, we had gone through several iterations of refining the process. In one revision, we re-arranged and added seating for a hallway in the ED that was being repurposed into visitor overflow. In another revision, we made the transfer process from the ED to the infusion area clearer by adding a color-coded visual queue to the alert the nurses in the clinic received when a patient had received their Medical Screening Examination and was ready to go upstairs.
During this time, the ED was setting daily records for volume. But LWBS rates were low and patient satisfaction was climbing. Additionally, in June, I had helped the team implement a Sepsis bundle compliance program in the ED; compliance was 100% in July, the first month of the surge.
Moving the Infusion Area
By late August, the new bottleneck was the existing infusion area, where patients received monoclonal antibodies on an IV drip. Space was limited and patients were backing up the ER.
The hospital identified a large conference room space on the hospital campus to convert into an ER clinic area. On August 23, I went back down to Monroe to help set up the new space as a dedicated space for an infusion area that could see 30 patients at a time:
We set up a command center area (shown above) on the conference room’s raised platform. We again revised the split-flow registration process to identify infusion patients and send them either by van or golf cart shuttle to the new clinic.
The shift to the new space lifted a huge burden from the existing ED and hospital spaces, and the new area became a huge patient satisfier. There was a lot of anxiety among patients and their families over getting a relatively new drug, and our nurses, NPs, and PAs did an amazing job of communicating to them about what the therapy would entail, how long they were likely to be there, and what they could expect moving forward.
Benefits to the community and the hospital’s reputation
Patient satisfaction scores exceeded the 90th percentile for the month of August. Being there and talking to patients and the clinical staff, you could really tell the community was enormously grateful for the smooth process at St. Francis.
In other facilities around the area, you had to schedule appointments to receive the monoclonal antibody treatment. At St. Francis Medical Center, our team and the hospital’s team together made sure patients who needed it could walk in, and get that potentially life-saving treatment fast.
A phenomenal team pulling together
By the end of September, volumes were down enough that the staff moved the infusion area back into the hospital.
It has no doubt been a trying summer, not just for the team at St. Francis but for every team at every hospital in the country that is managing this Delta surge.
It is enormously hard work, and the registration personnel, transporters, environmental services personnel, patient care technicians, nurses, APPs, and physicians who do it deserve our highest praise. They are in protective equipment all day, gloves and masks. It’s hot and they are exposed to COVID all day long. It’s mentally taxing and can be emotionally draining. We’ve all seen pictures of the people at the end of 12-hour shifts, the lines of the masks creased on their face. They are doing an extraordinary job under very difficult circumstances.
What can we in healthcare learn from this summer?
That healthcare is hard, healthcare has been strained, and burnout is real. That quality, focused physician services management really matters. And that lean process implementation can really help your hospital deal with surges in volume.
Also, when the chips are down and people need help, healthcare professionals step up to the task and do what is needed to care for the sick and further their healing mission.