The Emergency Department (ED) Return Visit Quality Program launched in 2016 with the goal to foster and continuously improve the culture of quality in Ontario’s EDs (learn more on our website). In this program, participating EDs are provided with data reports that identify return visits resulting in admission that involved their site. They conduct audits to investigate the causes of these return visits, identify any quality issues or adverse events that may be present, and take steps to address these issues.
Participating EDs have continued to learn and evolve their approach to this program since its launch. One ED that has recently revamped their approach to the program is Brant Community Healthcare System. We spoke to Dr. Laura Shoots, Emergency Physician and Director of ER Quality Improvement at Brant Community Healthcare System, to learn more.
What have you been working on recently for the ED Return Visit Quality Program?
In February 2019, I attended the webinar hosted by the ED Return Visit Quality Program team about the approach to conducting audits and identifying adverse events (view the recording here). Based on this webinar, I decided to completely revamp the approach to the program at Brant Community Healthcare System.
Our new approach involves holding small group sessions where about 10 emergency physicians and ER physician assistants join me for a half-day teaching session. The small group session focuses on:
- Teaching emergency physicians how to review patients’ charts
- Guiding how to identify, classify and analyze quality improvement issues
- Reviewing common pearls and pitfalls of reviewing charts and documentation
- Discussing any challenging cases as a small group
- Debriefing what it’s like to ‘make a mistake’, with emphasis on recognizing system errors and reviewing the Reason approach to separating blameless errors from system errors, negligence and abuse.
Emergency physicians at our site are mandated to attend the session, a decision we made jointly as a team at a staff meeting. The session is unpaid, but lunch is provided and participants earn CME credits for attending.
Previously we had one person conducting all 50 audits for the program. Now, at these small group sessions participants are paired off and assigned a selection of charts to review together. This revamped approach led to 56 QI issues being uncovered in 2019, compared to 11 in 2018. This has provided a lot more meaningful data to advocate for change. For example, lack of timely access to imaging was one common trend identified. This data has helped our department to advocate for 24/7 reporting and access to CT scans, a process now due to be implemented within the next few months.
Providing individual return visit data to physicians
I have also simultaneously implemented a system with the help of our data support team, whereby physicians are electronically sent an individualized list of their return visits each quarter. With time, the aim is to have each physician independently review their own cases, with a second-level review occurring at the small group sessions.
Sharing learnings from case reviews
When the case required it, we conducted multi-disciplinary reviews engaging multiple specialties, allowing other specialties in our community hospital to see the value of the review process. One complex case was thoroughly presented as a morbidity and mortality review, with several action items determined as a result of the review. Two cases were identified as cases to review through our quality care review process (currently pending review).
Can you tell us about any quality improvement initiatives you’ve implemented as a result of the program?
We have recently implemented a new physician scheduling software in an attempt to improve our wait times. We know that wait times impact a multitude of benchmarks in the ED, including the number of patients leaving against medical advice, which was highlighted in our return visit summary. We have successfully revamped our entire physician schedule and now utilize a schedule based on our volume patterns by the hour and day of the week. We are utilizing a scheduling software company and have hired a physician scheduler lead for the department to support the transition and liaise with the company. This change was implemented in November 2019, after much planning, data mining and preparation. Data collection will be ongoing, but we have already seen some encouraging improvements in our time to physician initial assessment (PIA):
Did your hospital collaborate with other hospitals or organizations when working on quality improvement initiatives arising from this program?
Yes. During the review of one of our cases, we recognized a significant quality improvement issue that occurred while the patient was admitted as an inpatient. The patient had a substantial delay in receiving a transesophageal echocardiogram, which we do not perform at our site and requires patient transfer to Hamilton General Hospital.
We engaged in a multidisciplinary discussion reviewing the case with infectious diseases, internal medicine, intensive care, emergency medicine, and hospitalist medicine physicians. This led to our physicians engaging with the echocardiography lab in Hamilton to improve and streamline our process for accessing urgent transesophageal echocardiograms.
Concluding Remarks
Revamping this program has been extremely worthwhile for our center. The benefits have extended beyond discovering/demonstrating data for needed quality improvement initiatives or issues discussed above. Individual physicians highly value the feedback of reviewing their own cases, while also having the small group sessions to recognize how their colleagues are documenting and managing various cases. Our physician group decided that during COVID they would still prefer to continue the program, and review charts other than their own as they found the process high yield. Those who have already completed the small group session with me will participate this year.
I’d highly encourage other ERs to speak with their data team to think about providing individuals with all of their return visit data for them to start reviewing, even if they are not formally trained in the chart review process. The added benefit of CME credits to do so makes it easy learning!
I would be happy to discuss further with anyone that has any questions about the program or that wants to introduce something similar at their site – please comment
below to share your thoughts.