Quality improvement programs in Emergency Department.

Abdus Salam Khan, MD FACP
May, 2019

Patient care is a team work especially in all emergency departments. It is because of the fact that the care is dependent on multiple factors. The patients are either unstable or have the potential to become unstable. They may be in pain and need immediate relief. There is always a mismatch between the Emergency Department resources and the load of the patients presented to it. Many tasks of different nature happening at the same time in a limited space in the emergency. Sometimes it is rightfully labeled as mini-hospital within a hospital. (1) (2)

People who work in the emergency departments know that it is a very complex task and providing care is not easy. The difficulty is both on the clinical as well as non-clinical fronts. On the clinical front it is the broad-based problems presented to the emergency care that has to be sorted out quickly thus requires a physician and nurse staff that is well versed in all most all disciplines from Pediatrics to gynecology to neurosurgery. On the non-clinical front, it is equally daunting task to make sure that all the work is done smoothly. Starting from the availability of bed in the emergency to the electricity, water and stationery on one hand and then all functioning equipment to availability of ward and ICU beds on the other hand, is all considered equally important.

The patient satisfaction hangs well in balance due to the interplay of all the above factors and then some more. The satisfaction depends upon the quality of clinical care as well as the process of care delivery. Improving the quality will improve the satisfaction. Although a good team of physicians and nurses who are well trained in emergency care would mean provision of better care, yet there is always room for the improvement(3). Similarly improving the process of care delivery improves the satisfaction.
Every modern emergency department should have a program of quality improvement. This way the ED assures that the care delivered is of the highest quality and that the points of care which require enhancement are identified and being worked on. There are plenty of quality improvement ways, like the PDCA cycle (Plan-DO-Check-Act), Six Sigma and lean management and plenty of others. These process improvement modalities work within the system and show the result by improving the process and decreasing chances of error. These work as a continuum and with the completion of each cycle the system is improved and then the people continue for the second cycle to improve it further. (2,4–6)

In the emergency departments across the world there are plenty of processes that need continuous improvement and so the emergency department staff takes these projects as part of the self-improvement as well as part of the improvement of patient care, and make it a lifelong commitment. This way the safety of the patients is ensured and there is trust of the patients and satisfaction level with the system. Without the trust the whole care is compromised. (7)

Quality projects that the people working in the emergency department can choose like outcome based audits and studies or satisfaction centered audits. In outcome based studies, we see different mon satisfaction centered audits, we see how satisfied the group of patients were with the care they received in the emergency. Both types of studies actually aim to look into the areas and points where improvement brings satisfaction to the patients and also can lead to better outcome. (7)(8)

Our emergency department should adopt these ways to improve the care and make it safe as well as trust worthy for our patients. Being a leading emergency department of Pakistan, we are hoping on the quality improvement journey to get all the benefits of improved and safe care for our patients as well as to teach our newly trained residents the mindset needed to provide the safe and effective care. We also plan to teach these initiatives to all our fellow emergency physicians across Pakistan so that what we feel is the benefit for all should come to all in the literal sense.

I can be reached at askhan65@yahoo.com.

References:

1. Gagel BJ. Health Care Quality Improvement Program: a new approach. Health care financing review. 1995;16(4).

2. Lattimer V, Brailsford S, Turnbull J, Tarnaras P, Smith H, George S, et al. Reviewing emergency care systems I: insights from system dynamics modelling. Emergency medicine journal : EMJ. 2004 Nov 1;21(6).

3. Wilson M, Welch J, Schuur J, O’Laughlin K, Cutler D. Hospital and emergency department factors associated with variations in missed diagnosis and costs for patients age 65 years and older with acute myocardial infarction who present to emergency departments. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2014 Oct;21(10).

4. Dellifraine J, Langabeer J, King B, King B. Quality improvement practices in academic emergency medicine: perspectives from the chairs. The western journal of emergency medicine. 2010 Dec;11(5).

5. White BA, Baron JM, Dighe AS, Camargo CA, Brown DFM, Brown DFM. Applying Lean methodologies reduces ED laboratory turnaround times. The American journal of emergency medicine. 2015 Nov;33(11).

6. Maniago E, Ardolic B, Peana J. ED Patient Flow: Utilizing the Six Sigma Approach to Reduce Emergency Department Overcrowding. Annals of Emergency Medicine. 2005 Sep 1;46(3).

7. Boudreaux ED, O’Hea EL. Patient satisfaction in the Emergency Department: a review of the literature and implications for practice. The Journal of emergency medicine. 2004 Jan;26(1).

8. Arts DGT, de Keizer NF, Scheffer G-J. Defining and improving data quality in medical registries: a literature review, case study, and generic framework. Journal of the American Medical Informatics Association : JAMIA. 2002;9(6).

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