Benchmarking the Emergency

Department
Mark Reiter MD MBA FAAEM
St. Lukes Hospital Bethlehem, PA

Objective
To introduce the concept of benchmarking as a
tool to improve emergency department performance

To identify benchmarking metrics relevant to

emergency medicine

Disclosure

Dedicated to Emergency Medicine performance

excellence through benchmarking and
process improvement

Robert Camp PhD

brought benchmarking
to Xerox in 1981
ASQC Quality Press, 1989

Robert Camp PhD

Benchmarking is a proactive process to
change operations in a structured fashion
to achieve superior performance.
The benefits of using benchmarking are
that functions are forced to investigate
industry best practices and incorporate
those practices into operations.

Benchmarking
Process of measuring and comparing
performance
Identify and incorporate best practices
Goal is to improve performance
Internal vs. external benchmarking
Needed to effectively evaluate success of
process improvement

Metrics without goals are just

interesting data.
Charles G. Cobb
(Digital Electronic Corp)

From Quality to Business Excellence

American Society for Quality 2003

Gas Station Analogy

When low on gasoline many turn into the
station with the lowest price
In doing so, many assumptions are made
relating to presumed sameness
Gallon accurately measured
Comparable octane
Equipment working

ED Performance Measures and

Benchmarking Summit
19 individuals representing different EM groups met in
Atlanta, GA in February 2006
Goal of summit was to establish consensus regarding
benchmarking terminology
Time definitions (i.e. arrival time, MD contact time,
decision to admit time, left ED time)
Time interval definitions (door-to-doctor TAT, laboratory
TAT)
Process definitions (i.e. active acuity level (ESI), daily
boarding hours)
Space definitions (i.e. ED, pediatric ED)
Welch S, Augustine J, Camargo CA Jr, Reese C.
Emergency department performance measures and
benchmarking summit. Academic Emergency Medicine.
2006 Oct;13(10):1074-1080. Epub 2006 Aug 31

Benchmarks Turnaround
Times
Flow

Tests

Door-to-Triage

Door-to-ECG

Door-to-Doctor

Order-to-Blood

Collected

Door-to-Discharge Decision

Order-to-Urine

Collected

Door-to-Admit Decision

Order-to-X-Ray/CT

Discharge Decision-to-Depart

Order-to-Lab

Admit Decision-to-Depart

Time-to-Read

Result
CT/US

Gap = 5 min

Where Are Your Bottlenecks?

Reception
Triage
Registration
Nurse evaluation
Physician evaluation
Testing
Treatment
Consultation
Disposition
Leaving the ED

Benchmarks in Emergency
Medicine
- Crowding measures (i.e. LWBS, hallway use)
- Staffing measures (i.e. pts per hour, midlevel supervision)
- Patient satisfaction measures (i.e. satisfaction survey results, patient
callbacks)
- Staff satisfaction measures (i.e. job satisfaction, attrition)
- Clinical best practices (i.e. early goal directed therapy for sepsis,
therapeutic hypothermia)
- ED operations best practices (i.e. bedside registration,
decontamination protocol)
- Outcomes measures (ASA on arrival, time to PCI)

Six Sigma Overview

Developed by Motorola
Experts called Black Belts
Based upon no defect in 99.9997%
negligible at 6 SD (some per million)
impractical for most ED benchmarks
Example: LWBS
2 sigma= 15%
poor
3 sigma = 3 %
average
4 sigma = 0.3% excellent

6 Sigma Concept of Defects

Defect means outside tolerance limits
Time to triage
> 15 minutes
Defect
< 10 minutes
Average
< 5 minutes
Goal
Defect opportunity is the chance for a defect to
occur
Reviewing outlier cases offers insight into
process improvement
Common in EM management

6 Sigma Process Improvement:

RDMAIC

Recognize an opportunity
Define via process maps, customer needs
Measure baseline, trends process maps
Analyze problem, cause, collect data
Improve by developing solutions, implementing
a change plan, and measuring benefits
Control stay in control
maintain gains and seek new opportunities
training, policy development

Lab Test Example

Flow Mapping
Reconstruct all
steps of process
Find redundancy
waste

Estimate TATs
Seek to improve
any part of the
process

The TQM Culture

Quest to improve results

Driven by customer needs/expectations
Meets needs of all stakeholders
Transition from reactive to proactive problem
solving
How?

Benchmark
Survey
Engage all stakeholders / Hospital-wide impetus
Reward/Recognize successes

Questions?