Lately at work in the emergency department, I’ve noticed an increased attention to metrics. For example, how many minutes, on average, does it take for a patient to be greeted by a provider form the time they walk through the doors of the waiting room and into the triage room? Measurements even get provider-specific. For instance, how long, on average, does it take Erin, NP to input treatment orders once she has greeted a patient vs. Dr. X? But, where does this information-gathering all lead?
Frankly, the attention to metrics can get exhausting. E-mails pepper my inbox encouraging providers to get greet times down from 16 minutes to 14, saying orders aren’t being put in fast enough and that triage times are too long. In the midst of a busy workday when I am responsible for eight patients at once, metrics are the last thing I want to worry about. I’m all for efficiency, but what this attention to metrics leads to is more of a messy game rather than actual procedural changes that make the emergency department run more smoothly.
Here’s what happens. A patient walks into the waiting room, and is greeted for triage. Under pressure from administrators, the triage nurse indicates that the patient has been placed in ER room 1 in the computer deflecting the time clock form monitoring the time it takes for the nurse to triage to timing the number of minutes it takes for a provider to greet the patient. However, in reality, the patient is not yet in room 1, they are still being triaged. Score: Nurses 1, Providers 0.
Meanwhile, I, as a nurse practitioner, see my computer screen flicker indicating a patient has been placed in room 1. I sign up on the computer to be the provider treating the patient, my “greet time”. Fortunately, I wasted no time signing up making my “greet time” next to nothing. My metrics for the day look good so far. Score: Me 1, The Metrics System 0. I waste two precious, closely monitored minutes marching over to room 1 to examen the patient only to realize none is present. I mill around for a moment to see if a patient appears. No luck. The patient is still in triage…on my time clock.
So, I return to my desk keeping an eye on room 1 while tying up a few loose ends in my charting. In the meantime, the clock is ticking on my “greet to order” time unfairly. I can’t order a test on a patient I haven’t seen, right? Wrong. Since I know my times are closely monitored and the patient I will be seeing is a 24 year-old female with abdominal pain, I presumptively order a urinalysis to pad my “greet to order” time. Score: Me 2, The Metrics System 0. I have done no work, provided no value to the patient, but still I look good to the eyes of administrators.
When I notice the triage nurse wheeling a patient, finally, through the doors of room 1, I immediately go to see the patient. After taking a quick history and doing an exam, I return to my computer to input my remaining orders. Then, I must rely on the nurse to carry them out.
Unfortunately, a patient coding on a stretcher is rushed through the doors of the ambulance bay subsequently tying up the nurse for room 1. My 24 year-old very much alive, non-critical patient becomes low on the priority scale. The nurse does not have time to administer medications, collect the urine sample, or start an IV significantly lengthening the patient’s visit. My times for this visit won’t be good, even though I have fulfilled my job responsibilities efficiently. No one is at fault for the length of this visit, emergencies happen in the ER, but I will personally take a hit for the length of this visit in regards to my metrics. Score: Me 2, The Metrics System 1.
Finally, the nurse is freed up and the patient’s visit is complete. In an effort to make my numbers as favorable as possible, I click “depart” in the computer system before I have actually completed my discharge instructions. This ends the visit time and deflects the timer from me, the provider, to the nursing staff. The nurses are now on the clock to get the discharged patient out of the ER as quickly as possible, even though I haven’t quite finished my end of the job. Score: Nurses 1, Providers 1.
While closely monitoring times is prevalent in hospital systems, the practice is present in outpatient clinics as well. I have heard of urgent care clinics that place timers on the doors of patient exam rooms. When the provider enters the room, the nurse sets the timer for 5 or so minutes. When the provider hears the timer ring through the door, they know their time with the patient is up.
Monitoring “door to greet” times”, “disposition to discharge” times, and the like is of course necessary in a hospital system. After all, hospitals are businesses and time is money. Metrics give valuable information as to where systems can be improved. But, I can’t help but think the process could be implemented in a more effective manner. Pressuring nurses and providers to improve on their times can effectively turn one against the other in the metrics game. If executed poorly, monitoring metrics encourages nurses and providers to simply fudge their numbers rather than actually improve the quality and efficiency of their work.
If monitoring metrics never leads to institutional changes, such as saying goodbye to staff members who don’t do their jobs, or hiring additional employees when staff are under stress, it all becomes a dreaded game, a game that demoralizes and discourages teamwork.
Does your hospital play the metrics game?