Innovations

Tri-City Medical Center (TCMC) was founded in 1961 by a mandate from the residents of North Coastal San Diego County to establish a modern, full-service medical facility. Over the years, it has grown to meet the needs of the area's growing population - always striving to provide the highest quality level of care to those in the community it serves.

Beginning in 2003, TCMC's senior leadership, including the Chief Executive Officer, Chief Financial Officer and the Vice President of Systems Improvement, began the process of implementing a program they called Team Accountability. It is a hospital-wide merit review system that holds literally every staff member accountable for improving hospital-wide patient flow.

Once TCMC's Board of Directors approved the concept, leadership quickly got to work by creating the following three internal teams to help shepherd the Team Accountability process and monitor its progress:

ED Internal Flow Initiatives Team

House-wide Flow Initiatives Team

Steering Committee Initiatives Team

See Patient Flow Team Representatives

"More than anywhere else I have been in my 34 year-career, our senior management believes in eliminating silos within the organization and working as a hospital-wide team to address issues," said Sharon Schultz, R.N., Service Line Leader for Emergency Services at TCMC and a representative on two of the three internal teams.

Schultz says that TCMC is not measuring anything much different from what other hospitals typically measure related to patient flow - diversion hours, bed turnover times, patient satisfaction, percentage of patients who leave without being treated, etc. What is markedly different, however, is who is being held accountable for these measurements. At TCMC, the answer is everyone - from President and CEO Arthur Gonzalez, Dr.P.H., FACHE, to part-time staff members in every department of the hospital.

While the patient flow-related goals are highest for TCMC leadership staff, even part-time staff are considered an invaluable part of the team and are held accountable for the Medical Center's ultimate success, including quality of care provided, patient satisfaction, and financial goals. The staff is very supportive of Team Accountability now that it has been in place for awhile and the program's coordinators have gained staff trust.

TCMC Employee Success Sharing Incentive

Monetary Increase Based on Improvement in:

Contribution Margin (Left Without Treatment = Lost Revenue)

ED Patient Satisfaction (Delays in Flow = Decreased Patient Satisfaction)

Consequences of Not Achieving Goals

20% of performance review for TCMC ED staff dependent on achievement of initiatives

TCMC staff success sharing bonus at risk if patient flow goals not achieved

TCMC leadership merit increases at risk if patient flow goals not achieved

(FY2004 goals were not achieved and resulted in a 0% merit increase for leadership.)

"This program has actually caused us to experience slightly higher position vacancy rates than others in our region. Some people feel that they work so hard, they should receive their merit increases and bonuses regardless of how the Medical Center performs," said Schultz. "However, most of our staff not only work, but also live in the community. They know that the better they pull together as a team and provide for our community, the rewards will follow."

The next fiscal year for TCMC begins July 1, so the team is currently in the process of reviewing and evaluating goals set for the past fiscal year and evaluating how they should be changed for the year to come. TCMC's diversion hours have gone down so much since the Team Accountability approach began, they will no longer be the biggest measurement in holding the team accountable. Instead, the priority focus will be decreasing the number of individuals who leave without being treated - a challenge faced by nearly every ED during the busiest times.

One of the biggest differences Schultz said she and her colleagues see is that staff in other areas of TCMC no longer view ED overcrowding as just a problem in the ED. Patients holding in the ED while they wait for an inpatient bed are now viewed as 'the hospital's' rather than 'the ED's' patients.

An example of how this is working to achieve hospital-wide success was the challenge recently put forth that every department needed to identify a one percent savings. When ED staff were challenged with how the ED could save one percent, their proposed solution was to decrease the number of patients who leave without treatment, otherwise known as LWOTs.

TCMC's 41-bed emergency department sees more than 56,000 patients per year. Yet another 4,000 potential patients leave the ED every year without being treated. Unfortunately, they don't just leave TCMC. With the closest ED nearly 14 miles away, these local residents are actually leaving their community to seek treatment elsewhere.

When the ED proposed reducing the number of LWOTs as their solution, other departments quickly came to their aid. "Everyone wanted to know how they could best help us keep more of these 4,000 community residents - our neighbors - from leaving," said Schultz. "We explained that if other departments could admit people and transfer them to inpatient beds more quickly, we could reduce the number of people who were walking out."

Selected Goals Achieved to Date

Increased patient satisfaction: Min. of 21%, Max. of 78%

37% increase in revenue/charge per patient

4.5% decrease in LWOTs

32% decrease in diversion hours

5% decrease in time to inpatient bed

Sharon Schultz and her colleagues would champion a Team Accountability approach for any hospital striving to improve: "There's no better way to evidence - what every staff member does and what every department contributes, really does make a difference."

For more information about Team Accountability, Click Here to download the full presentation (70 KB)

Sharon Schultz, R.N.
Service Line Leader for Emergency
Tri-City Medical Center
Oceanside, CA