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Urgent Matters E-Newsletter
Volume 6, Issue 1 

September/October 2009
Special Focus Issue- Performance Measurement

 

Perspectives

Looking Through Different Lenses: Multiple Stakeholder Perspectives on ED Performance Measures

 The drive to maximize emergency department (ED) operations and ensure the quality of care they deliver has been the focus of experts – not just in the United States, but around the world – for decades. Access to effective and efficient emergency care is critical to a community, and EDs are the safety net that must provide that care whenever it is needed. A well managed ED increases the quality and safety of patient care and strengthens the healthcare infrastructure.
 
As a former manager of acute care academic centers, including EDs, and now as an academic researcher, improving the ED and delivery of care is something that I care about passionately. For years I have witnessed both as a firsthand and as an outside observer the forces that challenge EDs to maintain a stable and controlled care delivery environment.
 
Perhaps the aspect of ED operations that has most fascinated me is the range of measures used to define success. Covering the full continuum of a patient’s journey through the health care system, there are standards for everything from managing patient admission, to staff adherence of standardized quality improvement practices. These are an inescapable part of our modern health care environment, and there is no debate that such measures are critical to maintaining a high-quality, efficient and effective health care experience.
 
But despite their importance and the seemingly comprehensive nature of ED performance measures, the fact is they still fall short of offering us a full understanding of ED operations because they were not developed with the vision of multiple stakeholder perspectives.
 
The rationale for including a variety of ED stakeholder perspectives in the development of performance metrics stems from scholarship on organizational performance and management. This methodology tells us that a complete and objective evaluation of an organization’s performance must recognize the subjective nature of the opinions involved, and must consider the full breadth of variables at play in its operations. Failing to do so can lead to skewed or incomplete results.
 
To that end, it is important to step back and look at the bigger picture: EDs are more complex and diverse worlds than existing performance measures recognize. They operate within the broader health system and encounter a wide variety of adjunct stakeholders every day. From the pre-hospital care provided by paramedics, to in-hospital care by nurses and physicians overseen by hospital administrators, to home care received after discharge, the outcome of care delivered in an ED involves more than just the staff under a hospital’s roof. In order to truly understand how successfully the ED is operating, we have to account for all of their diverse perspectives.
 
Even though we recognize that these unique stakeholders’ perspectives exist in the ED, most performance measures do not account for them. The results of this approach yield performance measures developed on subjective perspectives of success and in environments filled with competing values. Therefore, we are left without a complete systematic evaluation of ED performance.
 
Consider, for example, the potential for differences in perspectives among physicians, nurses and paramedics on the ED quality measure of door-to-treatment time for stroke patients. Our recent research found that these groups approached the treatment from completely different perspectives. Nurses and paramedics thought primarily of the clock and focused on meeting the time guidelines, while physicians approached it with more of an outcome mindset and instead were primarily concerned with the efficacy of thrombolysis for stoke patients. Queried independently, it’s clear to see how the different perspectives of the physicians, or nurses and paramedics would influence the development of a performance metric for stroke patients with the potential for vastly different results.
 
This is not a unique example. One study I conducted examined the responses of 1,100+ ED stakeholders from across the continuum of care as they developed performance measures. Stakeholders were asked to rate a list of 104 ED performance indicators. I found similar perspective biases pervaded everything. Most were interested in measures related to their role and capacity to provide care and assessed, and articulated their opinions of ED success through that lens. The greatest variations in the ranking of the performance indicators was seen between hospital stakeholders (physicians, nurses, managers) and non-hospital stakeholders (homecare and emergency medical technicians) The table below shows the top five ED performance indicators rated by stakeholder.
 
Consequently, it is clear that EDs intent on identifying high-quality performance metrics must bring multiple stakeholders representing all aspects of the ED environment to the drawing board. Only by identifying their differences and arbitrating them into the development of the measures can one achieve a full and balanced set of indicators for the evaluation of success. While the failure to do so does not necessarily result in poor care or performance, it can certainly play a powerful role in driving lasting institutional improvement.
 
 
Top 5 ED Performance Indicators Rated By Stakeholder
Ranking Physician Nurse Manager Home Care Pre-Hospital

1

 Time to Thrombolysis for AMI Time to Thrombolysis for AMI Time to Thrombolysis for AMI Appropriate Patients are Referred to Community Staff Time to Thrombolysis for AMI
2 Access to Primary Care in the Community Staff Satisfaction Visits by Triage Category Time to Thrombolysis for Stroke Time to Thrombolysis for Stroke
3 Staff Satisfaction Time to Thrombolysis for Stroke Client Satisfaction- Quality of Care Time to Thrombolysis for AMI Time to Triage
4 Physician Workload Opportunities for Staff Training/Certification Client Satisfaction- Outcomes of Care ED and Community Staff Examine Scope of Care Time to MD Assessment
5 Cycle Time for Diagnostic Tests Client Satisfaction- Outcomes of Care Time to MD Assessment Access to Primary Care in the Community Ambluance Redirects
 
 
Deborah Tregunno, RN, PhD, Associate Professor, Ontario Ministry of Health and Long Term Care Senior Nurse Research Award, York University, Toronto, Ontario, Canada