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10 April 2015

Blood Management Programs Help Improve Quality and Reduce Costs

Blood transfusions are among the most common medical procedures at US hospitals. In this case, however, more is not always better.

The Need for Blood Management

Blood transfusions are often necessary lifesaving procedures, but hospitals must be careful of overusing transfusions when unnecessary. The inefficient use of blood transfusions is both risky and wasteful. Transfusions bring higher risks of mortality and other dangerous complications. They are also costly. The direct cost of one unit of red blood cells is $200 on average, but there are numerous supplemental costs such as the transportation, testing, inventory management and storage of the blood. A 2010 study published by Transfusion, a peer-reviewed academic journal, estimated that blood transfusion costs actually range from $522 to $1,183 per unit of blood. Additionally, transfusions can impact the length of stay for a patient if infections or complications occur, driving costs up further. If a hospital is not careful in its management of blood transfusions, it can rack up hundreds of thousands of dollars per year of unnecessary added costs.

Characteristics of Effective Blood Management Programs

In today’s value-based, cost-sensitive healthcare market, an effective blood management program can help hospitals lower costs and improve quality of care.

The first component of these programs is the establishment of standardized guidelines that help doctors determine whether a transfusion is necessary or avoidable. National blood transfusion protocols do not exist, so hospitals are responsible for developing and propagating their own guidelines. Necessary guidelines include developing a standard order to transfuse, mandating that transfusion orders be required and documented during all surgeries, setting acceptable pre-transfusion blood lab values and creating a consistent informed consent process for patients that may encounter a transfusion.

Once hospital-wide transfusion guidelines are defined and implemented, applying some of the blood management strategies recommended by the Society of Cardiovascular Anesthesiologists (SCA) and Society of Thoracic Surgeons (STS) can help build out a comprehensive multimodal blood conservation program. Some of those strategies include:

  • Working with cardiologists before surgery to make sure the patient is not on unnecessary doses of blood thinners and to ensure anemic patients have the proper pre-op medicine
  • Carefully rationing IV fluids so the patient’s blood concentration does not drop unnecessarily during surgery
  • Drawing a unit of blood from the patient the day of surgery, in case it is needed
  • Reducing the amount of plumbing in the heart/lung machines so that they use less blood-diluting fluids
  • Standardizing the way anti-bleeding medications are given during surgery

Education is also a critical component of an effective blood management program. Hospital staff need to be fully informed about the risks, benefits and alternatives to transfusions. Education helps doctors and staff achieve a patient-centered decision making model that is integral to quality improvement.

Example of a Successful Blood Management Program

A Sheridan anesthesiologist, Dr. Robert Brooker, initiated a blood conservation program to improve the transfusion rates at Memorial Regional Hospital in South Florida. The hospital started following an established protocol in 2008 and conducted a five-year study of the results of more than 1,000 patients. Over the span of those five years, Memorial Regional Hospital was able to:

  • Reduce surgical transfusions in cardiac patients by 68%
  • Reduce the amount of blood needed by 80%, saving the hospital $715.14 per unit
  • Reduce the number of heart surgery-related deaths, infections, strokes and re-operations by 50%
  • Reduce infections by 100%

These reductions have helped earn Memorial Regional Hospital its current 3-star rating from the Society of Thoracic Surgeons (STS), the highest rating awarded by the organization.


Transfusions will always be necessary on some level. A blood management program is not aimed to reduce these procedures across the board, but rather to target where transfusions may be unnecessary and might actually be putting patients at risk. As Dr. Brooker explained, “Blood transfusions in heart surgery, or anywhere, are only good for you if you really need it.”

26 March 2015

Aligning the Board Room and the Operating Room

At its core, leadership is about helping a group of people with diverse skillsets and perspectives work together effectively. Generally, a team with a broader collective skillset is able to produce more valuable products and services than a more homogenous team. However, the realization of that added value almost always hinges on a leader’s ability to focus the team members’ diverse perspectives on a common goal. The more divergent perspectives a leader can align, the more value he or she can create; put simply, more difficult challenges yield greater rewards.

This concept was highlighted in a recent piece in the New York Times’ The Upshot column, titled “In Hospitals, Board Rooms Are as Important as Operating Rooms.” In the article, health economist and researcher Austin Frakt makes the case that the most significant hospital process improvements won’t come from a clinical team alone; instead, they develop by aligning the goals of the clinical and business leaders within a hospital. As the primary intersection between clinical leaders and the board of directors, CEOs and other senior leaders are uniquely positioned to bring about that alignment.

For obvious reasons, this is easier said than done. Besides the overall success of the hospital, clinical leaders and board members have few priorities in common. Boards, for the most part, are primarily interested in the facility’s financial health, and many members have little experience with the intricacies of the healthcare industry. Clinical leaders, on the other hand, are focused on the efficiency of the departments they oversee and the care and satisfaction of their patients. These issues are two sides of the same coin – an insolvent facility can’t function, and the link between reimbursement and patient satisfaction means quality of care directly affects the bottom line. The hallmark of a good leader is the ability to bridge this gap.

This means improving communication between the two teams, and – as the New York Times article makes clear – one of the best ways to do so is by borrowing management practices from the manufacturing and technology sectors. One of their most successful management practices is Kaizen, which Sheridan Healthcare has been helping hospital leaders implement for decades. Kaizen is particularly useful for improving communication between parties with different perspectives. As the article puts it:

“These management practices include eliminating inefficiencies and variations, fostering collaboration, setting targets and tracking progress toward them.“

Kaizen encourages a continuous stream of feedback from all stakeholders in a particular process. It helps eliminate waste from a process while ensuring the resulting improved process meets the needs and goals of everyone involved. The Times article highlights instances of Kaizen and other “lean” management techniques

reduc[ing] the time it takes between when a heart attack patient arrives at a hospital and when he’s treated, improving outcomes. Other work found good management is associated with better quality of care in intensive care units.”

Through a management technique like Kaizen, hospital CEOs and other leaders can facilitate the creation of streamlined hospital processes that meet the goals of physicians and other care providers, as well as the C-suite and board. This alignment of diverse skillsets and perspectives drives clinical, financial and organizational improvements for a hospital, simultaneously.

To learn more about Kaizen and how it’s been successfully implemented in the past, watch our video here.

26 February 2015

Improving Patient Care Through Efficient Processes

In many hospital systems, quality improvement efforts focus primarily on an outcome rather than the process that produces it. This may make sense intuitively, but experience has shown it to be the wrong strategy: in the vast majority of cases, small investments in process improvement can lead to outsize improvements in the final product.

This concept was highlighted in a recent FierceHealthcare guest post by Dr. Tom Scaletta, the Medical Director of Emergency Services at Edward Healthcare in Naperville, Illinois. In the article, Dr. Scaletta explains how a seemingly minor change to his organization’s patient follow-up processes – contacting patients immediately after discharge rather than with a mailer several days later – translated into significant improvements in patient outcomes and patient satisfaction scores. By contacting patients immediately after discharge, the hospital improved their survey response rate significantly and generated hundreds of “valuable real-time opportunities to improve patient care, reduce readmissions and understand important patient perceptions.”

Although they often sound simple, process improvements can be surprisingly difficult to implement. This is because designing and implementing improved processes requires critical thinking from the entire team, deep understanding how the current process works and buy-in from all affected employees. Overcoming these challenges and unlocking this potential for improvement is a critical function of the modern healthcare executive.

Process Improvement Systems

C-level hospital executives can’t be personally involved in driving improvement in every one of their organization’s processes – there’s simply too much to do. Instead, the executive’s role should be establishing systems that encourage process improvement and building a culture that helps employees find and implement them. This is, arguably, a much more difficult task than simply implementing, but the results are certainly worth it. Achieving the types of process improvements detailed in Dr. Scaletta’s article is much easier when such a system is in place.

Fortunately, management frameworks exist that can help healthcare organizations achieve this goal. One such is Kaizen, a methodology for continuous process improvement that was most famously implemented by Toyota. Kaizen is a powerful framework that helps employees improve and standardize processes, and it excels in clinical settings. The Kaizen approach works especially well with multi-disciplinary teams and allows for rapid implementation of new processes. Furthermore, it encourages a culture of continuous improvement as staff are encouraged to provide feedback through the entirety of a process – before, during, and after its implementation. In a nutshell, Kaizen makes processes more reliable and less wasteful while simultaneously encouraging meaningful employee involvement.

Implementation Challenges

While implementing a new process is hard in any organization, those in the healthcare industry know it is particularly challenging in a clinical setting. Buy-in, particularly among physicians and nurses, is tough to get, yet critical to success. Convening – let alone assigning importance to – opinions is equally challenging, and the energy to carry out the new process can wane over time. But such measures are necessary to develop and implement a process that works for patients and the systems in which they are treated.

As healthcare organizations look to improve processes facility-wide, it’s critical to remember the importance of a solid process improvement framework such as Kaizen. In addition to improving culture, these frameworks have been shown deliver a remarkable return on investment for the organizations that implement them. As the healthcare landscape continues to change – be it towards patient-focused care or another front – process improvement frameworks will help ensure that the industry evolves with it.

To learn more about how the Kaizen approach can improve hospital processes, visit our resource center.

24 February 2015

Combating Concussions

Evidence of the potentially life-threatening consequences of severe head injuries is growing, and recent lawsuits have thrust sports-related head injuries in particular into the national spotlight. Ray Easterling filed the first lawsuit against the National Football League in 2011, but Easterling committed suicide before the trial ended. He was posthumously diagnosed with chronic traumatic encephalopathy (CTE), a progressively degenerative disease that develops as a result of multiple concussions or traumatic brain injuries (TBI). Since that first lawsuit, the National Football League has agreed to pay out more than $765 million in settlement money to its 18,000 retired players because of concussion-related brain injuries.

This dramatic increase in high profile CTE cases has drawn significant interest in the medical research community, and one of the most prominent research supporters has been retired Jets quarterback Joe Namath. According to Namath, he sustained his fair share of concussions during his 13 seasons in the NFL, and he had recently begun experiencing fatigue and decreased cognition. His concern peaked in 2012 when he learned that star linebacker Junior Seau’s highly-publicized suicide may have been caused by CTE. As part of his treatment, Namath started undergoing hyperbaric oxygen therapy, a relatively new therapy recommended by his friend Dr. Lee Fox, a radiology medical director with Sheridan Healthcare. The treatment involves breathing 100 percent pure oxygen (compared to the 21 percent oxygen in the air that we normally breathe) for an hour or more while lying in a pressurized chamber. Originally conceived as a way to help deep sea divers recover from decompression sickness, the treatment has become increasingly popular in treating a number of diseases. Oxygen therapy helps stimulate the growth of new blood vessels, which can be critical to recovering from blood loss in the brain caused by a violent blow to the head.

The benefits of hyperbaric oxygen therapy have yet to be demonstrated in a formal clinical study, but Dr. Fox – along with his colleague Dr. Barry Miskin, chief of surgery at Jupiter Medical Center – are looking to change that. After seeing improvements in Joe Namath’s cognition and memory functions as a result of his continued hyperbaric oxygen therapy, they decided to test their results further. Working with Sheridan, they developed a groundbreaking protocol for the use of hyperbaric oxygen therapy for TBI and recently received approval from the FDA to launch the therapy’s first clinical trial.

Namath himself has pledged $10 million in support of the trial and the work that Dr. Fox and Dr. Miskin are doing. “Having Joe’s support is a huge boon to both the financial needs of the research and to the visibility of our work,” said Dr. Fox. “We hope his support will lead to a successful outcome for our study and more research in the area of TBI.” The trio’s pioneering efforts have led to the creation of the Joe Namath Neurological Research Center at the Jupiter Medical Center in Florida, which is supported by Sheridan’s clinical research and innovation programs.

To learn more about how Sheridan helps hospitals develop innovative physician teams, please visit our resource center.

To learn more about the clinical trial, visit

28 January 2015

Emergency Department Burnout: The Right Leaders with the Right Tools

More than 50 percent of ED doctors suffer from burnout at some point in their career. Burnout is particularly acute in this specialty: emergency medicine and critical care specialists suffer burnout at a 16 percent higher rate than the next highest specialty (family medicine), according to a 2013 Medscape Medical News study. The problem is made even more difficult by the widespread labor shortage in the emergency medicine market, which is expected to last for at least the next few decades.

In the face of these challenges, how can hospitals maintain a stable ED team and ultimately deliver better patient outcomes and experiences? While there is no silver bullet to solve this problem, one option is to provide ED physicians with resources that help them perform more efficiently and – in some cases – even report higher job satisfaction.

ED Physician Tools and Resources

Sheridan’s ED Physician Portal provides resources to address some of the concurrent issues that lead to burnout. The stressors that cause physician burnout can be sorted into two primary types: practical and emotional. Practical stressors are clear steps in a process that lead to dissatisfaction. The Medscape study lists several of them in its top 10 causes of burnout: “Too many bureaucratic tasks,” “Too many hours at work,” and “Income not high enough.” Emotional stressors are oftentimes vague and are usually more about empowering the individual than changing an ED process. Medscape lists “Feeling like just a cog in the wheel” as their #3 cause of burnout, for example.

Sheridan Emergency Medicine offers several resources to address both stressor types and can help the broader organization identify the best ways to serve its emergency medicine physicians:

  • The Emergency Medicine Practice Support Team link connects Sheridan’s local ED physicians to Sheridan’s national Emergency Medicine Leadership and Support Service teams, which includes Sheridan’s Kaizen, Operations and Clinical Quality teams. Sheridan’s Clinical and Operations leadership teams are always accessible to provide guidance and support to our Clinical Chiefs and clinicians. Likewise, the Suggestion Box allows ED physicians to air their concerns and be sure that Sheridan’s Emergency Medicine Leadership will see them.
  • Sheridan’s Leadership Development Program enables leaders at all levels to grow and enhance their ability to elevate the overall performance of their departments. Educational resources are made available, including programs from The Sullivan Group on risk mitigation, as well as premier education websites and audio series for emergency physicians.
  • ClearPATh ED helps ED physicians execute on efficiency and throughput. This lean workflow streamlines the patient experience and ensures the timely, appropriate evaluation of ED patients.

Preventing burnout among ED staff will be one of the greatest challenges facing hospitals over the next few decades. While a physician portal is by no means a complete solution for burnout, it does offer features that can provide critical support to a much larger physician satisfaction strategy.

21 January 2015

Sheridan Pioneers Anesthesia Care for Pediatric Patients with Autism

Guest post by Dr. Sandra Kaufmann, Chief of Pediatric Anesthesia, Chief of Pediatric Pain, Joe DiMaggio Children's Hospital

According to the CDC, around 1 in 68 American children are affected by autism spectrum disorder — representing a ten-fold increase in prevalence over the last 40 years. It is not surprising that these children, on occasion, will require anesthesia for various procedures and examinations. At Joe DiMaggio Children’s Hospital we have gained extensive experience over the years caring for autistic children, and have developed methodologies that address both the behavioral and metabolic issues that are associated with this disorder. The perioperative needs of a child with autism differ in almost every way from the traditional processes, and our hospital is committed to pioneering procedures and practices that best serve this growing subset of patients.

Preoperative Strategies

At the very onset, we understand that children with autism are challenged by new surroundings and a change in their routines and life patterns. We try to minimize their fears as much as possible by mirroring their routines where possible and trying to make their hospital visit as brief as it reasonably can be. Our autistic patients are usually the first case on the operating room’s schedule to reduce any waiting time. All rooms in the pre-operative area are private and quiet, where the family can stay with the patient. We also have a team of child life specialists, as well as in-house therapy dogs, who are available to provide comfort and entertainment.

Autism Friendly Medical Regime

Choices of medications for autistic patients are determined by their clinical presentations, any concomitant medical issues and the degree of sedation required. We have devised our own Autism Friendly Regime to minimize any ill effects while optimizing the operative experience. This regime begins with an oral medication to reduce stress, calm the patient and provide a degree of amnesia. If necessary, with the assistance of the caretaker, we camouflage this medication in whatever drink the patient is familiar with to make the first step as easy as possible. If the patient refuses the oral medication, we work closely with the family to devise an alternative plan.

Customized Anesthesia Plan

Family apprehensions about the anesthesia plan usually revolve around two issues. The first concerns the intraoperative medications. We make every attempt to avoid polypharmacy, which has been found to be problematic in these children. Specific medications thought to be detrimental to children with associated mitochondrial disorders are clearly avoided. The second concern is always the IV. This is placed once the child is asleep, and it is extremely well secured. It is also removed earlier than usual in the recovery room to minimize undue anxiety.

In essence, the anesthesia team at Joe DiMaggio is very conscious of the fact that our autistic patients require special care. Every child is different, and our flexibility and creativity are the cornerstones of ensuring that all of our patients receive the best treatment possible.

16 January 2015

Emergency Medicine’s Changing Role

In today’s healthcare landscape, it could be argued that “emergency department” is a misnomer for the typical ED. Emergencies happen, but the majority of patients come into the emergency department for more minor issues, or even just to be admitted to a department deeper within the hospital. In many hospitals, 60-80 percent of admitted patients come in through the emergency room, compared to 30-50 percent in decades past. Since more people are using this place as the point of entry to a hospital, patient satisfaction scores—and thus revenue—will increasingly depend on the patient experience in the emergency department.

Reasons for Emergency Medicine’s Changing Role

Though busy emergency rooms are often attributed to a large population of uninsured patients, a shift in how patients are diagnosed is also a contributing factor. Diagnostic technology has improved tremendously over the past few decades, and this quality improvement has been accompanied by increased cost. These costs are primarily a concern for Primary Care Physicians (PCPs): in cases where diagnostic tools are relatively cheap and low-tech, a private PCP can perform many of the same diagnostic procedures as the staff within the emergency department with a minimal investment in tools and instruments. But in cases where more expensive diagnostic devices are necessary – an MRI scanner, for example – achieving the same diagnostic sensitivity as an emergency department is cost prohibitive for PCPs. In effect, increased instrument costs have made it impossible for PCPs to achieve the sensitivity necessary to provide maximally accurate and legally defensible diagnoses for patients that present with certain symptoms.

Emergency departments, which have much more diagnostic and financial resources than private PCPs, have picked up the slack. Many now function as a sort of “rapid diagnosis and treatment center” – they serve, for all intents and purposes, as the general intake department for their hospital. The significant uninsured population, in concert with the continuing advancement of diagnostic technology, ensures that this trend will continue for years to come.

Prioritizing Patient Experience

The emergency department has become the starting point for diagnosis and care for emergency and non-critical patients alike. It has also become a patient’s first impression of his or her hospital experience. As Dr. Richard Petrik of Sheridan partner Ocala Regional Medical Center puts it: “If patients don’t have a good experience in the ER, they’re primed not to have a good experience on the inpatient side.”

The obvious metric influencing a patient’s experience in the emergency room is wait time. As patient volume increases, hospitals should evaluate their processes to identify any opportunities to cut down on door-to-provider times. Another area with room for improvement, says Dr. Petrik, is the communication between PCPs and ED physicians. As more primary care doctors send patients to the emergency room for further testing and evaluation, Dr. Petrik explains, a patient’s quality of care and time spent here can be greatly improved if the PCPs effectively communicate what they have learned in their initial meeting with a patient and what they had in mind when sending the patient to the emergency room. Better communication facilitates better care and ensures that a patient’s time isn’t wasted while emergency medicine physicians collect the same information the PCP already gleaned.

Small process changes can make a big difference in the patient experience, and increased patient volume means that these small improvements can quickly snowball into large benefits. As long as the emergency department continues to act as the “front door of the hospital,” making these shifts to better the patient experience will be of critical importance.

5 January 2015

How Leadership Drives ED Efficiency: Physician Teams Benefit from Communication Practice Drills

It’s hard to believe, but many errors in the emergency department come as a result of communication errors, not technical errors. Effective communication is especially critical in the ED, where time is limited and pressure is heightened. By instituting regular “practices” for their teams, physician leaders in the ED can drastically improve the quality of communication and decrease the number of errors.

Practice, Practice, Practice

Sports teams undoubtedly benefit from hours of daily practice in their preparation for actual games. At Baptist Hospital of Miami, Dr. David Mishkin began leading practice drills in the ED to drive communication improvements between nurses and physicians. He created high-pressure simulations in which his teams could practice clear, effective communication influenced by crisis resource management principles like standard communication scripts, checklists and mandatory debriefings. The simulations generally involve straightforward medical diagnoses but focus on the communication issues that may arise in stressful scenarios. Dr. Mishkin noticed a dramatic improvement in his team after just 3-4 hours of practice. Not only did the quality of communication improve, but so did the collaboration and general comfort level between team members.

Simulation-Based Team Training

The healthcare industry has long acknowledged that teamwork is critical to the quality and safety of patient care, and that teamwork is improved through team training. The Journal of Emergencies, Trauma, and Shock published a study in 2010 about the benefits of one specific type of team training, Simulation-Based Team Training (SBTT). As the study explains, simulation is effective because it “provides a safe, yet realistic mechanism for developing and fine tuning skills without serious consequential risk.” Traditional team training methods (e.g., presentations and lectures) do not allow for engaged practice amongst learners and do not mimic the pressure that real-life situations induce.

Physicians are the captains of their teams in the emergency department. As leaders, it is up to them to improve the quality of communication and ensure that their teams are prepared to execute efficiently when real high-pressure situations test their teamwork.

5 December 2014

Sheridan Leaders: Ken Colaric, M.D.

At Sheridan, our commitment to the personal and professional development of our clinical providers has been the cornerstone of our growth. We believe that strong leadership drives efficiency, quality and safety in the hospitals we serve.

To ensure our healthcare providers have the resources and support they need to develop into true leaders, Sheridan created the Sheridan Leadership Academy, a comprehensive program that provides development, training and education to our clinical leaders to equip them with the knowledge they require in their daily responsibilities, empower those who have natural leadership skills, and assist them in evolving into true team leaders. All Sheridan medical directors participate in this collaborative environment, which provides tools and training on effective communication, process improvement and other operational topics. Clinical leaders are able to assess and augment their personal leadership styles or learn to refine decision-making expertise. The purpose of this program is to offer a curriculum with a multi-faceted approach to building leadership skills.

Annually, Sheridan’s Leadership Academy gathers at a conference to participate in panels and workshops. At the conference, awards are given to individuals who demonstrate exceptional achievements in the areas of leadership or innovation. This year’s Diamond Award, which honors a Sheridan physician who demonstrates outstanding leadership and commitment to Sheridan Healthcare’s goals and values, was given to Ken Colaric, M.D.

Dr. Colaric is the Director of Emergency Services at Sheridan partner hospital Saint Mary’s Medical Center in Blue Springs, Missouri. Dr. Colaric has been in practice for more than 18 years and has served as the medical director of Saint Mary’s since 2012. He is also the Medical Director for three regional EMS services. Dr. Colaric has improved the staffing, technology, patient flow and a variety of other metrics, making his ED an AHA Stroke and AHA Platinum Chest Pain certified facility and the winner of the 2013 Department of the Year at St. Mary’s. 

Lean Process Improvement

Two years ago, Dr. Colaric facilitated a Kaizen event at Saint Mary’s that drastically modified patient flow through the department. Until that point, Saint Mary’s had been operating in the 50 year-old model of sequential ED care: after registration, a patient would be seen by a triage nurse, go to the waiting room, move to an exam room, be seen by another nurse and then ultimately see a doctor and any specialists. All patients went through this exact process regardless of their acuity. In the 3-day Kaizen event, a team of more than ten ED personnel — from registration clerks and ED techs to radiologists and house supervisors — developed strategies to streamline the care continuum.

The team, led by Dr. Colaric, landed on a new model of parallel care in which medical personnel can treat a patient as soon as they are available, rather than waiting for their turn in the traditional sequence of ED care. In the case of high-acuity patients, all providers assess and treat the patient in concert. The Kaizen team also introduced immediate bedding and bedside registration at Saint Mary’s.

This new model of care has improved nearly every metric of success for the department. Door-to-bed and door-to-doctor times were dramatically reduced, leading to a 30 percent shorter average length of stay for patients. The ED’s “left before being seen” rate was reduced by 88 percent. The Kaizen process allowed all members of the ED team to break out of the silos they previously worked in and collaboratively find areas for process improvement.

Implementation of EHR System

Dr. Colaric has also pioneered the development of Sheridan’s Inspire Quality (IQ) system  for the emergency medicine division. Under his guidance, Saint Mary’s served as a beta test for the new system that helps doctors track quality assurance and quality improvement data. Emergency department QA/QI data, like 72-hour return rates and patient satisfaction scores, are most effective when captured in real time. The IQ system facilitates this data collection and streamlines performance evaluation and the reporting necessary to re-accreditate physicians. The use of the IQ system at Saint Mary’s has been so successful that Sheridan plans to roll out the same technology at its other partner hospitals.

Pre-Hospital Coordination

Additionally, Dr. Colaric has worked to develop strong relationships between Saint Mary’s and the local EMS services. As a medical director for EMS providers, he recognized the importance of prehospital care and worked to extend the arm of Saint Mary’s emergency medicine beyond the ED and into the community to better coordinate care from the moment a patient enters their system. This collaboration with EMS services helped Saint Mary’s receive its stroke and heart attack accreditations.

We congratulate Dr. Colaric for his Diamond Award win and his fantastic work at Saint Mary’s Medical Center!

Click here to learn more about the 2014 Leadership Academy award winners.

1 December 2014

Strategies for Reducing ED “Left Before Being Seen” (LBBS) Incidence

Though the hope is that insurance expansion will encourage patients to seek care from health resources outside of the emergency department, EDs nationwide continue to see overcrowding. Patients who leave without being seen, typically because of long waits, represent the failure of an emergency care system to provide care to those most in need. In this way, reducing “left before being seen” (LBBS) rates should be at the top of an ED’s list of priorities, as high LBBS rates run in opposition to all dimensions of patient-centric healthcare:

  1. High LBBS rates represent a failure to meet the patient community’s medical needs;
  2. Long wait times and failure to receive care damage patient experience and satisfaction; and
  3. LBBS patients whose conditions worsen after leaving usually require more costly care down the line.

One of Sheridan’s partner hospitals struggled with a higher than acceptable LBBS incidence. Growing demand caused the ED to increasingly operate at full capacity, eventually causing the length of time between patient arrival and evaluation to creep to a level that was causing patient dissatisfaction and an increasing LBBS rate.  To solve this problem, they needed to perform a comprehensive audit of ED operations.

After running a three-day, on-site Kaizen event, the hospital’s executive leadership and clinical stakeholders identified two strategies for processing patients more efficiently.

Triage Color-Coding

First, they deployed a color-coded three zone system in the ED waiting room, grouping patients by high, medium or low acuity ailments. This method of organization enabled optimal matching of department resources with patient needs. Low-acuity patients who required minimal resources were directed to a “fast track” area to minimize their time spent in the ER and expedite discharge, improving their experience and freeing up staff to spend time with more critical patients.

Dedicated Triage Team

The second strategy the ED put in place was that, during times of forecasted high demand, a three-member team—comprised of a mid-level ED provider, an ED nurse and a medical technician—was deployed to the triage area. This new triage team could rapidly evaluate patients as they arrived to determine acuity level and initiate certain treatment protocols. Patients with low-acuity conditions had their issues immediately addressed. Patients with illnesses requiring further evaluation were directed to the appropriate color-coded care zone.


Within 90 days of implementing the process improvements, the hospital reduced LBBS occurrences from six percent to less than one percent. The facility also improved on measurements of ED patient satisfaction.

In the current healthcare landscape, ED success and profitability are dependent on efficient throughput, quality care and patient satisfaction. The color-coded zones and team triage approach, identified through a Kaizen evaluation, helped the hospital lower its LBBS incidence and reach all of these critical success factors.

Click here learn more about how the Kaizen continuous improvement philosophy can increase ED efficiency.