CAPTURING NURSING EFFORT IN THE EMERGENCY DEPARTMENT TO IMPROVE SOCIOECONOMIC EFFECTIVENESS
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Objective: This study was undertaken to create and examine a theoretical programmatic framework designed to improve socioeconomic effectiveness in the ED. Methods: At the Johns Hopkins Hospital ED, our study utilized a case study design as its framework. We will then test the theoretical framework of our study through both literal and theoretical replication across multiple EDs to generalize the case studies to theory. That testing will employ a holistic multiple case study design, but is outside the scope of this dissertation. The conceptual framework of the case study involved a program centered on maximizing nursing clinical care effort capture as a method to achieve improvements along three socioeconomic axes that collectively drove organizational effectiveness. The study team – a multidisciplinary assembly of clinical and administrative practitioners, subject matter experts from the ED and the hospital, and key opinion leaders from among the nursing staff – proposed fourteen “programmatic activities” designed to address identified shortcomings in nursing effort capture and to maximize compensated work through enhanced billing practices. These fourteen action items, grouped under three intervention areas, composed the Facility Billing Program that was our programmatic intervention. The activities of this billing program were structured to elicit short- and intermediate-term outcomes hypothesized to produce specific long-term departmental outcomes. This hypothesis was initially tested via a pilot program to improve nursing effort capture and improve revenue generation. The long-term departmental outcomes of the billing program were grouped into eight measures hypothesized to quantify the effect of the intervention. They were then aligned under three outcome constructs. The constructs were Financial Outcomes, Human Capital Outcomes, and Social Outcomes. Each construct represented one of the aforementioned socioeconomic axes along which the ED operated and which collectively drove its organizational effectiveness. As the eight outcome measures improved, we hypothesized the three outcome constructs they represented would also advance, and collectively energize improved socioeconomic effectiveness – the strategic outcome of this performance improvement initiative. Results: In this study, we found that we were unable to demonstrate a relationship between clinical effort capture and workforce outcomes. We found that social outcomes were improved. The study reduced organizational risk by eliminating out-of-date patient charges and enhancing the level of compliance built into our patient billing structure. We found evidence suggesting a positive association between study efforts to capture clinical output and positive financial outcomes. Such was the case in both our outcome measures of interest – revenue and production efficiency. The net programmatic benefit of our effort capture project was $1,198,703 in revenue during FY13. Our program also improved the production efficiency of the nursing workforce. Controlling for observation RVUs, we observed an improvement of $0.73 (p<0.01, 95%CI: $1.26-$0.20) in the marginal product of capital between baseline and intervention timeframes.