Why Integrate Clinical Service Lines? To Improve Patient Care and Throughput.

Posted on Thu, Dec 04, 2014
Why Integrate Clinical Service Lines? To Improve Patient Care and Throughput.

(an excerpt from “Integration Changes Everything”, an EmCare white paper by Kirk Jensen, Nathan Goldfein, and Mark Hamm)

Evaluating the Major Flow Managers
The emergency department (E.D.) is the front door of the hospital addressing urgent and acute care needs of patients who are sick or injured. For many patients, the E.D. is only the first phase of their hospital experience. Nearly half of all inpatient admissions come from the E.D. In many hospitals, this percentage is far higher.

In the E.D., efficiency and productivity are critical. Seconds count in an emergency and minutes count in E.D. metrics. Processes are carefully monitored for continuous improvement, and lean methodologies and rapid process redesign efforts focus on staffing, triage, registration and other factors that are critical to patient-centered care. Improving E.D. throughput has a distinct impact on value-based success. Centers for Medicare & Medicaid Services (CMS) goals for 2013 and 2014 include measures to record improvement in E.D. efficiency and throughput times.

While E.D. efficiency is important, it is not the only determinant of good patient flow. Patient flow controllers can exist throughout the hospital system including areas such as diagnostic radiology, laboratory, transport services, housekeeping and, most notably, inpatient services.

Hospital medicine physicians, or hospitalists, direct the aspects of care for patients who may require admission to the hospital for inpatient services. Some consider the hospitalist to be the quarterback of the patient care team, teaming up with multiple players: E.D. physicians and personnel, primary care physicians, specialists, nursing staff, case managers, laboratory staff, radiology personnel, patients, family members, program coordinators, home care agencies and long-term acute care hospitals, rehab facilities and/or nursing homes. As many full-service hospitals move to a model where laboratory services, radiology and other essential services are available 24 hours daily (and not just on a “7 a.m. to 5 p.m.” basis, as has traditionally been the case), the advantages of 24-hour hospitalist services will likely become even more dramatic. Because hospitalists provide the majority of clinical care for admitted patients, the impact of the hospital medicine group on HCAHPS scores is hefty.

As a hospital-based practice, hospitalists are positioned to effectively manage hospital admissions and discharges. Therefore, from a patient flow perspective, hospitalists have come to play a major role in improving flow efficiency, satisfaction and cost (McHugh et al, 2011).

The Conflict that Causes Slow Flow
Ideally, hospitalists and emergency medicine physicians should have the best relationship in the hospital because the functions of the two groups are so intertwined. They are handing off patients from one specialty to another – one physician to another – collaborating on services, care and outcomes. Yet often this is not the case.

At most hospitals, hospital medicine and emergency medicine physicians operate independently from one another and are concerned primarily with what is happening in their own areas, driven by overlapping but distinctly separate sets of priorities. There are conflicts due to the motivations of two different mindsets, two different pay structures and two different groups working in silos.

Efficiencies and Outcomes
Significant service efficiencies as well as improved clinical outcomes can be achieved through the efforts of both specialties, including:

Emergency Medicine
• Effective triage
• Professional, organized communication
• Lean thinking and patient-centered processes
• Continuous focus on improving flow and the patient experience

Hospital Medicine
• Patient rounding throughout the day
• Observing and understanding a patient’s needs
• Arranging appropriate services and assistance
• Managing the patient experience and creating a positive care environment

The patient suffers most, being caught in the middle of the conflict between the two physicians. And, boarding in the E.D. can delay necessary treatment for a patient who needs to be admitted as well as patients still waiting to see an E.D. physician, potentially leading to unnecessarily poor clinical outcomes.

Emergency Medicine Mindset
Emergency medicine physicians are driven by speed. E.D. lengths of stay are measured in minutes whereas inpatient lengths of stay are measured in days. So, E.D. physicians move fast and make critical decisions quickly. Since the E.D. is not intended as a setting for long-term care, the E.D. physician’s goal is to quickly evaluate patients and make the determination to treat and release or present the patient to the hospitalist for admission. Rapidly moving patients through emergency care in order to see the next patient is a necessary part of the E.D. practice.

E.D. physicians are concerned with how to triage, stabilize and determine the disposition of the patient whereas the hospitalist is more concerned with assessing the need to be admitted as well as where to admit the patient and what needs to be done before admission.

Emergency medicine physicians must rely on every other function in the hospital organization to pave the way for the patients who enter the hospital under emergency circumstances. They know they have to get patients who meet the admission criteria moved to an inpatient unit. Yet, they are powerless to do so without the cooperation of hospitalists.

When the hospitalist doesn’t immediately act on the emergency medicine physician’s request, it can lead the E.D. physician to view the hospitalist as an opponent. Thus, E.D. physicians may begin to think that hospitalists:

• Procrastinate about seeing patients, taking their time to get to the E.D. for patient evaluations
• Want more information and more tests than are needed, even when the diagnosis is obvious
• Don’t understand E.D. bed shortages that may exist

Hospital Medicine Mindset
Hospital medicine physicians tend to take more time and be more analytical and methodical. They are prone to research, discuss and collaborate on a decision. Hospitalists are tasked with treating the entire spectrum of patient issues instead of strictly focusing on the acute episode.

Hospitalists have to address all the conditions of the patient. They must consider not only the patient’s acute illness, but also chronic and secondary illnesses. They have to know the criteria for admission and the severity of the illness. Traditionally, when a poor relationship exists, the hospitalist may feel that E.D. physicians:

• Try to admit unnecessarily
• Don’t fully evaluate patients
• Don’t do a full work up in the E.D.
• Only uncover a single diagnosis
• Don’t consider alternatives to admission
• Don’t provide all the information needed for a hospitalist to make an admission decision

The patient suffers most, being caught in the middle of the conflict between the two physicians.

Different Incentive Structures
In some cases, the disconnect is due to measurements and incentives. Often, the hospitalist group is incentivized purely on the quality of the patient encounter and not at all on productivity. There may be little motivation for hospitalists to rush down to the E.D. to evaluate waiting patients. The hospital medicine group seldom has an inherent interest in key E.D. metrics, including the number of patients who left without treatment, hospital boarding time and patient satisfaction. Conversely, emergency physicians are incentivized based on efficiency and the number and acuity of patients seen. So it is critical for emergency physicians to see, diagnose and determine the disposition of the patient rapidly in order to free up the E.D. bed for the next patient.

Different Groups
The conflict in goals and performance standards can create a lack of trust, a strained relationship or even a competitive / adversarial relationship between E.D. and hospitalist groups. This is more likely to occur when two different management companies oversee the practices. The goals, reporting structure and productivity measures of the two are likely not the same, so the practices are more likely to work in silos.
Aligning Emergency Medicine and Hospital Medicine Groups Can Lead to Better Patient Care and Better Throughput

For more information about how this is accomplished, read the white paper here.

Thanks so much Dr. Stephens! Be sure to visit for the latest whitepapers!
1/13/2015 2:08:06 PM

Trish Stephens, MD
EmCare white papers are the best
1/13/2015 1:29:30 PM