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Quality Improvement & Patient Safety Section Newsletter - June 2011

circle_arrowThe Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowEditor’s Note - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowQIPS, EMI Win Grant to Study Meaningful Use Impact on EDs - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowEMPSF Hosts 1st Annual Patient Safety Summit in Emergency Care - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowAuthority Gradients: What Are They and Why do They Matter? - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowImproving Handoffs Between EMS and Emergency Medicine: A Call to Action - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowNormalization of Deviance - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowThe ACA-Driven ACO Movement: Implications for Emergency Medicine - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowQIPS Resident Quality Award 2011! - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowQIPS Tips - Quality Improvement & Patient Safety Section Newsletter, June 2011
circle_arrowEngagement Trilogy Part 1- Chain of Improvement - Quality Improvement & Patient Safety Section Newsletter, June 2011

The Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, June 2011


 

  Drew Fuller MD, MPH, FACEP
  Strategic Coordinator for Patient Safety
  Emergency Medicine Associates, PA. PC
  Germantown, MD
  

 

Drew FullerThe QIPS section has been very active this year in advancing issues important for the College and the field of Emergency Medicine.  Activities include: 


Editor’s Note - Quality Improvement & Patient Safety Section Newsletter, June 2011

Richard T. Griffey, MD, MPH
Washington University School of Medicine
St. Louis, MO
 

 richardgriffey
This quarter’s newsletter features some great articles on a variety of quality and safety-related topics including authority gradients, EMS handoffs, the normalization of deviance, ACOs and what they mean to EM, and the graying of the EM workforce. We increasingly benefit from the expertise and contributions of our section members. Please take a moment to complete the accompanying survey on what content you would like to see in the newsletter and as always we encourage section member submissions to the newsletter! You can forward ideas or submissions to me.  

 

Survey:
What Topics Would You Like
to See Covered in the Newsletter?
Click Here by July 30th

 

 


QIPS, EMI Win Grant to Study Meaningful Use Impact on EDs - Quality Improvement & Patient Safety Section Newsletter, June 2011

ACEP’s Section Grant Committee recently awarded the Quality Improvement and Patient Safety (QIPS) and the Emergency Medicine Informatics (EMI) Sections a grant to jointly study the unintended consequences and impact of EHRs and ED information systems (EDIS) on efficiency, safety, and quality of care. Kudos go to Dr. Heather Farley, QIPS Chair-Elect, and Dr. Kevin Baumlin, EMI Newsletter-Editor Elect for leading the project. The grant continues a series of successive awards for both Sections over the past few years, for conducting work deemed worthy of an ACEP grant. Both Sections felt such a study was timely and critical, given that hospitals are encouraging, and sometimes mandating, Emergency Department electronic health record (EHR) implementations in their quest to qualify for “meaningful use” funds.  The work product will be a comprehensive paper exploring the issue. 

Through a series of conference calls a QIPS/EMI EDIS Taskforce will be identified by Drs. Farley and Baumlin, and they will work together to gain consensus and ultimately draft a manuscript suitable for submission to a peer-reviewed journal.


EMPSF Hosts 1st Annual Patient Safety Summit in Emergency Care - Quality Improvement & Patient Safety Section Newsletter, June 2011

 

Dianne Vass - Executive Director
Emergency Medicine Patient Safety Foundation

 Emergency care and patient safety thought-leaders from across North America convened at the Four Seasons Hotel in Las Vegas in May 2011 to spend two days together to address the patient safety challenges and opportunities throughout the continuum of emergency care. The event was hosted by the Folsom, California-based Emergency Medicine Patient Safety Foundation (EMPSF), a national not-for-profit organization whose mission is to improve patient safety in the practice of emergency medicine through education, research, collaboration and training.  

The Patient Safety Summit brought together nearly 100 leaders and practitioners in the emergency medicine patient safety space from over 20 states and Canada. Launching the general session was a panel discussion moderated by Robert Wears MD, MS, of the University of Florida, Jacksonville and featuring Sandra Schneider MD, FACEP, president of American College of Emergency Physicians; AnnMarie Papa, DNP, RN, CEN, president of the Emergency Nurses Association; Diane Pinakiewicz, MBA, president of the National Patient Safety Foundation; and Michelle Hoppes, RN, MS, president of the American Society for Healthcare Risk Management. Key safety issues addressed at the conference included risks associated with patient boarding, ED crowding in general, hand-offs, communication and teamwork, medication errors and the value of pharmacists in the ED, technology and systems issues, access to specialist consults especially for rural EDs, a shortage of nurses and violence in the ED. 

The Summit ended with the national discourse on patient safety in emergency medicine newly energized. The participants acknowledged that the work ahead lies as much in creating an ongoing dialogue between stakeholders with shared access to data and insights on what works and what doesn’t as in getting more resources to research and apply patient safety initiatives. EMPSF announced that they are developing a series of live and on-demand online forums to help facilitate information sharing which will bridge future annual summits with the next summit scheduled for March 22-23, 2012 in San Antonio, Texas.  In addition, the conference renewed interest between patient safety organizations and clinical societies to seek opportunities to synergize their work together and stimulate future research and design of patient safety initiatives. 

For more information on the Emergency Medicine Patient Safety Foundation, membership and their fellowship and grant opportunities, visit www.empsf.org. Those interested in speaking opportunities at the 2012 Patient Safety Summit should contact Dianne Vass, executive director of EMPSF. 

 


Authority Gradients: What Are They and Why do They Matter? - Quality Improvement & Patient Safety Section Newsletter, June 2011

Drew Fuller MD, MPH, FACEP
Strategic Coordinator for Patient Safety
Emergency Medicine Associates, PA. PC
Germantown, MD
 

Drew FullerCase:  A new graduate nurse is working in the ED and notes that an asthma patient appears more dyspneic after their first set of nebs.  The nurse wishes to communicate this to the physician on duty but Dr. Jones is “very busy” with other patients and has a reputation for getting agitated when interrupted.  The nurse waits for a better time.  The patient, however, worsens, has a near respiratory arrest, is intubated and placed on a ventilator.  

This is an example of how an authority gradient can lead to an adverse outcome.

Authority gradients are essentially barriers to communication when there is a real or perceived differentiation of professional status. These gradients can be influenced by several factors including: professional role, highly hierarchical environments, personality and team dynamics to name a few.  While authority and structure serve important functions, it is when they are perceived or formulated in a manner that obstructs good communications that problems can arise.

The ability to exchange information and express concern when needed is essential to the safe function of an emergency department.  The high-risk environment of the ED often benefits from communication that is open, unguarded, and flexible.  A breakdown in communication is a common factor in errors and a leading contributor to sentinel events reported to The Joint Commission.

Strategies to reduce authority gradients can include: 

  • Awareness of possible gradients and acknowledging risk
  • Openness to communication
  • Team members understanding the collective responsibility of the group
  • Expressing appreciation and acknowledging team members who express concerns or bring forth issues
  • Engaging all members of the team by increasing familiarity and collegiality
  • Routinely sharing care plan with teams members (Huddle when needed)
  • Use of Team Training in the ED to educate all members to authority gradients and other communication factors        

 Source:  Croskerry’s Patient Safety in Emergency Medicine, Chapter 28. 


Improving Handoffs Between EMS and Emergency Medicine: A Call to Action - Quality Improvement & Patient Safety Section Newsletter, June 2011

John J. (Jack) Kelly DO, FACEP, FAAEM 

kelly
Communication, Communication, Communication:  this seems to be at the heart of best practice in Handoffs between Emergency Medicine caregivers.

About 2 years ago, a group of us in the QIPS section received an ACEP Chapter Grant and created the ACEP White Paper on Handoffs in Emergency Medicine.  All of us learned a lot from that work and publication.  Up to 25% of the claims against Emergency Physicians involve a faulty Handoff.  Now, 2 years later, I call members of the same QIPS Handoff Group to come back to the table to work on another complex communication process:  Handoffs between EMS and Emergency Medicine.

This is a brief thin-slice analysis of the ideal EMS to EM Handoff: 

  1. Pre-Handoff Phase: here the medics bring together their combined synopsis of the pre-hospital patient’s key medical complaints and life-threats and current treatment, as they near the Hospital.  This gives medics best “situational awareness” of the case about to be delivered to the ED.
  2. Handoff Phase:  here the medics bring the patient to the ED bed, and the ED staff allows the medics a “quiet minute” to provide a brief, templated verbal report of initial findings and complaints, patient history and meds/allergies, vitals, immediate assessment and emergency treatment, response to treatment.
  3. Post-Handoff Phase:  here the Emergency Physician can begin bedside assessment of the patient and still have the medics close-by to further clarify pre-hospital details and treatment.  Only the medics have this insight, and once they leave the ED this insight is gone (unless a written EMS report is left with the ED at the time of the Handoff).

Sadly, each of these ideal Handoff strategies are rarely employed in real-life.  There are many complex issues that interfere with progress toward best communication between EMS and Emergency Physician:   EMS personnel are often volunteer EMTs with minimal medical knowledge.  EMS personnel may be forced by their system or by finance to immediately leave the ED for another emergency call.  There is no National Standard for EMS Handoff; EMS is regulated by each state (and this brings political process into the improvement plan).  There is no rule that EMS must leave a written report; most systems write a written report that may be dropped off or faxed or emailed to the receiving hospital hours or days later.

How can we as EM Quality experts and national leaders fix this difficult problem?  We must join with EM EMS leaders to assure we have both Quality and Pre-hospital experts working together.  We must begin to outline all of the issues and potential solutions. 

We must design the best strategy, keeping it simple, and attempt to make it a national policy.  We must measure and track this. 

There may be benefit in making this an ACEP Council Resolution that we submit with the Quality and EMS sections and with the Pennsylvania Chapter (my PaACEP colleague Doug Kupas is Commonwealth EMS Medical Director).  As a Council Resolution, it will be heard by our ACEP Councilors who represent our state chapters and all of our ACEP sections; this could help us recruit a workgroup that has the most state-level experience in the issues and solutions.  There will also be strength in our linkage to NAEMSP as we brainstorm and plan this call to action.

I am drafting the Council Resolution this month, and welcome your help with this special project. Please email me


Normalization of Deviance - Quality Improvement & Patient Safety Section Newsletter, June 2011

 Elaine Thallner, MD, MS, FACEP  

Elaine ThallnerIn 2003, NASA’s Challenger space shuttle broke apart shortly after takeoff, resulting in the deaths of all people on board (including the first non-astronaut, an educator) and impacting future NASA funding.  Investigators determined that the cause of the accident was an injury to the left wing caused by a piece of foam that broke off during take-off.  The term, ‘normalization of deviance’ was coined by Barbara Vaughan in her book The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA published in 1996.   Vaughan used the term to describe a gradual shift in what is ‘normal’ after repeated ‘deviant behavior,’ during which people deviate from safe operating procedures, for example bypassing safety checks, cutting corners, and ignoring alarms.  The organizational and cultural issues within NASA that failed to prevent this disaster have been severely criticized.  Safety compromises gradually became the cultural norm.  In fact, the thermal protection system was not designed to withstand impacts, but impacts were a common occurrence.  Since there were no consequences (until this disaster), this design issue was repeatedly overlooked as likely to cause a catastrophic event. 

Patient safety experts understand the similarities in healthcare errors, where the errors occur at multiple levels of system: individual level, team level, management level and so on.  Traditionally, it is only at the provider level that blame is assigned, although there are certainly multiple levels contributing to the error.  Let’s consider now our ED practices.  How close to the edge of safety are we performing?  What has become so ‘normalized’ that we no longer view it as a patient safety risk, and simply accept it as an inevitable part of our job?   Overcrowding?  Boarding? Staffing shortages?  Lack of mental health beds?  Lack of on-call specialists?  Workplace violence?  A crowded waiting room?  Maybe we have no choice but to become adept at accepting our realities, while also being mindful that we need to also envision a patient safety-focused care health care system by continuing to challenge the status quo and relentlessly work towards this goal.


The ACA-Driven ACO Movement: Implications for Emergency Medicine - Quality Improvement & Patient Safety Section Newsletter, June 2011

Michael Gerardi, MD, FACEP
Board of Directors, ACEP
Senior Vice President, Emergency Medical Associates
Livingston, NJ
 

Michael Gerardi
The content and opinions are solely those of Dr. Gerardi. Although he is the Board Liaison to the EM Practice Section, the views expressed here are not those of the College or its Board.
  

PPACA was passed a little over a year ago and what it means for the future of health care in the United States is a subject of much debate.  More vexing is the fact that there has been a focus on expanding primary care and the creation of Accountable Care Organizations (ACOs) but little discussion about the effect of PPACA on the health care safety net – Emergency Medicine.  This article has been written to start to create a framework for discussion from an emergency medicine practice perspective.  Hopefully it will initiate more robust and prolonged discussions within our Section and the College.
 

Questions to consider:   

  • Why is the U.S. Government, through PPACA and CMS, promoting ACOs
  • What is an ACO?
  • What are threats to the successful deployment of ACOs?
  • What are the implications for Emergency Medicine and where will emergency physicians be able to insert themselves into the ACO environment?
  • Why is the specialty of EM particularly well suited to address the problems that are trying to be solved by ACOs?
  •  

I. Perceived Problems in Current Health Care System That Have Spawned an ACO Era  

a. Focus on the Individual Provider and “Transactional Medicine”  

The monitoring and payment systems in today’s healthcare environment focus on the individual provider.  Physicians and hospitals are paid for services provided and for the equipment and materials used.  These units of health care delivery are called “transactions” and many federal leaders and health care economists think that we have to move away from transactional medicine to bend the health care cost curve down to a manageable number.  Unlike a capitated model in which all services are included in a global fee, the current health care system recognizes the variations in expenses to deliver medical care for any given illness allow for reimbursement for thousands of different types of transactions.  

Because care is focused on the individual physician, hospital, etc. there is poor coordination of care.  The numerous providers involved with any one patient and the transitioning of consumers between providers is thought by some to create significant gaps in quality.  These gaps in quality are best demonstrated by Medicare spending, which can vary up to 300% within different regions of the United States while showing no tangible benefit in quality for the higher spending regions. Utilization of medical services is ever increasing, largely due to a fee-for-service payment system that inadequately provides incentive to the individual provider for minimizing cost, leading to increasing waste and cost. This fee-for-service system leads to consumers being moved through practices at a quicker pace in order to generate more volume, and takes away any incentive to manage disease by coordinating correct delivery of care. 

b. Lack of Coordination of Care 

With multiple providers located in different settings, who are all given incentives to generate volume and sometimes order the most expensive treatments possible, coordination of care suffers. Lack of adoption of electronic information technology is also an issue. This lack of coordination of care can lead to inefficient and inaccurate diagnoses, unnecessary and redundant treatments and higher admission rates.  Some critics of the U.S. health care system consider this arrangement to be a financial boon to the providers in a fee-for-service model. 

c. Lack of Disease Management  

Seventy-five percent of all U.S. healthcare spending is for the management of chronic diseases related to COPD, congestive heart failure, depression and diabetes. Lack of management of these conditions can lead to such cost-increasing events as hospitalization or readmission, ER visits, ICU usage, excessive ancillary usage and over-medication. 

The Accountable Care Organization is gaining traction as a realistic model for addressing these utilization issues.  ACOs are being designed to help ensure that providers are adequately compensated while utilization is decreased.  Despite decreased utilization, quality measures are being designed to assure that care is not negatively impacted. 

II. What Is An ACO?  

An ACO is a provider-centric organization which focuses on three main goals for a specific population of consumers

1. Reducing Cost – through enhanced preventative care and disease management which will result in reduced preventable readmissions and other avoidable usage of hospital or ambulatory services; as well as creating economies of scale and avoiding the duplication of services that currently exists in today’s health care industry.

2. Improving Quality – through coordination of care and the existence of quality-related, rather than transaction / volume-related incentive programs, as well as defining best practices through experience and evidence-based medicine.

3. Developing Skills and Resources – to meet the cost and quality goals in the present and future as the healthcare industry moves forward. 

For an ACO, these goals will be applied to a group of consumers who are assigned to that ACO. While these consumer populations will usually be broad and cover a wide range of demographic bases, there may be opportunities for more specialized ACOs that focus on specific demographic subgroups in the future.    

In addition to these consumer-focused goals, the ACO will also need to focus on three additional administrative-related goals, which are: 

1. Developing Information Technology Infrastructure – to track data related to quality and cost within that consumer population, and to collect and mine clinical and claims data to develop support for evidence-based protocols within the ACO, as well as assist in the overall coordination of care.

2. Developing Payer Contracting Strategy – to ensure the ACO is properly reimbursed for care that it is managing, as well as making sure the performance standards for each payer don’t create an administrative burden for the collection of data related to those standards.

3. Allocating Payments – Developing the ability to accept and appropriately allocate some form of capitated payment or incentive payments from a payer or multiple payers related to the care of that consumer population and the associated cost of that care. 

III. Several Reasons Why ACOs Could Fail and What Role Emergency Physicians Can Do to Make Them Successful  

If recent decades in health care have taught us anything, efforts to manage costs have left a legacy of a lack of success by government, private insurers and health care providers.  Initiatives are particularly ineffective when there are no constraints placed on the patient / consumer side.  Although PPACA and CMS envision a major health care coordination role for ACOs, they may not be able to accomplish their objectives.  

  • What are the reasons that cost-saving and quality-improvement efforts are in jeopardy? 
  • What can emergency physicians and our specialty of emergency medicine do to partner with ACOs to increase their chance for success?  

  1. Lack of Collaboration Between Hospitals and Physicians 

The ACO model will require collaboration between hospitals and physicians who overall have not collaborated well with each other in the past.  In regions throughout the United States, health care systems and physician groups have engaged in significant and sometimes bitter competition with each other for control of lucrative ambulatory services, such as advanced imaging, ambulatory surgery, and radiation therapy.  This has created some mistrust and animosity, along with duplication of services. In some communities, physicians have controlled the lion's share of ambulatory, diagnostic and surgical cases, to the point of damaging the local hospital financially. 

It may not be possible for these groups and health care systems to get along in a hospital-centered ACO.  Not only are there economic competition and trust issues, but there's a new disconnect between most community physicians and medical or surgical services provided in a hospital.  Instead, hospitalists and intensivists have taken over much of that role. There is no such thing as an ‘extended medical staff.’ The medical staff consists of physicians who actually practice at the hospital, which is a shrinking percentage of the physicians in most communities.  As hospital-based specialists, emergency physicians are particularly well poised to continue a supportive and collaborative relationship with their hospitals.  

Emergency physicians have a potentially critical role if the ACO model was changed to more accurately reflect the relationships which exist among physicians and between them and hospitals. Most healthcare that is delivered can be placed into three categories:

  1. Primary care
  2. Unscheduled emergencies and urgencies with 10% of visits to EDs coming because of convenience, accuracy and efficiency.
  3. Diagnostic physician care and services from one or multiple specialties such as oncology, orthopedics, cardiology, etc. 

ACO’s should reflect the existence of these categories, even if it makes the ACO structure more complex. In this advanced model, emergency physicians interface regularly with primary care physicians and are the specialty of choice for acute and unscheduled care.  EPs also regularly get inserted in the care of patients with complex conditions and care plans.  

2.  Delayed Implementation of EHRs  

The vast majority of physicians still do not have the sort of electronic health record (EHR) systems that many established emergency medicine practices use and that hospital systems possess to manage non-hospital care across their patient populations. Despite financial incentives from the Health Information Technology for Economic and Clinical Health (HITECH) of the American Recovery and Reinvestment Act of 2009,  it remains to be seen how much of this technology gap can be bridged, and how soon.  Even with the purchase of elaborate systems, physicians have been slow to embrace them and use them because of loss of productivity and technical issues. 

Fortunately for hospitals and the specialty of emergency medicine, emergency physicians appear to be leading the house of medicine in adopting and adapting their practices to the use of EHR.  Many emergency medicine practices are also very adept at data sharing with their hospital partners. Although emergency physicians often share their clinical findings electronically with primary care physicians and specialists, there are huge strides that need to be made in sharing of clinical coordination data.  The experience of emergency physicians with EHR will probably make them more advanced collaboration partners from a data-sharing perspective. 

3. Who wants to see income redistribution, especially when physicians have little or no control over it?  

The reward for managing and/or participating in an ACO is to receive a share of savings if collaborators are able to reduce Medicare cost escalation.  A major impediment is that these gain-sharing type programs are being incorporated into a payment system that continues to reward hospitals and individuals for increasing the volume of clinical services, transactional medicine.  High-earning specialists, particularly surgeons and those providers who rely on revenue from advanced imaging have far more compelling incentives to keep their volumes (and incomes) up than do primary care physicians, psychiatrists or diagnosticians who use less sophisticated technology.  Another problem is that there have been very few demonstration gain-sharing projects that have produced savings touted by ACO advocates.   Another major hurdle for ACOs in the near future is the fact that many high-earning specialists have consolidated into single-specialty practices to avoid efforts to make them share or redistribute their income.   Finally, there have to be revisions in the Stark regulations that will allow physicians and hospitals to collaborate to share risk and reap benefits of cost-saving initiatives. 

Despite all of these barriers with regard to income redistribution, emergency physicians are in a much more advantageous position than other physicians to collaborate either with a primary care/specialist physician-directed ACO, or a hospital-based ACO.  Emergency medicine reimbursement is a highly evolved and technical enterprise with far smaller variations in the majority of its charges compared to many specialty and hospital fees. This could lead to an advantage for EM as a specialty to negotiate its value and fair charges for a well-delineated spectrum and volume of services. Most importantly, the emergency physician charges and costs both represent a relatively small portion of the compensation pie.  However, emergency physicians have to be integrally involved to control access to a much larger portion of the medical expense pie, e.g. the decision for admission versus discharge. 

4. Lack of Patient Incentives  

There is no requirement for patients to be actively involved in joining an ACO.  Rather, they are more likely to be affiliated with a particular ACO based upon an affiliation of their primary care physician.  Regardless how they are enrolled, the patients themselves will probably have no incentive to cooperate with strategies to reduce cost. For example, government programs to date, and even after PPACA, often require minimal to no co-pay and/or deductibles. Since life-time spending caps have been removed, there are absolutely no patient incentives to decrease health care consumption.  How will ACOs deal with unchecked demand for services by populations with varied levels of health?  Perhaps there will have to be community rating and compulsory enrollment to avoid cherry-picking and imbalances of healthier versus chronically ill patients.  

Regardless of incentives or disincentives implemented in the future, emergency medicine is particularly experienced with meeting demands on its services, regardless of payment schemes. Since EMTALA’s inception, no other specialty approaches the amount of uncompensated and discounted care delivered by emergency physicians. It follows that our specialty has developed an expertise to create efficiencies to assure quality care 24/7 regardless of payment schemes that have historically inadequately addressed fair patient incentives to consume health care responsibly.  

5. Cost Management Inexperience  

Most physicians and hospital administrators lack actuarial or insurance expertise. They also do not have access to the health care consumption and expenditures by populations, whether linked by geography or disease entities.  It would follow that they would be unlikely to be able to successfully manage health costs of a population. Even if there is community rating with pooling of risks, the actuarial calculations required to predict expenditures will have a large margin of error that would easily eclipse any shared savings. 

Emergency medicine is different when calculating risk, in that those representing emergency physicians in an ACO would not need to be aware of the entire expenses for a patient population.  Emergency physicians prescribe and order a fairly well circumscribed panel of procedures, tests, pharmaceuticals, and admissions.  Variable expenses for budgets are fortunately limited and quantifiable. These variations are miniscule compared to variable expense risks for at-risk populations. 

6. When Will a Health Care Model Address Cost Shifting?  

As currently written, PPACA will increase the number of patients on Medicaid and also will expand coverage through the creation of health insurance exchanges. A major problem for sustaining expanded coverage through federal programs such as Medicare and Medicaid is that these programs usually do not cover the expenses for their enrolled patients and reimbursement rates leave no margins for incentive programs.  Penalty programs have been unveiled but the incentives proposed do not come close to matching the pain of the penalties.  As patients leave private insurers for lower cost federal and state-subsidized, programs, private insurance companies will have to raise their premiums because of increased cost shifting and possible loss of healthier populations. 

Since emergency physicians provide care at or below costs on a regular basis, a marked decline in reimbursement schemes are more likely to dramatically affect other specialists more than those in emergency medicine.  The disproportionate burdens of cost shifting on those who care for Medicare and Medicaid patients will become more apparent to others who have not been caring for the underinsured as much as emergency physicians.  Within emergency medicine reimbursement circles, there is an increasing demand for the development of fair methodologies to assure that the value and quality provided by emergency physicians is recognized. Since emergency medicine provides an incredible value by any measure, addressing cost shifting can only strengthen its financial footing. 

What Next? 

CMS is scheduled to release long-awaited regulations for ACOs in March – April, 2011.  The constitutionality of PPACA has been challenged with judges in two states (VA and FL) ruling that it is unconstitutional and several in other states coming to an opposite conclusion. As there are further developments, please stay tuned to this newsletter for more opinions and discussions! 


QIPS Resident Quality Award 2011! - Quality Improvement & Patient Safety Section Newsletter, June 2011

In 2010, QIPS established an annual QIPS Resident Quality Award for 2011 graduating resident emergency physicians or fellows who demonstrate excellence in, and a passion for quality improvement.  Nominations for this year’s award are due by August 4th.Nominations will again be solicited from program directors across the country.  

Submitted projects will be judged on their overall importance, innovation, approach and applicability to the general ED community. Award recipients will receive a free 1-year QIPS membership, be recognized at the QIPS Annual Meeting at ACEP Scientific Assembly, and enjoy a brief synopsis of their work in our Newsletter.  

At last year’s QIPS Annual Meeting in Las Vegas, QIPS Chair Dr. Thallner presented two residents with the Award for 2010: 

  • Kara S. Kim, MD, of the Regions Hospital Emergency Medicine Residency Program was awarded for her project to improve patient care and safety by decreasing the lapse time for reinstating medications for current and chronic medical conditions in psychiatric patients transferring from the emergency department to the in-patient psychiatry floors. 
  •  
  • Nicole Riordan, MD, of the Indiana University School of Medicine Emergency Medicine Residency Program, was awarded for her development of the “Patient Safety Officer” (PSO) system, where residents volunteer as PSOs and participate in development and implementation of a variety of efforts to improve patient safety. 

 A nomination form, due August 4th toAngela Franklin may be found at this link. We look forward to reviewing the 2011 applications and offering recognition for important quality improvement work!


QIPS Tips - Quality Improvement & Patient Safety Section Newsletter, June 2011

The Graying of Emergency Medicine 

Shari Welch MD, FACEP 

Shari WelchThere is no denying that physician performance does decline in later years. Evidence shows that cognitive and motor skills decline with aging and most hospital bylaws stipulate a maximum age for surgeons to perform surgery and a maximum age for physicians to maintain privileges.  (Pilots in the US face mandatory retirement at age 65). Emergency Medicine as a specialty has not truly begun to address these realities.  

The newest generation of emergency physicians (The Millennials) put lifestyle issues above salary and clearly want to work less. Emergency Medicine physician contracts from the 1980’s typically involved over 1900 clinical hours a year.  Fast forward and many groups will consider 1100 hours as full time. Couple this with the looming physician shortage and one thing is for certain: We do want the older physicians to work as long as possible. They add elasticity to the schedule and are often available to work when physicians with younger families desperately need off.  

Having a physician workforce with varied histories, capabilities, interests and skills can be positive for a group. One intriguing example of this was offered from an attendee at a recent ED Operations Management Course.  The physician was over 65 and commented, “I think older physicians are a great resource, particularly for “physician in triage” models.  If there is one thing guys like me have honed, it is the ability to recognize sick/not sick. Sometimes I think I am too old and tired to man the back of the ED.  But I am really good at that blink response in triage. The younger guys want to be in the back in the middle of the action.  I am happy to make hundreds of front end decisions in triage!”    

There is another area where the older physicians can make a contribution and, Greg Henry has noted this in his recent “Oh Henry!” columns. Younger physicians have less interest in administrative and management work, whereas more senior physicians often enjoy this type of work.  Groups would do well to take advantage of such interest and expertise.  

The point is this:  The physician workforce in emergency medicine, just like the physician workforce at large, is aging and with this comes changes in our collective practice as a specialty.   Physician groups need to begin exploring ways to continue to utilize older physicians in the practice of emergency medicine while acknowledging that we will all march through these professional phases. Flexibility all around, such as job sharing, part time work, split shifts, and flexible schedules should be part of the exploration.  Crafting policies that make use of the special expertise and limitations of older physicians is where it all has to start.


Engagement Trilogy Part 1- Chain of Improvement - Quality Improvement & Patient Safety Section Newsletter, June 2011

Mark Jaben, MD 

 

This is really born out of a recent medical trip to Bolivia, reading Drive by Daniel Pink, my wife's struggle as curriculum director in a pre K-12 private school and the faculty's frustration at students' seeming lack of motivation, and a dinner I had with Ricardo Peyerda, a Bolivian businessman, who works with large corporation boards. His main focus is to help these boards think about how they develop relationships. As an emergency physician and in trying to promote Lean concepts and practices in health care, I have struggled with how to help people take the leap from an attraction to Lean ideas to being willing to carve out some time and effort to devote to their use. It seems that, despite their interest, nobody has any time or energy. 

In Bolivia, I watched as my 13 year old son, David, and a retired engineer, named Dick, both without any medical experience, gradually become more and more involved in figuring out ways to help our eye surgery go better in our makeshift operating room. We didn't ask them to do more; they took it upon themselves.  Their motivation and engagement only took off once they had enough mastery in the tasks we asked them to do, like running the A scan machine ( a device that measures patients for the right size lens implant), sterilizing the equipment, turning the room over between operations, coordinating surgeries with consults, performing eye screenings, and medicating patients. We all understood our hope was to improve people's eyesight.  

This is what I think I learned: 

Purpose + Mastery = Motivation + Autonomy = Engagement  

PURPOSE- reason to act; what is needed to be successful; recognition that the problem at hand impacts your ability to be successful at what you are doing; this creates an interest to act 

MASTERY, enough competence to act, which creates the sense that you can be successful 

So, RELEVANCE, the reason to act, and 

ABILITY, the competence to act, together create a foundation for MOTIVATION, the willingness and confidence to extend oneself 

ADD AUTONOMY, the latitude to act;  

LEADS to ENGAGEMENT, actually extending oneself to act. 

In practical terms, engagement requires establishing an atmosphere where people can act without having to fear the consequences, if their actions fail to achieve the aims. Dan Pink's research indicates that once fair compensation is established, autonomy is promoted through giving people control over their time, tasks, technique and team.  

His work also indicates that mastery requires training and appropriate feedback. Mastery includes not only the skill and knowledge to perform the task at hand, but also the skill and knowledge in how to solve problems and learning to improve.  

But what creates relevance and purpose?  This is where Ricardo's insights were illuminating. Purpose and relevance are built upon establishing mutual goals; and this depends on each party understanding what each needs to be successful; and this is based on their assumptions about their world, how to be successful in it, and what does work and what won't work. The dialogue necessary to expose these assumptions will only occur once a relationship is established, where the parties recognize they need each other to be successful. 

For David, once he understood that removing the cataract was only the first step, and that the right implant was crucial to getting the desired result, he recognized that his job running the A scan machine was incredibly important and a valuable step- he had a reason to act. Once he gained enough skill, by using TWI (training within industry) methods to get him up and running quickly, he was motivated and then found better ways to also keep the schedule on track and document the work. He was engaged in the work because we provided him enough skill and because we gave him the encouragement and support to act (we had little choice if we wanted to get all the surgeries done!). Sharing in the happiness of removing the eye patch of a patient the next day and discovering that person could now actually read for the first time in years was feedback enough. 

Sometimes, however, what constitutes success is not so obvious. Often, we have not clearly defined what success entails, or the workplace environment makes this sharing difficult or even risky. Occasionally, people are very willing to share their beliefs about what success means to them, but often this is difficult because it revolves around deeply held, personal beliefs that people don't often feel comfortable sharing with others.  Unless these assumptions are acknowledged, and either validated or refuted, it is hard to move further up the chain of improvement. And this is the importance of relationship building. 

Purpose <-- shared goals <--understanding success <-- surfacing assumptions

<--dialogue <-- relationships  

Ricardo is very interested in how societies and cultures over time have developed their rituals to foster these relationships, particularly, when the topic is difficult or painful. Perhaps there is some guidance in how best to advise us on relationship building.  

Peacebuilding, by Lisa Schirch, suggests that rituals work to inactivate social structures that feed conflict.  Creating shared identities through rituals helps individuals alter their world views and perceptions, allowing problems to be reframed and approached in new and novel ways. 

Lean practice supplies its own set of rituals, most of which do establish a common method and language to allow such dialogue to occur when it is otherwise difficult or too risky. For instance, a kaizen event places everyone in the same room, removes the obstacles of their day to day work lives, and puts those with the insight together with those who have the ability to make the changes happen.  A value stream map puts the actual current situation on paper, enabling everyone to agree on a common place to work from. The A3 format creates a platform to focus on the truly important information and acts as a guide for how to proceed. A PDCA cycle might really be needed to test the validity of an assumption, so as to better understand someone’s notion of success. Unless these aspects are addressed, you may never get to the engagement needed to learn how to get results. 

Cultures and religions certainly have defined protocols for the proper way to initiate communication inside the group, with outside parties and even with adversaries, and certainly with their central figure. So where people find it difficult to share their assumptions in the workplace, we can create rituals to assist.  

For instance, a communication kata might establish these ground rules: 

  1. How I will give information to you, i.e., email, visual board, newsletters, communication book, calls, personal contact
  2. How exactly you can give information to me, i.e., visual board, email, personal contact,
  3. A pledge as to how I will respond, i.e., ‘I will always listen earnestly and take into account your views'; ‘my default response to any issue is to examine the process, not cross examine the person.'
  4. What to do if you feel at any time I am not fulfilling this pledge, i.e., establish a personal accord; a visible sign, for example, like raising a finger, that we agree will serve as your signal to me that it does not appear I am complying with this pledge.
  5. What we will do together with the information, i.e., problem solving.

In the Lean community, we all recognize how to get the results and learning through continuous improvement. It is the engagement that I have struggled with. Now I think I have a better insight and understand that sometimes before I even first work to put the Lean practices in place, I really need all of us to understand that getting results depends on learning how to get those results (i.e., innovation).  This requires people to even be interested in pursuing these results, (i.e., engagement). This depends on relationships: what success actually means for people, and establishing an infrastructure for sharing difficult, closely held assumptions.  

I believe this is where the basic concept of Respect for People applies, and why it is so essential to the chain of achieving results.  

RESULTS <-- LEARNING <--- ENGAGEMENT <-- RELATIONSHIPS 

These linked steps in the chain of improvement provide a troubleshooting guide to assess your organization, or those you have been tasked with helping, to better understand what needs to be in place before learning and results can occur and where efforts need to be focused when there is resistance and pushback.  

The point is to be mindful of where you are along this chain.  It may be that in your current situation, the purpose of the lean tool you choose is not really to achieve a result, or even to make the problems visible, but to be a ritual that creates the conditions where a relationship can be established, a common denominator can be found, a dialogue can emerge and an assumption can be safely challenged. As my lean mentors always repeat, “what’s the problem?” Determining the right need is always the first step. 


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