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QIPS TIPS #32: Cutting Edge Scheduling for ED Docs

Shari Welch, MD, FACHE, FACEP

Shari WelchTexas Harris Health Fort Worth is part of a 25 hospital system and one of the busiest emergency departments in the country. With 635 inpatient beds the hospital houses a 100-bed emergency department which treated 120,000 patients last year. Their admission rate is high at 24% and they have a high ambulance arrival rate (30%). The emergency department boasts five zones spread across 75,000 square feet. Even before moving to the new facility (the old one was only 1/3rd the size), the department had a reputation for service quality and efficiency.

The Texas Harris Health Fort Worth ED boasts unrivaled performance in both clinical and operational metrics. Most of their Core Measures metrics (pneumonia, stroke, STEMI, sepsis) had performance at above 95%. Further, their operational metrics are unheard of in emergency departments seeing over 350 patients a day:

  • Door to Doc = 20 minutes
  • Overall LOS = 185 minutes
  • LOS admitted patients = 291 minutes

What are some of their strategies for such outstanding work flow, patient flow, and clinical quality? This emergency department is staffed by an extremely stable physician group with strong leadership and a long history of service quality. Interestingly they boast some half a dozen physicians that came up through the ranks as nurses or scribes and then returned to Texas Health Fort Worth after completing medical training! 

The ED leadership team has designed one of the most unique and original physician scheduling models we have come across. First, this physician group recognizes that there are fast physicians and slow physicians. Doctors are monitored for productivity and classified as “green, yellow or red” indicating the highest to lowest productivity. This is not used in a punitive fashion, because this group recognizes that each physician member contributes to the good of the group in some way. However, when the clinical schedule is crafted there is careful effort not to schedule consecutive or concurrent “red physicians”.

In addition, physicians progress through a daily schedule that has them move from the highest acuity area to the lowest acuity area during a shift. They “fall back” from High Acuity, to Major Medical, to Quick Care (Fast Track) and then to Procedures. Interestingly all procedures are handed off to a physician that at the end of his shift only does procedures. This will probably be the most controversial aspect of this scheduling paradigm. But it was explained to us by one of the physicians in a way that every emergency physician understands: Say you are intensely involved with a patient that may be septic, but you have a complex facial laceration to close. You are interrupted and distracted repeatedly as you do the procedure and feel afterward that you did not do your best. Imagine if all you had were procedures to do in series and without interruption! Since every physician works through the progression every physician has the opportunity to perform procedures.

The model is also noteworthy for placing the most rested physicians in the area with the most clinically complex and ill patients. The shift finishes in the minor care area which excludes patients with abnormal vital signs. Physicians are encouraged to make efficient and rapid dispositions of patients because if they are unable to tidy up a zone as they progress through it, then they may have active patient care going on over a large ED footprint. The physicians admitted that on occasion the geography and the physician progression model seem at odds and a physician is doing a lot of running, but the doctors explained that their model had many advantages when viewed as “What is good for the patients?”

This is an innovative way to optimize the scheduling of physicians and is definitely Cutting Edge! Would it work for you?

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