Phase I Course Descriptions

Addressing The Problem Physician

One of the most difficult situations an ED director must confront is the problem physician. You were never taught how to address the practitioner who aggravates staff, patients, and medical staff, is resistant to necessary change, or provides substandard care. Using examples, this course will identify some of the more common types of problem practitioners and describe communication techniques and corrective actions with measurable outcomes and endpoints. List indicators, including methods of identification of the problem physician.

  • List typical practitioner problems requiring intervention.
  • Describe effective methods of confronting practitioners (direct, “Cup of Coffee conversation,” private, with data, etc.)
  • Discuss counseling techniques (conversations, documentation issues, and when witnesses are necessary.
  • Develop corrective actions with measurable outcomes.
  • Define endpoints, i.e. when terminating the relationship is best for both parties.

Billing and Coding

Most emergency departments generate money the old fashioned way – they earn it by caring for patients. The key is to convince the payers that the providers are due reimbursement for the clinical services provided. Several basic principles of documentation, E/M coding, CPT definitions, RVUs, billing, charge structure, write-offs, bad-debt, accountability, compliance, etc., will be discussed. Several time tested methods of improving reimbursement will be discussed, as will be methods to monitor your ED’s performance in this critical area. Additionally, the presenter will identify and suggest how to prevent billing, coding, and supervision issues subject to fraud and abuse.

  • Define basic terminology of the billing and coding system.
  • Describe the specific components of the billing process.
  • Explain the professional and technical components of E/M coding and billing.
  • Identify how E/M coding and billing interrelates to the hospital reimbursement.
  • Differentiate between billing performed by a group, hospital, or billing company with respect to general approach, ongoing monitoring and management.
  • Identify areas of emergency billing, coding, and resident supervision where fraud/abuse can take place.

Bringing Up Young Leaders

Leaders are not born, they are created by intrinsic motivation combined with opportunity, empowerment, mentoring, and feedback. And yet those with great potential are often overlooked because of implicit bias, preventing current leaders from recognizing and encouraging other group members. Others are held back by our inability to delegate and create accountability. We must create opportunities for others and develop them. Done successfully, everyone wins.

  • Describe advantages of bringing up young leaders.
  • Define “Implicit Bias” and give examples of how it influences thoughts and behaviors.
  • Explain components of successful leadership development, such as providing opportunity, sharing experiences, providing encouragement, delegating responsibility, setting expectations, giving constructive feedback, and allowing for failure.

Conducting Effective Meetings

“Oh no! Not another meeting!” The presenter will review when to and when NOT to have a meeting, and how to make the meetings you do have more effective and rewarding. Learn how to guide the overbearing, the sarcastic, the bashful, and the detractor. Discover effective methods to open and close discussions. This meeting will help to improve the rest of your meetings.

  • Describe when to and not to have a meeting.
  • Describe effective meeting planning and preparation.
  • Develop an effective agenda.
  • List problems that occur during a meeting and methods to resolve them.
  • Review common traps that chairs fall into, such as wandering discussion, taking a side, berating members.
  • Describe what to do when the meeting has concluded.

Containing Cost While Providing Prudent Care

The effective ED leader must understand cost appropriate care and efficient utilization of critical resources. Financial realities place pressure on all participants in the healthcare environment and frequently necessitate a critical review of utilization. Too many CTs, admitting patients eventually denied by third party payors, unnecessary laboratory tests, staff cutbacks, etc., are all areas of frequent ED review. Critical review, peer comparisons (locally and nationally), and effective communication all play a role in defining appropriate utilization. The presenter will describe methods of encouraging practitioner (utilization) behavior change, when appropriate.

  • Define resource utilization and cost containment.
  • Identify the major types of over-utilized resources in the delivery of ED services (imaging studies, staff, inpatient services, laboratory studies, etc.)
  • Describe several tools available to the ED director and management team to assist with demand forecasting and cost management.
  • List institutional leaders traditionally most concerned about over-utilization.
  • Describe the potential risk of under-utilization.
  • Describe successful methods of demonstrating findings and creating behavior change.

Customer Relations and Patient Satisfaction

Do you know who your customers are and what they really want? Hospital leadership is placing increasing emphasis on patient satisfaction survey scores. Emergency department leaders are being held accountable to be able to interpret scores and develop and implement an action plan to improve scores on an ongoing basis. This presentation will offer a discussion on developing a work team, motivating and training staff, survey development, monitoring, and implementing responsive programs to address issues in a timely and effective manner as they arise.

  • Determine specific emergency department patient expectations; facility, environmental, staff performance, medical care, and patient flow.
  • Identify key patient issues creating satisfaction and dissatisfaction.
  • Examine strategies to meet, change, or exceed patient expectations.
  • Describe development and implementation of a customer relations program.
  • Evaluate key components of customer satisfaction surveys, telephone surveys, and patient focus groups.
  • Determine whether to make or buy a survey tool.
  • Determine strategies to analyze and interpret data from satisfaction surveys.
  • Develop strategies to provide timely and pertinent feedback to key staff members.
  • Utilize case studies, and describe methods to develop an action plan to improve patient satisfaction scores.

Driving Hospital Quality

The Emergency Department can be a major driver of hospital quality. Typically 40% of hospital admissions come through the ED and, as such, opportunities to "jump start" quality care for a broad array of inpatients exist. Leaders of EDs should seize the opportunity not only to provide exemplary care of their own patients but also to take a broader role in being a champion for hospital quality. This presentation will focus on the opportunities that emergency department leaders have to impact the quality of care not only provided in their departments but throughout the hospital.

  • Describe multiple techniques to affect inpatient care not only as the result of initial treatment in the ED but through other hospital initiatives.
  • Explore many of the hospital-wide CMS/JCAHO medical quality and safety measures and present strategies by which the ED medical leadership can help impact these in the hospital.
  • Explain the primacy of medical staff leadership in driving medical quality and how the ED medical leadership can play an important role in this process.

Effective Conflict Management

Callousness, anger, frustration, and tantrums are commonplace in the stressful environment of the emergency department. Many of our customers are in crisis. Everyone – emergency caregivers, private practitioners, patients and administrators – has needs that must be met. Explore what causes “communication breakdown.” Participants will discuss the origin of common ED conflicts and successful methods to resolve them.

  • Describe the common causes of conflict and the origins of stress in the ED environment.
  • Review ineffective individual responses to stress and conflict.
  • Define the necessary communication skills to effectively address conflict, such effective listening, eye contact, avoiding emotion, etc.
  • Describe the "Theory of Yes" and the concept of focusing on issues, rather than positions.

Engineering Patient Flow I: Theory, Metrics, and Application

Your ability to operate an efficient emergency department is paramount to your success and tenure. This becomes one of our greatest management challenges. The speaker will describe methodologies to identify barriers and bottlenecks that compromise efficient patient flow. A discussion of queuing theory, crowding, and essential metrics will help you develop strategies to improve workflow, build effective relationships with ancillary providers, and incorporate structural redesign into the already complicated picture. The manner in which informed participatory decisions can improve operational efficiency and throughput also will be discussed.

  • Describe queuing theory.
  • Discuss issues of crowding.
  • List common ED operation metrics.
  • Describe the application of metrics to the ED.
  • Identify ED technologies that can help improve patient flow.

Engineering Patient Flow II: Directing Change

Once the director has analyzed the patient flow issue, the next step is to make improvements. The director must be able to implement specific changes to remove barriers and avoid the clogging points of his/her ED. Several specific case examples will be provided to demonstrate effective “best practices” that can be used to improve patient turnaround time and patient and staff satisfaction. These will include rapid triage, bedside registration, effective documentation methodologies, nursing protocols, expedited lab and imaging processes, and rapid admission procedures.

  • Describe improvement processes and concepts of "benchmarking" and "best practices".
  • Describe implementation programs to reduce delays, improve patient throughput, and enhance patient and provider satisfaction, such as rapid triage and bedside registration; documentation methodologies, handwritten chart, templated systems, scribes, dictation.
  • Discuss methods to create “buy-in” from administration.

Interactions that Create/Prevent Malpractice

Emergency physicians develop a style of professional communication that is intended to create rapport, develop confidence, put patients and staff members at ease, and communicate critical information. Unfortunately the intent is not always achieved as some physicians do not take or have the time to effectively communicate. Worse, occasionally words and phrases are used that are misinterpreted and body language is incongruent with the intended message. These may lead to frustration, anger and claims of malpractice. This course will review types of words and phrases that are frequently misunderstood and lead to legal jeopardy. Additionally, the presenter will provide tips on how to deal with group members that are ineffective communicators.

  • Describe linguistic theory of communication.
  • Discuss difference between intention and reception.
  • List common words/phrases that are likely to be misunderstood.
  • Describe verbal and non-verbal approaches to effective communication. Instruct members of group on features of effective communication.

Keeping Your Contract: Preventing and Dealing with Problems

Emergency department directors are confronted with problems from every direction. Effective directors seek to recognize and resolve problems as they arise. Superb directors establish mechanisms to identify issues before they arise. This experienced panel will describe methods to recognize, resolve, and even prevent the most common and serious issues that threaten your relationship with the institution. Participants will be given time to describe their particular problems so that the panel members may comment.

  • Describe the most common issues that cause contract loss.
  • Explain how effective and ineffective directors deal with those issues.
  • List processes to identify problems before they occur.

Legally Interviewing, Hiring, and Terminating

Interviewing, hiring, and terminating is substantially more complex than it would appear to a new director. This presentation is designed to familiarize the medical director with the basics of employment law with the necessary approach, documentation and communication involved in legally hiring and firing. The presenter will provide case studies to demonstrate appropriate and inappropriate techniques of interviewing, hiring, counseling, and firing personnel. A full understanding of the essential steps in this common process protects the interests of all parties.

  • Explain relevant federal and state labor laws, i.e., Civil Rights Act, FMLA, etc.
  • Define “at-will,” ADA, and other employment issues.
  • Describe appropriate and inappropriate questions and approaches to the interview process.
  • Explain methods of counseling (corrective actions) that are likely to pass legal muster.
  • List the required components to terminate an employee with least risk to you and the organization.

Malpractice Litigation Stress: Doctor Beware

Many of you and members of your team will be sued during your careers. Litigation is a major cause of stress and burnout in emergency medicine. Physicians who have been sued often practice defensive medicine, order unnecessary tests and consultations, and are more likely to make errors, all creating additional malpractice risk during this stressful period. As medical directors, you may have additional risk and accountability related to your departmental policies, procedures, and supervisory responsibilities. The presenter will describe the impact a malpractice claim has on an individual physician and emergency department.

  • Review common signs and symptoms experienced by a physician undergoing litigation stress.
  • Describe the impact a malpractice claim may have on the emergency department.
  • Depict the anatomy (stages and timeline) of a lawsuit.
  • Explain what a medical director is allowed to discuss with a staff physician being sued.
  • Review cases of lawsuits aimed at medical directors for administrative negligence.
  • Develop strategies and review resources to help physicians undergoing litigation stress.

Negotiating Skills

It has been said, “You don’t get what you deserve; you get what you negotiate.” The presenter will describe and demonstrate critical negotiating principles and techniques that you can use in your professional and personal life to get you what you want and deserve. Critical concepts of time, deadline, starting position, and concessions will be described with real examples. Participants will recognize how effective negotiators use power techniques such as competition, expertise, and higher authority.

  • Define the principles of negotiation.
  • List the components of successful negotiating, including attitude, information and aspirations, time, power, and planning.
  • Describe negotiating processes, including starting, concession behavior, and overcoming obstacles.
  • Describe effective responses to common negotiating ploys.

New Physician Recruiting and Orientation

Does your system consist of (a) "You want to interview, OK come see me during my shift tomorrow", and (b) "Now that you have completed the tour, here is a copy of the chart. Good luck!"? The presenter will describe the successful and effective recruitment and orientation processes to ensure success. Successful recruitment requires an elaborate organization of reviews and interviews and a thorough understanding of the candidate’s capacity and aspirations. Effective orientation incorporates substantial exposure to the EDs processes, policies, support systems, and operations prior to beginning clinical activities. The participant will be given a case study guidebook to help you develop orientation materials for your own emergency department.

  • Develop and implement an effective recruitment process.
  • List necessary recruitment reviews and interviews.
  • Explore candidate’s capacity and aspirations.
  • List necessary components of practitioner orientation.
  • Design orientation checklists and materials.
  • Define and give examples of physician orientation plans.

Patient Complaint Management

“Oh no…not another complaint!!” People complain when they are dissatisfied. Add the anxiety, confusion, and potential peril of an emergency and the number and seriousness of complaints increase. Complaint recognition and management are critical components of the successful ED director. When handled properly, a dissatisfied and angry person can achieve satisfaction. Alternatively, the improper management of a complaint can lead to a disgruntled person who seeks retribution. Leaders that recognize the relationship between quality and consumer satisfaction seek opportunities to improve by taking steps to reduce the root cause of dissatisfaction. The presentation will consider three issues: (a) Who complains, why they do and methods of prevention; (b) Successful program (process and tools) for complaint and compliment management; and (c) Several classic ED complaints with underlying issues and methods of resolution.

  • Identify who complains and the reasons they complain.
  • Describe techniques to prevent complaints, including the application of the “Yes” theory, Realistic Triage, Resetting Expectations, Letting them know that you know, etc.
  • Explain methods to investigate complaints from patients, staff, administration, etc.
  • Implement a complaint management form and tracking system.
  • List classic complaints, the underlying issues, and prospective and retrospective solutions.

Physician Contracts

The success or failure of the contract between a physician and the group/hospital is based on effectively recognizing, discussing, and negotiating the difficult issues in advance. It is critical to clarify the important issues, expectations, and responsibilities when relationships are good, but what happens when they are not and termination is inevitable? What are the expected responsibilities, duties, and compensation? What is breach, is there a “no-cause” termination clause, what procedures exist for resolving disputes, and what are the restrictions?

  • Describe the key differences between independent contractor and employee relationships.
  • Describe the major elements of physician contracts.
  • Identify the key financial considerations.
  • Explain contracting entities (physician and group/hospital) perspectives on key contract clauses of: compensation and benefits, duties and responsibilities, restrictive covenants, term and termination.
  • Identify common areas of contract problems and methods to avoid them.

Preventing Errors in Emergency Medicine

Mistakes happen! The Institute of Medicine report has focused significant attention on the ubiquitous nature of medical errors and the associated morbidity and mortality. This course will specifically focus on types, theories and causes of errors in emergency medicine as well as situations, practices and systems that are most likely to lead to mistakes. In addition, this course will look at system-based (process) solutions to errors.

  • Describe the magnitude medical errors in medicine / ED, recounting the IOM report and its implications.
  • Define safety and error in medicine.
  • Distinguish error from harm/injury.
  • Discuss various theories of error (system, process, accident, mistake).
  • Identify moments and patients at high risk for common medical errors.
  • Describe system based solutions to error.
  • Discuss the development and implementation of safety standards/policies in the ED.

Reimbursement Issues

The bottom line is the bottom line. Without appropriate financial resources, your ED and group will fail. ED groups and hospitals are dependent on patient care revenues to support the mission of the department. Medicare cuts, managed care practices, and heavily discounted fee schedules may threaten the financial viability of ED practice. The presenter will provide an overview of today’s trends in ED reimbursement issues, including APCs, discounted arrangements, denials, etc.

  • Define the overall system of how emergency physicians and hospitals get paid for providing emergency services.
  • Discuss the trends in EM reimbursement and the factors influencing these trends.
  • Demonstrate the differences between what is charged for EM services and what is collected and why.

Rescuing Victims - A Primer on Recognizing and Addressing Human Trafficking and Domestic Violence

Human Trafficking, modern-day slavery, is ubiquitous and largely unrecognized. You have unknowingly taken care of patients who have been coerced into becoming sex or labor slaves. We also take care of patients who are routinely subjected to domestic violence. Few of us have been prepared to recognize, let alone address the problem. The good news, information, programs, and resources now exist to make a difference. The presenter will briefly describe the issue and potential responses.

  • Define the various forms of human trafficking and domestic violence – Awareness
  • List common presentations (behaviors and signs) – Recognition
  • Describe methods obtain more information, private communication – Create a safe zone
  • Communicate options to the victim and alert those who can help – Response
  • Participate in the development of an institutional program – Resources

Risk Management

Time, expectations, communication, errors, etc. all conspire against us to create dissatisfaction and poor outcomes. We and our colleagues all experience situations leading to less than optimal care. Preventative techniques will substantially reduce risk and improve the perceptions of care and caring by those receiving it. There are many known high-risk situations that when identified can be controlled and the impact limited. Among them are operational situations, such as change of shift (sign-out) and return visits, clinical presentations, such as chest pain and pediatric fever, behavioral issues, such as AMAs and communication. The speaker will review the major causes of malpractice and methods that you and others in your practice may use to avoid them.

  • Describe the components of malpractice.
  • List high risk:
    • Behaviors and interpersonal communications
    • Clinical presentations
    • Operational situations
  • Identify methods of determining high-risk behaviors in ones own ED.
  • Describe methods to decrease risk.

The Role of the ED Medical Director: Developing Leadership and Communication Skills

The ED has substantial impact on the institution’s and community’s provision of health care. Effectively leading the ED, its staff, and programs requires navigation through a myriad of complex processes that may at first seem daunting. The presenter will highlight the issues of leadership and change in the complex organization. Specific examples of effective leadership and a description of the importance of effective communication skills (written and verbal) for the successful ED physician leader will also be discussed.

  • Identify the traits and methods used to be a successful leader.
  • Describe planning, implementation, and evaluation of all emergency department functions.
  • Identify the steps necessary for creating a vision, communicating the vision, and empowering others to act on that vision.
  • Describe change management and departmental integration strategies.
  • Identify the steps necessary to properly manage and control resources.
  • Define commitment to customer service (patients, family, administration, medical staff, etc.)
  • Describe the components of effective administrative, intra- and inter-departmental communication, including both verbal and written.

Staffing and Scheduling Methodologies I and II

While the responsibilities of an ED director can be demanding, perhaps most daunting is addressing staffing and scheduling. ED leaders must define the right mix of physicians and advanced practice providers (APPs) and optimize provider productivity to ensure efficient care, satisfied patients, and proper revenue/cost. Patient demand and operational efficiency drive staffing demands and the derived schedule must ensure optimal throughout, provider wellness, and cost efficiency.

During the first part of the program, the presenter will engage the participants in a discussion that will define staffing needs based on demand patterns, skill mix, and productivity targets and methodologies, including the influence of scribes and how to consider staffing changes.

The second portion of the program will comprise an interactive workshop, during which the participants will work through a simulated staffing problem and apply the lessons learned. Students will be required to calculate an optimized demand profile, determine the mix of providers, and create a sample schedule based on the available number of FTEs.

There is mandatory pre-work related to queuing theory and Lean Healthcare that will greatly enhance the attendee’s acquisition of the material presented and allow for workshop activities that are a better use of classroom time.

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