ED Operations: How YOU fit into the Big Picture

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ED OperationsHow YOU fit into the Big Picture

• Brent Asplin, MD, MPH
• Head, Department of Emergency Medicine
• Regions Hospital, St. Paul, MN
• Associate Professor Vice Chair
• University of Minnesota Dept of Emergency
  Medicine
• E-Mail Brent.R.Asplin_at_HealthPartners.com

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Four Areas to Consider

• People
• The Business of Emergency Medicine
• Patient Experience
• Quality and Variation

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Perspectives

• Member of your group
• Educator
• Where will most of your residency graduates
  practice?
• What factors will be the major determinants of
  their career satisfaction?
• What behaviors are you modeling for your
  residents and students?

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What Drives our Behaviors?

• How we think
• How we feel
• How we act

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Life Takes Place Between the Ears

• We rehearse our negative emotional states 100
  1,000 times more often than we rehearse our
  positive emotional states

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People

• True or False?
• Conflict requires cooperation.

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Functional vs. Dysfunctional Conflict

• Functional Conflicts
• Dysfunctional Conflict
• Any conflict that does not serve your values

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The Choreography of Conflict

• Behaviors
• Perceptions
• Values

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Options to Avoid Conflict

• Influence the behavior of others
• Alter the way you perceive the behavior of others
• I wonder what pain gives rise to that behavior?
• Choose not to respond with behaviors that will
  threaten the values of others
• Under what conditions would it make sense for
  you to do __X__?

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Perspective

• Its strange, but wherever I take my eyes, they
  always seem to see things from my point of view.

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You are 100 Responsible for Your Effectiveness

• Get clear on what you want from people
• Get clear on what is important to them
• I.e. what values do they need to serve?
• Change your behavior to alter their perceptions
  in a way that links the two

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Listening

• One advantage of talking to yourself is that you
  know at least one person is listening.
• -Franklin P. Jones
• We dont assume that just because someone can
  see, they can read so why do we assume that just
  because someone can hear, they can listen?

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Increasing your Influence

• Understand your personal values
• What are you passionate about?
• Remember that you are the only one who will take
  care of your values
• Nobody is on the face of the earth to take care
  of you.
• People will react to you based on their
  perceptions of your actions
• Take their values into consideration
• Search for value-rich alternatives

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People Take Home Points

• Know your values
• Dysfunctional conflict has the potential to be
  the single greatest career dissatisfier for you
  and your trainees
• Model influence and cooperation rather than
  dysfunctional conflict
• Take 100 responsibility for your effectiveness
  when interacting with others
• Cultivate and practice listening skills
• Consider getting a personal coach who is informed
  by anonymous 360 feedback data

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The Business of Emergency Medicine

• Were here to take care of patients, not worry
  about what level were charging.
• Sheltering students/residents from the business
  aspects of emergency medicine is a great
  disservice for their training

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Key Business Questions for Your Practice

• What is your payer mix?
• What is your total RVU/patient?
• What is your average collection rate (i.e.
  /RVU)?
• Does your hospital subsidize the practice, and if
  so, are there performance criteria involved?

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Key Business Questions for Your Practice

• Where am I in relation to my colleagues
  regarding
• Average patients/hour
• Average RVUs/patient
• Percentage of patients with critical care charges
• Total throughput time for discharged patients

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Patient Experience

• KEY POINTS
• Patients substitute experience for quality
• Patient satisfaction surveys are not science, so
  dont evaluate them with the same tools
• You can know whether a difference is
  statistically significant without saying (or
  knowing) anything about whether the data are
  representative (non-response bias)
• Variable compensation based on patient
  satisfaction data will be commonplace
• It isnt going away, so get used to it

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Quality and Variation

• The quality movement represents both our
  biggest opportunity for fulfillment and our
  second biggest potential for dissatisfaction
  (behind dysfunctional interpersonal conflict)

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Emergency Physicians as Systems Experts

• We continue to get the best medical students
• We make decisions with incomplete data
• We communicate quickly with a wide range of
  stakeholders
• We rely on teams
• We practice in the best laboratory in healthcare
• Patients come with both system barriers and
  clinical problems
• We are responsible for the most expensive routine
  decision in healthcare (going home or coming in)

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IOM - The Urgent Need to Improve Health Care
Quality

• Serious and widespread quality problems exist
  throughout American medicine. These problems,
  which may be classified as underuse, overuse, or
  misuse, occur in small and large communities
  alike, in all parts of the country, and with
  approximately equal frequency in managed care and
  fee-for-service systems of care.

Chassin and Gavin Institute of Medicine National
Roundtable on Health Care Quality JAMA.
19982801000-1005
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IOM - The Challenge of Improving Quality

• Meeting this challenge demands a readiness to
  think in radically new ways about how to deliver
  health care services and how to assess and
  improve their quality. Our present efforts
  resemble a team of engineers trying to break the
  sound barrier by tinkering with a Model T Ford.
  We need a new vehicle or perhaps, many new
  vehicles. The only unacceptable alternative is
  not to change.

Chassin and Gavin Institute of Medicine National
Roundtable on Health Care Quality JAMA.
19982801000-1005
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Central Truth

• Every system is perfectly designed to get the
  results that it gets
• If we want different performance, we must change
  the system
• To fundamentally change the system, we must think
  in different ways

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Quality of Care Problems

• Underuse -- The failure to provide a health care
  service when it would have produced a favorable
  outcome
• Overuse -- Occurs in the circumstances in which
  its potential for harm exceeds the possible
  benefit
• Misuse -- Occurs when an appropriate service has
  been selected but a preventable complication
  occurs and the patient does not receive the full
  potential benefit of the service

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Quality of Care Underuse

• Failure to use effective treatments for acute
  M.I. --gt 18,000 preventable deaths each year
• 79 of eligible elderly M.I. Patients did not
  receive B-blockers --gt subsequent mortality at 2
  years was 75 greater
• 59 of hypertensive patients did not have
  controlled blood pressure in FFS compared with
  45 in managed care
• Those without health insurance had a 25 greater
  chance of dying within 12 years

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Quality of Care Overuse

• 21 of all antibiotic prescriptions (23.8m) in
  1992 were for colds, URIs, or bronchitis
• 17 of coronary angiographies, 32 of carotid
  endarterectomies, and 17 of UGI endoscopies were
  for inappropriate indications
• 23 of children for ear tubes were inappropriate
• 20 of cardiac pacemakers were inserted for
  inappropriate indications

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Quality of Care Misuse

• Patient injuries resulting from the
  administration of medications occur at the rate
  of about 2000 per year in each large teaching
  hospital -- 28 preventable -- each adds 5,000
  to the hospital stay
• Medicare patients receiving poor care while
  hospitalized experienced 74 greater mortality at
  30 days

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The Checklist

• Three research functions funded by NIH
• Understand the biology of disease/injury
• Designing effective therapies
• Ensuring that therapies are delivered reliably

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A Call To Action

• A highly respected Minnesota labor leader
  Looking at care utilization levels of the
  insurance plans said, Whats costing us right
  now is an epidemic of care. If this keeps up,
  this epidemic of care will bankrupt us We want
  the best care but we need to figure out how to
  get it for less money.

Halvorson Isham, Epidemic of Care, Jossey-Bass
2003, ch 18 pg 241
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The Future of the Quality Movement

• What will it take to make healthcare more
  patient-centered and value-driven?
• What opportunities do we have as emergency
  physicians to help transform the way hospitals
  work?

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Zen and the Art of Physician Autonomy Maintenance

• This paper calls for physicians to practice the
  science of medicine as a profession so that
  society will allow physicians to continue
  practicing the art of medicine as individual
  professionals. In a Zen-like paradox, physicians
  must give up autonomy in order to regain it.
• -Jim Reinertsen, MD

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References

• Chassin and Gavin Institute of Medicine National
  Roundtable on Health Care Quality JAMA.
  19982801000-1005
• Reinertsen JL Zen and the Art of Physician
  Autonomy Maintenance Ann Intern Med.
  2003138992-995.

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References

• Gawande Atul The Checklist The New Yorker.
  December 10, 2007.
• Institute of Medicine Crossing the Quality
  Chasm National Academies Press. Washington, D.C.
  2001.

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References

• Dwyer CE Taking positive steps Physician Exec.
  2004 Nov-Dec30(6)6-9.
• Dwyer CE The Use of Power and Influence
  Managing without Authority J Am Pharm Assoc.
  2003 Sep-Oct43(5 Suppl 1)S40-1.