Bruce Siegel MD MPH, Marcia Wilson MBA, Khoa

Nguyen MPH, Marsha Regenstein PhD

Academy Health

June 6, 2004

Improving the Performance of the Safety Net:

Findings of the Urgent Matters Project

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Program Origins: RWJF Surveys the Landscape

2000 IOM report on the safety net The safety net is “Intact but endangered” Report recommends we monitor and assess local safety nets

Drumbeat of media coverage: Overwhelmed EDs with diversion and long waits ED’s overwhelmed: 62% of hospitals report being “at” or “over

capacity” (Lewin 2002) ED’s as the “safety net for the safety net”

Take all comers, by custom and law - EMTALA

ED Volume Rising While Number of EDs Shrinks 1992-2002: Annual ED visits up 23%, Number of EDs down 15%

(CDC 2004)

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Selection Process Applications solicited from all public/not-for-

profit level I and II trauma centers in US. 2/3, or 287 submit detailed on-line letter of intent

10 selected as grantees Criteria:

Evidence of crowding ED volume, market share Payer mix Track record in achieving and sustaining change Senior leadership commitment

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The 10 Hospital Learning Network

Grady Health System – Atlanta, GA Boston Medical Center – Boston, MA Henry Ford Hospital – Detroit, MI Inova Fairfax Hospital – Fairfax County, VA BryanLGH Medical Center – Lincoln, NE The Regional Medical Center at Memphis – Memphis,

TN St. Joseph’s Hospital and Medical Center – Phoenix, AZ Elmhurst Hospital Center – Queens, NY University Health System – San Antonio, TX University of California at San Diego – San Diego, CA

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Urgent Matters Input/Throughput/Output Model

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Learning Network Elements

Tool kit of best practices on patient flow Data collection methods Strategies for work flow re-design Organizational buy-in strategies Implementation strategies

Training and Reinforcement on Rapid Cycle Change Plan, Do, Study, Act

Core Metrics 17 key performance indicators (weekly and monthly

reporting)

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Learning Network Structure

Web-based management Tool kit, new developments and other resources Action plans and data submission Run-charts Monthly project reports “Celebrating Success” Shared data – shared outcomes

Peer Collaboration 3 group meetings 3 consultant site visits to each site, with phone consultation Monthly conference calls with topic presentation, update

from each site Listserv

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Closing Thoughts: Operations

It’s The Hospital, Stupid!!

Rapid Cycle Change: Rapid Is Key Early Results More Important Than Consensus Communications are critical

Data Systems Lag But it’s doable

Executive Management Buy-In Is Key

Collaboration? Or Competition?

Productivity May Increase Dramatically

Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

Closing Thoughts: Policy

Do We Really Need All These New ED’s? Are we just building bigger reservoirs? And what are we putting in them?

Changing EMTALA Is Not the Answer

Barring the Door, or “Triaging Out”, Is Not the Answer Either

What are the Implications for Surge Capacity?

Maybe We Need to Rethink the Role of the ED as “Provider of Last Resort”

The Safety Net CAN Improve Its Performance With minimal external resources And that goes for Academic Health Centers as well