Monday, November 15, 2004

Thriving in an Environment of Imperfection

But first maestro, a small fanfare . . . Yes! I took and passed the 2004 Lifelong Learning and Self Assessment (LLSA) on-line examination! No, it wasn't bad at all. In fact I rather enjoyed the on-line testing.

Despite having read everything ABEM published about Emergency Medicine Continuous Certification and the LLSA process, I was still intimidated by it all. I spent a day off work scanning the 20 articles I'd previously read and marked up over a period of months. I quizzed and was quizzed by a colleague before each of us logged on and took the examination late on a Friday afternoon. It was an investment of time that gave me confidence in dealing with the test, but next year I'll just take the 2005 exam after I finish reading the articles and not make such a major event of the whole thing. For the LLSA seems more about learning than about testing. I especially liked being able to go back and reread sections of the articles for the questions I fumbled and get that, "ah ha" of understanding, even if late in the game.

Such imperfections as may exist in the LLSA process and my imperfection in taking the examination--no, I didn't score a 100%--along with the multitudes of failings in daily work and leadership constantly remind me that living is the ultimate humbling experience.

Adherence to JCAHO requirements is often fraught with imperfection. The 2004 national patient safety goals newly challenged us when a consultant raised questions about how we had implemented the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery(TM) in the ED as of July 1, 2004. This JCAHO requirement has generated a fair number of questions both locally and among participants on various email lists as it has become apparent that it applied equally to our less urgent procedures performed in the ED. I've heard concerns about physicians overlooking the "time out" component when only they are at the bedside, regardless of how the resulting documentation reads. Some in EM question the circumstances when site and side must be marked before performing procedures.

A few months ago I suggested that when speaking to hospital administrators an emergency physician leader might rely less upon the pronouncements of our professional societies and more upon the recommendations of organizations that speak to administrators. I received some negative feedback from physician colleagues and an admiring note from an administrative colleague. Indeed, that kudos is why I write this column, in an effort of persuasion addressed to you, my physician colleagues, that we must be heard by those in the hospital with whom we work.

A colleague recently wrote, "We are in a time of increasing strife between physicians and hospitals. Physicians who figure out how to compromise and work with their institutions will survive and prosper. Hospitals are changing, economic forces are changing, and so we too must adapt." Compromise with hospital administrators sounds like the very definition of imperfection to me.

My colleague went on to write in an email message, "When physicians ask me what sets them or a practice apart, it is the expertise and commitment they bring to the organization. It might be in business management, technology adoption or risk management; but it is no longer clinical expertise which is now pretty much a level playing field. For hospital leaders it is the ability to 'play well with others', to work to maximize the financial viability of the hospital--not necessarily of the group itself--and to serve the mission of the organization."

The practice model doesn't matter in this partnership with the hospital; a democratic group devoted to one institution might achieve these goals or a larger entity with the economies of scale that support the development and exercise of the required expertise. The physician owners/partners/employees of all the possible practice partners to the hospital may all practice high quality care, but the edge will go to the practice that can do it all in partnership with the institution.

As to individual physician leaders, hospitals urgently need those who understand the 'dysfunctional system' from an advocacy and finance perspective and who can work with the hospital to optimize patient, family and community service while continuously improving operational efficiency and revenue. In this imperfect environment, each physician should choose the model that best fits their clinical practice and personal needs and tolerance for risk, yet also consider their own desire for participation and expertise with relevant non-clinical tasks. Thriving in an environment of imperfection requires not that we personally undertake every last detail of partnership with our institutions, but that we do support--at least equally--our colleagues who embrace those challenges.

As to the challenge of implementing the Universal Protocol(TM) . . . and assuring adherence, I refer you to the JCAHO and ACEP while I join you in training our respective staffs while seeking to minimize onerous documentation requirements. At least for our sickest patients, remaining at the bedside obviates the site and side marking requirements and I've been cheered by the number of staff I see checking wristbands lately.

My colleague who unknowingly provoked this month's column with his question: "One must thrive in an environment of imperfection to really enjoy EM--don't you think?" was recounting an anecdote about the criticism supplied by a specialist utilizing the clinical retrospectoscope. Those of us who lead a practice of emergency medicine surely grasp his point--don't you think?

Friday, October 15, 2004

Colleagues, Conferences, Clinical Guidelines and Communication: Collaborative Medical Practice Today

Mornings are not my favorite time of the day, but I’m finding myself in the cafeteria before 7:00 AM several days a week now. No, I’m not getting coffee before an early shift, but I am doing so before the Surgery Morbidity and Mortality or Multi-specialty conference or just sitting down with a pack of proceduralists in radiology, GI, cardiology and other specialties.

I started back at this ritual, one I undertook for several years when I first started at Maimonides because I was hearing a growing number of complaints about our practice. Several physicians complained about the number of unnecessary cardiac enzyme studies drawn at triage, another complained about the one set of blood cultures rather than two, a third complained about antibiotic selection. What’s going on here?

In addition to breakfast, I went to meetings with the complaining physicians and the Chairman of Medicine. I went to meetings with the Chairman of Pediatrics and his staff. Our COO visited with physician staff and shared his observations about the complaints. At the sessions I attended, I listened, I took notes and mostly I heard about communication. Listening to the anecdotes and recounted (one-sided) telephone conversations, I realized that our colleagues were focused on their one patient, while our attending (or resident) was often distracted by other concerns and information even when they were on the telephone. Or worse yet, the call was “intended” but never completed.

I’m not saying that the clinical concerns originally raised as the issue don’t have merit and aren’t happening. In ~46,000 adult visits and ~20,000 admissions, more than 20% over age 65, I’m sure that clinical errors have and will happen. The real problem is that our admitting physicians don’t know our emergency physician staff well enough. It is a huge medical staff with over 400 internists and we’re a group of more than two dozen, but that’s no excuse. Sure we’re distracted and constantly interrupted while working in the ED; “You chose that practice,” our colleagues remind us.

Where would you go from here? I’m interested in your ideas since as leaders and members of your practice you’re challenged to introduce your newer colleagues to long-time medical staff members.

The usual advice we’ve all taught and heard is that the relationship between emergency physician and voluntary primary care physician is formed over the patient. Certainly this was my experience. Today, with most physicians in the hospital less, the telephone has become more important, perhaps we should train our emergency physician staff for telephone communication.

One thing I see, is as hospitalist practices develop and solo and small group practices diminish in number, my emergency physician colleagues are focusing on those physicians they see the most. Perhaps this is an artifact of our community teaching hospital and those of you practicing in non-teaching hospitals continue to see your primary care colleagues regularly. I’m sure diverse practice environments and hence professional relationships with colleagues foster different approaches to the problem.

We’re going to use the regulator’s growing evaluation of adherence to practice guidelines as one tool for improving communication. I’m not quite clear on the details—in fact we’re still working them out—but reminding colleagues of the JCAHO “Core Measures” for pneumonia (Figure 1) which includes evaluation of the timing of antibiotic administration allows us to put the emergency physician on the same team as the internist who is charged with assuring pneumococcal and influenza vaccination among other requirements. It will also present an opportunity to suggest that if they prefer a different antibiotic, they need not continue the antibiotic we’ve started—a choice we make using our infectious disease division’s recommendations as built into our ordering pathway.

I’m hoping that we can pull together a joint conference on the combined emergency department and inpatient management of the several core measure related disease processes we care for together: pneumonia, myocardial infarction and heart failure. Discussing our processes may enable learning that can improve the way we work, but will at least develop an appreciation for the difficulties we each face in our own clinical milieu.

With these efforts we’ll have precipitated a discussion around clinical pathways which is a pretty good place for physician colleagues to start learning about each other. Certainly it will be more productive than arguing over the timing of calls for notification of patient admissions.

If you’ve been coping with similar challenges I’d love to hear from you. Please share your problems and solutions with me by email and I’ll share them with all readers if you’ll let me.

In the meantime, I expect I’ll be dragging myself to surgical morbidity and mortality conference on Friday mornings at 7:00 AM for many years to come.

Figure 1. Pneumonia Core Measure as of April 2004

  • Oxygenation assessment

  • Pneumococcal vaccination

  • Blood cultures

  • Adult smoking cessation advice/counseling

  • Antibiotic timing

  • Initial antibiotic received within 8 hours of hospital arrival

  • Initial antibiotic received within 4 hours of hospital arrival

  • Initial antibiotic selection for PN immunocompetant – ICU

  • Initial antibiotic selection for PN immunocompetant – Non ICU

  • Influenza vaccination

Tuesday, September 14, 2004

Billing for your Group’s ECG Interpretations: Decision-making at the Intersection of Power and Money

Are you billing for ECG interpretations? Are you being paid? Have you been billing for years or did you just start recently? Increasingly emergency physicians are submitting bills for ECG interpretations for payment by third party payers, both commercial and governmental. Since you and your colleagues are doing the work of interpreting the ECG and making the decisions that directly affect the patient, its right that you be paid. But, uh oh, here comes a cardiologist in high dudgeon.

Advance notice of a change in billing practices, a “no surprises” policy, would have alerted your administration and other interested parties—such as that cardiologist—that you intended to begin billing for the work you and your staff are doing: interpreting the ECG and making the relevant clinical decision.

The Centers for Medicare and Medicaid Services (CMS formerly HCFA) has been quite clear in saying:

“In the case of a licensed physician who has furnished a covered service (that is not payable through another code) to a Medicare beneficiary in an emergency room, it is not readily apparent to us upon what basis the claim can be denied. There is no portion of the Act upon which to base a decision that only board-certified radiologist can furnish x-ray interpretations or board-certified cardiologists can furnish EKG interpretations. (Where the Congress has determined that there should be special qualifications in order to furnish a service, as in the case of mammography, a provision was made in the statute.) Our proposed policy for x-ray and EKG interpretation is consistent with how we generally treat other physician services.”

So there’s no question you’re well within the law in billing and pursuing collection for ECG interpretation and reporting. There are many sources of information on requirements and process for billing for ECG interpretation, one of these on the ACEP website includes information on all aspects of the law, regulations and billing process. Query your billing service and find out if they are billing for other of their customers. Certainly a consultant can help but is probably not necessary. I won’t elaborate on the process here since I’d rather discuss the leadership and change-management opportunities and pitfalls.

But in billing as in life just because a thing is possible, doesn’t mean it’s the right choice. Is billing for ECG interpretation and reporting the right choice for you at your hospital? I raise the question because just as with politics, so too all EDs are “local”. Your local practice environment, your relationship with the medical staff and your relationship with hospital administration may all factor in to a decision whether or not to bill for ECG interpretation.

First you should evaluate just how much will you make by billing for ECG interpretations. What’s the likely collection for the ECGs you presently perform. Look to your billing database or if ECGs aren’t separately tabulated there, sample your charts and count the number of ECGs done and look at the payer mix and the patient dispositions for those patients who have ECGs. That way you’ll know how much revenue you’ll collect from each payer and for admitted vs. discharged patients.

Now that you know the potential gain, consider the relationships and what you may lose in those relationships when you pursue the additional revenue, billing for ECG interpretation will bring your practice.

For example, as I write some New Yorkers are avidly watching the musical chairs game playing out among hospitals and their cardiac catheterization groups. One name group relocated recently and now several others are reportedly “in play.” While the $9-10 per ECG that Medicare pays (and comparable amounts from other payers) doesn’t seem like much of a “loss” to a cardiology group, it’s not the money that’s really the issue, it’s the image—and power. Relinquishing income to the “ER group” is not something you’ll find much support for when your hospital CEO is negotiating to keep a busy invasive cardiologist happy and on staff.

Alternatively, you could approach your cardiologists yourself. Rather than demand that they forgo billing for ECG interpretation for your patients, suggest a consulting arrangement for the purpose of assuring the quality of the emergency physician ECG interpretations. Offer a fixed rate, perhaps as little as $2-3 for over-reading of your interpretations as the studies flow into your hospital’s ECG filing system and medical records. No, they won’t be happy about the reduction in income, but you’ll get a hearing and using the information on the ACEP and CMS websites you may be able to persuade them that they face some risk of fraud allegations. At least you’re offering a way for them to preserve some of the ECG income.

In most environments, the issue will really be just about the money and in that setting you’ll have to carefully undertake an educational approach to the regulation and payment policies of CMS with regard to electrocardiography in the ED. In any case, simply implementing the change and precipitating the likely consequent shouting match across the hospital CEO’s desk isn’t the best plan for though you may prevail in this instance, the ill-will generated can only hurt you and your colleagues in the long run. Yes, the money matters, but so does the way you claim it.

Saturday, August 14, 2004

The Signal-to-Noise Ratio when Communicating to Administration

As with many of these columns, this month’s edition is inspired by a recent experience. I hope that by reading and thinking about this story of a “teaser” subscription, you’ll learn some of the same lessons I’ve learned, but less painfully.

Administrators at Maimonides Medical Center commonly forward me copies of advertisements, newsletters and anything that mentions emergency medicine, “ED” or “ER”. Yes, I see solicitations for contract staffing groups that want to staff our ED, but that’s not what I want to talk about today. I want to tell you about what your hospital administration is reading, because it sure scared me to learn that my administrative colleagues were reading this junk.

I recently received a sample newsletter forwarded by the VP for Regulatory and Professional Affairs. The newsletter, produced by a subsidiary of a large, renowned medical newsletter publisher (that also operated a famed consulting organization subsidiary) was apparently one of a series devoted to credentialing standards for physicians in different specialties. This subsidiary of the publishing company publishes a monthly newsletter devoted to credentialing information for hospitals. Each “professionally produced” 16 page newsletter gives the appearance of rigor and credibility. The back list was impressive covering every specialty I’ve ever heard mentioned. Of course, the one in my hand was devoted to emergency medicine.

Discussion of the regulatory basis for credentialing and privileging generally were followed by detailed descriptions of two emergency medicine professional societies’ policy statements on credentialing of emergency physicians. The professional societies themselves were first briefly described. A one page boxed summary of recommended credentialing guidelines ended the document. At first glance, it seemed pretty well done. Then I examined it in detail; I was appalled. Did you know that you can be credentialed as an emergency physician if you see as few as 100 patients/year? When I wrote the publisher, seeking a source for the recommendation, I was told:

“In regard to the recommendation that an emergency medicine practitioner must be able to demonstrate that he or she has provided emergency medicine services to at least 100 patients in the past 12 months, we tried to come up with a number that hospitals could work with but which was not unduly restrictive for practitioners. As we talked to people in the emergency medicine field, it was considered that an average of two patients per week was not unreasonable. The number is not etched in stone, and hospitals can establish their own criteria according to their needs.”

In other words, let the hospital staff with anyone who is available so long as they have seen two patients weekly. Forget training, board certification, full-time practice in our field; your hospital administration is being told that 100 patients/year is sufficient for credentialing as an emergency physician.

As a clinician seeking to stay abreast of current clinical practice in emergency medicine, we’ve all selected a means of accomplishing that goal. We read journals, participate in CME programs on the web, attend conferences locally or with travel; but we’re familiar with the authorities in our field and we have the knowledge and the contacts to help us make an informed selection. Yet, we’re constantly receiving solicitations for all manner of publications beyond those we’ve already selected. It’s the American way of marketing and because we’re exposed to new publications, the “old ones” have to maintain a standard or we’ll switch.

The same thing pertains in hospital administration and your hospital’s administrators are equally inundated with publications. “Sample Issues” are a particularly potent form of marketing. Combine that marketing approach with the “quality” content I’ve described above and you could find yourself on the wrong side of an issue with your administration.

How might you avoid the problem or respond effectively in the event your administration raises an issue brought up in one of these sample newsletters from publishers or consultants?

Begin by reading the document yourself. Don’t attack the source. Express your reservations, “I’m not sure I consider this material authoritative. I’d like to have a day or two to find some other material that might be more on point.”

Then, go to our professional societies’ web-sites and search for material on the topic and read it. Do not anticipate that this content will solve your problem. Your administration is looking at the issue from the point of view of the hospital while you and the professional society are looking at it from the point of view of the physician. To you, your administration’s sample newsletter has lots of noise and very little signal; to administration, your professional society’s policy position also has more noise then signal.

After you feel informed on the topic, go to sources your hospital administration will value. Look at your regional or state hospital website—if your regional or state hospital website doesn’t have much content, look to other states or regions. Both California and New York have extensive web-sites as does the Greater New York Hospital Association. Obviously if you’re working at a small semi-rural hospital, there won’t be much on point at GNYHA, but then you can look to other more rural states’ hospital associations.

Another authoritative source used by more than 50% of the hospitals in the country is the Healthcare Advisory Board. If you’re on the medical staff of a hospital that’s a member, you can have access for free; the hospital has already paid for it. Look to authoritative sources beyond these free sources. It may cost you some money, but Joint Commission Resources, is widely viewed as an authoritative source. I’ve included the web-site URLs for all of these organizations below.

Disagreeing on an issue with your administration is a regular occurrence for emergency physician leaders. Establish your credibility and authority by referencing sources your administration considers credible. They are more likely to tune in and hear your message through the noise.

Greater New York Hospital Association

Hospital Association of New York

California Healthcare Association

California Healthcare Foundation

American Hospital Association

Joint Commission Resources

Healthcare Advisory Board

Wednesday, July 14, 2004

Incentive Compensation and training residents. How shall we manage the intersection? (Part 2)

Last month I told you about the economic challenges we were confronting out of the transformation of our practice into one with both clinical and academic missions. I wrote about our charting improvement initiative and engaging concerned staff colleagues in both developing solutions and seeking the engagement of the broad group in the implementation of the solutions. I’ve promised that this month I would discuss modifying incentive structures so that an academic mission can be explicitly accommodated. Let’s consider some relevant observations.

As long-time readers know I have a bias towards quantitative evaluation whenever possible, thus, the recent publication[1] of a relative value scale for teaching gives me some hope for including more quantitative evaluation of teaching contributions among physician staff; however, this tool alone, even fully implemented as described by the authors probably won’t serve as the sole measure for academic productivity. Aside from my general reluctance based on Deming’s warning about management on numbers alone (see my July 2003 column) in the case of teaching and scholarly activities, how shall we assign value when the work done benefits the worker—the teaching physician—too?

Just as maximizing revenue isn’t unique to clinical practices—as an emed-l poster commented, “academic programs in particular, considering the payer environment most of them are in, need the clinical production efficiency every bit or more than the community ED.” referring to using RVUs as the driver for all compensation. Yet, in a double coverage ED, the process of supervising residents, particularly supervising senior year residents who are themselves overseeing the work of more junior residents, I would accumulate many more RVUs/hour worked than a physician in the same ED just seeing patients. Since the other physician's work indirectly facilitates me spending time with the residents and accumulating their RVUs, some adjustment is probably appropriate to fairness.

In the context of direct teaching activity, while Khan and colleagues’ approach shows some merit, as another poster has opined in the past, “One must have adequate protected time (which is quite expensive) to further the department's goals. Someone who runs the department, runs the residency, runs a course in the medical school, directs the research for the department—all of these need protected time. I've seen papers published about how protected time is counted, and am quite shocked, to be frank, that attendings are given (paid) protected time to attend (not teach, just attend) resident conferences and faculty meetings. Not that I don't think they shouldn't attend. But, if you have to divvy up for every minute that your faculty member spends beyond strictly clinical hours and reward it with paid protected time, you're paying out hundreds of thousands of dollars a year just to have your folks come sit in a room, with little to show at the end of the year. It is crucial that protected time unfunded by outside resources be used wisely, if we hope to progress as a specialty. If you have to ‘spend’ it for every minute outside of a clinical shift, nothing will be left for the larger stuff, like having a productive department as a whole.”

This colleague works where the group has come to a common understanding, where certain duties are “just part of the deal . . . there were some irreducible contributions as faculty which would not be measured against ‘protected time’. This included attending faculty meetings, grand rounds, and being asked to give a talk on some subject every month or two, if needed. It may also include participation in hospital and medical school committees.”

You might argue that we should be separately compensated or supported for all of the non-clinical activities and that's a nice idea but not reality at our hospital or in the academic environments I know. I don't think full support for academic activities exists anywhere; that corner of our society is still a bit of a social welfare state.

So taking all these inputs together, I've chosen to consider the issue along the lines of the “Leading Beyond the Bottom Line” principles I've written about, adapting these principles first articulated by American College of Physician Executive authors.

It seems to me that our developing clinical and academic department should strive for the pareto optimum among patient care, community service, organizational economic well-being, staff well-being (economic, professional development and others) and unique to the academic environment, a fifth good: academic accomplishment (perhaps measured through RRC approval, peer academic recognition, scholarly productivity including grant funding and others as per Khan). I don't believe that it is possible to divorce clinical center productivity from the rest and optimize it alone. We teach residents from almost every specialty, a significant fraction of patients admitted in most teaching hospitals come through the ED, we teach medical students, etc. These academic interactions matter in our institutional standing, and for those at the medical school seeking promotion and tenure (hence compensation) and other tangible and intangible aspects of life in our clinical and academe.

I still think we're in an era of “local solutions.” I'm a big supporter for all of these metrics as inputs, but not direct drivers of resource allocation decisions or incentive pay. Ultimately, in seeking a pareto optimum, I subscribe to Deming’s admonition (his seventh “deadly disease”) that not all measures are known or even knowable. As a consequence a degree of subjectivity remains and it's the leader's responsibility to exert that subjectivity “fairly.”

Yet, as we at Maimonides Medical Center undertake to develop a fair allocation method, I’ll offer this essay and references to my colleagues on our Faculty Practice Finance Committee and seek their solutions and their engagement of their colleagues in crafting a solution. When we get there I’ll let you know how it turns out.

[1] Khan NS, Simon HK. Development and implementation of a relative value scale for teaching in emergency medicine: the teaching relative value unit. Acad Emerg Med, 10(8):904-7, 2003.

Monday, June 14, 2004

Incentive Compensation and training residents. How shall we manage the intersection? (Part 1)

Next month our third class of EM residents will start and we’ll have attained a full complement of emergency medicine residents, taking another step in our transformation from a purely service focused organization to a department delivering service and education while undertaking scholarly activities.

As I write this column the transformation comes to mind since we’ve just distributed our semi-annual profit-sharing and incentive payments, based as in the past on measurable clinical, academic, administrative productivity and my subjective evaluation of the individual physician’s contributions to the department. One quarter of the profit-sharing “pot” attributable to each factor. (I’m describing only our profit-sharing plan and not our base compensation plan which is that of hospital employed physicians.)

The residency program has imposed its own demands on practice earnings, though we’re not a medical school and thus pay no “dean’s tax.” I had agreed long ago when contracting with the hospital, that the faculty practice would support certain aspects of the residency in lieu of a dean’s tax. That agreement and the steadily increasing pressure on revenues all of us in medical practice have experienced over the years have appropriately raised staff concerns about profit-sharing income.

This month and next I’m going to describe our department’s efforts at improving financial performance while broadening the group members’ understanding of practice finances and fulfilling our educational mission. This month I’ll focus mostly on our billing improvement and educational efforts. Next month I’ll share some early thoughts about transforming our incentive program in keeping with the transformation of our department.

Recently, several outspoken physicians have worked on improving our charting quality as a first step to improving our revenues. We long ago had implemented straight-forward, housekeeping improvements: assuring charts were completed and signed, making sure we didn’t lose charts for billing, confirming that updates of insurance information to the hospital were shared with the practice. These and other best practices have been taught by many and I won’t review them here.

What’s new is our giving of near real time feedback to our physicians regarding the completeness of their charts. Though the value of regular feedback is obvious to all, making it happen can be a challenge with emergency physicians working shifts—coming and going each on his/her own schedule. In the era of paper charts and given realistic concerns regarding billing practices it had been impossible for us to accomplish. However, more recently our electronic medical record and the hospital’s virtual private network have permitted our staff to logon from home to complete their charts. One of our physician staff built a web based application that our coders use to send email to each physician about their incomplete charts and that tracks the physician’s completion of these incomplete charts as appropriate. Not all charts are appropriate for completion.

In consultation with hospital compliance and legal staff and discussion with several professional EM chart coding companies, we decided that only charts missing entire sections: history of present illness, past medical/surgical history, social history, family history, review of systems or physical examination would be referred for completion. Charts that addressed each area but appeared to our coders as lacking usual documentation would be referred for “educational review” but no expectation of chart completion would attach to the referral and coding and billing would be based on the original chart. We set a 72 hour limit on the physician’s response to the request. After 72 hours, even woefully incomplete charts are coded as-is.

Through this feedback and education process, coupled with attention to our coders’ training we’ve seen a reduction in incomplete charts and a general improvement (measured as RVUs/patient) in charting quality. It’s no surprise that some physicians have shown greater improvement than others. We anticipate revenue improvements as these early charting improvements translate into higher charges.

I’m sure you’re equally enthusiastic for improving collections, but not everyone has an electronic medical record and a hospital supported virtual private network. Yet, everyone does have colleagues who are not as preoccupied as you are. Engaging them in solving your revenue problem makes all the difference. It’s not merely a matter of demanding the behavior change; rather you want others invested in making the behavior change across all group members and make the change stick.

Supporting those junior colleagues requires both structure and constant mentoring from you. For a structure, I’ve created a faculty practice finance committee that will I expect develop further improvement ideas. For mentoring, I’ve offered my time and unfettered access to the semi-annual accounting of the practice plan’s revenues and expenses—though individual physician’s compensation will be available only in aggregate. I’ve also just ordered them each a copy of a book I first mentioned in my May 2000 column: Fisher and Sharp: Getting It Done: How to Lead When You’re Not in Charge. HarperBusiness, 1999; ISBN: 0887309585

With these efforts I expect that our team will not only develop solutions, but will bring others in the group in so as to improve upon the solutions the committee itself develops. Next month I’ll discuss how our group, now engaged in both clinical service and residency teaching might go about developing a profit-sharing plan that suits all medical staff even though physicians’ activities differ.

Friday, May 14, 2004

Patient Satisfaction Surveys and the Emergency Department

We just received preliminary and sobering results of our annual fourth quarter patient satisfaction survey, but more about our results later. The process we and our hospital use differs from the usual commercial patient satisfaction survey so, but since its value to us in the ED is so great, I thought it might be worth sharing with you. I’ve also recently learned of another approach—driven by the emergency physician group practice itself—that may hold some interest for you. So let me review these approaches; while neither may work as a “drop-in” for your environment and both have real expense, perhaps you can learn something you can use.

Our hospital conducts structured over the telephone interviews on admitted and discharged patients, interviewing sufficient numbers of patients to garner completed interviews with 100 patients monthly. Patients are interviewed in their language of choice including English, Spanish, Yiddish, Russian and more recently Mandarin Chinese. Arabic may be next. During the months of October, November and December both Pediatric inpatients and ambulatory patients are surveyed. We also survey ER outpatients and the care-givers of pediatric ER outpatients using an instrument designed in parallel with the adult/pediatric inpatient tool. The inpatient tool attempts to determine both by direct questioning and by confirmatory questions whether the patient was first whether the patient was admitted through the ER and if so asks seven questions relevant to the ER experience, only one of which could be considered to ask about the emergency physician. The question is broadly focused asking about all physicians that may have been involved in the patient’s care. We do not tie the individual patient’s comments back to a specific provider.

Both we and hospital administration look at the survey results as giving us useful information about systems and processes, not individual providers. What we do get is wonderful information that allows us to compare the experience of adult and pediatric patients admitted and patients discharged from the ER as well as longitudinal results over time.

Results include an analysis of both positives and negatives. We aim for no more than 10% in the bottom “strongly disagree” box and 90% in the top two “agree” and “strongly agree” boxes. Survey items are all posed in the affirmative. Our results since 2001 (survey conducted monthly, results reported quarterly) conform to Boudreaux and O’Hea’s findings that patient satisfaction is most affected by the quality of interaction with the ED provider.[1] Waiting time, perceived or real and the discordance among perception and expectation were a secondary factor in this literature review and analysis of opportunities for further study.

I’ve learned of two variations on an emergency physician centered patient satisfaction “survey” both of which I would characterize more as “callback” efforts intent upon enriching the patient encounter and improving patient satisfaction themselves. In both instances the emergency physician practices themselves conduct the process.

Tom Scaletta, MD, Chair, Dept. of Emergency Medicine, Edward Hospital in Naperville, Illinois, the emergency physician who designed and implemented the process describes his approach thusly:[2] “The callback clerk attempted to reach a cohort of all discharged patients. She called about 3,000 a month and reached about one-third. What she said was carefully scripted. Patients getting worse were told to call their PCP [primary care provider] or come back to the ED immediately. No further medical advice was given by the callback clerk though, if requested, the call was transferred to a nurse. The cost (about $36K a year) was about $1 per patient attempted or $3 per patient reached. This was a fulltime position by an administrative assistant with great interpersonal skills. Her job was facilitated by a callback database (FileMaker Pro™) which uploaded the prior day's census, automatically dialed, and served as a user-friendly way to store the data.”

“The callback information was used to improve satisfaction—the act of checking on patient’s well being was positively received. We uncovered problems quickly and made recommendations to correct or documented improvement and assured adequate follow-up. All this helps minimize risk. Finally, we collected data on opportunities for the physician, nurse, and system to improve. We used a letter grade since patients immediately understood what we were getting at and a portion of the doctors’ bonus was tied to this grade. Overall, the docs received an ‘A’ 70% and a ‘B’ 25% of the time. The ratio of A:B was more influential than A/B:C/D/F in comparing the docs. The docs received monthly feedback and many were able to change their means of interacting with patients and improved their scores significantly.”

The other physician driven approach takes advantage of integrated information systems and telecommunications technologies to use automated dialing to leave a message in the physician’s voice to the patient. The message advises the patient to call 911, return to the ED or see their primary care provider if not improved or worse. It then goes on to solicit feedback with any concerns or comments regarding the patient’s care or experience in the ED. A patient request for a callback from the physician receives that response.

Our patient satisfaction survey results served as a sharp rejoinder to any complacency, reminding me that while excuses abound: space, staffing resources, upstairs-downstairs communication and conflicts; I must periodically remind myself and re-energize all staff in our commitment to care of our patients within the resources available. Patients and their families take for granted that they are getting good clinical care; caring for the patient must go beyond the clinical realm alone.

[1] Boudreaux ED and O’Hea EL: Patient Satisfaction In The Emergency Department: A Review Of The Literature And Implications For Practice, J Emerg Med 2004; 26(1) 13-26

[2] viewed on 2004 March 16