Thursday, December 14, 2000

When Bad Things Happen to Good People

This column is dedicated to the memory of Richard C. Wuerz, MD who in life reminded me of the joys of teaching and in whose death reminds me of the subject of this column. Still early on in a career as an Emergency physician academic, view the summary of his work with the Emergency Severity Index and for those with access to Academic Emergency Medicine[1], his legacy is summarized in Ron Walls' superb editorial about the emergency severity index.

All of us practicing in emergency medicine have experienced death in our practice. This month, I’d like to briefly describe a useful resource for helping all ED staff manage the aftermath of a patient death, but then I’d like to go on and discuss Critical Incident Stress Debriefing (CISD) and its role when death strikes closer to home.

Patients die in the emergency department or before arriving and we perform in the role of the "failed" healer and announce to those assembled that indeed their family member or friend has died. In this role, more akin to that of the ancient Roman "temple priest" who led the worship of Aesculapius than to Hippocrates who founded scientific medicine, we physicians struggle to inform the patient’s loved ones and yet move on to care for others in our busy emergency departments.

I’ve recently had the chance to view some of Ken Iserson’s materials published under the imprint of Galen Press. Ken, a faculty member at the University of Arizona Emergency Medicine Residency Program, and Director of the University’s Bioethics Program has produced favorably reviewed texts, videos and training programs that are useful in teaching death notification to physicians. He also now includes a pocket guide that is convenient memory jogging device to carry in your white coat pocket—or waist pack—during a shift. If you or your staff has ever struggled with death notification—and who has not—some formal training is useful and if all are trained to a single approach, then you will have more confidence in accomplishing the difficult, but necessary and timeless ritual.

Sometimes though, death and clinical crises strike closer to home. In the past six-months in our emergency department we experienced the sudden unexpected death of one nurse found in her bed by her teenage son, the near-death of another nurse in a motor vehicle crash on her way to work, the motorcycle crash death—observed by his wife—of the son-in-law of one of our emergency physicians followed shortly thereafter by that physician’s hospitalization with unstable angina and most recently the hospitalization for pneumonia with mild hypoxia of one of our patient care technicians that turned into an ICU stay when he developed respiratory failure from which he has fortunately recovered.

These events, drop into our lives as just one more stressor in what all of you know is already a stressful time for all of us in emergency medicine. Every hospital confronts fiscal uncertainty and emergency department volume continues to grow, adding the sudden unexpected death of a colleague, co-worker and oft-time friend can cause even the most "normal" of people to collapse or respond abnormally in the crisis. As a leader, how might you respond?

In a well written piece on the Prehospital Perspective site and supported by an extensive bibliography of scientific evidence on his own website, Bryan E. Bledsoe, DO, FACEP, EMT-P debunks critical incident stress management in a rationale that resonates for me.

Critical Incident Stress Debriefing (CISD) is a technique that has increasingly been deployed in the EMS community over the course of the past decade. Many community EMS providers are aware of trained CISD practitioners in or nearby to your community. Oft-times, EMS providers themselves have been trained. I first became involved in the early practice of CISD while I was Philadelphia’s EMS Medical Director in the 1980’s. At that time, in this fire department based service, the death of a firefighter while on duty was a near apocalyptic event marked with all sorts of elaborate, formal ritual. Yet, little beyond the ritual was offered to the members of the fire company who may have worked alongside the one who perished. "Survivor guilt" was common and was manifested at times in a variety of inappropriate and personally destructive means. My first exposure came when a firefighter on-duty died from a medical catastrophe in a firehouse that housed a paramedic squad, which had tried, but failed to save their colleague’s life. Was that ever a bleak time in that firehouse. At a closed meeting, I sat in the firehouse kitchen along with the rest of the company and discussed the events, the hopelessness of the resuscitation efforts and yet confirmed the appropriateness of the efforts. I’ve since met firefighters, years later, who remember the debriefing and thank me for it.

The Critical Incident Stress Debriefing (CISD), developed by Jeffrey T. Mitchell, Ph.D.[2], , is a group meeting or discussion about a distressing critical incident. A critical incident is any event, which has a stressful impact sufficient enough to overwhelm the usually effective coping skills of either an individual or a group. Providing crisis intervention and education, the CISD meeting (lasting approximately one-to-three hours) may reduce the impact of a critical incident.

Critical Incident Stress Debriefing as described by D. G. Mitnick.:
· Is not therapy or substitute for therapy
· Should be applied only by those who have been specifically trained in its uses
· Is a group process, group meeting, or discussion designed to reduce stress and enhance recovery from stress. It is based on principles of crisis intervention and education.
· May not solve all the problems presented during the brief time frame available. Sometimes it may be necessary to refer individuals for treatment after a debriefing.
· May accelerate the rate of "normal recovery, in normal people, who are having normal reactions to abnormal events."

Following the motor vehicle crash which nearly took the life of one our nursing staff—she was resuscitated and stabilized at our emergency department—we held CISD meetings for the staff taking advantage of the CISD team that was staffed in part by members of one of our community’s volunteer ambulance services. Separately, we had also supported the ethnic rituals of co-workers and friends of the nurse who had died earlier in the year.

Perhaps because I’m in mid-life and these events pile on me more frequently than ever before, I’m ever more aware of the effect on my colleagues and myself. Inevitably, we aging baby-boomers will experience these losses ourselves, not just with our patients. As a leader, you can yourself learn and then teach the best ways to notify others about the death of a loved one and reach out for help for yourself, colleagues and ED staff when that moment comes into your own lives.

[1]Walls RM: Dr. Richard Wuerz's Emergency Severity Index. Acad Emerg Med 2001 8: 183-184.

[2]Mitchell, J.T. & Everly, G.S. (1995). Critical incident stress debriefing: An operations manual for the prevention of trauma among emergency service and disaster workers. (2nd ed.). Baltimore, MD: Chevron.

Tuesday, November 14, 2000

Leading Beyond the Bottom Line: Part 2 (updated)

Last month I introduced the conceptual model of the Pareto Optimum espoused in Leading Beyond the Bottom Line. I explored how that model might provide a philosophical basis for recasting our relationship with our hospitals. As a reminder, LBBL suggests that as physicians act evermore like managers, focusing solely on the bottom line, they’ve foregone the physician-manager’s unique opportunity in healthcare. The physician-executive authors of the LBBL approach assert that rather than only assure an operating margin, the physician-manager can assist the health care entity in reaching the Pareto Optimum among: Patient Care, Financial Health, Employee Well-being and Community Commitment.

This month I’d like to take up the far thornier—and closer to home—challenge of discussing how emergency physician leaders who embrace the LBBL approach could strengthen their practice itself and, perhaps, help us in emergency medicine emerge from the dichotomizing rhetoric of the past half-decade in our specialty’s ranks.

Before explaining this difficult thesis, I must digress and explain some of the concepts I will use below, particularly that of the “zero-sum game.” Theorists describe a zero-sum game as any circumstance in which the balance gained and lost among any number of “game players” (read this as negotiators, warriors or doctors and hospitals) adds up to zero. Wins and losses add to zero for the group as whole. We’re also familiar with the metaphor of “growing the pie” consequent to which all that “play” gain, even though holding only a constant portion of a growing endeavor.

Nonetheless, moving the LBBL concept from the macro level down to our own practice, whether salaried, fee-for-service or an amalgam of both entails a parallel description of the apparently “competing goods or objectives” that we might strive to balance within our practice, even as LBBL offers a model for use by the hospital and the communitarian movement[1] proposes a particular model of balance for our greater society.

As always, our patients are the reason we strive for the Pareto Optimum in our practice. Our personal and economic well being parallels the need for the hospital’s financial security and engagement with our hospital both at the general medical staff level and with administrative leadership parallels the hospital’s engagement with its broader community. Lastly, engagement with both physician colleagues in our practice and those who work along-side us in our emergency departments identifies the fourth component of our practice environment’s Pareto Optimum.

Few of us have consciously addressed the competing interests in our personal and professional lives at a conceptual level. Most of us make tradeoffs between personal and professional commitments that compete for our time and attention, but few of us do so within an explicit framework. Self-help books abound and it’s not my intention to fit one into this month’s column. Rather, just as I asserted in July 2000 when I wrote about the pyramid of medical staff development, leadership requires making that which is implicit, explicit for your colleagues. Thus, the open, but structured discussion of how well—or poorly—you as a group are succeeding in meeting competing objectives broadly grouped in the four categories I’ve described above, can begin building a new, strengthened group purpose.

So, how can we actually strengthen our practice team and reduce the din of the argument among us while re-affirming our leadership within medicine as publicly concerned caregivers and safety net providers? I recommend open, structured discussion as the first step.

How to begin? Just as last month I suggested you share the LBBL article with your administration, so too you should share it with your physician colleagues. At a subsequent staff meeting raise one issue that is current within your group. Perhaps it is turnover or income or conflict with members of another hospital department—or perhaps it is restiveness over the administrative charge paid from practitioner earnings to your management group. Whatever it may be, raise it and make it explicit to all and proceed to characterize it within one or more of the four categories.

As an example, the resentment of some group members over what appears as apparently confiscatory administrative charges might be mitigated by the complete neglect by those same staff members of participation on medical staff or hospital committees or project task forces. If all of that work falls on the group leaders, should they work the same clinical hours in order to maintain income? Here we see that within the group the balance between individual economic well being and “community participation” may be out of kilter. Conversely, arbitrary disciplinary actions taken by the group manager against a staff member ostensibly engendered by an effort “to save the contract” suggest that collegial support and economic performance are similarly unbalanced.

I’m not denying that throughout the history of emergency medicine, charlatans and thieves have harmed patients, colleagues, hospitals and communities. Undoubtedly malefactors among emergency physicians, both practitioners and managers, continue thriving parasitically upon some emergency physicians today. Yet, I’m equally certain that the cause of resentments and conflict in the average group practice is more often the failure to explicitly address the apparent conflict and competition among the four components of the LBBL model.

Few practice leaders have management training and believing themselves smart—probably correctly—and while wanting “to do the right thing,” most have little knowledge and still less experience in balancing competing human interests beyond clinical work during a busy ED shift. Consequently, just as most humans avoid confronting difficult tasks, it’s natural for a practice leader to avoid confronting colleagues with the process of striving for balance. Particularly so since once undertaken, striving for the Pareto Optimum becomes a continuous effort, much as physiological systems depend upon continuous homeostasis for balance, so too will the gathering of colleagues known as “the practice” require continuous effort to maintain the Pareto Optimum.

Explicitly seeking your group’s Pareto Optimum among patient care, personal financial security, engagement in our hospital and medical staff community and engagement with colleagues and co-workers presents the opportunity of including not only those who depend upon us in our personal lives but also those dependent upon our medical safety net services even as we enhance the quality of our professional lives in the process of reaching our own Pareto Optimum.

[1] The communitarian movement, attempts to address a just society’s dual need for both social order and individual autonomy. Their concepts also inform my view; although, I assure you I’ve not embraced that particular movement and neither do I have the space, the inclination or my editor’s permission to discuss political theory in this column.

Saturday, October 14, 2000

Leading Beyond the Bottom Line (updated)

It’s a philosophy refreshing and thought-provoking on the larger scale of hospitals and health care delivery systems and on the more parochial level of emergency medicine. Presented in July-August issue of The Physician Executive (pp. 6-11) published by the American College of Physician Executives (ACPE, not to be confused with ACEP), Leading Beyond the Bottom Line was followed by an online cyber forum during August.

Leading Beyond the Bottom Line is a concept that suggests that physicians who act more like managers is a failed approach that vitiates the physician’s unique role in health care. The physician-executive authors of this approach assert that rather than ensure profit, the health care entity must reach a Pareto optimum among financial health, patient care, employee well-being, and community commitment. The Pareto optimum is named for Wilfred Pareto, who first articulated the optimum as a socioeconomic concept of balancing competing and cooperating interests. Balancing these interconnected objectives goes beyond conducting a “stakeholder analysis” or the 360° assessment that Leading Beyond the Bottom Line articulates as a philosophy for guiding action.

Because I’d like to take this month’s column to discuss how the Leading Beyond the Bottom Line concept might apply in emergency medicine, I don’t have sufficient space to detail the thesis. Read the entire series on the ACPE website.

I believe that the philosophy inherent in Leading Beyond the Bottom Line connects to us in emergency medicine very directly. My hope is that it may provide a philosophical basis for recasting our engagement with our hospitals while also leading us out of the dichotomizing rhetoric of the past half-decade within our specialty’s ranks. This month I’ll address only the potential for recasting your interaction with your hospital.

Adopting this philosophy can facilitate the creation of a shared mission for your hospital and emergency physician group, and the process will develop your communication and negotiation skills. Yet, confronting the need for the struggle and then entering into it with people on the “other side” with whom you have “history” may be a daunting challenge.

Begin by engaging hospital representatives. Sharing a copy of this article with almost any hospital administrator is a good way to start. The nursing administrator for the ED may be the most accessible representative of the hospital and a good person with whom to start. However, there’s no need to limit your approach to a single individual, and indeed approaching as many of the hospital managers as you can may generate momentum and at the least will stimulate some interest among your hospital administrators that can facilitate opening the dialogue.

Entering upon an effort to recast your “working” (notice I’ve said nothing about your contractual) relationship with your hospital with nothing new in your approach will doom the effort to certain failure. The Leading Beyond the Bottom Line philosophy as a starting point can only succeed if you sit down and talk together. Your quiet insistence about the importance of meeting coupled with your equanimity when denied can go a long way to bringing even the most contrary hospital manager to the discussion table. Confrontation is not about fighting with your administration; it’s about addressing squarely — face to face — the issues before the respective groups. Rehearsing your approach, words, and facial expressions in the mirror, trite though it may sound, will make it easier for you to stay focused if baited by the “opposition.”

Once engaged in dialogue, the most important task entails moving beyond philosophy to successfully making something real happen through the use of the framework. The arrival of the ambulatory payment classification (APC) method for outpatient prospective payment provides an almost ideal focus. Although implementation began in August, by the time you read this, it’s likely that you will have heard from your administration in one form or another about the negative effect on hospital revenues the implementation of APCs has wrought.

Challenge any demand from a hospital administrator by calmly stating how unproductive such a demand is to the improvement they seek and the dialogue essential to gain the improvement. Point to the copy of the Leading Beyond the Bottom Line article you’ve sent around. Suggest that calm dialogue about the hospital and practice’s concerns will more likely reach a useful resolution for both.

Lastly, point out that pitting the hospital against the practice assumes a “zero-sum game” in which for one to “win” the other must “lose,” and that you’re confident that neither the hospital, the particular administrator nor the practice wants to “lose.” Suggest that finding the Pareto optimum for the practice and the hospital around the larger objectives noted will benefit everyone. Advise the particular administrator that he has nothing to lose and everything to gain by entering into the work with you because of the consequences of effective teamwork: better and more consistent results requiring less continuing attention as working together becomes more the usual way of doing business.

Your ace in the hole is that facility billing with APCs is entirely dependent upon the quality of the documentation. Either physician or nursing documentation must support medical necessity and document the delivery of the services. This is another reason to involve the ED nurse administrator because documentation that isn’t present in the physician note entails more reliance upon nursing notes for proper coding. Yet, a well-written physician note can suffice for the facility’s coding purposes as well as the practice’s.

In this endeavor, the physician group and the nursing staff are natural allies in meeting the needs of the process, and cooperation with nursing provides leverage in bringing the hospital financial administrators — and by extension operating administrators — to the table for direct confrontation on the issue. Are you and your administration together leading beyond the bottom line?

Thursday, September 14, 2000

Residents, Recruiting and Retention

Today, as I write, the “R” of September prompts me to contemplate not oysters, but the three “R’s” of residents, recruiting and retention. The upcoming ACEP meeting in October coincides with the beginning of the recruiting season for senior emergency medicine residents and that too spurs me to offer a few thoughts about these aspects of an emergency physician leader’s job. The specialty’s publications, including Emergency Medicine News, see a spurt in positions offered advertising and the recruiters will be out in force looking to collect the curricula vitae of as many senior residents as they can. Ah, the sound of the whirring fax machine as it spits out all those pages of accomplishments into your and my in bins.

I’m addressing you who are recruiting or as is equally likely, hoping to retain the fine physicians who are already among your staff and colleagues. How well does the annual position chase serve your needs? Does this annual rite of autumn bring you concern that your some or many (!?) among your staff are searching for greener pastures? What can you do about it? What can you do about it now?

Retention begins during recruitment, by not over-promising nor failing to address the real questions of the candidates you interview. But, today you are contemplating the possibility that you will be one or two physicians short of full staffing in just a few months and you’re wondering if you can or should forestall their departures. Well, I’ve learned from sad experience that in the main a leader should not counter-offer or negotiate with a staff member who has already announced his/her resignation. It’s unlikely to really re-engage the departing physician and those that remain are likely to suspect that a “special arrangement” not available to them has been negotiated. As a consequence, you may receive other “resignations” intended to extract a “special arrangement.”

Nonetheless, talking to a restive colleague or staff member to learn why he or she is unhappy or looking elsewhere is a useful undertaking. The long-standing member of the group may simply be reassessing his or her value in the greater world of emergency medicine or seeking to learn more about a fundamentally different type of clinical practice: rural or urban, academic or community, urgent care or other sub-specialty. Staff members seeking to move to different geography or practice type deserve your best assistance. Introductions to colleagues elsewhere or referrals for informational interviews through the network of other directors and leaders you may know gives evidence of your support for the individual physician and enhances the likelihood that the departing physician will speak well of your practice. Assisting those individuals who are determined to leave also demonstrates to those who remain that you are interested in their individual careers. And, that’s the key to retention: Support the individual physician and his/her unique career aspirations.

Many resident graduates who you have recruited will need individualized attention if you wish to retain them on your staff. Much has been said in other venues about whether or not newly graduated residents are worth recruiting and I don’t intend to discuss the pros and cons here. Suffice it to say that after more than 20 years of preparing residents to go out into the world, I also actively recruit both our own graduates and graduates of other residency programs, but I’ve learned that newly minted residency trained emergency physicians do require additional effort on the part of practice leaders. That practice is not like residency seems obvious, but for the residency graduate who enters practice in a different environment, the experience may be more unsettling than is initially apparent.

So, starting today and regardless of your past failings, set aside the time to meet with individual staff members and learn their aspirations. For those physicians who tell you they only want to come to work and make a living, consider enumerating the opportunities available in your local environment, through professional associations at the state or national level or in sub-specialty niches. I’ve listed just a few of the many niche opportunities in Table 1.

Consider breaking down the problems you face into “bite-sized” pieces and sharing them with your restive staff members, along with your support and hand-holding to get the problem solved. It may take you longer, but you will have developed a new level of interest and commitment. For still others, you may wish to encourage exploration of the competitive landscape with the request that you want to know what they learn so that you can maintain your practice’s competitive position.

A theme mentioned several months ago: the pyramid of medical staff development also provides a tool to re-engage restive staff members. Begin by articulating a consistent set of expectations for practice members, but move to evaluation in light of those expectations quickly for those most restive. Your goal here is not truly to evaluate, but rather within the structure of your clearly articulated expectations, shore up the understanding of those expectations and allow for the most restive—and perhaps outspoken—to share their misgivings and concerns. The goal is personal attention to the individual and creation of an opportunity to turn inward looking staff members into engaged colleagues, concerned, as all should be, for the well being of the practice, hospital and the community. When staff members are engaged in improving the well being of the practice, the hospital and the community served, retention comes naturally.

Lastly, fair compensation and benefit arrangements accompanied by humane working conditions with sufficient staffing, the opportunity for meal breaks and arrangements for call-in staffing when overwhelmed can go a long way to assuring your staff and colleagues that you want them with you for the long-haul.

Table 1: Niche opportunities in emergency medicine

Air Medical Transport
Continuous Quality Improvement
Critical Care Medicine
Cruise Ship & Maritime Medicine
Disaster Medicine
Emergency Medical Services
Emergency Medicine Practice Mgmt and Health Policy
Emergency Medicine Research
Emergency Ultrasound
Hyper-baric Medicine
Injury Prevention and Control
International Emergency Medicine
Medical Informatics
Pediatric Emergency Medicine
Rural Emergency Medicine
Short-Term Observation Services
Sports Medicine

Monday, August 14, 2000

The Why’s and How’s of Relative Value Units (RVUs)

I’m necessarily digressing below from the theme begun in last month’s column on using “relative value units (RVUs)” in measuring physician work and productivity. What follows briefly describes what RVUs are and from whence they come. For more information on how the RBRVS and RVUs work read the two-part article on the ACEP web site: “Basics of Reimbursement” (ACEP membership is not required).
On January 1, 1992, federal regulations that implemented federal resource-based relative value scales (RBRVS) for the payment of physicians under Medicare went into effect. Since that time all federally sponsored physician payment programs and many others have adopted the RBRVS method of payment. ACEP estimates that over 70% of all payments for physician services are based on the RBRVS data, so that even if Medicare patients are not a large part of your practice, RBRVS will impact what you are paid for a given service (see web page citations above).

The RBRVS method uses RVUs to measure the work involved in performing a clinical service, the expense involved in delivering the service and the malpractice risk associated costs of performing the service. The “work RVUs” incorporated in the method explicitly include the physician work expended on a patient service before, during and after the service itself. Thus work RVUs provide an explicit tool to measure and compare physician work and productivity across a varied mix of services, including the services delivered by emergency physicians.

Each clinical service an emergency physician provides to a patient is billed through the use of a “CPT Code”. The book, Current Procedural Terminology (CPT), is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties.

Each CPT code is associated with an RVU value that is segmented into work, practice expense and malpractice costs as noted above. The association of RVUs with the CPT codes that most apply to your practice can probably be best obtained from your billing service. The entire list of CPT codes and associated RVUs including the segmentation can be downloaded at the Centers for Medicare & Medicaid Services site.

Once we understand that every physician delivered clinical service has a CPT code with an associated RVU, this allows us to use the measurement of RVUs to begin the process of comparing our physician group members. Measurement of RVUs billed, adjusted for clinical hours worked, or “RVUs per hour” provides a far more reliable tool—better able to compare productivity among physicians—than does the traditional emergency medicine measure of patient’s per hour. Why? Because over equal intervals physicians can no longer assert that their productivity is unrecognized because their patients are sicker: The very measure, relative value unit, adjusts for that phenomenon. Only in the event that one or another group member is routinely assigned to a distinct clinical population (e.g., “minor-care,” “fast-track” or pediatrics) or to a distinct schedule (e.g., all nights) should that individual’s productivity be excluded from direct comparison with colleagues.

Let me once again emphasize that not everything about a doctor can be told from measurements of clinical productivity as measured by RVUs per hour. In fact, this one measure will give a hugely distorted evaluation if not coupled with at least measures of patient waiting times or throughput intervals and measures of medical staff, ED nursing and support staff and patient satisfaction. Other subjective evaluations such as “group citizenship” also matter. Some current approaches to economic benchmarking also seek to evaluate emergency physicians’ comparative utilization of laboratory tests, imaging studies and consultations.

Someday perhaps we’ll have other quantitative measures of physician quality, but in the meantime RVUs are one useful guide. Nonetheless, RVU measurements should not be used to bludgeon physicians, but rather used as a measure for comparison to articulated expectations as I explained last month in describing the pyramid for medical staff development. Measurement and comparison of RVUs with adoption of the pyramid by your medical director or ED chief speaks to enlightened leadership; bullying by your group’s leader over productivity and RVU comparisons suggests it may be time to move on.

The group should measure monthly for one year before identifying baseline performance expectations. Monthly measurement with reporting of the group’s overall performance at the 20th, 50th, 80th and 99th percentiles should complement monthly reporting to each group member of individual performance. Provision of individual performance data in this fashion, supported with explicit feedback will over time tend to reduce the variability of performance among the group on this one measure. Remember, not to lose sight of other important subjective and objective measures as mentioned above.

Reporting productivity in this fashion will quickly unmask differences in quality of documentation among members of your group. Exhortation to improve documentation is not the answer and neither is a new system for documentation whether dictation, templates or electronic. Rather, investing energy in identifying the best documentation captured by members of your own group and using these “best documentation practices” when teaching the rest of the group will improve documentation overall while simultaneously optimizing revenue capture which is based upon documentation. In those groups in which physician earnings are based upon the individual emergency physician’s own documentation, the incentive is obvious. But rare is the group that does not depend at least in part on direct clinical revenues and reminders of the importance of clinical revenues to the group’s well-being associated with other feedback as part of the implementation of the pyramid for medical staff development may help.

If physician productivity measurement is used as a threat, it is probably time to look for another job, if possible. Yet, when used as one measurement in implementing the pyramid for medical staff development it can be an invaluable tool for both assisting in the maturation of the group practice as a whole and in retaining excellent emergency physicians.

Friday, July 14, 2000

Measuring Productivity Means Setting Expectations, and—Possibly—Managing Poor Performance

I’ve begun to hear from some of you commenting upon earlier columns. In particular, several have asked about ways of getting started with measurement so as to help you decide when to add a partner to your group or when to intervene with a partner who is only seeing one-half as many patients as the other group members. In the second example just noted, if you are actually measuring the “one-half as many” you’ve already started your measurement. If it’s merely an impression, than you are yourself raising barriers by asserting the ratio without the evidence. Correspondents have asked me to recommend a text or other literature that they could peruse to educate themselves on the measurement of physician performance. Unfortunately, almost nothing is available that has been actually validated in practice. Yet, models with some face validity may be found, mostly among consulting organizations.

My hospital recently employed a consulting group as part of an external assessment of our medical staff credentialing and peer review processes. At an instructive presentation at our executive committee meeting the consultants proposed a “pyramid” for medical staff development. While proposed for the general medical staff, applicability to any department, including my own was obvious.

Figure 1: Pyramid of Medical Staff Development
The pyramid (figure 1) begins with the obvious: Get the best people you can onto your team. Since I’ve only one column this month, we’ll leave recruiting for another time. The interlocking components of setting expectations, measuring and giving feedback are the key components of the change process. Like you, I believe that most physicians want to “do the right thing.” Unfortunately, most of us are increasingly uncertain as to what the “right thing” is these days, which is why clearly setting expectations is so important to beginning measurement.

Let’s face it, what I am talking about goes by many names, but measuring productivity is a component of physician profiling. By itself measuring physician productivity is value neutral, but as I’ve previously written (April 2000, EMN) productivity measurements can be used as a bludgeon or as a teaching tool. Unless the three stages of setting expectations, measurement and feedback are in place, jumping to “managing poor performance” or “corrective action” is simply bludgeoning your staff. Thus, if some measurement of physician productivity is put in place it must be implemented based on some clearly articulated expectation of productivity. Well, what shall we use? Probably, the most widely used measure is patients per hour (PPH), which is also the most easily measured. While I do not think this measure has as much value as another—I prefer to measure relative value units (RVUs) per hour—I’ll discuss how PPH might be measured since so many of you have expressed interest.

Several sources suggest that 2.5 PPH is an appropriate benchmark of physician productivity.[1],[2] But is it? Should you even set a benchmark? Or should you develop baseline information in your local environment first? I derive my answer from the pyramid, which suggests that measuring and comparing to articulated expectations is the desired process. Given the uncertainty of what constitutes appropriate productivity despite the references cited below and the excellent discussions by Tom Scaletta, MD at the AAEM web site (see "Rules of the Road Q & A) and elsewhere including the emergency medicine internet mailing list (subscribe by sending “sub emed-l” to, I believe it is far more important to measure your own team’s productivity over-time before setting your own baseline rather than subscribing to another’s. For example in our adult acute area having measured our PPH for more than two years we still see a PPH of less than 2.0, but then our admission rate in that part of our ED nears 45%.

Returning to my correspondents’ questions, how shall we measure PPH? An easy route to measurement of PPH is asking your billing contractor to provide your patient volume by physician for the dates of service of interest and count your scheduled clinical hours over the period for which you’ve measured patient volume. Measure PPH for a month at a time or at least for a period that includes approximately 150 patients and track results over a minimum of six months before making any decisions. Graphing the results of PPH, RVUs/hour and RVUs/patient against the 20th, 50th and 80th percentile for the group tells quite a story (figure 2). Besides as the pyramid advises us, feedback is the next step after measurement. More on RVUs next month in Part II.

Figure 2: Physician Productivity by RVU/Hour, RVU/patient, Patients/Hour

Most physicians, provided the monthly graphical feedback about PPH described above, will over time adjust their performance to the mean of the group. When this productivity measure (or RVUs/hour) is coupled with measures of patient waiting times or throughput intervals and measures of medical staff and patient satisfaction then decisions about improving productivity or altering staffing will become apparent.

What about the physician who does not come into line? The physician who insists that her or his patients are more sick or complex or otherwise more difficult to evaluate? Relative value units per hour more closely reflect the patient complexity by more directly measuring the physician work done in patient care, but RVUs are harder to measure. Yet, conversion to this measure should not be the answer, rather reaffirmation of the expectation clearly articulated at hiring and through regularly scheduled reviews and meetings assures that the physician is identified as non-compliant with the expectations s/he had earlier agreed to. Unfortunately, counseling or disciplinary corrective action may be required after a sufficient period of monitoring without response.

The medical staff development pyramid provides a basis for exerting leadership within a group in an open and aboveboard fashion. Implementing the pyramid approach no later than your group’s next annual review and planning session provides a basis for improving your group’s cohesiveness and performance the following year.

[1]Graff LG, Wolf S, Dinwoodie R et al: Emergency physician workload: a time study. Ann Emerg Med 1993; 22(7) 1156-1163.

[2] Weston, K: A difficult fix: staffing the emergency department to meet patient demand. Clinical Initiatives Center, ED Watch #1 1999. The Advisory Board Company, Washington, D.C.

Wednesday, June 14, 2000

The Technology Challenge for Emergency Departments

My recent weeks have been filled with technology. My department is preparing to take the plunge and install an electronic medical record for the emergency department that will be fully integrated into the hospital information system and provide complete ED functions including support of triage, tracking, orders, results, and discharging.

We’ve tried twice before, and both times the niche vendors we contracted with were not up to the challenge in our environment. Each of them has apparently successful installations elsewhere, but they have some failures elsewhere, too. No vendor can ensure success, and even those who have been successful elsewhere may fail if you and your hospital management — particularly, information systems (IS) — are not ready to undertake the installation. Those are the warnings, so how to proceed?

The most important lesson I’ve learned from our past failures is that the leaders of the hospital IS department must be engaged and confident. The leaders of hospital IS are conservative by nature and by their experience with the systems they have in place and maintain. In most hospitals, IS has been asked to do more with less every year — just like emergency medicine — and that demand is only increasing. Many hospitals don’t even support much of an on-site IS presence around the clock. Thus the system must be planned and sized so that the hospital can successfully implement and maintain it.

Exploring what is available in the market can be a never-ending task. Every vendor will tout the benefits of his system, yet most will have fewer than 20 active working installations. Those few that have more up and running do not necessarily have the best track record either. Other vendors will say how many sites they have under contract. This too can be misleading. There may be two vendors still counting my hospital.

Start with Research

A good place to start is by researching what is available at the International Symposium on Emergency Department Information Systems Site and a 2009 ACEP whitepaper (PDF), "ED Information Systems". These sites point to other resources, and are all-around good starting point for exploring computing resources for support of emergency medicine.

All is not lost if your facility has meager resources because vendors are increasingly partnering and creating systems whose price is based on patient volume and even charged on a monthly basis based on how many patients have been entered in the system. As the Internet has become a growing consideration in implementing all information systems, vendors are implementing systems as application service providers. Assuming the proper attention to information security and privacy (required by the Healthcare Insurance Portability and Accountability Act [HIPAA]), it is conceivable that one or more of these nascent vendors may provide what you need for your ED.

I’ve recently examined vendors’ offerings at several meetings. New approaches abound. The vogue for template charting remains unabated, but now several vendors compete in the template chart marketplace. More than a few have either developed their own electronic version of template charts or have partnered with an information system vendor and offer either electronic charting or more commonly, electronic storage of a hand-completed template.

That is, a paper template chart is completed as usual, but the completed chart is then scanned and stored in the computer for later access. Scanned storage does have limitations, but it also sharply reduces the amount of paper that requires handling and integration into a hospital’s permanent medical record. It also can facilitate transmission by fax — with the patient’s permission — of a chart to the patient’s primary physician, thereby enhancing communication. Lastly, with the coming of Outpatient Prospective Payment System for Medicare patients and the attendant Ambulatory Payment Classifications (APCs) and the consequent increased attention the medical record will receive from both hospital and physician practice billers, an electronic record, even one as simple as an image of the scanned ED chart offers significant advantages over a paper record.

Be Wary of Data Use

At the American College of Emergency Physicians Connections meeting in New York City during early April 2000, one vendor offered a prescription-writing kiosk. The kiosk is offered at no charge to the hospital, and the vendor assured me that integration into the hospital’s registration system was part of the no-charge package. I was told that discharge instructions would be included by later this year.

On its face, this is an intriguing offer. It addresses the growing concern about errors in outpatient medication dispensing through poor handwriting on prescriptions, yet it raises a series of questions. When I challenged the vendor about the advertising that would be put in front of the physician at the time of prescription writing, I was told that this was “physician education.” Yet, it was clear to me that certain medication names were prominently and permanently available as one-touch selections for the physician.

Although I failed to ask, you should ask the vendor what will become of the patient information (demographics and prescriptions today with discharge instructions coming soon) captured in the database? Will it remain at the hospital or passed on to the vendor? I see the potential benefit for patients and physicians of this and other advertiser-supported tools, but I fear the consequences. While an advertising model for free Internet connectivity may work, I’m troubled by this apparent parallel in providing computing support for health care.

No Panacea

Installing technology is no panacea to difficulties and barriers in delivering excellent emergency medical care. In fact, improperly selected and implemented systems by paving the goat paths rather than helping reorganize the way the ED staff works as a team may worsen rather than improve the clinical environment.

Technology can be a wonderful tool, but steamrollering over colleagues and co-workers can put painful barriers in the way of effective teamwork. The vendors will say how easy it is to install and operate. Increasingly they are correct, but will it work for your environment? Please remember the hard lesson I’ve learned: Technology is easy; people are hard.

Sunday, May 14, 2000

A Model for Those not in Charge: Lateral Leadership

Starting a new column in a monthly publication has been a strange experience. This second column, written without the benefit of any feedback from you, my physician colleagues, has been a far more difficult undertaking than last month’s maiden effort. I realized that espousing the importance of measurement is good, but how can that effort be undertaken that effort if you are not the boss or if measurement driven change would not be welcomed in the ED? Recent publications offer new insights into transcending both of these barriers to improvement.

Sometimes, we find ourselves charged with the responsibility for solving some problem but without the authority to proceed. Frustrating! Issuing direct orders won’t solve the problem; people will look at you as if you’ve just grown another head. Perhaps administration in preparation for an upcoming JCAHO survey — especially now that medical errors are in the news — has said all physicians’ must write their charts and prescriptions legibly. You know you would stand a better chance of having your neighbor’s cat roll over on command. In this situation, negotiation specialist Roger Fisher and his colleague Alan Sharp (Getting It Done: How to Lead When You’re Not in Charge, Harper Business, 1998) suggest a model of “lateral leadership.”

Messrs. Fisher and Sharp detail a five-step method that anyone can apply, thereby becoming a “lateral leader.” Establishing goals, thinking systematically, learning from experience (while it’s happening), engaging others, and providing feedback seem intuitive on first reading. In practice, rather than giving orders as if some distant leader from above, engage colleagues as partners right at the scene of the work. Applied consistently to meetings or projects, this will enhance the likelihood of successful accomplishment of the project.

As an example, if you’re not the boss, why would your feedback possibly matter to a colleague? We’ve all heard the expression, “You catch more flies with honey than with vinegar.” Appreciation, simply and genuinely expressed, is always valued. So, too, will helping a colleague get his point across by asking a feeling question: “How do you feel about doing it this way?” Genuine appreciation and support of a colleague will pay dividends later.

Persistence Pays

A new approach may be remarked upon or distrusted at first, but just as a new hair style is accepted in time, so too will a new way of working with colleagues — if you persist.

Yet, perhaps the ED isn’t ready for the changes precipitated by initiating measurement in support of evaluation and improvement. A recent commentary by Daniel DeBehnke, MD, (Acad Emerg Med 2000;7:282) offers a seven-step approach for organizational change. As Dr. DeBehnke observes, regardless of which model (QA, CQI, TQM, PI, etc.) the ED might adopt as a change process, the steps are basically the same and provide a worthy guide.

Begin by determining where you are, or as I wrote last month, “start measuring now.” Knowing where you stand when you start enables your later demonstration of the magnitude of your success. Deciding where you would like to be may be the mandate that’s been forced upon you — legible handwriting — or more optimistically, the consequence of your group’s effort at setting an ambitious but realistic goal.

You, whether the boss or lateral leader, will be the process champion and thus take charge of both measurement and the process change whose result you seek to measure.

Gaining Buy-in

Critically important, gaining buy-in to the process change is the next step. Engaging others and responding candidly to their questions and concerns will gain believers or at least quiet some dissidents. A few engaged, credible colleagues — especially those trusted by co-workers — are important to get started. Do not wait for 100 percent buy-in or group consensus; the process will never move forward. Early, credible supporters will bring others into the fold over time. Devote the time and personal attention one-on-one, early on to gain the support from opinion leaders.

Tools that support measurement and the change sought ease implementation. Examples of support tools include custom order sheets — such as a chest-pain order sheet — with boxes to check off that comply with practice guidelines. Optimizing physician charting is easier with a laminated pocket-size card with prompts for complete dictation or a paper chart with lightly printed prompts for all aspects of a standard history and physical examination. A charge-nurse end-of-shift report form can simplify measurement when solving problems of admitting patients to the hospital is the focus of the effort. Support tools make it easier for even a naysayer to participate while maximizing measurement and supporting change.

Giving feedback both to the group and to each individual is not sufficient. Specific advice on desired behavior change must be suggested. Most physicians believe they understand what is required, but results will improve if colleagues are engaged and everyone learns from experience by providing specific suggestions for an alternative action.

For example, I always go back to a referring physician after a patient complains that his physician told him, “The ED should have … [done something different].” I always listen to the physician, hear what he has to say, and encourage him to call me the next time, even page me if it’s an odd hour rather than complain to the patient about the ED. I tell them, “The patient can’t fix the problem in the ED, but I can if I know about it. Also, if you complain to me and I don’t fix it, you can complain about me to the hospital CEO.”

Re-evaluate Results

Make certain to re-evaluate the results. Measure more than once before deciding whether the goal has been accomplished or must still be tweaked. Accomplishing a goal of changing the organization or colleagues in a particular direction requires re-evaluation of progress and reinforcement of the desired behavior. Change in the emergency department and the physicians who work there is an ongoing constant, or should be. “Even if you’re on the right track, you’ll get run-over if you just sit there,” said Will Rogers.

Whether measuring and improving something about the emergency department or something about the practitioners who work there, effecting lasting change requires both constant effort and a multi-factorial approach. A systematic process for changing the ED and the application of lateral leadership can help achieve goals, without turning the leader into a two-headed monster in the eyes of colleagues.

Friday, April 14, 2000

Measurement of Operations Performance: An Invaluable Tool for Patient Care

Thomas P. (“Tip”) O’Neill, the late Speaker of the U.S. House of Representatives, once commented that “all politics is local.” So too are all emergency departments.

Our emergency departments’ clinical operations pose endless challenges, and the result I obtain in Brooklyn most assuredly will require a unique implementation in your world or it won’t work at all. Nonetheless, we can learn from each other, particularly if we are willing to look beyond the specific sought-after result to the processes that bring us to that result. “Best practices” described anywhere usually have some value everywhere. Garnering that value requires reliable measurement if success is to be obtained.

Measurement of operations performance is an invaluable tool for helping improve patient care and, as importantly, the patients’, community’s, and medical staff’s perception of the care we deliver in the ED. Yet resistance to measurement of operations performance is common among emergency physicians, and when measurement itself may be grudgingly accepted, arguing the validity of the findings is equally common.

Emergency physicians resist measurement of operations performance or disdain the results because by and large they were never taught how to use the results to improve care for patients. Unfortunately, most emergency physicians don’t take the time or are not afforded the opportunity to participate in interpreting results, and therefore they rarely gain the opportunity to learn about the processes of measurement and the value of the measurement. Rather, emergency physicians mostly learn about operational performance measures through someone else’s interpretation of a particular finding.

Bludgeon or Tool?

Too often, hospital or practice managers begin by using these measurements of operations performance as a bludgeon rather than a teaching tool. For example, over the past several years, physician productivity has become an oft-measured parameter, sometimes with dismal findings for one or more emergency physicians in the group. The dismal result and the management pronouncement that, “Something’s wrong, fix it,” fails to convey the importance of the finding and the real need to address it. It sets up a situation in which energy is diverted to a struggle over the quality of the data and the value of the particular measure.

Just as vital signs are vital but don’t tell the whole story about a given patient or clinical condition, so too are measures of physician productivity important but don’t tell the whole story of a physician’s value. Few of us make judgments in practice or in life on a single parameter. Even W. Edwards Deming, a statistician who popularized statistical-process-control and whose name has become nearly synonymous with continuous quality improvement (CQI), when speaking of his system of “Profound Knowledge” acknowledged that, “Not all facts, not all measures are known or knowable.”

Nonetheless, measurement has value in a variety of circumstances. Many practices may have one or more members who are perceived by some as unable to “move the room.” In practices with periods of multiple physician coverage, one physician may be seen as “slow,” causing colleagues to avoid double-coverage shifts with him. When confronted, the “slow” physician may ask for a more objective measure of his performance.

As an alternative example, a new member of the practice or perhaps a recent residency graduate may be thought of as a “slow” physician because of a subjective sense of the state of the department when this particular physician is working. In both of these instances, some measure, used over time to track change in performance, may be sought by the practice leadership, the physician, or hospital management. Many people singled out for examination seek objectivity and reliability in the evaluation. Yet, others remain uncomfortable with measurement, seeing productivity measurement as a two-edged sword that can be more harmful than helpful. I disagree; evaluation or improvement of operations performance requires measurement.

Credible Measurement Vital

Credibility in measurement is vital. Producing and exhibiting a number is a pointless exercise in an environment where no other numbers and the underlying data are unavailable to the subjects of the measurement. While measurement and reporting shouldn’t wait for each individual’s review of every datum, practices and EDs lacking transparency are not environments in which productivity measures, regardless of how carefully produced and published, will have the respect of those physicians subjected to measurement. Without respect for the process of measurement, there can be no hope for constructive change among the physicians or others whose work is subjected to measurement.

Some physicians are quick to dispute the validity of clinical operations measurements. Trained in science and the scientific method, most physicians are notably slow to embrace the “management analysis” implicit in clinical operations management. Management analysis shouldn’t be confused with the scientific method. The validity physicians anticipate when deploying prospective hypothesis testing differs from the validity of management analysis examining an operations issue. Accordingly, precision of measurement — by this I mean especially the repeatability of the method and the reliability of the result — are more important than absolute accuracy. Consequently, single measurements are of scant value; yet, repeated measurements over a period of time often prove a powerful and reliable tool.

Thus, the second point: Start measuring now. Don’t wait until you change something or have improvement efforts underway. Nothing will speak so resoundingly of your success in the future as a measurement with a dismal finding at the start and a strikingly positive trend over time. Beginning the process of measurement speaks to a seriousness of purpose that may be used to persuade your critics in management or elsewhere that you are committed to evaluation and, as necessary, improvement.

As I mentioned, even vital signs don’t tell the whole story about a patient, and neither will any one measurement of operations performance. Thus my third point: No single measurement itself induces immediate action. Responsible leaders will not be stampeded into imprudent action based on a single observation. Whatever the interval of measurement, usually seven or more observations should be recorded before any action is contemplated. Thus, one could wait seven months before acting on a measurement made monthly. Rather than acting precipitously, it would be better to measure more frequently than monthly, if the pressures of the real world require action sooner.

Improvement of operations performance requires measurement, which is best started as soon as possible, but no single measurement itself requires an immediate response. We have no choice in the matter, for without measurement how will we know that the changes we plan to undertake are an improvement?