Bruce Siegel MD MPH, Marcia Wilson MBA, Khoa Nguyen MPH, Marsha Regenstein PhD Academy Health June 6, 2004

1. Improving the Performance of the Safety Net: Findings of the Urgent Matters Project Bruce Siegel MD MPH, Marcia Wilson MBA, Khoa Nguyen MPH, Marsha Regenstein PhD Academy Health June 6, 2004

2. Program Origins: RWJF Surveys the Landscape • 2000 IOM report on the safety net • The safety net is “Intact but endangered” • Report recommends we monitor and assess local safety nets • Drumbeat of media coverage: Overwhelmed EDs with diversion and long waits • ED’s overwhelmed: 62% of hospitals report being “at” or “over capacity” (Lewin 2002) • ED’s as the “safety net for the safety net” • Take all comers, by custom and law - EMTALA • ED Volume Rising While Number of EDs Shrinks • 1992-2002: Annual ED visits up 23%, Number of EDs down 15% (CDC 2004)

4. Selection Process • Applications solicited from all public/not-for-profit level I and II trauma centers in US. • 2/3, or 287 submit detailed on-line letter of intent • 10 selected as grantees • Criteria: • Evidence of crowding • ED volume, market share • Payer mix • Track record in achieving and sustaining change • Senior leadership commitment

5. The 10 Hospital Learning Network • Grady Health System – Atlanta, GA • Boston Medical Center – Boston, MA • Henry Ford Hospital – Detroit, MI • Inova Fairfax Hospital – Fairfax County, VA • BryanLGH Medical Center – Lincoln, NE • The Regional Medical Center at Memphis – Memphis, TN • St. Joseph’s Hospital and Medical Center – Phoenix, AZ • Elmhurst Hospital Center – Queens, NY • University Health System – San Antonio, TX • University of California at San Diego – San Diego, CA

6. Urgent Matters Input/Throughput/Output Model

7. Learning Network Elements • Tool kit of best practices on patient flow • Data collection methods • Strategies for work flow re-design • Organizational buy-in strategies • Implementation strategies • Training and Reinforcement on Rapid Cycle Change • Plan, Do, Study, Act • Core Metrics • 17 key performance indicators (weekly and monthly reporting)

8. Learning Network Structure • Web-based management • Tool kit, new developments and other resources • Action plans and data submission • Run-charts • Monthly project reports • “Celebrating Success” • Shared data – shared outcomes • Peer Collaboration • 3 group meetings • 3 consultant site visits to each site, with phone consultation • Monthly conference calls with topic presentation, update from each site • Listserv

16. Closing Thoughts: Operations • It’s The Hospital, Stupid!! • Rapid Cycle Change: Rapid Is Key • Early Results More Important Than Consensus • Communications are critical • Data Systems Lag • But it’s doable • Executive Management Buy-In Is Key • Collaboration? Or Competition? • Productivity May Increase Dramatically

17. Closing Thoughts: Policy • Do We Really Need All These New ED’s? • Are we just building bigger reservoirs? • And what are we putting in them? • Changing EMTALA Is Not the Answer • Barring the Door, or “Triaging Out”, Is Not the Answer Either • What are the Implications for Surge Capacity? • Maybe We Need to Rethink the Role of the ED as “Provider of Last Resort” • The Safety Net CAN Improve Its Performance • With minimal external resources • And that goes for Academic Health Centers as well