The emergency department is an integral component of hospital operations because the ED is often the key entry point for the majority of hospital inpatients. However, an inefficient ED can also be a key source of financial loss for a hospital. In order for hospitals to operate successfully and see continued growth, the ED needs to avoid financial pitfalls. Barbara Blevins, COO of Hospital-Based Services for TeamHealth, and Jeff Wood, RN, vice president of HBS for TeamHealth, discuss how to address common problem areas for hospital ED finances.
Question: Physician staffing can often be a problem area for hospital emergency departments, both in terms of anticipating ED volume and recruiting/retaining strong ED physicians. Can you elaborate on why staffing can cause problems financially?
Barbara Blevins: Inappropriate staffing is probably one of the biggest issues EDs face — when there are too many or too few of the right providers on hand in relation to the ED's patient volume. ED physicians have many of the same needs as other hospital employees — they want to work in a collaborative environment centered around good patient outcomes, they want to live in a place that meets their lifestyle needs and they want competitive compensation. If those issues are not being addressed or recognized, it can lead to chronic physician turnover, which can create the need to hire temporary staff and increase costs.
Jeff Wood: In addition, if you're bringing in new physicians all the time, that results in individuals who aren't familiar with the department's processes. That can back up patient flow, create frustration for both physicians and patients and result in patients leaving without being seen. It could also mean ED physicians are not familiar with the hospital's systems, which could lead to poor documentation and hurt reimbursement. Inappropriate staffing may also require overtime hours, which costs the hospital a premium.
Q: What can ED's do to improve physician retention?
JW: One of the things we do at TeamHealth to help improve physician retention is work with the healthcare improvement firm Studer Group. They've done years of research to determine the tactics that improve retention. For example, we do monthly rounding on all of our facility medical directors, and we do monthly rounding on all providers to make sure they're demonstrating good care, to discover opportunities for improvement that the provider has identified in the ED and to see if there are people that providers want to recognize for doing extraordinary work. It is all in the vein of learning, improving, building and nurturing good relationships.
Q: What other factors, besides inappropriate staffing, might negatively affect an ED's finances?
BB: Other things that can negatively impact finances are over-utilization of diagnostic testing, poor payor mix, poor revenue cycle management and poor leadership. Often an ED with poor leadership and management may experience frequent turnover, which can create the need for hiring temporary expensive nurses or physicians.
JW: Another sometimes-overlooked factor is the ED's relationship with emergency medical services. EMS professionals often choose the hospital to which they deliver their patients. If the paramedics are positive about your ED and they'd feel comfortable taking a loved one to your ED, then they'll bring more volume to you. And, these patients are typically higher acuity patients who need an inpatient admission. If you have a poor relationship with EMS, you could be risking that potential for additional volume and revenue.
Q: What best practices can hospitals implement to avoid these damaging factors and have successful operations and finances in an ED?
BB: Make sure you have the right physician and nursing leadership in place and that those two people operate as a team to run the ED efficiently and effectively. The No. 1 success indicator in high functioning EDs is having a highly effective physician medical director and a highly effective nursing director. That’s the most important thing hospitals can do to make sure they're hiring and retaining the right people.
Hospitals must also take the time to analyze and improve patient flow so there are available beds for patients presenting at the front door and for patients presenting from EMS. One important part of that analysis is looking at patient arrival times against staffing levels to make sure the right number of staff are available to treat the volume of patients in the ED so there aren't long queues causing patients to leave. Other measures include making sure the right people and processes are in place to bill and collect optimally, as well as analyzing the department's culture to make sure it is welcoming to patients and providing compassionate care.
JW: In addition, the ED needs to make sure it has systems and processes in place to optimize patient flow and adjust staffing levels to accommodate that flow. You want to have the right resources available for care; if you have too many resources, you take a financial hit, and if you have too few, patient waits can escalate.
Q: If a hospital were to have suffered some financial losses as a result of the above-mentioned factors, what could be done to turn around the negative impact?
JW: The most important thing is to be proactive instead of reactive in managing risk. That means specifically addressing how well the ED follows evidence-based practices and the speed with which the ED is able to recognize and treat the most urgent patients as quickly as possible. It means that the ED team of physicians, mid-level and nursing providers must know how to communicate well between themselves and with patients. Additionally, the careful and thorough documentation of care is very important to that communication.
BB: In addition, ED leadership should work to identify high-risk cases and educate the physician and nursing staff about them in a systematic and consistent way so the providers can optimally treat those patients and minimize risk. This education process should be ongoing, pre-emptive and hardwired with the ED monitoring its performance. And, it means educating staff when a negative situation occurs from a high-risk situation so it doesn't happen again.
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Question: Physician staffing can often be a problem area for hospital emergency departments, both in terms of anticipating ED volume and recruiting/retaining strong ED physicians. Can you elaborate on why staffing can cause problems financially?
Barbara Blevins: Inappropriate staffing is probably one of the biggest issues EDs face — when there are too many or too few of the right providers on hand in relation to the ED's patient volume. ED physicians have many of the same needs as other hospital employees — they want to work in a collaborative environment centered around good patient outcomes, they want to live in a place that meets their lifestyle needs and they want competitive compensation. If those issues are not being addressed or recognized, it can lead to chronic physician turnover, which can create the need to hire temporary staff and increase costs.
Jeff Wood: In addition, if you're bringing in new physicians all the time, that results in individuals who aren't familiar with the department's processes. That can back up patient flow, create frustration for both physicians and patients and result in patients leaving without being seen. It could also mean ED physicians are not familiar with the hospital's systems, which could lead to poor documentation and hurt reimbursement. Inappropriate staffing may also require overtime hours, which costs the hospital a premium.
Q: What can ED's do to improve physician retention?
JW: One of the things we do at TeamHealth to help improve physician retention is work with the healthcare improvement firm Studer Group. They've done years of research to determine the tactics that improve retention. For example, we do monthly rounding on all of our facility medical directors, and we do monthly rounding on all providers to make sure they're demonstrating good care, to discover opportunities for improvement that the provider has identified in the ED and to see if there are people that providers want to recognize for doing extraordinary work. It is all in the vein of learning, improving, building and nurturing good relationships.
Q: What other factors, besides inappropriate staffing, might negatively affect an ED's finances?
BB: Other things that can negatively impact finances are over-utilization of diagnostic testing, poor payor mix, poor revenue cycle management and poor leadership. Often an ED with poor leadership and management may experience frequent turnover, which can create the need for hiring temporary expensive nurses or physicians.
JW: Another sometimes-overlooked factor is the ED's relationship with emergency medical services. EMS professionals often choose the hospital to which they deliver their patients. If the paramedics are positive about your ED and they'd feel comfortable taking a loved one to your ED, then they'll bring more volume to you. And, these patients are typically higher acuity patients who need an inpatient admission. If you have a poor relationship with EMS, you could be risking that potential for additional volume and revenue.
Q: What best practices can hospitals implement to avoid these damaging factors and have successful operations and finances in an ED?
BB: Make sure you have the right physician and nursing leadership in place and that those two people operate as a team to run the ED efficiently and effectively. The No. 1 success indicator in high functioning EDs is having a highly effective physician medical director and a highly effective nursing director. That’s the most important thing hospitals can do to make sure they're hiring and retaining the right people.
Hospitals must also take the time to analyze and improve patient flow so there are available beds for patients presenting at the front door and for patients presenting from EMS. One important part of that analysis is looking at patient arrival times against staffing levels to make sure the right number of staff are available to treat the volume of patients in the ED so there aren't long queues causing patients to leave. Other measures include making sure the right people and processes are in place to bill and collect optimally, as well as analyzing the department's culture to make sure it is welcoming to patients and providing compassionate care.
JW: In addition, the ED needs to make sure it has systems and processes in place to optimize patient flow and adjust staffing levels to accommodate that flow. You want to have the right resources available for care; if you have too many resources, you take a financial hit, and if you have too few, patient waits can escalate.
Q: If a hospital were to have suffered some financial losses as a result of the above-mentioned factors, what could be done to turn around the negative impact?
JW: The most important thing is to be proactive instead of reactive in managing risk. That means specifically addressing how well the ED follows evidence-based practices and the speed with which the ED is able to recognize and treat the most urgent patients as quickly as possible. It means that the ED team of physicians, mid-level and nursing providers must know how to communicate well between themselves and with patients. Additionally, the careful and thorough documentation of care is very important to that communication.
BB: In addition, ED leadership should work to identify high-risk cases and educate the physician and nursing staff about them in a systematic and consistent way so the providers can optimally treat those patients and minimize risk. This education process should be ongoing, pre-emptive and hardwired with the ED monitoring its performance. And, it means educating staff when a negative situation occurs from a high-risk situation so it doesn't happen again.
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