Kevin Spiegel, FACHE joined the Chattanooga, Tenn.-based Erlanger Health System as President & CEO in 2013, and under his leadership the system established a unique call center to streamline the patient transfer process. This innovative center has been a main driver of the health system's 15 percent net patient revenue growth and greatly improved Erlanger's market share, finances and payer mix.
The seventh largest public health system in the U.S., Erlanger, is an academic medical center comprised of six hospitals.
Since fiscal year 2013, Erlanger has seen an average annual growth rate of 15 percent, which puts the organization "in the top percentile nationally for nonprofit health systems," explains Mr. Spiegel
Here, Mr. Spiegel and Senior Vice President and Chief Strategy Officer Mathew Gibson, PhD, FACHE discuss the call center that has contributed to the health system's organic growth.
Question: What is one pioneering idea you've implemented at Erlanger?
Kevin Spiegel: One idea that has gained traction and is responsible for our organic growth is called the Erlanger Regional Operations Center (EROC) , a state-of-the-art disaster preparedness and transfer center and its auto-accept policy.
Four years ago, a committee that included executive team members among others had an extensive discussion about how services ran. As an outcome of that conversation, we established, by protocol, admitting privileges for critical care nurses. We realized many community and rural hospitals, while they provide positive patient care for the community, were not always prepared to handle seriously ill patients. So out of that discussion came the idea for a streamlined transfer process, where [rural and community hospitals] relied on us and trusted us to provide care. This is how EROC emerged.
EROC, or the call center, improves the efficiency of patient transfers. At the Erlanger call center, critical care nurses actually answer the phones. We have from six to 12 certified nurses answering the phones in the call center at all hours of the day. It's a bank of operators, but they are critical care nurses so they have the medical information, bed board information and knowledge about which doctors are on call.
The calls come into the call center and a telephone tree gets the call to the next available nurse. The nurse who answers the phone goes over the case with the sending doctor and the nurse accepts the patient on the spot. It is instantaneous. [The call center operates under] an auto-accept policy, meaning transfer requests are not denied. After nurses accept the patient, an air or ground ambulance is sent automatically to the rural or community hospital sending the patient.
Once that process is complete, the nurse writes a comprehensive note detailing the conversation with the sending doctor. This note, which says whether the patient is arriving by air or ground and when the patient will arrive, is directly sent to the on-call doctor. The on-call doctor is then awaiting the patient's arrival so they can meet him or her in the surgical unit, directly in the patient's room or emergency department, based on the patient's condition.
In the new program, doctors are awaiting transfers - they are neither operating nor taking calls. They are paid to be on call and to receive patients from the region. The call center logs the times of each call, logs when the patient came in and we trend on-call doctor's behavior and give them a scorecard based on those results.
Q: What types of insights can be made from the data collected by the call center that is presented on the scorecard?
Dr. Matthew Gibson: EROC is staffed with certified critical care registered nurses who must have a minimum of five years of bedside nursing experience before qualifying for EROC. Our EROC RNs operate off of service line physician-approved algorithms for patient acceptance. The EROC RNs are measured by several metrics including: calls answered in less than six seconds, less than a 4 percent abandoned call rate, a hold time of less than 10 seconds and a time of call to patient acceptance less than six minutes.
Our accepting service line physicians have agreed to an auto-acceptance algorithm for patients, to expedite the transfer process. All transfer requests are reviewed by the EROC medical director and put through a multi-layered quality assurance process to assure compliance with the auto-accept program. Any accepting physician can flag a transfer for quality assurance review if they feel there was an issue with the transfer.
Q: How did the admitting process work before EROC was established?
KS: Erlanger was the typical health system with an admissions office. Calls would come into the office or the ED and get routed by traditional pagers to the doctor on call. Once the doctor received the page, the doctor would call the operator and the operator would say, 'Dr. Smith at XYZ hospital is trying to transfer a patient.' Then the doctor would ask, ‘What's his phone number,' and would call Dr. Smith to get the details. It was a doctor-to-doctor discussion. It didn't really have any parameters or rules.
In this scenario, clearly the sending doctor was overwhelmed because his or her hospital couldn't properly care for the high-acuity patient. But this traditional way of transferring a patient had setbacks, because the receiving doctor could've been in the middle of surgery, taking call at a different hospital or maybe just too tired after receiving their fourth transfer of the day. There was no consistency in this approach, no transparency with a scorecard, and no turn-down policy in existence.
Q: How this has impacted your organization?
KS: By streamlining the admitting process through this call center, community and rural hospitals' loyalty and reliance on Erlanger increased and demand for services and alignment strategies enhanced. One outgrowth from this: We have signed 15 affiliation agreements with community hospitals. They all had an acute need to further align with a larger hospital system to ensure proper patient care, which was not available before this. Additionally, our admissions grew exponentially, and so has our efficiency from the auto-accept policy in EROC. By opening our doors to community and rural hospitals, we saw a better payer mix, an improved case mix, and regional growth — significantly above what we saw when we used to have on-call doctors screen all of those transfer calls.
MG: Affiliates of Erlanger are, on a regular basis, thankful to us for adding the services and improving the quality of care for them because they often don't have the capability, physicians or workforce to handle high-acuity patient cases. Also, before this program and streamlined process, they were forced to treat severely ill patients without the proper resources.
Additionally, as a result of this process, we have been able to grab more market share and are now the clear leader in market share in our greater region.
Further, our 'culture of yes' has helped improve momentum and team morale because we have so much pride in the growth that this organization has seen in recent years — especially since we used to just be a safety-net facility. We have so much pride in the call center, too, which is unlike anywhere else.
Q: What inspired this idea?
KS: Above all, the idea that we are keeping a promise to the community: Our doors will always be open.
But, I can take a step back. Leadership changed at Erlanger about five years ago. [Executive Vice President and] COO Robert Brooks, FACHE and I were both pre-hospital care providers in a different life. Both of us understand the flow of patient care and how strategies with the prehospital care community affect the acute care hospital. When we both got here about five years ago, we knew the pre-hospital relationships were fractured. So we met and aligned with every pre-hospital care company in Northwest Georgia, Eastern Tennessee, Alabama and North Carolina, and soon understood what was happening. We then worked to strengthen those relationships. Rob and I had a unique skill set to align with pre-hospital care companies, which included various EMS agencies such as ground and flight, because we lived in those shoes before.
Q: What were some of the challenges you encountered while implementing EROC and the streamlined transfer program?
KS: When we first implemented this, some of the doctors on call were used to being able to manage and defer admissions. The doctors had total autonomy; they were able to deny admissions and no one would challenge them. We moved from a closed system to a very open and transparent system. Data is very transparent, everyone's on-call behavior is known, and everyone is given a scorecard about how quickly and efficiently they run their service. By losing that autonomy there was some level of frustration among physicians. This led to a small group of doctors moving from active medical staff status over the change. Sometimes you and I may think [transparency] is the way it should be. But this transition may not be as palatable if you are used to operating the way it was done 30 years ago.
MG: Another challenge I would add — largely because of the success EROC has achieved — is meeting the demand from these new affiliates, which is definitely a good challenge.