What U.S. Emergency Care Value Transformation Can Learn From Canadian Efforts to Improve Emergency Department Throughput

In this issue of Academic Emergency Medicine, Rotteau et al.1 detail findings from interviews with local stakeholders across 10 hospitals in Ontario, Canada, participating in an emergency department (ED) process improvement program aimed at improving ED patient flow. The authors identified several factors linked to program success, including having strong support from hospital executives, forming teams focused on tasks and outcomes, and creating accountability for sustaining interventions. They concluded that incorporation of these factors into planning and executing similar interventions could boost chances of success. The broader question was how to successfully transform multistakeholder, multidisciplinary environments, like hospital EDs. The answer to the transformation question is rapidly becoming central to health care organizations in the United States as new pressures mount from payers to reduce costs and improve quality. The catalyst is the Affordable Care Act of 2010, which supports new payment models that will reward organizations that can deliver care more efficiently. In early 2015, the Secretary of Health and Human Services, Sylvia Burwell announced an accelerated plan to move away from traditional fee-for-service payments.2 There is a target for 30% of Medicare payments to be reimbursed by 2016 in alternative payment models, such as accountable care organizations, which will increase to 50% by 2018. For the remaining fee-for-service payments, 85% will be tied to quality by 2016 and 90% by 2018. These new targets have upped the stakes as health care organizations start realizing that transformation just may be a necessary step in economic survival. Yet, transforming clinical practice is not an easy job, and in particular revamping ED practice is a particular challenge, as EDs have their own unique set of conditions.3 Emergency departments are highly complicated units to manage because of the large daily and seasonal fluctuations in care demands. Some surges occur predictably, and some do not, making it essential to have extra space and staff in reserve, as well as back-up plans to maintain performance. EDs also rely on perhaps the broadest group of health professional stakeholders to function efficiently, from emergency physicians and nurses, some who work many and others who work few hours per week, along with nonphysician staff such as technicians, administrative, and other services. Beyond ED staff, a myriad of other stakeholders and departments are required for efficient ED functioning, such as laboratory, pharmacy, social work, and radiology services, along with non-ED physicians and hospital floor staff. In many cases, incentives of stakeholders in hospitals are aligned; but in other cases, they are not. For example, EDs are in the “speedy care” business, while other interdependent units that EDs rely on and outside physicians tend to care less about speed and more their own workflows, ensuring that their own units run efficiently. This can lead to delays not just from poorly planned processes, but from different goals. Finally, EDs have many more hours in a day to transform than other health care settings: EDs run 168 hours a week, compared to 40 hours for a standard clinic. In the study by Rotteau et al., these challenges in transforming complex EDs became clear in the context of a multihospital ED throughput improvement program. In the beginning, most participants felt that their organizations lacked the structure, resources, or experience to successfully transform. This was reflected by initial cynical responses from frontline staff who had seen many prior improvement efforts fail.1 Indeed, many EDs today find themselves so challenged with the day-to-day that transformation may seem unrealistic. To enhance chances for successful transformation, team selection and make-up were critical. It was important to have representatives from both the ED and the inpatient teams and a variety of staff roles from administrators to frontline clinicians. Engaging frontline clinicians, particularly inpatient physicians, was a major challenge. However, this was overcome with the active involvement of physician leads within departments. Teams were more successful when they focused on specific outcomes and tasks, rather than having less detailed goals.1 There was a constant worry of “slippage” or an inability to sustain improvement over time as priorities changed. Ensuring accountability of leadership was seen as the most important factor when it came to sustainability. Accountability came in the form of long-term staffing of improvement team positions and, at the leadership level, explicit accountability around performance metrics. Visible and consistent support along with presence from senior management was also seen as key to success. So how can we export these principles to the new ED transformation that will likely occur as the U.S. hospitals gear up for accountable, value-based health care? It is first important to realize that ED value transformation will need to involve many more different stakeholders than flow improvement initiatives. Value transformation involves not only issues within hospitals, but also how hospitals interact with the community, which will create added complexity. Getting staff on board to change care patterns will be key, particularly in safety net hospitals that may find improving efficiency even harder than improving flow due to historical challenges in the community, such as poverty, violence, and substance use. Ensuring early and sustained leadership in the ED, hospital, and from community partners will be vital. Groups will need to come together to achieve a common mission to improve emergency care across the continuum by bolstering connections between the hospital and community. Teams need to include a variety of frontline staff who work at different times to ensure that the same mechanisms are in place during days, nights, and weekends. Improving emergency care will be about enhancing care coordination and building bridges with community physicians and other partners such as case managers, social workers, and nursing homes.4 Additionally, value transformers will need to set clear goals and targets that are achievable and under the control of frontline staff.5 While an overall goal may be to reduce ED costs, this is too far removed from staff tasks; better goals will be more specific, such as reducing hospital admission rates for specific patient populations through alternative care pathways or ensuring that the local health information exchange is queried for every patient. One successful way to enhance staff buy-in will be to develop solutions to issues salient to the everyday ED job experience. For example, frequent users programs are successful in improving efficiency and reducing care and are a real staff satisfier.6 Similar to flow interventions, efficiency interventions will also be prone to “slippage,” particularly if care coordination becomes systematically greater work to providers. The key will be to create accountability for leadership to ensure the construction and long-term functioning of clinical pathways. For example, having a clearly articulated pathway for low-risk chest pain so patients can get stress tests within 72 hours will be a satisfier not only for inpatient physicians, but also for patients who can avoid hospital stays. It will be important to ensure that ED providers have the time, resources, and systems they need to carry out new tasks. As more pressure comes to admit fewer patients and reduce practice variation,7 functioning systems will be needed to ensure that patients have their needs met outside the hospital. This will require changing ED practice patterns and building new clinical pathways in collaboration with outside stakeholders. Finally, value transformation will require investment, particularly if efforts are to be sustained. This investment will come in additional staff and systems to help coordinate care and in regular positions to closely monitor success and sustainability. The emergency care value transformation may be one of the greatest challenges to the future of U.S. hospitals. However, there is an important difference between the structure of new payment models and hospital flow interventions: aligned incentives. Properly designed payment reform will align provider, leadership, and community incentives to deliver efficient patient-centered care, where everyone will benefit from investing time in coordination, delivering seamless transitions and ensuring long-term sustainability.

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