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

2. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only. 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 EDs overwhelmed: 62% of hospitals report being at or over capacity (Lewin 2002) EDs 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)

3. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

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. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only. 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. Josephs 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. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only. Urgent Matters Input/Throughput/Output Model

7. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only. 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. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only. 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

9. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.

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

17. Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only. Closing Thoughts: Policy Do We Really Need All These New EDs? 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