Bruce Siegel

The Past, Present, and Future of Urgent Matters: Lessons Learned from a Decade of Emergency Department Flow Improvement

Over the past decade, emergency departments (ED) have encountered major challenges due to increased crowding and a greater public focus on quality measurement and quality improvement. Responding to these challenges, many EDs have worked to improve their processes and develop new and innovative models of care delivery. Urgent Matters has contributed to ED quality and patient flow improvement by working with hospitals throughout the United States. Recognizing that EDs across the country are struggling with many of the same issues, Urgent Matters-a program funded by the Robert Wood Johnson Foundation (RWJF)-has sought to identify, develop, and disseminate innovative approaches, interventions, and models to improve ED flow and quality. Using a variety of techniques, such as learning networks (collaboratives), national conferences, e-newsletters, webinars, best practices toolkits, and social media, Urgent Matters has served as a thought leader and innovator in ED quality improvement initiatives. The Urgent Matters Seven Success Factors were drawn from the early work done by program participants and propose practical guidelines for implementing and sustaining ED improvement activities. This article chronicles the history, activities, lessons learned, and future of the Urgent Matters program.

Practical Implications of Implementing Emergency Department Crowding Interventions: Summary of a Moderated Panel

Emergency department (ED) crowding continues to be a major public health problem in the United States and around the world. In June 2011, the Academic Emergency Medicine consensus conference focused on exploring interventions to alleviate ED crowding and to generate a series of research agendas on the topic. As part of the conference, a panel of leaders in the emergency care community shared their perspectives on emergency care, crowding, and some of the fundamental issues facing emergency care today. The panel participants included Drs. Bruce Siegel, Sandra Schneider, Peter Viccellio, and Randy Pilgrim. The panel was moderated by Dr. Jesse Pines. Dr. Siegels comments focused on his work on Urgent Matters, which conducted two multihospital collaboratives related to improving ED crowding and disseminating results. Dr. Schneider focused on the future of ED crowding measures, the importance of improving our understanding of ED boarding and its implications, and the need for the specialty of emergency medicine (EM) to move beyond the discussion of unnecessary visits. Dr. Viccellios comments focused on several areas, including the need for a clear message about unnecessary ED visits by the emergency care community and potential solutions to improve ED crowding. Finally, Dr. Pilgrim focused on the effect of effective leadership and management in crowding interventions and provided several examples of how these considerations directly affected the success or failure of well-constructed ED crowding interventions. This article describes each panelists comments in detail.

Enhancing work flow to reduce crowding.

INTRODUCTION Approximately one third of hospitals in the United States report increases in ambulance diversion in a given year, whereas up to half report crowded conditions in the emergency department (ED). In a recent national survey, 40% of hospital leaders viewed ED crowding as a symptom of workforce shortages. Many health systems are implementing a variety of strategies to improve flow and reduce crowding. DOMAINS OF IMPROVEMENT Virtually all work-flow initiatives use operations management techniques that include some or all of four domains: performance measurement, demand forecasting, flow redesign, and capacity management. These are often implemented using rapid improvement techniques. Most initiatives tend to focus on functional increases in inpatient capacity. IMPLICATIONS FOR PRACTICE AND POLICY Successful strategies to improve patient flow are distinguished by an organizationwide commitment to measurement, transparency in data reporting, and sustained management attention. Focusing on transitions between ED and inpatient units and maximizing overall hospital capacity appears necessary for improvement. Hence, reductions in ED crowding require strategies that go far beyond the ED. CONCLUSION Health systems can take tangible, immediate steps to improve flow and reduce crowding. Efforts would be enhanced by more controlled trials of existing strategies in the context of uniform performance measures.

Leveling the field--ensuring equity through national health care reform.

Members of racial minority groups have higher rates of disease, poorer health, and more limited access to care than their white counterparts. Dr. Bruce Siegel and Lea Nolan write that any meaningful reform must, at a minimum, confront disparities in care.

A quality improvement framework for equity in cardiovascular care: Results of a national collaborative

&NA; Disparities in the quality of cardiovascular care provided to minorities have been well documented, but less is known about the use of quality improvement methods to eliminate these disparities. Measurement is also often impeded by a lack of reliable patient demographic data. The objective of this study was to assess the ability of hospitals with large minority populations to measure and improve the care rendered to Black and Hispanic patients. The Expecting Success: Excellence in Cardiac Care project utilized the standardized collection of self‐reported patient race, ethnicity, and language data to generate stratified performance measures for cardiac care coupled with evidence‐based practice tools in a national competitively selected sample of 10 hospitals with high cardiac volumes and largely minority patient populations. Main outcomes included changes in nationally recognized measures of acute myocardial infarction and heart failure quality of care and 2 composite measures, stratified by patient demographic characteristics. Quality improved significantly at 7 of the 10 hospitals as gauged by composite measures (p < .05), and improvements exceeded those observed nationally for all hospitals. Three of 10 hospitals found racial or ethnic disparities which were eliminated in the course of the project. Clinicians and institutions were able to join the standardized collection of self‐reported patient demographic data to evidence‐based measures and quality improvement tools to improve the care of minorities and eliminate disparities in care. This framework may be replicable to ensure equity in other clinical areas.

Improving cardiovascular care through outpatient cardiac rehabilitation: an analysis of payment models that would improve quality and promote use.

Background:Much attention has been paid to improving the care of patients with cardiovascular disease by focusing attention on delivery system redesign and payment reforms that encompass the healthcare spectrum, from an acute episode to maintenance of care. However, 1 area of cardiovascular disease care that has received little attention in the advancement of quality is cardiac rehabilitation (CR), a comprehensive secondary prevention program that is significantly underused despite evidence-based guidelines that recommending its use. Purpose:The purpose of this article was to analyze the applicability of 2 payment and reimbursement models–pay-for-performance and bundled payments for episodes of care — that can promote the use of CR. Conclusions:We conclude that a payment model combining elements of both pay-for-performance and episodes of care would increase the use of CR, which would both improve quality and increase efficiency in cardiac care. Specific elements would need to be clearly defined, however, including: (a) how an episode is defined, (b) how to hold providers accountable for the care they provider, (c) how to encourage participation among CR providers, and (d) how to determine an equitable distribution of payment. Clinical Implications:Demonstrations testing new payment models must be implemented to generate empirical evidence that a melded pay-for-performance and episode-based care payment model will improve quality and efficiency.

Assumed equity: Early observations from the first Hospital Disparities Collaborative

&NA; Disparities in healthcare represent a failure in the equity domain of quality. Although disparities have been well documented, little has been written about how hospitals might use improved data collection and quality improvement techniques to eliminate disparities. This article describes early findings from the planning phase of the first hospital‐based disparities collaborative. The authors also discuss the changes in policy and practice that may speed hospitals in placing disparities and equity on their quality agendas.

Health Reform and the Safety Net: Big Opportunities: Major Risks

Bruce Siegel Marsha Regenstein Peter Shin illions ofAmericans are dependent on what is often called the “safety net.” These loosely-organized networks of health M and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care. The Institute of Medicine (IOM) repo*AmeriCa’s Health CaTe Safety Net: Intact but E&ngeTed, called attention to both the fragility and the resilience of this health care safety net.’ The IOM report underscored the critical importance of the safety net to the health and well-being of millions of individuals and called for efforts to strengthen it and improve the nation’s ability to monitor its viability? Given this central role, any health care reform efforts need to be fully informed by an understanding of what the safety net includes, how it is financed, and how it is responding to a series of challenges it now faces. They also must consider the nature of the role of the health care safety net in radical health care reform, like universal coverage. As this article discusses, universal coverage would change, not eliminate, the need for the safety net. It may offer opportunities for these providers to better meet their core missions, but such reform potentially poses major risks as well.

Measuring healthcare disparities and racial segregation in Missouri nursing homes.

&NA; Measuring and, ultimately, addressing disparities in long‐term care quality continue to be a challenge. Although literature suggests that disparities in healthcare quality exist and nursing homes remain relatively segregated, healthcare professionals and policymakers stand to benefit from improvements in measuring both racial segregation and healthcare disparities. This paper quantifies the relationships between healthcare disparities and racial segregation using the disparities quality index and dissimilarity index. Results suggested that the more segregated the nursing homes, the greater the observed disparities. Multivariate regression analysis indicated that the proportion of Black residents in nursing homes is the variable that best predicts disparities.

Interventions to Provide More Equitable Health Care: Emerging Evidence and Next Steps

Multiple studies have shown that racial and ethnic minorities often experience lower quality of health care when compared with white patients (Institute of Medicine [IOM], 2002). Even after taking into account various factors like differences in access to care and disease severity, racial and ethnic disparities in care remain, and are often associated with worse health outcomes (IOM; Mead et al., 2008).