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Page 1 PRESENTING: ED‐HOSPITALIST SYNERGY Presented by: Sareda Nur, MD Robert Moskowitz, MD MBAMedical Director of Hospitalist Services Medical Director of Emergency Dept Southern Hills Medical Center Mercy Hospital Nashville, TN Miami, FL

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Page 2OBJECTIVES • Examine common inefficiencies in care/flow during a patients hospitalization • Outline the synergistic effects of aligned incentives between ED physicians and hospitalists • Describe a patient‐centric model that encompasses a patients entire hospitalization • Offer our personal experiences and outcomes in assessing and integrating the Door‐to‐Door model • Offer a template for hospitals looking to increase efficiencies that are sustainable

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Page 3ED ‐ HOSPITALIST SYNERGY 1. Initial State 2. Roadmap for Success 3. Future State

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Page 4ED ‘SILO’‐ISMS 1. Sole focus on getting the patient ‘door to floor’ or ‘out the door’ 2. Define efforts in minutes 3. Quick handoffs/soft sells 4. Minimizing testing 5. ‘Faceless Voice’ syndrome 6. Ignorant of inpatient resources 7. Reactive feedback to patient care

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Page 5HOSPITALIST ‘SILO’‐ISMS 1. Defining efforts in days 2. ‘Ribbon‐on‐the‐box’ syndrome 3. Reanalyze ED workups 4. Faceless Voice syndrome 5. Ignorant of ED resources 6. Floor to Door focus 7. Dealing with Consultants

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Page 6ADMINISTRATION ‘SILO’‐ISMS 1. Departmental meeting structures 2. Information sharing between departments 3. ‘Stick to your Stethoscope’ syndrome 4. Visitation fly‐bys 5. Departmental budgeting 6. Staffing

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Page 7SYNERGISTIC FLOW MODEL Transfers Transfers • SNFs • ALFs • Home • Family MembersWalk‐ins DOOR TO DOOR • Group Homes • Shelters • Rehabilitation • Psych/Detox EMS Direct Admits Post‐Op Cases

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Page 8WHAT ARE WE MISSING? Better Understanding of: Learning to: • Terms • Allocate roles • Utilization • Share information • Resources • Reassess efforts • Comparable • Educate/Implement • Successes/Failures • Trust

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Page 9ROAD MAP FOR SUCCESS: LARGE SCALE LEAN PROJECTFlow Improvement in the ED: Streamline the Inflow and OutflowFlow Improvement House‐Wide• These can occur in parallel or overlap in the details, but they both need to occur• Requires active involvement of Hospital Administration

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Page 10GOALS OF A PATIENT‐CENTRIC SYSTEM 1. Maximizing efficiency and eliminating waste in the staffs’ routines 2. Efficient workups and dispositions 3. Streamlining admission process from the ED 4. Improving discharge processes from the floor 5. Improving transfers within the hospital 6. Improving bed management systems 7. Reassessments/feedback systems 8. Accountability 9. Tracking data

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Page 11SOUTHERN HILLS MEDICAL CENTER • Annual ED Volume 36,000K as of 5/2011 • 18 Bed ED (12 main, 6 bed Fast Track) • 132 Beds Hospital • 10% Admission Rate • Prior to 2011 ‐ Separate ED provider and Hospitalist Groups • 5/2011 ED Contract changeover • 11/2011 Hospitalist Contract changeover

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Page 12SOUTHERN HILLS MEDICAL CENTER• At outset ED struggled with: • Throughput times • LPT/LPMSE rates • (lower end of division) • Patient satisfaction• At outset Inpatient Medicine struggled with: • Permanent/Committed staff • Relationship between ED and Med Staff• Opportunity/Environment right for change

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Page 13SOUTHERN HILLS TIME LINE ED LEAN event ‐ Summer 2011 • 3 and 6 Month Goals Hospital LEAN event ‐ February 2012 • 3, 6 and 9 Month Goals Incremental improvements in • All throughput metrics • Increased patient satisfaction scores • LPT/LPMSE rate decrease (front runner in division) • Improved hospital culture and interdepartmental relations • Increased ED and EMS volume

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Page 14ASSESSMENT OF PROCESSES AND PERSONNEL • ED Director & Hospitalist Director meetings • Separate provider meetings • Combined provider meetings • Provider committee involvement • Utilization meetings • LEAN Events ‐ with all staff • Multidisciplinary Rounds • Flow Meetings ‐ • Separate department meetings with ancillary staff • Step‐down fashion after LEAN events….but they NEVER end

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Page 15FUTURE STATE Redefine the culture at the hospital by implementing a process that is: • SUSTAINABLE • PATIENT‐CENTRIC • ACCOUNTABLE • RE‐ASSESSABLE

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Page 16ROADMAP FOR SUCCESS • Not an overnight process • Constant communication and reevaluation • Continuous education • Intestinal fortitude

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Page 17QUESTIONS/DISCUSSION