1. Genesis Cup
Recognizing Innovation in the ED
ED OPTIMIZATION
MODEL
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

2. 2
COMMUNITY HOSPITAL SOUTH
Indianapolis, Indiana
Over 40,000 annual E.D. visits
• Community Health Network - a leading not-for-
profit health system in Indianapolis, Indiana
• Community Hospital South (CHS) - serves the
south side of Indianapolis and Johnson County
• June 1, 2012 the journey began…
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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3
THE CHALLENGE
OF INSTITUTIONAL CHANGE
Need to improve the overall quality of care and patient
metrics of the emergency department
Desire for increased patient volume
Epic EMR roll-out set for August 2012
Previous E.D. physician group unable to attain the
ambitious goals of hospital administration
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

4. 4
NEED TO SUCCEED
Improvements to E.D. dynamics and
overall efficiency were expected and
they needed to happen fast.
Expert vision and strategy was required
to drive these changes and
to optimize patient care quality.
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

5. 5
NEED TO SUCCEED
• Expert operational assistance
• Strong practice management
• Recruiting and retention of excellent providers
• Utilization of extensive resources
• Partnership with CHS leadership
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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6
IN THIS NEED TO SUCCEED
Expert execution,
support
and results
Expertise were delivered. Delivered
Execution Results
Support
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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STRATEGY AND IMPLEMENTATION
EmCare utilized a top down approach designing
and implementing a whole new E.D. culture
Step 1
Step 2
Integration of a
strong E.D. Step 3
Identification and
Chairman and retention of Collaboration with
retention of the providers capable nursing leadership
existing Site of thriving under and hospital
Medical Director the new EmCare administration to
model improve the
department
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
Andy Mulvey MD, FACEP
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
Strong Physician leadership
 Create a vision for the E.D. and stay the course
 Enable key players to ensure success is achieved
 Great leaders foster the success in others
 Establish partnership with nursing leadership
Institute an E.D. culture of success
 Patient centered care highest priority
 Teamwork and competitive environment
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
• Implement a patient focused E.D. staffing
model wherein excellent, efficient care is the
gold standard
• Improve staff teamwork and physician-nurse
collaboration
• Optimize physician-patient interactions
• Optimize utilization of physicians, mid levels and
scribes
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
So what is
The Secret Sauce?
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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RESULTS MATTER
• The Secret Sauce is all about your leadership and
quest for excellence
• When you lead by example, the other pieces fall into
place
• Strong leadership is willing to fight for what is right
• Strong leadership doesn’t always make new friendships
• Successful leadership upholds patient advocacy
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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IT ALL STARTS WITH THE DETAILS…
Continuous analysis and improvement
of all E.D. dynamics.
All decisions are data driven.
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
Patient throughput is the key metric:
• Neither triage nor the E.D. is static - your patient
care should not be either
• Bedside triage and registration implemented
• Patient care is seamless and coordinated
• Patient care is not linear, multiple things can
happen at the same time
• Anticipating and being prepared for all
possibilities enhances delivery of care
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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PATIENT TO PROVIDER STAFFING IS
CRITICAL
• Ensure that physicians are doing physician level
work
• Appropriate patient to provider staffing ratios
established based on acuity and care needed
• Provider staffing adjusted to volume and acuity
trends
• Physician and MLP team at patient bedside is
enhanced
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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PATIENT TO PROVIDER STAFFING IS
CRITICAL
• Appropriate use of mid level providers for lower
acuity and time consuming procedural work
• Use of scribes to manage secretarial work and
promote MD efficiency
• EmCare office support to reduce non-clinical
burden
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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PATIENT TO PROVIDER STAFFING IS
CRITICAL
6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12am 1am 2am 3am 4am 5am
Physician with Scribe
Physician with Scribe
Physician with Scribe
Physician with Scribe
Mid-level
Mid-level
Mid-level - Fast Track
Mid-level NEW SHIFT
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED EFFICIENCY
• Team nursing implemented to further expedite
patient care
• E.D. teamwork promoted
• “Yes we can” attitude upheld (Disney model)
• Fierce drive to be better than the competition
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED EFFICIENCY
• Departmental interdependency, not silo mentality
• Ancillary partnerships and teamwork
• Recognize that the E.D. is heavily dependent on
efficient ancillary operations
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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DISPOSITION, DISPOSITION,
DISPOSITION
Reduce LOS
• Concentration on disposition, not diagnosis
• Hospitalist interface, RAP&GO
• Stream line admission process
Emergentology
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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IMPROVE CARE TO THE
COMMUNITY
• Excellent, efficient care to become the
expectation
• ED Leaders to uphold no patients leave without
being seen
• “Express Care” marketed to public
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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IMPROVE CARE TO THE
COMMUNITY
EMS relationships are extremely valuable
• EMS control and education expanded
• Engaged medics in team approach to patient care
• Established place for EMS within E.D.
• Teambuilding events for EMS and E.D. staff
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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OPERATIONAL RESULTS
Results
Driven
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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RESULTS
Strong leadership and
operational expertise paid off
with significant metric
improvements in less than
six months.
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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RESULTS
Left Without Being Seen Rates
Dropped from 3.8 percent to 0.24 percent
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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RESULTS
Average E.D. Length of Stay
Improved from 351 minutes to 281 minutes
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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HCAHPS AND PATIENT SATISFACTION
SCORES ARE RAPIDLY IMPROVING
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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OPTIMIZATION EQUATION
Patient
Arrivals + Acuity
Physician
Factor for
Staffing
ED LOS, RAP&GO Superior nursing care Model
Bedside Triage Administrative support
Ancillary services Operational efficiency
Scribes
Mid-levels
Continual Adjustments
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
Unwavering
leadership
Fight for what
Obsession
with the
is right
operational Physician Patient Patient
details
Develop centered care
dynamic
nursing and
ED team
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
So back to The Secret Sauce,
is that it?
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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A FEW MORE INGREDIENTS
TO THE SECRET SAUCE…
• Data driven decisions never end
• Recruitment for the best talent never ends
• Provider satisfaction is paramount to retain the best
talent
 EmCare established provider contracts with incentives/
“skin in the game”
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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A FEW MORE INGREDIENTS
TO THE SECRET SAUCE…
• Eliminate the bottom 10% of low-performers annually
• Continuous documentation education is critical to
decrease risk and capture billables
• Stay aligned with hospital leadership and their goals
• Epic EMR was implemented with success - “Planned
Internal Disaster”
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
Remember that culture of excellence?
It was developed.
• Studer presentations, 1:1 provider coaching
• Endless ED improvement meetings and brainstorming
events
• Engaging staff in Best Practice and Lean methodologies
• Team building events
• Outreach events events to all hospital departments,
supporting specialties and our patient population
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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ED OPTIMIZATION MODEL
In this journey of success,
we “optimized” when our team unified
in providing the best care for our patients.
The “ED Optimization Model” provides
the framework and leadership
to make that happen.
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.

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QUESTIONS?
Andy Mulvey, MD, FACEP
cell: 317-850-0236
email: awmmdp@yahoo.com
Richele Wright MSN, FNP, BC
cell: 469-236-5361
email: richele.wright@emcare.com
© 4/2013 Andy Mulvey, MD, FACEP. All rights reserved.