In 2011, we took it upon ourselves to break down our patient care and examine it from the time the patient arrived (regardless of method) to the time they departed (again, regardless of method). Over the next year, we developed and implemented an end-to-end strategy of patient care and flow, where all decisions were under the scrutiny of what was deemed to be ‘patient-centric’. This process of self-improvement led us to develop a scalable, replicable template for hospitals of all shapes and sizes. Too often, patient flow hurdles and patient care problems are addressed solely through the vantage of individual departments at the expense of efficiency. Our presentation is the result of a personal, real-time experience.

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

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OBJECTIVES
• Examine common inefficiencies in care/flow during a patient's
hospitalization
• Outline the synergistic effects of aligned incentives between ED physicians and
hospitalists
• Describe a patient‐centric model that encompasses a patient's 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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ED ‐ HOSPITALIST SYNERGY
1. Initial State
2. Roadmap for Success
3. Future State

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ED ‘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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HOSPITALIST ‘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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ADMINISTRATION ‘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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SYNERGISTIC FLOW MODEL
Transfers Transfers
• SNFs
• ALFs
• Home
• Family Members
Walk‐ins DOOR TO DOOR
• Group Homes
• Shelters
• Rehabilitation
• Psych/Detox
EMS Direct Admits
Post‐Op Cases

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WHAT 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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ROAD MAP FOR SUCCESS: LARGE SCALE LEAN PROJECT
Flow Improvement in the ED: Streamline the Inflow and Outflow
Flow 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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GOALS 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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SOUTHERN 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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SOUTHERN 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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SOUTHERN 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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ASSESSMENT 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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FUTURE STATE
Redefine the culture at the hospital by implementing a process that is:
• SUSTAINABLE
• PATIENT‐CENTRIC
• ACCOUNTABLE
• RE‐ASSESSABLE

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

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QUESTIONS/DISCUSSION