Organization and Management of the Emergency Room of a Hospital

Organization and Management of the
Emergency Department of a Hospital
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
March 1, 2018

Greetings and Salutations
From
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

All hospitals must have an emergency
department.
(Levels 1 to 3 Hospitals – DOH AO 2012-0012)

Nomenclature
EMERGENCY
Emergency Department – Emergency Room –
Emergency Center – Accident and Emergency

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Department Design and Development Framework
Regular Performance Evaluation and Continual Improvement Program
Administrative Design and Development Program
Architectural Design / Engineering / Construction
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care Services
Cost-efficient
/ Value-based
Services
Maximal
Utilization of
Services

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Emergency Department Design and Development Framework
Regular Performance Evaluation and Continual Improvement Program
Administrative Design and Development Program
Architectural Design / Engineering / Construction
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care Services
Cost-efficient
/ Value-based
Services
Maximal
Utilization of
Services

Emergency Department (ED)
Purpose of ED
A facility in the hospital that is put up to cater to
patients needing and seeking emergency medical
services without prior appointment 24/7.
Emergency medical services = immediate
attention and management for patients with
serious medical conditions (serious - by medical
and layman’s perceptions)

Purpose of ED
A facility in the hospital that is put up to cater to patients
needing and seeking emergency medical services without
prior appointment 24/7.
General Functions (Authorized) of ED
Cater to patients consulting and brought to ED needing and seeking
emergency medical services without prior appointment 24/7.
Provide emergency medical services to patients consulting and
brought to ED without prior appointment 24/7.
Specific Functions (Authorized) of ED

Provide emergency medical services to patients consulting
and going to ED without prior appointment 24/7.
• To provide emergency medical services 24/7 to the
following patients consulting or brought to the ED:
1. Traumatic and non-traumatic patients
2. Victims of mass casualty incidents
3. Patients who perceive they have serious medical
conditions

• To provide the following general emergency medical
services to patients consulting or brought to the ED:
1. Cardiopulmonary resuscitative measures to patients with
life-threatening medical conditions
2. Medical examination and assessment
3. Medical treatment within the limits of the ED
4. Referral to appropriate physicians for follow-up or
definitive management after being seen in the ED

• To provide a system of triaging and response during
patient surges particularly from mass casualty incidents.
• To provide a system of triaging to identify patients who
need to be placed in special areas (such as isolation rooms
and decontamination rooms) and who need to be
transferred to another hospital for one reason or another.
• To network with emergency departments of nearby
hospitals particularly during mass casualty incidents.
• To network with other hospitals for transfer of patients
who cannot be admitted into the ED or hospital.

Purpose, General Functions, Specific Functions of ED
Quality Control
Congruent / Compliant with expectations (implied or
expressed) of
• Community
• Department of Health
• PhilHealth Benchbook
• International standards (JCI, ACI, others)
• Owners
Provide documentary evidences.

Purpose, General Functions,
Specific Functions of ED
Emergency Medical Services
24/7
For Traumatic and non-traumatic
patients; victims of mass casualty
incidents; patients who perceive
they have serious medical
conditions
Resuscitation measures
Medical assessment
Medical treatment
Referral
Management of patient
surge
Triaging with special areas
Networking with other
hospitals
Services to Provide
Emergency medical
services 24/7
• For specified types of
patients
• Resuscitation
• Medical assessment
• Medical treatment
• Referral
• Management of
patient surge
• Triaging with special
areas
• Networking with
other hospitals

Services to Provide
Emergency medical services
24/7
patients
• Resuscitation
• Referral
• Management of patient
surge
• Triaging with special areas
• Networking with other
hospitals
Goal:
Integrated value-based services at ED
Services that improve health care outcomes
per unit cost of care through integrated
management systems
Use of integrated management systems to
create value in the delivery of health care
services
Examples of Integrated Management
Systems (within ED and with whole hospital
system)
Quality Management System
Risk Management System
Financial Management System
Records Management System
IT system
Training Program

Integrated Value-based Healthcare Services
For every healthcare service rendered, on the part of the
patient-clients,
there is a perceived value for the money spent.
Cost of the service may be the running rate or higher.
However, as much as possible, efforts must be exerted to
bring the cost down to
reasonable and acceptable level to both the clients and
healthcare service providers.
Value is usually defined as
health outcomes over cost of delivery of the outcomes.

The adjective “integrated” is used to
emphasize the
need for optimal integration among the
different healthcare services and providers
so as to produce excellent health outcomes
within reasonable and acceptable cost.

Integrated value-based healthcare services are
expected to lead to patient-clients’ delight.
With patient-clients’ delights, the hospital will be
more attractive to the community.
Being more attractive, the hospital will have more
patient-clients’ seeking its services which in turn will
promote sustainability of the hospital.

Services to Provide
24/7
patients
• Resuscitation
• Referral
surge
hospitals
Goal:
management systems
Services of Value to Clients
Prompt services
Effective services
Efficient services
Cost-effective services
Client delight
Maximal utilization of ED services
ED Sustainability

Key Performance Indicators
Financial Viability and Sustainability
Positive net income with at least an acceptable
operating margin every year
Maximal Utilization of Existing Services
(maximal number of patients / number of
procedures that can be maximally done in ED in a
year)

Excellent Clinical Outcomes of Patients Served
(excellent treatment results; lowest possible
adverse event rate per year)
Overall and by type of medical condition
Excellent Turn-around Time for Patients Served

Excellent Patient-Client Feedback
Amount of returning (patronizing) patients per
year
Amount of patients expressing delight
Amount of patients complaining
Amount of medicolegal suits

Services to Provide
24/7
patients
• Resuscitation
• Referral
surge
hospitals
Goal:
Policies and
Procedures
Clinical Practice
Guidelines
Clinical Pathways
Service Pathways
Services of
Value to Clients
Prompt services
Effective services
Efficient services
Cost-effective
services
Client delight
Maximal utilization
of ED services
ED Sustainability

ED integrated throughputs
• Equipment and material
• Human resource
• Data, documents, records program
• IT-enabled system
• Business development program
• Risk management program
• Physical structure
• DOH licensing & structural
requirements
• Architectural design, engineering,
and construction
• Budget program
Purpose, General
Functions, Specific
Functions of ED
Services to Provide
Goal:
Policies and
Procedures
Clinical Practice
Guidelines
Clinical Pathways
Service Pathways
Services of
Value to Clients
Prompt services
Effective services
Efficient services
Cost-effective
services
Client delight
Maximal utilization
of ED services
ED Sustainability
Hospital concept and design;
governance - operations policies and
procedures
Interfacing units operations policies
and procedures

ED integrated throughputs
• Equipment and material
• Human resource
• Data, documents, records program
• IT-enabled system
• Business development program
• Risk management program
• Physical structure
• DOH licensing & structural
requirements
• Architectural design, engineering,
and construction
• Budget program
Purpose, General
Functions, Specific
Functions of ED
Services to Provide
Goal:
Policies and
Procedures
Clinical Practice
Guidelines
Clinical Pathways
Service Pathways
Services of
Value to Clients
Prompt services
Effective services
Efficient services
Cost-effective
services
Client delight
Maximal utilization
of ED services
ED Sustainability
Hospital concept and design;
governance - operations policies and
procedures
Interfacing units operations policies
and procedures
Develop and
provide
documents –
design and
development
plans; licenses;
records; etc.

Policies and Procedures
Policies and Procedures for Clients
Policies and Procedures for Staff
• Communicated
• Oriented
• Educated
• Implemented

Manual of
for Staff

Manual of Policies and Procedures
Importance
•Guide for present and future staff
•Promotes effectiveness and efficiency
Should be reviewed and revised periodically

Manual of Policies and Procedures
• Service
• Training
• Research
• Governance

• Emergency Medical Services at ED
• Referrals (Internal / External)
• Account Settlement
• Deposit
• Triaging
• Emerging and Re-emerging Infectious Diseases
• Patient Surge Situations
• DOA
• DNR
• Firearms
• Others

Pertinent Statutes and Administrative
(Regulatory) Orders
• Deposit
• Emerging and Re-emerging Infectious Diseases
• Reporting of Reportable Diseases

ER – DOH Standards
Department of Emergency Medicine
Tertiary care hospitals shall be given until 2010 to
comply with this requirement.
If the hospital has no Department of Emergency
Medicine, it must have an Emergency Service.

Clinical Practice Guidelines
on common (initially) and all medical conditions
encountered in ED
• Stroke
• Heart attack
• Trauma
• Cardiopulmonary Resuscitation
• Asthma
• Others

Clinical Pathways
on common (key) medical conditions encountered
in ED
• Stroke
• Heart attack
• Trauma
• Cardiopulmonary Resuscitation
• Appendicitis
• Others

Service Pathways
• Account settlement
• Referral to other hospitals
• Others

The Medical Referral System
Only immediate medical treatment
that can be rendered within the
limits of the ED setup are
administered.

Most patients will be needing
follow-up or further treatment.

Contributes to effective and
efficient achievement of
objectives of ED

Equipment and Materials
Needed to provide effective and safe, efficient,
and prompt services in ED
See Services to Provide
See Policies and Procedures, Clinical Practice
Guidelines, Clinical Pathways, Service Pathways

Equipment and Materials
In consideration of the key functions and services
of the unit, statutory and regulatory
requirements, and other objectives like business
development, risk management, and IT-enabled
system ,
identify equipment and materials needed to
facilitate an effective and efficient functioning of
the ED.

Equipment
Equipment should have preventive maintenance
and calibration at planned intervals to ensure
accuracy and safety in their use and longer life
span.

Equipment
and
Facilities

Equipment and Facilities
Based on objectives, minimum essential
- cardiopulmonary resuscitation
- those needed to resuscitate and
stabilize patients with life-threatening
conditions before a more definitive
treatment can be done within the
hospital proper.

General Determining Factors:
•government regulations
•needs and expectations of the community
•allowance for future expansion -
anticipated increase in patient load
and new trends in ED medicine
•cost-benefit considerations

•Effective and of high quality
•Efficient in carrying out objectives of ED
-Stored in cabinets with proper labeling
-Always available when needed
-Convenient to use by personnel

•Airway adjuncts
•Breathing adjuncts
•Electrocardiographic equipment
•Emergency drugs and IV fluids
•Surgical equipment and supplies

•Obstetrical equipment and supplies
•Diagnostic equipment and facilities
•Record system
•Transport system
•Telecommunication system

• At least one ambulance
- extension of the ED
- fully equipped with at least basic and
advanced life support system

Human Resource Requirements
• Physicians
• Nurses
• Nursing Aides
• Clerks
• Security guards
• Driver of ambulance
• Others
Adequate in number and in competency

Medical Staffing
•By Interns
•By Residents
•By Consultants
•By Physicians hired by the hospital

Pattern of medical staffing is dependent
on:
1. Presence of trainees
2. Willingness of consultants to go on duty
3. Economic feasibility and viability of
employing MDs to man the ED
4. Consent of medical staff and
administration

Whatever be the pattern of medical
staffing
there should be adequate coverage by
competent physicians who are
physically present in the ED and who
are supported by medical staff with full
clarification of all professional, legal,
and financial implications.

Who should man the ED?
•Any full-pledged MD will do as long as
he knows what he is supposed to do
However, the best person will be an
emergency room specialist.

The
Emergency Department Officer
A physician who has a license to practice
medicine and who mans the ED

The
Emergency Department Officer
Five general functions:
•Administrator
•Physician
•Medicolegal Officer
•Trainor
•Patient Surge Incident Commander

The
Emergency Department Director
Five competencies expected:
• Administration
• Emergency Medicine
• Health Profession Education
• Research
• Risk and Disaster Management

Data, Documents and Records Program
In consideration of the key functions and services
of the unit, statutory and regulatory
requirements, and other objectives like business
development, risk management, and IT-enabled
system ,
identify the data, documents, and records
needed to facilitate an effective and efficient
functioning of the ED.

IT-enabled System
Use of computing technology, such as hardware,
software, networking, and Internet
•to promote efficiency in performance of
functions and accomplishment of services ;
•to manage information of unit – getting, storing,
protecting, processing, transmitting as necessary,
and later retrieving as necessary;

IT-enabled System
Use of computing technology, such as hardware,
software, networking, and Internet
•to create interconnection with other units in
hospital for timely communication, coordination
and collaboration in accomplishment of services
of unit;
•to communicate with the patient- and physician-
clients both in and out of hospital.

Business Development Program
Presence of a structured and comprehensive
program that will develop the business of unit to
make it viable and sustainable!

The objective of program is to attract new patient-
clients and maintaining previous patient-client
base.
Another objective of program is to attract new
physician-clients and maintaining previous
physician-client base.

Strategies:
Marketing
Public Relations
Reputation Enhancement
Attractive to patient-clients and physician-clients
to utilize services of ED!

Risk Management
Risk management program is a planned and
systematic process / program
to reduce and/or eliminate the probability of a
“risk”
that usually results in injuries, losses, and legal
suits.

Risk Management
It consists of three distinct, yet interrelated areas:
• risk identification and loss prevention;
• loss reduction;
• risk financing.

Risk Management
Risk Identification
Types / Categories of Risks in ED
• Risk for natural disasters (earthquake, flood, tsunamis,
fire, etc.)
• Risk for man-made disasters (fire, felony, bomb threat,
terrorism, etc.)
• Risk for medico-legal suits (arising from patient care)
• Risk for non-medico-legal suits (not arising from patient
care)
• Risk for tarnished reputation

Architectural Design, Engineering, and Construction /
Physical Structure
DOH Licensing Requirements
DOH Guidelines in the Planning and Design of a
Hospital And Other Health Facilities – 2004
Safe Hospital Initiative – structural, non-structural,
and functional indicators
Building Code
Fire Code
Local government requirements
Others

Architectural Design, Engineering, and
Construction / Physical Structure
Physical structure of a unit refers to a geographical
space or area in the hospital, constructed to
receive patient- and physician-clients requesting
for services and to house the staff who will
perform the functions of the unit.

Architectural Design, Engineering, and Construction / Physical Structure
Determinants:
Statutory and regulatory requirements
DOH Licensing Requirements
DOH Guidelines in the Planning and Design of a Hospital And Other
Health Facilities – 2004
Safe Hospital Initiative – structural, non-structural, and functional
indicators / Building Code / Fire Code
Local government requirements / SPECIALTY requirements
Business development program
Quality Standards
Community expectations
Efficiency
Case load
Owners’ wants

Physical Structure
Indicators:
• Compliant with DOH and other requirements–
particularly on location and size
• Accessibility – with clear signage
• Adequate size (not cramped for staff and client
movement)
• Adequate lighting
• Adequate ventilation
• Aesthetics – attractive, with a welcoming, friendly and
therapeutic environment
• Provision for privacy as needed
• Comfortable waiting areas

The Location
•Accessible to the public
Not deeply situated inside the hospital
• Adequate road signs and signboards

The Location
•near supportive departments such as labs
and radiology
• where hospital routines will NOT be
disrupted when there is a sudden and
great inflow of patients to the ED

The Size
Can adequately house
• essential equipment, facilities, and personnel
for it to function effectively and efficiently
• usual number of patients coming in at any
given time for consultation and treatment

Physical Structure
The Size

Physical Structure
The Architectural Design
•Must be guided by how an effective and
efficient function can be maximally
achieved.
•Must consider
equipment personnel
functional areas patients
facilities

OB & Pedia
Area
Conference
Room
Sink
Cardiac
Area
Trauma
Area
EmergencyMeds.
Info/Reception
Coffee
Area

Treatment
Areas
Entrance
Triage Counter
Reception
Monitoring Center
Treatment
Areas
Treatment Areas
Treatment
Areas

Some Tips
Entrance must be of a size that can
accommodate a standard stretcher
bed.

Some Tips
Curtains or varifolds are recommended
for cubicle dividers.
To give a larger space when
needed

Some Tips
Stretcher-beds are preferred over
stationary examining tables and
standard hospital beds.
For mobility and flexibility

Some Tips
Piped-in gases and suction contribute
to convenience and efficiency.

Budget Program
Objectives:
•To project future income and expenses of the
unit which are reflected in a document (budget).
•To use projected future income and expenses of
the unit (budget) as guide for day-to-day
performance and financial evaluation at planned
intervals.

Budget Program
Expected Outputs:
•Achievement of financial targets
•Effective and efficient utilization of resources
•Controlled expenses

Budget Program
Processes / Procedures:
• Formulate a structured business plan for the
forthcoming year inclusive of new and existing
programs / projects /activities, staff
requirements, equipment and materials,
renovation, etc.
• Quantitate / project income (if any) and
expenses in pesos

Budget Program
Processes / Procedures:
• Prepare document that contains the two
abovementioned processes which is designated
as “budget” of the unit
• Have the budget approved by an office in
charge of hospital budget

Regular Performance Evaluation and Continual
Improvement Program
Appraising extent of accomplishment of the unit
in its authorized functions and business plans at
planned intervals (quarterly, biannually, and
annual).
To determine areas of improvement and to act on
them.

Improvement Program
At the start, must have performance measures,
performance indicators, and targets, which must
be measurable and realistic.
Use of “balanced scorecard” – financial, customer,
process, and learning and growth perspectives

Improvement Program
Always and forever looking for ways to improve
something in the system, with details on what
work is to be done, by whom, when, and what
means or resources will be used.

Improvement Program
As a commitment to excellence.
Minimum of one new structured continual
improvement project per year.
Can have a duration of 1-3 years for total completion
and institutionalization. A 2- to 3-year project should
be broken down into annual milestones.

Services to Provide
24/7
For specified types of patients
Resuscitation
Medical assessment
Medical treatment
Referral
Management of patient surge
hospitals
Goal:
management systems
Services of Value to Clients
Prompt services
Effective services
Efficient services
Cost-effective services
Client delight
Maximal utilization of ED services
ED Sustainability
Regular
Performance
Evaluation and
Continual
Improvement

Services to Provide
24/7
For specified types of patients
Resuscitation
Medical assessment
Medical treatment
Referral
Management of patient surge
hospitals
Goal:
Policies and
Procedures
Clinical Practice
Guidelines
Clinical Pathways
Service Pathways
Services of
Value to Clients
Prompt services
Effective services
Efficient services
Cost-effective
services
Client delight
Maximal utilization
of ED services
ED Sustainability
Regular
Performance
Evaluation and
Continual
Improvement

Excellent Clinical Outcomes of Patients Served
(lowest possible adverse event rate per year)
Excellent Turn-around Time for Patients Served

Common Problems
Categories Common Problems Suggested
Strategies
MAN
Consultants
Residents
Colleagues in other
units
Chief of Hospital /
bosses
Competencies
Quantity
Integration,
coordination,
collaboration
Personality
Leadership and
managership
Investor in People
Standards
Managing your boss
Use of a multisectoral /
multi-professional
committee
memberships

Common Problems
Categories Common Problems Suggested Strategies
SYSTEM AND
METHOD
Lack of
systematization
Lack of standardized
procedures
Use DOH
requirements
Use quality standards
(PhilHealth
Benchbook, JCI, ACI)
Policies and
procedures
Clinical practice
guidelines
Clinical pathways

Common Problems
Categories Common Problems Suggested
Strategies
MACHINE /
EQUIPMENT
Lack of
management
system
Lack of calibration
Lack of preventive
maintenance
Policies and
procedures
MONEY
Other resources
Limited Leadership
Innovativeness

Common Problems
Categories Common
Problems
Suggested Strategies
TRENDS Rapid changes -
difficulty in coping
Knowledge
management system
(constant tracking and
continual education)
Benchmarking
Innovativeness

The Trends

The Trends
Types of Patients
Any person with whatever medical
problem who walks into or is brought
to the ED should be served.

The Trends
Types of Patients
Do not discriminate anymore whether
the patient has real emergencies or not.
Assume all patients in ED have an
emergency problem.

The Trends
Emergency department medicine is
already established as a specialty.

The Trends
The most qualified emergency room
physician will be a graduate of a
training program in emergency
room medicine.

Welcome Feedback and Queries
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

Organization and Management of the Emergency Room of a Hospital

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