The Nature and Necessity of Operational Flexibility in the Emergency Department

Ward, Michael J.; Ferrand, Yann; Laker, Lauren F.; Froehle, Craig M.; Vogus, Timothy J.; Dittus, Robert S.; Kripalani, Sunil; Pines, Jesse M.

doi:10.1016/j.annemergmed.2014.08.014

Cited by 37 publications

(21 citation statements)

References 23 publications

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“…Researchers from disciplines as varied as Emergency Medicine, OM, Accounting and Strategy have recently examined ED operations from multiple perspectives. Ward et al (2015) address the tension between cost and flexibility in the ED. They draw on operations research and organizational theory to describe five forms of flexibility: physical, human resource, volume, behavioral, and conceptual.…”

Section: Academic Viewmentioning

confidence: 99%

Strategic Management of Operations in the Emergency Department

Venkat

Kekre

Hegde

et al. 2015

Production and Operations Management

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T his study is based on the analysis of field data on the revenues and patient flows that we collected on all adult emergency department (ED) visits to a level-1 trauma, tertiary referral center. Our objective was to provide researchers in operations a rich overview of the processes, resources, and metrics of financial and operations performance in the ED. We analyze how patients, physicians, hospitals/physician employer groups, and payers are party to the value created and financial workflow of the ED. A waterfall model for professional services revenue is developed that highlights the impacts of changes in processes, resources, scale, complexity, and mix of patients treated in the ED. We also discuss future implications of new compensation models and potential scenarios that will focus upon controlling costs while maximizing population health and patient satisfaction. These models will necessitate re-engineering of operations in the ED from a strategic perspective. Four major thrusts for selecting the capacity portfolio in the ED operations to align the interests of all the stakeholders are recommended. New avenues for research are also identified.

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Section: Academic Viewmentioning

confidence: 99%

Strategic Management of Operations in the Emergency Department

Venkat

Kekre

Hegde

et al. 2015

Production and Operations Management

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“…Multiple strategies hold promise. For example, activating EMS transportation prior to PCI center activation, 24 using the 911 system to transfer patients, 25 using operations research tools to enhance the operational flexibility of the ED, 26,27 enhancing regionalization efforts to reduce EMS response times, 28,29 standardizing the initial interaction with EMS (eg, patient staying on the stretcher), 24 enhancing hospital-EMS relationships, 22 and appropriate use of ground-based (rather than helicopter) EMS. 19,20 …”

Section: Discussionmentioning

confidence: 99%

Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction

Ward

Kripalani

Storrow

et al. 2015

The American Journal of Emergency Medicine

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Objectives Most U.S. hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion and referring EDs are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs. Methods We retrospectively analyzed a secondary dataset used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), time periods that comprised DIDO (door-to-EKG, EKG-to-PCI activation, and PCI activation-to-exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval). Results We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (IQR 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was comprised of: door-to-EKG 5 minutes (IQR 2,11), EKG-to-PCI activation 18 minutes (IQR 7,37), and PCI activation-to-exit 44 minutes (IQR 34,56). DIDO accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability=1.37) of these intervals. Conclusions In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision-making and transportation coordination following PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI.

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“…We found that there is an increased reliance upon part-time emergency physicians to provide clinical care. While human resource flexibility can be an important operational strategy to respond to the changing operational demands of the ED, 13 they receive little training, and may have less experience and familiarity with a facility’s operational policies, culture and practice. 14,15 Temporary ED staff have also been found to affect patient safety in the ED.…”

Section: Discussionmentioning

confidence: 99%

Emergency medicine in the Veterans Health Administration—results from a nationwide survey

Ward

Collins

Pines

et al. 2015

The American Journal of Emergency Medicine

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Study Objective We describe emergency physician staffing, capabilities, and academic practices in U.S. Veterans Health Administration (VHA) EDs. Methods As part of an ongoing process improvement effort for the VHA emergency care system, VHA-wide surveys are conducted among ED medical directors every three years. Web-based surveys of VHA ED directors were conducted in 2013 on clinical operations and academic program development. We describe the results from the 2013 survey. When available, we compare responses with the previously administered survey from 2010. Results A total of 118 of 118 ED directors filled out the survey in 2013 (100% response rate). Respondents reported that 45.5% of VHA emergency physicians are board-certified in emergency medicine and 95% spend the majority of their time in direct patient care. Clinical care is also provided by part-time (<0.5 full-time employee equivalent) emergency physicians in 59.3% of EDs. More than half of EDs (57%) provide on-site tissue plasminogen activator (tPA) for acute ischemic stroke patients and only 39% can administer tPA 24/7. Less than half (48.3%) of EDs have emergency OB/GYN consultation availability. Most VHA EDs (78.8%) have a university affiliation but only 21.5% participated in the respective academic emergency medicine program. Conclusions VHA emergency physicians have primarily clinical responsibilities, and less-than-half have formal emergency medicine board-certification. Despite the majority of VHA EDs having university affiliations, traditional academic activities (e.g., teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women’s health.

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The Nature and Necessity of Operational Flexibility in the Emergency Department

Cited by 37 publications

References 23 publications

Strategic Management of Operations in the Emergency Department

Strategic Management of Operations in the Emergency Department

Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction

Emergency medicine in the Veterans Health Administration—results from a nationwide survey

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