Improving the Performance of the Safety Net:
Findings of the Urgent Matters Project
Bruce Siegel MD MPH, Marcia Wilson MBA,
Khoa Nguyen MPH, Marsha Regenstein PhD
Academy Health
June 6, 2004
Program Origins: RWJF Surveys the
Landscape
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2000 IOM report on the safety net
 The safety net is “Intact but endangered”
 Report recommends we monitor and assess local safety nets
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Drumbeat of media coverage: Overwhelmed EDs
with diversion and long waits
 ED’s overwhelmed: 62% of hospitals report being “at” or “over
capacity” (Lewin 2002)
 ED’s as the “safety net for the safety net”
 Take all comers, by custom and law - EMTALA
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ED Volume Rising While Number of EDs Shrinks
 1992-2002: Annual ED visits up 23%, Number of EDs down 15%
(CDC 2004)
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Selection Process
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Applications solicited from all public/not-forprofit level I and II trauma centers in US.
 2/3, or 287 submit detailed on-line letter of intent
10 selected as grantees
 Criteria:
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Evidence of crowding
ED volume, market share
Payer mix
Track record in achieving and sustaining change
Senior leadership commitment
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
The 10 Hospital Learning Network
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Grady Health System – Atlanta, GA
Boston Medical Center – Boston, MA
Henry Ford Hospital – Detroit, MI
Inova Fairfax Hospital – Fairfax County, VA
BryanLGH Medical Center – Lincoln, NE
The Regional Medical Center at Memphis – Memphis,
TN
St. Joseph’s Hospital and Medical Center – Phoenix, AZ
Elmhurst Hospital Center – Queens, NY
University Health System – San Antonio, TX
University of California at San Diego – San Diego, CA
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Urgent Matters Input/Throughput/Output Model
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Learning Network Elements
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Tool kit of best practices on patient flow
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Data collection methods
Strategies for work flow re-design
Organizational buy-in strategies
Implementation strategies
Training and Reinforcement on Rapid Cycle Change
 Plan, Do, Study, Act
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Core Metrics
 17 key performance indicators (weekly and monthly
reporting)
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Learning Network Structure
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Web-based management
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Tool kit, new developments and other resources
Action plans and data submission
Run-charts
Monthly project reports
“Celebrating Success”
Shared data – shared outcomes
Peer Collaboration
 3 group meetings
 3 consultant site visits to each site, with phone consultation
 Monthly conference calls with topic presentation, update
from each site
 Listserv
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Closing Thoughts: Operations
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It’s The Hospital, Stupid!!
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Rapid Cycle Change: Rapid Is Key
 Early Results More Important Than Consensus
 Communications are critical
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Data Systems Lag
 But it’s doable
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Executive Management Buy-In Is Key
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Collaboration? Or Competition?
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Productivity May Increase Dramatically
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.
Closing Thoughts: Policy
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Do We Really Need All These New ED’s?
 Are we just building bigger reservoirs?
 And what are we putting in them?
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Changing EMTALA Is Not the Answer
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Barring the Door, or “Triaging Out”, Is Not the Answer Either
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What are the Implications for Surge Capacity?
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Maybe We Need to Rethink the Role of the ED as “Provider of Last Resort”
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The Safety Net CAN Improve Its Performance
 With minimal external resources
 And that goes for Academic Health Centers as well
Confidential information. For use by Urgent Matters and the Robert Wood Johnson Foundation only.