Freestanding emergency departments have varying degrees of market penetration in a community. Dependent upon state legislation and the constraints placed on their construction (by certificate of need: CON-restrictions), some states have relatively few freestanding emergency departments. Other states with less restrictions, like Texas, have a competitive approach to such health care entities: Houston has 35 freestanding EDs. Health care reform intends to increase access to care, with more dispersed centers for health care delivery away from hospitals. In this regard, the Texas model probably has it right.
Greater Houston Emergency Physicians (GHEP) is a physician-owned staffing company and multihospital democratic physician group. It has more than 12 high-volume EDs located predominantly in the Houston area, with a few sites in San Antonio and Austin. The group is performance- and metrics-driven, and staffs exclusively HCA hospitals. The president of GHEP, Tim Seay, MD, is an entrepreneurial physician leader, and under his leadership, GHEP has invested in an ambulatory surgery center and now three freestanding EDs. Dr. Seay and his colleague Abe Longoria (vice president for freestanding ED development) built their first freestanding emergency center on two premises: high-quality health care delivery can be profitable and strategically located, and patient-centered facilities will be rewarded. So far they have been right on both counts.
GHEP designed, invested in, and built its first freestanding ED in 2009. It turned a profit within the first year of operation. This Houston facility, named EliteCare 24 Hour Emergency Center, is situated in trendy Rice Village, adjacent to Rice University and in immediate proximity to the towering St. Luke's Episcopal Hospital, the Methodist Hospital, and Memorial Hermann-Texas Medical Center. The seven-bed emergency department does more than just nod to aesthetics. The waiting room looks and feels like a hotel lobby. Designer fabrics cover the comfortable sofas and chairs, and the room is accented by artwork, plants, and pottery. Patients and their family members can help themselves to snacks and drinks placed on granite-topped cabinetry. There is a flatscreen television on the wall and magazines on the coffee tables. The waiting area is painted in warm, contemporary colors, and it has elegant rugs placed over gleaming hardwood floors. The colors and textures are comforting, and the space is quiet.
Patient care rooms are spacious and also boast warm colors, built-in cabinetry, and wall-mounted LCD televisions. These rooms are so clean they sparkle. They have all of the monitoring equipment of any emergency department treatment room, but comfort is supplied by the aesthetics, creating less of an institutional feeling than most places. Besides the visual effects and attention to noise, Rice EliteCare is also patient-centered in other ways. Research shows that patients prefer physicians in white lab coats. The doctor's lounge has starched, monogrammed, crisp white coats supplied and cleaned for every physician. Patients begrudge the waiting times in most emergency encounters, in particular unexplained and uninformed waits. The proximity of patient care areas and staff work areas encourages contact and communication with patients. Though delays in care are infrequent, patients never lack for information about the status of their visit. Staff are trained to be generous with their time, information, warm blankets, and comfort measures. And patient satisfaction with the experience of care is high. The physical layout, staffing, and culture of service quality combine to create a no-wait ED.
But this freestanding emergency department is not just a pretty face. It is a full-service ED, and has moderate complexity lab capability with all CLIA-waived tests. (Most blood and urine tests are now done on cartridges, and can be done at sites other than hospital laboratories). The in-house lab at EliteCare can do troponins, full chemistry panels, and even lipid screening with lab turnaround times of less than 30 minutes. Besides plain film radiography, this freestanding ED has a four-slice CT scanner with teleradiography capability and real-time readings. During my shift at the ED, the radiology turnaround time from order to results was less than 30 minutes. GHEP has chosen T-System for documentation, and it was built with prompts for each chief complaint. The discharge instructions are computerized and available in multiple languages. They are very intuitive, easy to use, and written in patient-friendly language: simple and straightforward with a big emphasis on follow-up.
In a bit of industrial tourism, I worked a shift in the EliteCare 24 Hour Emergency Center. One of the best parts about my foray into practicing medicine in this environment was that the patients were pleased with their care and that made for a pleasant and rewarding work environment. Often, emergency medicine with its long waits, inherent inefficiencies, and failure to put the patient at the center of the encounter leads to an adversarial relationship between patient and staff. Expectations aren't met and energy is spent (usually unsuccessfully) trying for service recovery. During my night at EliteCare, I felt a partnership with my patients. I had time to discuss treatment plans and options, and provided care that was tailored to the individual patient and family. One indicator of how satisfied the patients are at EliteCare: The patient complaint ratio is consistently an astonishing 0.6 complaints per 1000 visits.
My shift in this freestanding ED was a professionally positive experience. And just as Eric McLaughlin, MD, (the current medical director of EliteCare) had promised, “It is the kind of medicine you always wanted to practice. What is good for the patients is good for us!”
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