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Quality Matters: The Reform-Ready ED

Welch, Shari MD; Augustine, James MD; Asplin, Brent MD, MPH

doi: 10.1097/01.EEM.0000406949.97994.73
Quality Matters


One thing is certain: Many facets of health care reform will affect the emergency department. Changes will be required involving processes, space, and technology. The transformative change that health care reform is poised to jumpstart involves a major paradigm shift. Before, physicians, hospitals, and health systems toiled in an environment where only patient and service volumes were rewarded. The goal of health care reform is to create a system that rewards something else entirely: value.

The current health system facilitates and rewards high utilization, readmissions, and treatment of hospital-acquired complications. It does not penalize waste, redundancy, errors, and patient safety lapses. But the new health system will. The Patient Protection and Affordable Care Act (PPACA) is a comprehensive piece of legislation that attempts to steer our health care system in an entirely new direction.

Whatever anxieties and objections physicians may have about the particulars of the PPACA, there is reason Part 1 in a Two-Part Series to support its overarching goals. Health care providers, workers, and administrators have been on the fee-for-service hamster wheel for decades. Reform will help us all exit the wheel in the pursuit of health care value.

What is value in emergency medicine? In short, it is the ratio of quality (clinical outcomes, patient safety, and service) over cost. Health care at large and emergency medicine in particular have been so focused on clinical quality that the other elements have not been given adequate attention, though they are imperative for providing clinical quality. Service quality, including patient safety and the efficient and cost-effective delivery of health care, is beginning to get the attention it deserves.

The National Quality Forum, which has served as the final clearinghouse for emergency medicine quality measures, has endorsed five operational metrics, and the Centers for Medicare and Medicaid Services is moving forward with them. These quality measures for ED operations include overall length of stay (LOS) for admitted and discharged patients, door-to-provider time, left-without-being-seen rates, and admit-decisionto-departure time. All will focus attention on service quality in ED operations. CMS is moving forward with reporting of LOS and admit- decision-to-ED-departure metrics next year. If executed well, improvements in these parameters will lower costs, and improve patients' experience of care.

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Hospital Readmissions

It is well recognized that health care delivery is fraught with waste, particularly when there is no continuity of care and no accountability for patients' progress. The PPACA contains provisions that create incentives for reducing waste in the delivery system. A recent study, for example, demonstrates that 20 percent of Medicare patients are readmitted within 30 days. While there is considerable disagreement about what the percentage of readmissions should be and no one expects the readmission rate to be zero, most experts agree that 20 percent is too high. Beginning later this year, hospitals will have strong economic incentives to avoid these readmissions. For certain key diagnoses, Medicare will penalize hospitals that have higher readmission rates than their peers. (Initially, community-acquired pneumonia, congestive heart failure, and acute MI, will be our old friends, with asthma care likely to follow in short order.) Over time, the financial penalties become quite substantial, which definitely will raise the heat on decisions made in the ED.

Emergency medicine will always be at the interface of inpatient and outpatient care. We make the most expensive routine decisions in health care: Who goes and who stays (admissions)? How will the readmissions initiative change your emergency department? It is likely you will need a place for patients for whom you are trying to avoid readmission, but who need time to ensure they can safely be discharged. In some cases, the aging population with increasingly complex care needs may need home and follow-up care established before discharge from the ED. This takes time to arrange. Some health systems are wisely hiring more case managers in anticipation of the increased need for ED services, and they are adding space to the ED for these workers to do their jobs. (Do you have a place in the department for social workers, crisis workers, and case managers?) A clinical decision unit for housing patients while arrangements are made and identifying beds in or adjacent to the ED for this purpose makes sense.

A word of caution: Placing every “readmission” in the hospital under observation status is not an option; CMS will be auditing the use of observation status to ensure that it is not being used to avoid readmission penalties when patients meet inpatient clinical criteria.

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Hospital-Acquired Conditions

A second important tenet in the PPACA involves the promise from CMS that it will no longer pay for complications and the results of poor care. The commonly occurring hospital-acquired condition will not be funded. Section 3008 requires Medicare reimbursement penalties to begin in 2015 for hospitals with high rates (those in the top 25 percent) of conditions or infections acquired while in the hospital. These include hospital-acquired Infections (HAI), falls, surgical complications and medication errors. The expected impact on those hospitals is at least $1.4 billion. This will also affect emergency departments.

Some organizations are planning to operationalize a “defensive” approach with a SWAT team that will assess patients being admitted through the emergency department for pre-existing conditions. This team will likely collect urine specimens, culture skin and noses for MRSA, and photograph the skin to show pre-existing decubitus ulcers (urinary tract infections, wound infections, and skin ulcers are the big unfunded hospital-acquired conditions). This may create a need for an express admission unit where this screening process would take place. For hospitals that have been considering establishing such a unit, this may be the incentive to establish one, to avoid the bottlenecking of admitted patients via the implementation of this new admission processing model.

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Value-Based Purchasing

Under Section 3001, a new value-based purchasing program for hospitals will require a percentage of Medicare payments for some common, high-cost procedures (such as cardiac, surgical, and pneumonia care) to be tied to quality. The program begins in 2013, and quality measures included in the program will be developed and chosen with input from external stakeholders. This model of paying for quality by allowing hospitals to collect payments at previous rates is established as a funding mechanism. The value-based purchasing model will involve 70 percent performance on quality parameters and 30 percent patient satisfaction scores, though the details are still to be determined.

This means it is time to walk through the emergency department looking for sources of patient dissatisfaction. What can be done to make the ED a better place to receive healthcare? Cleanliness, accessibility, decreased noise, privacy, and a sense of security and safety have been shown to have an impact on patient satisfaction. The “Big Five” correlating with patient satisfaction require no remodeling or changes to the physical plant at all: Good interpersonal interactions and empathy, timeliness (decreasing perceived waiting time), rapid and adequate pain control, regular information about progress, and technical skill all correlate with positive patient satisfaction. ED policies and procedures that focus on these issues will be big winners in the reform-ready ED.

Next month: Technology, accountable care organizations, and reductions in charity care funding.

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Dr. Welch is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. Dr. Augustine is the medical director of the emergency department at Mercy Hospital Anderson in Cincinnati, the director of clinical operations at EMP Management in Canton, a clinical associate professor in emergency medicine at Wright State University in Dayton, the chair of the Joint Commission's Hospital Professional and Technical Advisory Committee, and the vice president of the Emergency Department Benchmarking Alliance. Dr. Asplin is the president of the Fairview Medical Group in Minneapolis, has twice been named one of the 100 Most Influential Health Care Leaders by Minnesota Physician Publishing, and is the president of the American College of Emergency Physician's Quality and Performance Committee.

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In Brief

S. aureus Increases at Texas Hospital Community-acquired Staphylococcus aureus pneumonia increased in children at one Texas hospital, according to a study at the Baylor College of Medicine Department of Pediatrics.

According to the study, 117 patients from Texas Children's Hospital had S. aureus pneumonia from August 2011 to April 2009. The rate per 10,000 admissions increased from 4.81 hospitalizations in year one to 9.75 in year seven. Methicillin- resistant S. aureus caused 74 percent of infections and methicillin- susceptible S. aureus caused the other 26 percent. Patients with MRSA were younger (median 0.8 years) than patients with MSSA infections (median 2.5 years). Clinical presentation was pneumonia with or without effusion in 30, empyema in 72, or lung abscess in 15 cases. Viral coinfections in 18 of 68 patients tested were associated with respiratory failure. Thirty-five children were intubated and 68 had intensive care unit care. Eighty-nine, 25, and three had video-assisted thoracoscopy, thoracentesis, and lobectomy, respectively. Improvement or cure occurred in 103 patients (88%), unscheduled visit or readmission related to the same problem in six, respiratory sequelae in seven, and death in one patient.

© 2011 Lippincott Williams & Wilkins, Inc.