Answer: According to the College, the 2010 attendance broke all records (5900 registered). All I knew was that the corridors, meeting rooms, and the exhibit hall were crammed. I suspect the lure of Las Vegas had something to do with that but, curiously, the show itself seemed to be a bit dull.

Most significantly, there wasn’t that “gee whiz” idea or buzz-generating exhibit like there’s been in the past. While many of the booths sported new graphics and displays, most of the products and services seemed to be “yesterday’s news.”

I don’t mean to use this forum for political commentary but I’m inclined to attribute much of that to all the uncertainties surrounding this year’s health reform.  Companies aren’t inclined to make big bets on new initiatives when there are so many unknowns—whether it’s the talk about significant repeal or revision, all the unanswered questions and unfinished regulations, or the implications for reimbursement.

But there was evidence on the exhibit floor of the operational and logistical overhang associated with Healthcare Reform. Given the government’s big push, it isn’t surprising that exhibitors hawking Electronic Health or Medical Records were probably the most numerous vendors on the floor. As my colleague, Dr. Hellstern observed, “EMR’s are like treatments for a disease, when there’s so many options it generally means none of them work very well!”

Ironically, the newest category of vendors at ACEP (they didn’t exist five years ago) is those promoting scribes—human interfaces to operate between the computer and the physician.

So now we have all the costs and complications of the technology either the enterprise version or the boutique solution.  And coming along behind them are rapidly growing (both in number and size) organizations selling an additional service at an additional cost so we can overcome the productivity compromises created by the EMR.

I suppose some call that progress!

Answer: If they’ve not already done so, administration is likely to begin searching for advice on achieving the desired performance improvement. That means searching online and calling fellow CEO’s to find a consultant to conduct an assessment and recommend organizational and operational changes.

Why CEO’s Use Consultants

Most administrators genuinely value an outside perspective. Even if they believe they know what the problems are, most feel that a new set of eyes is the best way to gain insight on the resolution of those difficulties. They may want a better understanding of the key contributors to those identified problems or believe they need the assistance of someone’s who has successfully resolved these issues elsewhere.

In some cases, a CEO just wants confirmation of their existing conclusions and intentions. They’re looking for reassurance or they need validation (some call it cover) for actions they’ve already planning.

Divining your CEO’s intentions is you next challenge. Doing so correctly is critical; it requires both very discreet intelligence gathering and an objective (and potentially painful) evaluation of your performance. Start with a careful review of your relationship with the hospital’s senior leadership team and the nurse management in the ED. Has anything changed in recent months—fewer contacts, less communication, etc.?

Evaluating Your Options

If you conclude that your situation is perilous, that the group is likely to be identified as the weak link, you may want to initiate an all out effort to salvage the contract. That usually means calling in all the favors with key medical staff and board members, hoping that will be enough to force administration to back down. Be advised, however, that such a strategy is rarely long-term. If administration is determined to get you, they usually do!

Take Initiative

If you’d rather not go to war or if you conclude you don’t need to but would rather not just wait for the scenario to unfold, there is another alternative. You and your colleagues can seize the initiative. Surprise administration by being the one to suggest the retention of a consultant to conduct an assessment. Do your own research and have a firm you can recommend to do the job. And here’s the real surprise…offer to pay for part of it!

Doing the unexpected creates cognitive dissonance. If things are really bad, such a disruption in administration’s presumptions could be enough to change their entire perspective. In either event, by taking the lead, you’ll signal to administration that you have the insight and initiative to play an active role in finding a solution.

If you’re concerned that administration might not go for it or has already retained a firm, hire your own consultant. If you have to put a fight, having committed the time and expense to conduct an objective assessment of the ED’s performance could be very effective in securing support of key medical staff and board members.

Finish What You Start

But like other endeavors, don’t start this process unless you’re prepared to finish it. Be diligent in your research. Make sure your suggestions and recommendations are sound. Be certain that the consultant you chose is as well respected by other hospital executives, as they are by fellow physicians. When you’re investigating different firms, be sure to ask for both physician and CEO references.

And be prepared to make a major investment—consultants with a proven track record don’t come cheap. Daily rates can exceed three, four, even five thousand dollars per consultant! A typical assessment project can run into the mid five figures and the implementation of recommended changes can be two or three times that amount.

For many single campus emergency groups, that kind of money can be a real issue. So you’ve got to decide what keeping the contract is worth and evaluate the cost of losing it.

Answer: As a consultant, I’m frequently asked to offer insight on improving the working relationships between these two practices. The nexus of their interaction is the phone call regarding a patient needing an admission.  An amusing example of their respective perspectives is contained in “dueling” videos produced by two physician bloggers.

• The hospitalist perspective is offered on this Hospitalist vs ER Medical Video.
• The ER perspective is offered as a reply by ER Stories: ERP tries to admit a patient.

As the videos confirm, there is ample opportunity for conflict between the two. They frequently interact and the actions of one will certainly impact the workload, productivity, and efficiency of the other.

Attitudes and Objections

In addition to the barriers and objections to admissions posed by the Hospitalist, Emergency Physicians’ have other frustrations with the process. Those include:

• The time required for the Hospitalist to respond to the ED
• The use of Emergency Department space, equipment and personnel by the Hospitalists to conclude an examination prior to admitting the patient

The Hospitalists’ respond that they have a duty and obligation to effectively conclude whatever tasks they may be already engaged with when that call from the ED comes in, as well as one to the patients they may be have previously committed to see/treat/admit/discharge. They also insist that if they are to be the final arbiter of an admission, they need to have the means and opportunity to conduct a thoroughly examine before the patient gets to an in-house bed.

Common History and Interests

As two specialties and practices that share considerable history and circumstance, the antipathy that can characterize their relationships still comes as a surprise. Both are relatively new specialties, both came about, at least in part, as a means of relieving existing medical staff of on-call duties and responsibilities, and both have had to work extremely hard to convince medicine’s old guard that they are deserving of professional respect and appreciation.

Because of those commonalities (assuming they’re aware of them), no one is likely to be more sensitive to the plight of the Hospitalist than the ED Physician and vice versa.  For example, getting multiple admissions dumped on a Hospitalist just before the end of shift will certainly resonate with Emergency Physicians who have the same challenge in trying to conclude their shifts when the “bus pulls up at the ER.”

Before the advent of Hospitalists, many Emergency Physicians were expected to routinely respond to in-house emergencies in addition to seeing patients in the ED. In their efforts to be relieved of that duty, ER doc’s rightly argued that the expectation obligated them to be in two places at once, creating a potential claim of patient abandonment.  If they’re listening, Emergency Physicians should hear that argument echo in the Hospitalists’ dilemma!

Emergency Medicine was a “commodity” sold by third-party vendors long before it became a clinical specialty. In-Patient Medicine has that same heritage. As result, the hard earned improvements in the relationships between Emergency Physicians and Contract Management Groups (CMGs) offers significant lessons for Hospitalists in their dealings with Contract Services, if they choose to learn from them.

No Contact

In almost every engagement, my first revelation is the lack of communication between the two groups, their leadership and the physician members. Other than that phone call regarding admission or the occasional passing in the halls, the physicians typically have little interaction. As result of the “isolation” and as confirmed by the two video portrayals, the two specialties are convinced that no one (not another physician and certainly not administration) appreciates the unique demands and situations they encounter.

Given that lack of communication, one of my frequent recommendations is to increase that contact; the two physician groups need to recognize that they have much more in common than they may realize. Their appreciation of this reality could set the stage for a much closer alignment.

Both the ER Doc and the Hospitalist experience a common practice complication—the difficulty in getting specialist physicians and surgeons to respond. The two groups need to work together if they’re to effectively overcome the considerable financial and political clout of the surgeons and subspecialists. To do this they need to be allies, something that won’t happen as long as they constantly in conflict with each other.

Establishing and expanding communication between the two groups remains one of the best ways to convey that message. A good starting point is with leadership—the two physician directors should establish a regular schedule of meetings.

Meetings and Interactions

These meetings should also include the VPMA or another representative of the Administrative Senior Leadership Team. Their presence is suggested as a means of demonstrating the institution’s belief in and commitment to improving the effectiveness and efficiency of the relationship. Their being there also affords a conduit to the CEO and Board because the discussions are likely to reveal the need for changes to hospital policy, procedure, resources or facilities.

For example, the discussions may identify the need for a Critical Decision Unit so borderline cases can be observed until the appropriate disposition can be determined. They may establish the need to find alternative exam space (out-patient exam rooms, etc.) that could be accessed during peak volume hours when the ED is saturated. With that space plus nursing and technical personnel drawn from in-patient staff, the Hospitalist could conduct their admission examinations and do so without compromising ED operations.

Addressing questions about the appropriateness and timeliness of admissions should be a standard element on the agenda of the meetings between the two Medical Directors. Documentation on specific cases should be included for discussion, not just an exchange of rumor or anecdote. If questions persist about the legitimacy of admission requests/response, both the Emergency Department Medical Director (EDMD) and Director of Hospitalist Services should carefully and objectively examine the records to determine if their staffs or colleagues require additional supervision, training or education.

Routine information exchanges between the two groups can be extremely effective in providing exposure to the circumstances and conditions that characterize the respective practices. Many Hospitalist Practices have mid-day “stand-ups” that allow for communication between multiple Hospitalists. Having an ED Physician in attendance could improve the individual physician relationships. It could also help coordinate manpower utilization and scheduling so both services are better able to react when demand is high.

The Emergency Medicine Practice typically has monthly meetings, either in conjunction with the Emergency Department Staff or as a function of the group practice. Having a Hospitalist participate during that meeting could dramatically change the attitude and impressions of ED personnel and the Emergency Physicians regarding the life and times of the working Hospitalist.

You may want to determine if the Emergency Physicians are aware of the Hospitalists coverage hours and shifts? Ask if the Hospitalists know about the coverage pattern in the ED? Have the two compared those schedules to see if they’re ways to rearrange coverage to better respond to the needs of the patients and the respective physician services?

Compensation Complications

In its early years, Emergency Medicine was an hourly wage specialty. While some ER docs continue to be paid that way, most have now migrated to some form of “productivity compensation.” Because their pay is tied to the number and acuity of patients they see, anything that reduces their productivity by delaying deposition of patients or by occupying ED space or resources is going to be problematic.

In contrast, compensation methodologies among Hospitalists appear to be less uniform. Some are salaried; some are paid by the shift, others by the patient or by RVU.

If the ER staff and physicians “believe” that the Hospitalists income is “fixed” (either salaried or paid by the shift) such a perspective (whether accurate or not) will lead to the view that the Hospitalist is non-responsive because there’s no incentive to see new patients. Conversely, salaried Hospitalists may view an Emergency Physicians demand for rapid response as motivated solely by money. Such opinions enable negative attitudes that then provide the justification for resentment, resistance, even sabotage.

Administration may want to examine the respective compensation methodologies to determine if such differences are a contributing factor in the dysfunctional relationships. If so, an effort to align the incentives could significantly improve cooperation and performance.

Part Two: Removing the Obstacles

When considering whether to replace the EDMD, look for procedural, financial or organizational impediments to leadership performance. What historical circumstances or established expectations are limiting the person in this position. If barriers exist, it’s doubtful that the new doctor will be any more effective, even if you proceed with the transition.

Common barriers to success for EDMDs

CMG Interference

If you have a contract with a CMG, the local coverage physicians may believe or have been told that any new ideas or innovation for the ED is supposed to come from Corporate Headquarters. The division of responsibility between a local Medical Director and the CMG’s Regional or National Medical Director is often poorly defined, allowing for individual initiative but frequently resulting in confusion about assignments and authorities.

Limited Exposure

There are multiple reasons why a Medical Director fails to offer the desired initiative or innovation. In some cases it’s that, “they don’t know what they don’t know.” If the local doctors aren’t active in the American College of Emergency Physicians (ACEP), regularly attending ACEP’s Scientific Assembly and/or the Medical Director hasn’t attended or isn’t enrolled in ACEP’s Medical Director’s Academy, they may not be aware of the “best practices” of the specialty.

Insufficient Compensation

Often the membership of local groups fails to fully appreciate and adequately value the administrative tasks and responsibilities. As such, many EDMD’s have not been allocated sufficient time and/or adequate compensation to effectively perform their administrative duties. And, it isn’t just the local groups, CMG’s often target administrative compensation when they’re trying to “sharpen their pencils” in a competitive bid situation.

Start with the basics; how is the leadership physician paid? Is it just a bump in the clinical salary or hourly rate, or is there a dedicated stipend for the administrative duties?  If there’s a stipend, how was it established? Divide the stipend by the current clinical hourly compensation to determine the number of administrative hours “budgeted.” Or divide the stipend by the your expectation of dedicated administrative time to get an “estimate” of the hourly rate for the EDMD’s non-clinical time.

Not Enough Time

How do the total of the EDMD’s clinical plus administrative hours (actual, if you know it or using the estimate above) compare to the number of clinical hours provided by the other members of the group? If he’s working more total hours than his colleagues, it could be that he’s not receiving a dedicated stipend or its not sufficient, or because he’s trying to boost his income or because he’s the one who gets stuck filling all of the open shifts. Regardless, his administrative duties are certain to suffer!

Speaking of adequate time, if your ED is seeing more than 50,000 annual visits, the EDMD duties should require a full-time equivalent (FTE). So that the Director can continue to practice clinically, some of the duties should be assigned to the Assistant EDMD. The EDMD works 75% of his time administratively and 25% clinically. It’s the reverse of that for the Assistant. Lower volume departments may be able to get away with less than a full FTE but rarely can the leadership function be performed without the EDMD being allocated and compensated for at least 40 administrative hours a month.

If after completing the research and discussions, you still have the opinion that the new physician needs to serve as the EDMD, consider a transition period.

No Succession Planning

“Suggest” that the contract group develop a succession plan and that their 1^st step might be to create a 2^nd or even 3^rd Associate or Assistant EDMD position.  Then encourage the group to install the EM Residency Trained/Boarded Physician in that new position.  In doing so, be sure that the doctor is afforded adequate time to perform his administrative duties and is compensated so he’ll/she’ll be motivated to commit the time (and be willing to give-up clinical shifts) to do so.

If it’s not clear that the EDMD should be removed, that decision doesn’t mean that you have to continue to accept substandard level administrative services.

Undeveloped Leadership Skills

As you know, few physicians have any formal training in administrative duties or leadership. If the EDMD isn’t already attending ACEP’s Medical Directors Academy, strongly encourage him/her to do so.

No One to Talk To

Additionally, consider securing the services of an Executive Coach to assist the EDMD in the development of leadership, communication and dispute resolution skills. Make the Executive Coach a part of the transition plan so the Assistant EDMD, if and when there is one, gets the training as well. And if you’re determined to install the Residency Trained Physician as the EDMD, you’re advised to make every effort to insure that he’s successful in the role. With no experience in a leadership role, the new EDMD will have even more to gain from an Executive Coach.

Final Thoughts on Removing the Medical Director

If your contract is with a CMG make it clear that you want and expect more effective leadership and innovation from your ED Physicians.  While you’re at it, be sure that the management company agrees to give the local doctors both the specialized support and the authority to deliver that leadership.

If your contract is with a local coverage group, encourage them to consider securing professional management.  In selecting that management service the local group should be sure that the management firm has the specific talent, resources and experience needed to support the physician leadership.

Finally, if the decision is made to “remove” the existing Medical Director in favor of the EM Residency Trained Physician, make every effort to “soften the blow.”  Even if his performance hasn’t met every expectation, the current EDMD deserves to be acknowledged and his efforts applauded.  You’re advised to start the transition in private but finish it in a very positive and public manner.

Two years ago the first Emergency Medicine Residency Trained Physician began working in our ED. He’s energetic, enthusiastic, and ambitious. He’s impressed the department’s nursing leadership and staff, and they’re encouraging administration to have him designated as the ED’s Physician Medical Director (EDMD).

Our contract for ED Physician Services says we have approval over who serves as the Medical Director so we appear to have the authority to compel the change. How do you recommend that we proceed?

Answer: There are few things as potentially disruptive to the stability of an Emergency Physician Staffing Contract as the turnover in the Medical Director position. Whether your contract is with one of the Multi-Hospital Contract Management Groups (CMG’s) or with a local, independent practice, the departure of the Medical Director is almost certain to create waves. And the more the hospital appears to be responsible for that departure, the larger the waves can be.

That isn’t to say that a change can’t or shouldn’t be made. On the contrary there may be ample reason to take action. But before you began any effort in this regard, realize that there are likely to be complications—potentially serious ones.

Given the complexity of this situation, the response will be in two parts.

Part One: Costs and Complications

• Medical Director may leave
  At a minimum, a forced removal could result in the loss of the current Medical Director. Even if you’re not happy with his/her performance in an administrative role, are you prepared to lose his clinical contribution as well?
• CMG Objections
  Your CMG could also object! If you insist that they remove the EDMD, the firm may not be able to find a suitable replacement in a timely manner or may want to reopen contract negotiations if they do.
• Coverage Doctor Exodus
  Some or all of the other coverage doctors could join him or at least threaten to do so. That could certainly get the medical staff’s, the board’s, even the community’s attention. Are the reasons for making the change sufficient to warrant having to overcome resistance of that kind?
• Mass Exodus
  The reaction of a local practice, especially one that places considerable importance on their autonomy, could be even stronger. The threat of a mass exodus isn’t unprecedented, and the costs and complications associated a rush to replace them, can be enormous.
• Power Struggle
  Even if the group agrees to your request, you may discover that the reassignment doesn’t actually achieve any real transfer of authority. Today’s real leader of the local practice may be the Medical Director but after the forced change, the real power may reside with a newly designated President of the Practice. And that failure to recognize the authority of the new Medical Director can happen even without the creation of a new leadership position. The group members either individually or collectively simply fail to commit to the new Medical Director and actively or passively resists his initiatives. That reality may not be evident until the new EDMD quits in frustration because he can’t get the support and cooperation of his colleagues.

Given the potential complications, it is advisable for administration to be certain that there is a substantive basis for the change. Here are some questions to consider before making a move toward this important change.

• Justification
  Is this change for change’s sake or are their legitimate reasons to do so?
• Scope of Support
  Is it just the ED Staff or hospital personnel that perceive the problems? How about the Medical Staff or the ED Group? Some inquiry (either by you or by a consultant hired to evaluate ED services) may reveal that the membership of one or both is dissatisfied with the EDMD’s leadership and welcome a change!
• Self Awareness
  Is the current Medical Director aware that his services are thought to be inadequate? Has the ED Nurse Leadership or his senior management liaison discussed the need for him to evolve as the Medical Director, and how interested is he/she in doing so?
• Stepping Up
  Is he willing and able to “step-up” his game or really even interested in being the Medical Director? It’s certainly not unheard of for an EDMD to be a reluctant volunteer, who only took the job because no one else would. However, even if he’s not really committed to retaining the position, you’re advised to proceed with caution. As administrators know from experience, doctors (and not just the ED staff) can get their “dander up” if there’s a perception that administration is meddling in the affairs of physicians.

In part two of this response I will cover systemic issues—the operational factors that can restrain the effectiveness of an EDMD—and what to do about them. Stay tuned.

Answer: Efforts to reduce lengths of stay, decrease throughput times, and improve patient satisfaction are top priorities for most hospitals. In fact my colleagues and I have helped a number of hospitals achieve dramatic performance improvements. But as the article confirmed, it’s much easier to claim improvement than it is to consistently and continually produce the desired result.

Not So Easy

Reducing wait times in an ED is an enormously complex endeavor. It takes a concerted effort by a hospital’s senior leadership team in coordination with numerous hospital-based and admitting physicians as well as the nursing and technical staffs in multiple departments. While hospital personnel (doctors and nurses) can be urged to work faster, unless there are fundamental cultural and structural changes within the institution, most improvements realized aren’t sustainable.

A New Strategy

To be successful long-term, the EDs well-trained and dedicated doctors, nurses, and techs must be willing to completely rethink the way they practice! This type of introspection and willingness to embrace change is always difficult but in today’s exacting medical/legal environment, it’s particularly challenging.

Pull Till Full

Pull Till Full means that the patient won’t spend any time in the lobby or go through a lengthy Q&A at triage. Instead, the patient will be met at the ER entrance by a rapid response team (a nurse and registration person). They’ll detain the patient only long enough to determine the type of treatment bed needed and to get minimal identification information before sending them on to a treatment room.

This strategy requires that physicians be willing to accept that they may be the first provider to see the patient. If so, he or she must be willing to engage the patient without benefit of the customary medical data (even vital signs) routinely obtained during triage or secured by nurses or techs prior to the physician’s arrival.

No Patient Owns a Bed

This strategy means that many patients will be in a treatment room very briefly, only long enough for a decision to be made regarding disposition. Once an admit decision is made and the in-house physicians and staff are notified, transportation to an in-patient room should be standing by.

Patients to be treated and discharged will remain in a treatment room only long enough for tests to be ordered. From there the patient goes to a secondary waiting room (often called the “results are pending” room or RAP room) to, as the name implies, await the results.

Saturation Level in the ER

Despite these changes and the resulting increased “bed turns,” many EDs will still experience some hours during a day in which the department is saturated—with all beds full and no traditional treatment space available for new arrivals. In these circumstances, the providers (doctors, physician assistants and/or nurse practitioners) will need to begin seeing patients and initiating treatment in alternative spaces, even chairs in the waiting room. If so, a non-acute patient may never see a treatment room; instead they may remain in the waiting area most of their visit, with just a side trip to an ancillary department and/or a final stop in the RAP room.

Change You Can Believe In

Implementing these changes requires an institutional “leap of faith,” along with considerable coaching, team building, and coordination. It requires that patients and caregivers adapt to new ideas and processes, some of which may take some real adjustment. But the demand for emergency department services shows no signs of abating. And if the Massachusetts experience with “universal coverage” is any indication, the newly enacted National Health Reform will significantly increase that demand.

Have a question about Emergency Physician Staffing? Just ask.

Answer: Building on what you have is almost always preferable to starting over, so getting your CMG to focus on your current situation should be your primary objective.  Getting that done means that you need to be certain that they are clearly aware of your dissatisfaction and understand that you’re prepared to do something about it if the situation doesn’t improve.

Get a Objective Opinion

One way to get that message across is to bring in an outside consulting group to objectively assess the operational status of your Emergency Department, including the services of the Emergency Physician Group. Conducting such an assessment will provide you with the objective performance data you need to effectively evaluate the CMG and the coverage physicians.

Properly conducted, the assessment should provide considerable insight on what’s working and what isn’t.  It will also clearly announce to the CMG  that while you have taken no steps to replace them, you are prepared to do so unless they begin making tangible progress toward meeting your expectations.

But the assessment can offer both a “stick” and a “carrot!”  By assessing the performance of the entire department, you’ll clearly communicate to the Emergency Physicians and Contract Management Group that you’re committed to improving all aspects of the service, not just theirs.  Your commitment to improved performance and productivity should make the contract even more appealing to doctors and contract managers.

Notice of Intent Not to Renew

Another way to get their attention is via formal notice that you do not intend to allow the contract to renew unless improvements are made.  Even if there’s considerable time left on the term of the agreement, issuing a Notice of Intent Not to Renew will make it clear that you expect prompt attention to the performance deficiencies.

To be clear, this notice of non-renewal isn’t a notice of cancellation!  While it may come to that, this action signals your strong dissatisfaction but doesn’t trigger the termination countdown.

If your contract has an Automatic Renewal Provision (and most of them do) be sure that you take formal action before the Agreement has automatically extended. But even if there are weeks, even months before the deadline to prevent that renewal (which is usually 90 days prior to the end of the existing term) act now and issue notice that it is your intention not to automatically renew.

You can also use this strategy if your contract doesn’t have an Automatic Renewal Provision.

This technique will put your current contractor on notice that you’re not satisfied with their performance and are prepared to take action if improvements aren’t forthcoming.  Even if you’ve detailed your dissatisfaction before, doing so again in conjunction with such a notice of non-renewal will give that pronouncement much greater weight. By taking formal action early, a well-intentioned CMG should have time to effectively demonstrate their determination to meet your expectations before a final decision has to be made regarding an extension of the Agreement.

Time to Plan and Act

If you still don’t see improvement, these early actions will give you the means and opportunity to plan the next step.  You’ll have ample time to identify and consider alternative contractors and vendors, and nothing is more important in a transition of this sort, than time.

Have a question about Emergency Physician Staffing? Just ask.

Answer: The transition from private practitioners to hospital employees is frequently prompted by some external event that affects several doctors at once. As a result, the employment contracts for all of the ER doctors, and, for that matter, the radiologist and anesthesiologist often have common renewal dates. While this seemed to be the simplest approach when the agreements were first executed, many administrators are coming to realize that it can have a particularly adverse consequence! More and more, these administrators are discovering the challenges of “collective bargaining.”

One Renewal Date or Multiple Dates

If your institution is contemplating the employment of physicians and no contracts have yet been exchanged (much less executed), you may want to consider different expiration dates. Ideally, each agreement should have a unique date so each can be renegotiated without affecting the others.

Because of the loss of the collective leverage, however, getting the doctors to agree to that may be problematic. Even if you can get separate dates, the concessions made to one physician in his/her negotiations will probably need to extend to the others at the time of their renewal, if not before. The assumption that the terms of a recently renegotiated agreement can be kept confidential is simply unrealistic.

Additionally, different renewal dates will require that you are constantly preparing for, engaged in, or just concluding a round of negotiations. That may be reason enough to stay with a common renewal date.

But remember that engaging in collective negotiation will require significant planning and preparation. You need to start now to be prepared for the next round of negotiations.

Consequences of Destructive Negotiations

The failure to successfully conclude negotiations with a single physician can be significant, but the risks and complications associated with a breakdown in discussions with all of the providers of a particular clinical service can be devastating. One of the most frightening scenarios to confront a hospital is the threat of a collective work action by physicians whose services are critical to an institution’s medical mission and financial performance.

In the past, threats to withhold or suspend services have prompted administrators to secure the services of replacement physicians either as a means of “calling the bluff” of those threatening to suspend services, or as temporary or permanent replacements, once the threat has been carried out. While the use of this strategy is effective in preventing the loss of critical service or minimizing the time that services are suspended, its deployment is not without possible adverse consequences. Even when the use of replacement physicians prompts concessions and leads to an agreement, the lingering anger and frustration can produce long-term complications for the Hospital. This is especially true given the acute shortage of many physician specialties and an increased reliance on Hospital-based physicians to provide key Medical Staff Leadership roles.

Recent and future changes in regulation and reimbursement are only going to make negotiations of these agreements more difficult. But the contracts and agreements between hospitals and physicians must meet both the letter and spirit of the constantly changing laws and regulations.

Mediation – Improving the Odds of Success

Because these challenges substantially impact both parties of the agreement, it is imperative that both hospitals and doctors strive to construct agreements that meet real interests. Legal counsels should be used to insure that agreements are in compliance with laws, but identifying and understanding the interests of both parties is the first step.

Both parties must be prepared to invest considerable time and energy in open, honest, and yes, at times, painful negotiations. Sometimes adding an informed but impartial, 3^rd party mediator helps to facilitate the discussions.

Answer: Trying to improve on what you have is almost always preferable to starting over, but sometimes starting over is the only choice. If that’s your situation, you’ve got lots of catching up to do if you’re going to prepare yourself for an informed decision.

Knowing What You Don’t Know

What you don’t know will hurt you! And if you’re like most healthcare executives, demands on your time don’t afford you the opportunity to remain current on the information and issues critical to making this important selection.

Much has happened since you last went through the selection process but with only limited time for research, it’s going to be difficult to obtain all of the pertinent data prior to having to make a selection.

Contractors Change

Changes certainly occur that impact individual vendors. They can get bigger and more capable; or just bigger and more encumbered.  Or they can downsize, making them more eager for you business; or just smaller and less capable. Ownership can change—several CMG’s have gone public and just as many returned to private ownership.

And it isn’t just the individual organizations—there can be changes that impact an entire segment of the industry or all of it at once.

The One with the Information Wins!

Gaining that insight (the essential “inside” information) can be difficult, especially when time is short. It’s also hard to get objective data on one company’s service performance versus another. Often the only readily available opinion comes from the contractors themselves.

In contrast, the national and regional staffing organizations know all about you and your situation. Their sales and marketing staffs are focused on your institution and may know more about the status of your emergency department than you do. If it seems that the volume of sales calls or promotional mailings has increased recently, its probably because they already know that you’re contemplating a change.

Looking in All the Wrong Places

Administrator Referral: Asking other administrators for referrals are certainly a good source of info on vendor performance. However, differences in situation and circumstance mean that one hospital’s experience with a particular provider can have little or no implication for yours.

National Search for Local Services: And like the search for qualified employees, quality vendors are rarely the easiest to find. Those in your area may not be focused on finding new accounts, preferring instead to put the priority on meeting the needs of their existing clientele. So you may not find local contractor’s ads in the journals and they may not pop-up on an Internet search.

Do It Yourself: Successfully identifying the right vendors requires an in-depth knowledge of the staffing industry and operational specifics on all of the players. You can certainly invest the time to become the expert yourself. While you’re at it, be sure that you’re staying current on all of the hospital-based clinical services (emergency medicine, anesthesia, hospitalists, intensivists) you obtain via a contract service.

Hiring a Consultant

Or you can seek out an objective but informed consultant that can guide you through the entire selection process. They’ll be able to help you identify quality vendors, draft your request for proposal, evaluate the bids and coach your selection committee through their final decision. Yes, there are fees involved in hiring a consultant. But how much is it costing you now to go through this process again?

Have a question about Emergency Physician Staffing? Just ask.

Answer: While many hospital-based clinical departments haven’t yet fully exploited the benefits to be gained by the adoption of some of the proven process improvement protocols, a number of institutions have and still fell short of their goals. Many of those hospitals realize that if you’re not continuing to improve, you’re falling behind. As result, they’re all searching for the next break-through in performance enhancement.

Interestingly, the next wave of improvement may come from an obvious but less well understood area of individual and institutional behavior. So what is it that’s so obvious and why hasn’t something been done about it?

Unresolved Conflict

Numerous authoritative sources have concluded that the root of dysfunction in the health care environment is unresolved conflict. The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) believes that most sentinel events result from poor communication created by festering conflict. The American Nurse Association contends that the shortage of nursing personnel is due at least in part to the unrelenting workplace conflict confronting its membership. Finally, a survey of physician recruiters reveals that most established doctors looking to relocate are doing so because of continuing disagreements and disputes with their colleagues and co-workers.

Taken in combination, its estimated that healthcare workers spend more than 50% of their time confronting conflict. If that estimate is even close, the institutions that can find ways to effectively address conflict within their organizations will have a tremendous productivity advantage over those that don’t. But finding ways to improve the working environment and working relationships will require much more than good intentions and reassuring rhetoric.

Research in the workplace and among co-workers suggests that conflict is a constant. If so, then the conventional wisdom that the absence of conflict is the sign of a well-run organization isn’t just wrong, it’s completely counterproductive. It’s a wholly unrealistic expectation of human behavior and performance. Worse yet, retaining the perspective only serves to heighten the emotions of the workforce already frustrated by their own conflicts.

Effectively reversing this process requires a fundamental change in institutional culture. It begins with the “normalization” of conflict—a recognition and an acknowledgment by senior leadership that conflict is inevitability. When effectively established, such a change in thinking at the top of the organization results in a growing awareness within the workforce that the true measure of performance (theirs and the institution’s) isn’t the denial of conflict but rather how well conflict is dealt with when it does arise.

Systems Approach

It is believed that conflict functions as a system within an organization, much as the more readily recognized systems (e.g., payroll, promotion, discipline, etc.). To effectively address a system of conflict requires a systemic approach to dispute resolution. That requires a commitment from leadership to resist putative reaction to the presence of conflict and to refrain from dictating remedies. It also requires the provision of the resources needed to facilitate and promote the resolution of conflict by the participants to the disputes themselves.

If trying to do something on a hospital-wide basis seems too ambitious, consider tackling it on a departmental scale. Given the level of conflict in the ER, that could be the best place to start!

Have a question about Emergency Physician Staffing? Just ask.