A Hospital-Physician Partnership to Solve ED Crowding

William T. Choctaw, MD, JD, CSSBB

William T. Choctaw , MD, JD, CSSBB

Physician Advisor, The Joint Commission Center for Transforming Health Care

Published September 04, 2019

Doctor and hospital administrator shaking hands in hallway

How can hospitals transform their emergency departments (EDs) in challenging economic times when margins are slim? Too many approach change by cutting resources or slashing operating budgets. "No margin, no mission," they say when challenged.

But what if there were a way to turn that saying on its head? Personally, I like to believe that if you don't have a mission, you don't deserve a margin.

In this post, we'll look at how Emanate Health found a creative, collaborative solution to ED crowding. With its ED partner Vituity, the health system used a technique called Robust Process Improvement (RPI®) to create sustainable improvement over time. In just a year, RPI helped the system's three EDs achieve significant gains in throughput and operations. Here's our story.


Emanate Health (formerly Citrus Valley Health Partners) is a three-hospital system headquartered in Covina, California. Emanate Health's EDs serve a catchment area of about 1 million people. The largest, located at Queen of the Valley Hospital, receives more than 70,000 visits per year.

Emanate Health is committed to RPI, a process engineering approach developed by The Joint Commission. RPI leverages the principles of Lean Six Sigma and formal change management to effect measureable, evidence-based change. To promote RPI within the system, Emanate Health has trained hundreds of employees in this methodology, including executives, administrators, providers, nurses, and staff.

As Emanate Health's former Chief Transformation Officer, I was trained as a Lean Six Sigma Black Belt by The Joint Commission Center for Transforming Healthcare. For my Black Belt project, I chose to focus on the issue of ED crowding.

Like many health systems, Emanate Health counted ED crowding and diversion among its most frustrating challenges. At the time, the same national management group had held Emanate Health's ED contract for 17 years — and things were not going well. Patients in all three EDs were waiting far too long for care, and the departments were on diversion about 30% of the time. With ambulances routinely bypassing our hospitals, admissions from the ED were down. What's more, too many patients were tiring of waiting and leaving the ED without care.

As is often the case, ED crowding was a symptom of larger issues that stretched across our system. It was an expensive, highly complex problem — exactly the kind of issue that RPI was designed to address.

The vital importance of provider engagement

Our Lean Six Sigma project team gathered a wealth of information on the department through gemba walks and group and individual sensing sessions. Our goal was to isolate the root causes of ED crowding and develop a targeted solution. We thought it might come down to high patient volumes or inefficient processes. The answer shocked us all.

The bottom line was absenteeism. About 2–5% of the time, ED providers were missing work, coming in late, or leaving early. When this became clear, I was absolutely flabbergasted. As a physician myself, I could not imagine providers behaving this way.

Our fact finding also uncovered deficits related to our ED surge policy:

  • Inconsistent surge policies across hospitals (one had no surge policy, another had never been used)
  • Low awareness of surge policy among physicians
  • No clear definition of "surge"
  • No established warning system or communication plan to alert other departments during a surge

By applying Six Sigma methodology, we'd gained a clearer understanding of the systemic problems facing our EDs. Over the next several months, our newly established ED operations committee made positive strides forward, including creating a system-wide surge plan.

However, to turn the department around, issues of absenteeism and culture needed to be addressed.

Forming a new partnership

Our ED management company had served us for over a decade, but it was no longer producing the results we needed. We decided it was time to put out a request for proposals. After careful deliberation, our executive team interviewed five groups for the contract. Among them was Vituity (formerly CEP America), a national, multispecialty physician partnership headquartered in Emeryville, Calif.

When the physician representatives of Vituity walked into the room, the conversation immediately changed. Most groups came in talking about numbers. By contrast, Vituity's team talked up the physician leaders they planned to send us. They also explained their group culture and how their partnership model enhances physician engagement.

When I asked the question, "How many ED contracts have you lost due to poor operational performance?" I was startled by the response. "Zero," said the Vituity VP. "We've never lost a contract that way."

It wasn't even a close call. We selected Vituity as our new ED management partner by unanimous vote.

Change and resistance

Transitioning away from an underperforming physician group is always a challenge for hospitals and health systems. The politics involved can create administrative headaches — not to mention financial risks and reputation damage.

Right away, the leaders of the outgoing ED group made it clear that they would not leave quietly. They weren't interested in joining Vituity, and they proposed breaking away from their parent company to form a separate group and fight for their contract.

To diffuse the growing tension, the hospital tried to broker a compromise. Would Vituity take over the contract but keep the existing physician leaders in place?

Dr. Wesley Curry, Vituity's CEO at the time, wouldn't hear of it. He insisted on new leadership, culture change, and compensation models that supported the hospital’s mission, vision, and strategic plan.

Dr. Curry knew that the incumbent ED group was receiving a hospital stipend to assist with recruitment and retention. He vowed to end this arrangement. "Based on our projections, we won't need financial support," he insisted. He added, "If you partner with us, we will guarantee the results."

With those words, he sealed the deal on Vituity's contract with Emanate Health.

Fostering partnership

As the ED transition approached, administrators worried that providers might quit en masse, leaving all three departments understaffed. However, Vituity's leadership worked out a compromise. Existing physicians who joined Vituity would be placed on an accelerated pathway to partnership and the many benefits that come with it.

To sweeten the deal, Vituity clinical leaders and myself visited each campus multiple times to meet with providers and answer questions. "You will not be our employees," one of the Vituity medical directors explained to the team. "You will be owners in your local practices and partners equal to others in Vituity. Your work will be crucial to the success of these EDs.”

This outreach worked. A majority of the ED physicians opted to stay on and join Vituity. To demonstrate their commitment to their new teams, all three Vituity medical directors agreed to train in RPI and Lean Six Sigma.

Rapid Results

Six Sigma Black Belts strive for statistical significance (p-value <0.05). To this end, our project team collected a wealth of data throughout the ED transition in order to validate its results and ensure its sustainability. We were assisted by a Vituity practice management consultant, a nurse and Six Sigma Green Belt, who forged a trusting relationship with the nursing team.

The improvements to our operations were striking. Here are some representative stats from Queen of the Valley, our busiest hospital:

  • Improved scheduling (100% attendance is now the expectation)
  • Decreased walkout (LWBS) rates from 3.1 to 0.7%—well below national benchmarks for excellence
  • Decreased ambulance diversion hours by 33%
  • Increased patient satisfaction scores from percentile 2 to 72

All of these improvements occurred during a period when ED volume rose by 34%.

Though we didn't measure nurse satisfaction, we received great feedback on the transition from our ED nursing teams. Nurses told me repeatedly how happy they were with the Vituity physicians. They felt that they now had true partners in every sense of the word.

These improvements held steady over the next couple of years. During this period, we made significant facility improvements to two of the system's three EDs. It's normal for performance to dip a bit during a major renovation. However, our Vituity Medical Directors and consultants used Six Sigma methodology to bring the new departments online quickly while sustaining our quality metrics.

Emanate Health's improved ED performance resulted in several awards and honors:

  • Emanate Health — 2017 Vituity Practice of the Year (chosen from over 125 hospitals)
  • Sergio Hernandez, Queen of the Valley Medical Director — 2018 ACEP Community EM Excellence Award
  • Sergio Hernandez — 2018 Vituity Excellence in Leadership Award

What worked?

How did the partnership between Emanate Health and Vituity produce such extraordinary results?

First, I think our mutual commitments to Robust Process Improvement and Lean Six Sigma were crucial. The doctors from Vituity walk the talk of Six Sigma, leadership, cooperation, and change management. This gives us a common language and culture that fosters camaraderie and accountability.

Emanate Health and Vituity also share a mutual commitment to physician leadership. Physicians tend to get a lot of blame when things go badly. But we also get a lot of credit if things go well. With the backing of our hospitals, we are natural leaders who can fulfill expectations and take organizations to the next level.

Improved communication through system-wide emergency medicine meetings also played an important role. I originally initiated these meetings early in the project to bring together the medical and nursing directors from each ED. This created opportunities for "cross pollination" as they shared status reports and process improvements.

ED challenges aren't over for Emanate Health. The system will soon begin expanding its largest ED at Queen of the Valley Hospital from 24 beds to 60. This will be the biggest facility upgrade they've tackled since the contract transition. However, I have faith that their Vituity partners will steer them through this change while continuing to provide excellent care to their patients and communities.

To learn more about how Vituity helps EDs reduce crowding and improve patient satisfaction, visit our emergency medicine services page.

Partnering to improve patient lives

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