From Afterthought to Safety Net: Mayo Clinic Prioritizes And Standardizes Emergency Services

christopher-russiImproved patient satisfaction scores. Substantial cost savings. Reduced patient transfers. A dedicated workforce. Coordinated and integrated care delivery. These success measures are challenging enough to achieve within a single hospital or small healthcare system, but try making these work across a somewhat dysfunctional system with 22 emergency facilities that serve more than 350,000 patients every year. It may be difficult to think of anything as dysfunctional within the Mayo Clinic Health System, but that’s exactly where the Division of Community Emergency Medicine was just a few years ago. Today, however, it is realizing all of these success measures thanks to the vision, passion, and leadership of its chairman, Dr. Christopher Russi.

The Wrong Tools for the Job?

Dr. Russi and his team have made profound changes in how emergency care is delivered to the 21 communities served by Mayo emergency medicine (the primary AMC makes 22). Prior to their integration work, each community site operated in its own silo, working completely independently.

“There’s the flagship academic medical center in Rochester with bells and whistles and we do unbelievable work here,” says Dr. Russi, “but we have a surrounding health system in Minnesota, Wisconsin, and Iowa that was originally designed to feed people into Rochester who needed specialty care. Each of those sites were completely autonomous and functioning independently with their own bylaws and leadership structure.”

On top of that, there was an extremely variable or nonexistent workforce that wasn’t delivering emergency care to the degree required. One particular site couldn’t hire or retain a board-certified emergency physician for almost a decade. Dr. Russi discovered they were paying highly trained staff in the 20th percentile of the market. A large percentage of the emergency physicians were locum tenens, a status that wasn’t consistent with the mission, vision, values, and culture of Mayo.

Some of the community emergency sites also didn’t have the right tools in the right place. They weren’t equipped with basic devices such as ultrasound machines, an oversight that would send well-qualified, residency-trained emergency physicians running for greener pastures. Additionally, they needed to hire the right medical director.

“With all due respect to our friends in internal medicine, family practice, and surgical services,” Dr. Russi says, “residency-trained, board-certified emergency physicians want to work for a medical director who’s also an emergency medicine physician. It has nothing to do with the people, but with the approach and the mindset.”

So, a broken communication system, lack of basic equipment, and a fragmented workforce turned what was meant to be a feeder system for specialty care into a bypass system where all kinds of patients would drive up to two hours to be seen by an ED doctor in Rochester. They simply didn’t trust the community sites with their care.

Recognizing the Need for Change

Fast forward to 2011 and along came the Affordable Care Act.

“Now you’re talking about getting reimbursed on quality, mitigating costs, a capitated payment system,” Dr. Russi recalls. “And Mayo said, wow, we need to shore up this health system and Rochester to work together in solid coordination. There was no playbook. Mayo leadership simply said we’re integrating and they cut us loose. We had to figure things out as we went.”

Dr. Russi and his team had some tough conversations that led to difficult changes, but they were all done up front with the upper level leadership structure in each site. These conversations began with Dr. Russi illustrating the ED as the safety net of the hospital, accounting for nearly 70% of all visits to a particular site.

“They weren’t viewing it as the front door to their hospital. That was a big case for us to say, you know what, you’d better inject quality into the ED, and you’d better put the right people in there because that’s the face of your hospital. If patients have a great experience up front when they visit your ED, that trickles down to the inpatient stay and to their outpatient follow ups.”

From Silos to Safety Nets

Their discoveries took nearly three years to correct and they are finally to the point where they have a robust, standardized workforce with common FTE definitions and common salaries. Through all of the work they have done, the Division of Community Emergency Medicine at Mayo has elevated their game and each community has a true safety net and a reliable workforce that provides high quality emergency care. They have reduced patient transfers to the flagship medical center in Rochester and they have reduced service write offs—where patients didn’t think they needed certain tests—to the tune of tens of thousands of dollars per month.

At the beginning of this integration effort, Dr. Russi had to inject himself as a clinician into some of the community sites to really learn what was happening, doing what he thought was the right thing without the data to support it.

“Most organizations come at it from data and analytics, but we didn’t know anything about these sites,” he says. “We had to undertake a boots on the ground approach with lots of travel and handshaking. All we knew was how much money we were hemorrhaging, but the data and analytics came more after the fact.”

Dr. Russi now has some metrics that he is following, such as savings per new hire and transfer rates. The data now not only helps him validate his work, but it helps drive future projects forward.

“This is the happiest I’ve ever been in my career,” Dr. Russi says. “This is highly rewarding, very difficult work. Making profound change, having the autonomy and the authority to make that change, and then seeing it implemented and what it does for these communities, has been truly amazing and it’s something I’m just going to hang my hat on some day and be really proud of because we’ve done pretty well. It’s the most fun in my career as an emergency medicine doctor.”

Join Dr. Russi during his presentation titled “How Mayo Clinic Standardized Care Across 22 Emergency Departments,” one of the dynamic Outcomes Improvement Case Study breakout sessions during the 2015 Healthcare Analytics Summit this September.

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