To get patients in and out of the emergency room faster, ER doc Ed Bessman applied his MBA training. It worked.
Ed Bessman faced big challenges. As chair of the Department of Emergency Medicine at Johns Hopkins Bayview Medical Center, he was running an overflowing emergency department that served Baltimore City and Baltimore County.
Thirty percent of the hospital’s visitors had no health insurance, and 25 percent were Medicaid beneficiaries. Too often the place was so packed that patients had to wait in beds lining the hallways and ambulances had to be diverted to other hospitals. His team was handling 52,000 patient visits per year in a facility built for 34,000.
Bessman needed to provide quality patient care, manage a staff, justify budgets, and negotiate with hospital administrators who spoke a business language that was foreign to him. He was making many decisions by the seat of his pants. “All through medical school and postgraduate training we get no business training at all,” Bessman says.
As a result, doctors who move into management are not prepared to negotiate or understand their role within an organization, he says. It becomes too easy for hospital administrators to leave the clinicians out of their discussions, or as Bessman puts it: “You clinicians sit in the corner and color while we talk about important things.”
Then he started dating Ruth Stachura, who was earning her MBA at the Carey Business School. Her textbooks fascinated him. He constantly read over her shoulder and asked her to share articles, especially on economics. In one group project, she explored the opportunity cost of emergency department overcrowding; he became an unofficial consultant on the project. “I remember discussing it [during] a road trip,” he says. “While she was driving, I scribbled down a formula for estimating the revenue lost due to boarding inpatients in ED beds. Pretty exciting vacation conversation, don’t you think?”
“Boarding” means holding patients who’ve been admitted to the hospital in the emergency department for prolonged periods. Like a breakdown in an assembly line, boarding impedes the efficient movement of patients through the system for treatment and admission or discharge. According to Bessman’s road-trip calculation, boarding cost Bayview $6.8 million in 2006. And he had plenty of other examples—inside and outside his department—of processes that kept patients logjammed in the ED longer than they needed to be.
He wanted to make changes, but he needed to make his arguments in a way that would persuade business-minded administrators. So in 2007 he took Stachura’s advice and enrolled in the Carey Business School’s MBA program for medical professionals. Ever since, he’s been applying what he learned to bridge the divide between the medical side and the business side. He’s partnered with colleagues to tackle the ever-pressing issue of patient wait times by designing a new process to admit patients more quickly, developing an electronic triage system, and changing how certain injuries are handled. And he has not shied away from offering his two cents on how other departments do their work.
The biggest reason for crowding in most emergency departments is a lack of beds for patients when they need to be admitted. About 25 percent of Bayview’s emergency room patients are admitted to the hospital. When there are no beds available in the intensive care unit or Department of Medicine, or there is a bottleneck at any of several other points—radiology, lab services, pharmacy— the emergency department feels the pain, and so do other departments. Eric Howell, head of the Bayview hospitalists, remembers being sent down to deal with emergency department flow issues when he became chief resident in 1999. “Ed and I had a very adversarial discussion,” he recalls.
“It was a turf issue,” Bessman explains. At the time, when patients were to be admitted from the ED, a medical resident from the department where the patient was heading—General Medicine, Surgery, the ICU—would have to come down to assess the patient, basically to vet the decision made by ED staff. “This routinely resulted in delays.” Bessman proposed abolishing the practice. Disinviting residents, however, was seen as a hostile maneuver. “Eric, as chief resident, was duty-bound to protect their interests.” So Bessman shifted the conversation, focusing the problem on the patients’ perspective and the need to get them out of the ED efficiently. He also pointed out that having residents come down to the ED was a waste of their time and offered no educational value. He even proposed that they evaluate and publish results of any procedural changes they made, an appealing idea within an academic medical center.
“For me, it was a turning point,” Howell says. From that moment, he and Bessman built a relationship that has allowed them to take risks, many of which have paid off, he says. And when a risk doesn’t pay off, they have enough trust in each other to move forward. First they tackled the boarding problem, devising a process they call active bed management. The goal was to build a seamless interface between the emergency department and inpatient units to get patients where they need to be as quickly as possible. For each 12-hour shift, a single hospitalist handles triage. That person is in charge of assigning and transferring patients throughout the hospital, checking in with the ICU, and keeping on top of where patients admitted from the ED will go.
“We needed to increase the number of hospitalists. They wouldn’t be doing patient care, just captaining the ship,” Bessman says. “It’s an expense.” So he and Howell made a business case for why the investment would pay off. They explained to hospital administration that adding staff would enable them to recoup the expense twice over. They were given a year to prove themselves right.
Convincing other department heads to buy in was still a hard sell, Howell recalls. To make it work, other physicians had to give the hospitalist the power to decide whether a patient is admitted to the hospital, known as admitting privileges. Many of the ICU leaders didn’t want someone outside the ICU to triage patients from or to their unit. But Bessman made it happen. “Ed is very good at holding people accountable in a way that’s not threatening,” Howell says. He can engage leaders in other departments, be supportive of those leaders, but not lose focus on the important issues. “He’s hard on the problem but not hard on the people.”
Howell, Bessman, and colleagues published their results in 2008 in Annals of Internal Medicine, comparing a four-month period of active bed management with the same four months the year before. During the study period, the emergency department took care of 1,400 more patients and those who were admitted waited 98 fewer minutes—from seven hours to roughly five and a half hours—for a bed. The average academic medical center takes seven to 10 hours to admit an ED patient. In a year’s time, Bayview saw 8,000 more patients in the ED under the new system. With 25 percent of patients from the ED being admitted to the hospital, that’s 2,000 new admissions each year. Admissions equal revenue. “We more than recouped the investment in the program,” Bessman says.
Ambulance diversions—a revenue drain for a hospital plummeted as well. When a hospital is overloaded, the emergency department will notify the central emergency medical system that it has no room for more patients. Ambulances then transport them elsewhere. It’s not good for the patient and it’s bad business for the hospital. In 2006, Bayview had more than 900 ambulance diversion hours per year. Since active bed management has been in place, diversions have dropped closer to 100 hours a year.
The bed management system removed loads of red tape and turf battles, but there was still a tremendous amount of back-and-forth via telephone and paper. SoBessman worked with Kittane Vishnupriya, a Johns Hopkins assistant professor of medicine, and Michael Bartlett from Bayview’s information services to do away with pen and paper and make the system more transparent. They developed E-triage, a Web-based program that allows faster, more reliable information exchange between the ED’s attending physician and the hospitalist. The triaging hospitalist can sit at any workstation to see who the ED wants to admit, read the patient’s details, and quickly scan where the open beds are and which departments are overloaded. “It’s made life better for the hospitalists,” says Vishnupriya. “It was taxing to do the triage shift before. It’s still very busy, but much improved.”
Within the Johns Hopkins Medicine system of six academic and community hospitals, there are five acute care emergency departments. One other has adopted the active bed management protocol and two more are looking at it, according to Bessman. About a dozen other hospital leaders have come to Bayview to hear how Bessman and Howell do it. “We all drool over Ed’s situation and scenario,” says Jennifer Abele, medical director and chair of Emergency Medicine at Sibley Memorial Hospital in Washington, D.C., part of Johns Hopkins Medicine. “He and his lead hospitalist see eye to eye, and that’s the key. They’ve coordinated a great process that everyone has bought into. If Ed says a patient needs to be admitted, the hospitalist says, ‘Let me do what I can to pull him upstairs.’”
Every hospital, however, differs in its climate, processes, and obstacles. “What works at one site doesn’t always work at another,” Abele says. For example, Sibley doesn’t have enough admissions to justify stationing a hospitalist to oversee flow within the hospital, she says. Her group has incorporated a few of Bayview’s processes, with some positive impact, she says. “You take what works for your environment and try to implement it,” says Barton Leonard, director of the emergency department at Suburban Hospital in Bethesda, Maryland, also a part of Johns Hopkins Medicine. After meeting with Bessman, Leonard’s group opened a clinical decision unit for patients who need to be observed, but not necessarily admitted. It’s similar to the observation unit that Bessman has designed for Bayview’s expansion. Suburban implemented the CDU in September 2012 with success. “We were hovering at about 7.5 hours for our length of stay for admitted patients. Now we’re under six hours,” Leonard says.
By focusing on metrics, Bessman has been able to tweak several factors that affect emergency department throughput at Bayview. “He’s always excelled at taking care of individual patients of all types,” says Hardin Pantle, who did his residency in the Bayview ED under Bessman and is now vice chair of the department. “But over the past couple of years, he’s had a new focus on the patient population in aggregate.” He’s been seeking data to define what the system does now, to measure the impact of new procedures. That’s led to changes in radiology and pathology, as well as how the ED treats broken bones. “The radiology department has put in place a number of process refinements to shorten the time it takes for radiologists to interpret imaging studies so we can act upon that information,” Pantle says. Radiology recently announced that 98 percent of its studies are being reported in less than an hour. “That’s a considerable improvement compared to a year ago,” he says. The pathology department also sends lab results to the ED more quickly. “The common theme through all these efforts is trying to wring efficiency out of all aspects of the system while making sure that patient care is always the guiding light,” Pantle says of Bessman’s efforts.
Patients with certain kinds of broken bones may be benefiting from these efforts. In 2011, emergency department leadership worked with orthopedics and hand surgery to create a new process for dealing with fractures. Historically, a patient would have an X-ray, the injury would be identified, and a splint applied. Then emergency department staff would call orthopedics or hand surgery. A resident eventually would arrive to see the patient and get contact information for follow-up in the appropriate fracture clinic. It was a drawn-out process. Now certain fractures are splinted in the emergency department, and the patient is discharged without a consult. Patient information is entered into an online database. The appropriate fracture service reviews the X-rays and information the next morning, and can call the patient if a follow-up visit to the clinic is deemed necessary. “We feel the new system is faster,” Bessman says, and he has a Johns Hopkins medical student collecting and analyzing data to verify that. If the system works, Bessman hopes to apply similar changes to consults beyond orthopedics.
The result will be a three-story building, to be completed in 2014, that will boost capacity to 75,000 patient visits per year. The facility will include extra emergency department space, a new observation unit for people who need a 24- to 48-hour extended stay for extra testing or observation but don’t need to be admitted to the hospital. They are considered outpatients and remain under the care of ED staff. The building will also house a combined emergency and inpatient unit for pediatric patients.
When he’s not at Bayview, Bessman often can be found outside having vigorous fun. He competes on Bayview’s triathlon team, the Bayview Killer B’s. And he’ll ride any board he can get his hands on—skateboard, surfboard, paddleboard. An avid surfer since childhood, Bessman taught his four kids and Stachura’s daughter how to ride the waves. He’s eagerly awaiting the release of a sturdy inflatable surfboard (he says current inflatables aren’t up to snuff) so he can pack one whenever he travels.
That adventurous side, along with his rescuer mentality, led Bessman to become a member of one of the 28 Federal Emergency Management Agency urban search and rescue teams. After Hurricane Sandy ripped through New York and New Jersey last October, he and members of nine other FEMA teams knocked on 47,000 doors over 10 days to assess structural damage and make sure the occupants were unharmed. Task force members are trained to find, support, and rescue people trapped in tight spaces. Bessman, as one of two medical staff on the team, is also there to keep the other members, including the search dogs, healthy. “Ed is very understated about all this stuff,” says longtime colleague Pantle. “He’s done some really remarkable things with FEMA.” He searched room to room for survivors at the burning Pentagon on 9/11. In what he called the most disturbing work he’s ever had to do, Bessman sifted through the rubble of the day care center in the Murrah building after the 1995 Oklahoma City bombing.
For all his seeking of adventurous experiences outside Bayview, Bessman, who has been at Johns Hopkins since 1992, likes to help other physicians see the value of an MBA to a career spent in one place. “My point of view is that it helps even if you’re not planning to use it to start a new career or go in a different direction,” he says. “Especially for physician leaders in an academic center, having a business education makes you better at your current job.”