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“Be not afraid of greatness. Some are born great, some achieve greatness, and others have greatness thrust upon them.”

William Shakespeare, Twelfth Night, poet and playwright (1564-1616)

The healthcare sector is undergoing dramatic and disruptive change. National leaders and the pressures of the marketplace are mandating the provision of higher quality, lower cost care to an aging population. Like the quote from Shakespeare, survival and success during these uncertain times require strong leadership and collaboration among all healthcare providers. Emergency department (ED) leaders must approach these transformative changes with a steady nerve, sustained ingenuity, and a willingness to creatively embrace a new landscape while casting aside what is more familiar and comfortable—the status quo.

ED leadership and management must continuously assess, adapt, and redesign their approach to patient care and management. One constant is that EDs continue to grow in importance to their patients, communities, hospitals, and the entire healthcare system. While the ED does serve as a public “safety net,” it also is “the front door of the hospital” and healthcare system. More than 125 million patients are seen in EDs annually, with 38 million injury-related visits.1

A 2013 RAND corporation research report considered the value of the ED in the healthcare system.2 Though ED care is sometimes referred to pejoratively as “the most expensive care there is,” this overly simplistic view “ignores the many roles that EDs fill, and the statutory obligation of hospital EDs to provide care to all in need without regard to their ability to pay.” The ED has become the most frequent point of entry into inpatient care. There are fewer patients directly admitted from primary care physician (PCP) practices as PCPs increasingly rely on EDs to perform “complex diagnostic workups and [handle] overflow, after-hours, and weekend demand for care.” The report goes on to recognize that the physicians and nurses staffing the EDs “are increasingly serving as the major decision-maker[s] for approximately half of all hospital admissions in the United States.”

With approximately one-third of US health care dollars currently spent on patients admitted to hospitals,3,4 it is no surprise (and appropriate) that emergency care providers, and the care they administer, are increasingly scrutinized. Their decisions have substantial financial implications for bulging healthcare expenditures. On the current growth path, some would argue that healthcare costs might “bankrupt America.”5 All ED leaders are obligated to actively engage in the healthcare debate, and in so doing analyze their services, ensure increasing value, institute evidence-based best practices, provide a considerate and caring environment, build transparent and meaningful information systems, and inspire teams of caregivers to provide excellence. ED leaders must go beyond meeting critical metrics; rather, they must create a team that consistently delivers “acts of kindness … the highest level of compassion … one patient at a time.”6-7

To lead and manage EDs requires a deep understanding of systems and of delivering change across boundaries. According to Drucker, “The hospital [is] altogether the most complex human organization ever devised.”8 The ED, responding to the broadening needs of its numerous stakeholders, is an intricate, adaptive system that is certainly the most complex area of care within the hospital. The responsibilities of ED care have grown exponentially, resulting in previously unseen review and growing expectations by the myriad stakeholders. Caregivers must always focus on the patients and their families while administering care with competency, transparency, and compassion. “Getting it right” while carefully managing resources in a capacity-constrained environment is made more complex because of multiple factors, among which are

• Rapid advances in clinical care and medical technology
• Increasing access to multiple costly diagnostic tests
• Limited access to primary care
• Over-utilization of resources to avoid risk
• Patient lifestyle decisions leading to increasing illness (eg, obesity, diabetes, etc)

The purpose of this text is to help ED leaders respond to the complex and evolving environment by organizing the contained information into a unified body of knowledge. The intent is to provide both the broad philosophic concepts and the granular tools and techniques that illustrate pragmatic solutions through best- and evidence-based practices. Each chapter is intended to make the difficult job of ED leadership and management easier. The book is organized into 12 sections:

• Leadership Principles
• Operations: General
• Operations: Flow
• Operations: Emergency Department Specialization
• Operations: Informatics
• Quality and Service
• Finance
• Reimbursement
• Contracts
• Legal and Regulatory Issues
• Malpractice
• Human Resources

The chapters in this book convey the bedrock ideas and methodologies necessary for successful leadership and management. Each of these chapters goes beyond “theory” and provides a rich number of examples to practically illustrate the concepts. Many chapters outline the process of hardwiring excellence into the fabric of the organization. These sections and chapters cover the broad array of logistics and operations of an ED. Many chapters delve deeply into the multifaceted interactions and relationships among the various leaders and departments necessary to deliver coordinated and competent patient care. Above all, the chapters provide practical guidance to those ED leaders attempting to address the challenges of delivering flow in a rapidly changing, capacity-constrained environment.

The mission of this book is to develop and enhance the skills of those leading and managing ED services. The text is designed to support the ED and its caregivers—emergency physicians, nurses, department directors, administrators, and other staff members—in the provision of those services. It is our privilege as editors to provide a resource to assist in that endeavor.

Robert W. Strauss
Thom A. Mayer

REFERENCES

1. http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed June 27, 2013.

2. Morganti KG, Bauhoff S, Blanchard JC, et al. The Evolving Role of Emergency Departments in the United States. Santa Monica, CA: Rand Corporation, 2013. http://www.rand.org/pubs/research_reports/RR280.html. Accessed May 23, 2013.

3. http://www.nytimes.com/2013/05/21/business/half-of-hospital-admissions-fromemergency-rooms.html?_r=0. Accessed May 21, 2013.

4. http://money.cnn.com/2012/07/12/news/economy/health-care-costs/index.htm. Accessed July 15, 2012.

5. http://www.forbes.com/forbes/2011/0314/health-care-recession-expenditure-bankruptamerica.html. Accessed March 24, 2012.

6. Feinberg D. CEO UCLA Hospital System in a speech delivered to TEDx uploaded to youtube.com August 2, 2011. http://www.youtube.com/watch?v=cZ5u7p-ZNuE. Accessed November 11, 2011.

7. Michelli JA. Prescription for Excellence: Leadership Lessons for Creating a World-Class Customer Experience from UCLA Health System. Co-published by McGraw-Hill Companies and Second River Healthcare Press, Bozeman, MT; 2011.

8. Drucker PF, Classic Drucker. Harvard Business School Publishing Corporation, Boston, MA; 2006: 54.

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