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The most significant determinant of the financially successful emergency department (ED) is its payer mix. With sufficient revenue even the most poorly led and managed ED can be financially successful. Alternatively, financial success will be much more difficult with high levels of private pay and underinsured government entitlement program patients in even the most efficiently run ED. It takes money and vision to attract the best leadership and clinicians, to adequately support them, and to keep the physical plant up to the standards of the day. Unfortunately, the number of these type EDs is declining as average reimbursement declines. Between 1990 and 2009, the number of nonrural hospital EDs declined by 27%.1

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At the other end of the spectrum are those EDs that cannot continue to exist without a hospital subsidy. The number of these dependent EDs is growing as reimbursement declines. In the presence of a subsidy every expense is seen as adding to the economic shortfall and therefore it is more difficult to obtain dollars for leadership, training, and innovation. Financial success in these EDs is measured by being able to continue to function without an increase in the subsidy amount and “making due with less” is the rule. In these EDs, a lower subsidy while providing the same or improved services is considered a financial success.

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This chapter primarily focuses on those EDs in between the extremes, ie, there is enough revenue to fund the activities required for success and there is a strong commitment by leadership, physicians, and nurses. The same principles described in this chapter apply to the EDs on either end of the spectrum, but for the purposes of this discussion, the chapter will focus on ED attributes, metrics, and leader efforts that have the most profound positive outcomes.

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The success of an ED can be measured in many different ways—economically, the quality of the care, community reputation, patient safety, patient satisfaction, and so on. EDs do not achieve success by doing a few big things right, but rather through attention to detail and actively managing hundreds of small issues. These details might be as big as the average number of billable relative value units (RVUs) per hour of provider staffing cost or as small as the color of the cap on the urine sample that tells the lab technician that this is a stat test.

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No 2 EDs have the same collections per visit, provider RVUs per hour, or nurse staffing ratios, but all successful EDs share a set of common attributes characterized by standardized processes and attention to detail.

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Superior Leadership

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Other than payer mix, an ED's financial success depends more on its leadership than anything else. The medical director and nurse director must share and demonstrate respect for one another and share a set of common values and goals. They must both be committed to zero tolerance for ...

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