Rx for Emergency Care

by Vijay Govindarajan and Srikanth Srinivas

If you had an emergency tomorrow, say a stroke, chest pain, dislocation, or a fracture, what do you think are your chances of getting quality emergency care?

Not very good. According to the American College of Emergency Physicians (ACEP), the overall rating for the nation is a near-failing D+, with not a single state earning an A.  Even worse:

  • The national rating has deteriorated from a C- in 2009
  • Almost 50 percent of the states have an F for ‘Access to Emergency Care’
  • 20 percent of the states have an F for ‘Quality and Patient Safety’

You wouldn’t be happy with your child if they came back with such grades; and yet we have been accepting failing grades from a critical, front-line element of our healthcare system for years. Our emergency care needs emergency care.

With 136 million emergency visits a year – growing at twice the rate of population growth – and emergency room capacity shrinking at the same time, there is no letup in sight. While many emergency physicians chose the profession because they wanted to care for patients and make a difference, they are unable to live up to that vision. To quote the American College of Emergency Physicians (ACEP), “Emergency physicians work in a stressed system that operates in a near-crisis situation.” There is a dire need for disruptive solutions.

Fortunately, emerging role models are showing that such disruptive solutions are within reach. Take Adeptus Health, the holding company that operates First Choice ER, Dignity Health ER and UCHealth ER, for example. The company’s innovative model for delivering high quality emergency care is built on:

  • Convenient access: Adeptus Health’s facilities are integrated within communities and designed to provide more access to emergency care, as they have a small footprint and thus many more of them can be opened with less distance for people to travel.
  • Focus: The company’s state-of-the-art equipment is designed for precision and speed needed for emergency care, such as labs that can give results within 15 minutes, CAT scanners, portable x-ray machines to take to the patient and flexible chairs that can convert to beds.
  • Lean, Patient-centric design: Facilities are designed with the patient at the center, for a flow from reception to diagnostics and testing to the room where the patient can be seen, designed with parallel processing in mind. This design plays an integral role in expediting data; in less than 30 minutes all of the diagnosis data is in the physician’s hands, without the patient having to wait around.
  • Lean cell style staffing: Every facility has small, tight-knit, self-directed teams made up of a facility manager that has been a nurse before, an emergency physician, radiologist, and reception staff – all highly skilled people that are hand-picked and trained to work well as a team, supplemented by on-demand staff as needed for peak times.
  • Employee satisfaction: Adeptus Health Chairman and CEO Thomas S. Hall believes that employee satisfaction is key to patient satisfaction. Says Hall: “Patients show up when they need care. So it is meaningless to hold the facility staff accountable for number of patients, revenues and profitability. We ask them to focus exclusively on delivering the highest quality emergency medical care. It is management’s job to create a climate where employees are happy, and to take away all distractions so they can focus on the patient.”
  • Counterbalancing the ‘rush’: With this focus on patient care in mind, there is a consistent staffing model to ensure team members don’t feel rushed and patients get the attention they deserve. (There is more to it than meets the eye on this one. See the Good Samaritan study.) Explains Ruth Reynolds, RN who manages the Colleyville center: “I wanted to be in this profession so I could care for patients,” said Reynolds. “I have never been able to do this before in any of my previous jobs. Here, for the first time, I am able to focus exclusively on this, without any distractions. And this ripples through to my entire staff.”
  • Collaboration: A culture of cross-functional and cross-facility collaboration at facilities is key. In-person monthly meetings include all facility managers and primarily focus on continuous improvement, ability to get medicines and supplies from a nearby center in emergency situations, spot check-ins, and sharing staffers across facilities as needed.
  • Follow-up: Attending physicians call the patient personally a couple of days later to address any questions and make sure the patient has settled well.

Hall explains: “By creating more convenient access to the highest quality emergency medical care and environments where our team can optimally serve our patients, we are part of the solution that is transforming the delivery of emergency medical care in the U.S.” The Adeptus Health model seems to be resonating with patients, employees and even investors, with some impressive results:

  • Adeptus Health facilities far exceed the 95th percentile in patient satisfaction nationwide, earning the company Press Ganey’s Guardian of Excellence awards in 2013 and 2014
  • Average wait time is less than five minutes, [versus more than an hour in a typical ER department] with patients being seen by physicians almost immediately and x-ray, CAT Scan, blood work results ready for review in less than 30 minutes
  • Energized employees able to focus on patient care have named Adeptus Health one of the “Best Companies to Work for in Texas” in 2015
  • The Adeptus Health model is proving highly scalable – patient and employee satisfaction have remained consistently high even as the company has undergone rapid expansion, growing from one to four states and more than tripling its number of facilities and revenues over the past two years, with another strong quarter.
  • Investors have taken note; since going public in June 2014, ADPT’s shares have more than tripled in value.

But, challenges remain:

  • Penetration: In spite of the growth we highlighted, players such as Adeptus Health still account for far less than even one percent of ER visits. While the path has been illuminated, there is still a long way to go.
  • Awareness: There is a need for more education and awareness of the difference between urgent care centers, freestanding ERs and hospitals so people use resources wisely and go to the right care setting. Some patients are frustrated when they go to a freestanding ER for non-emergency care and end up paying much more than if they had gone to an urgent care, while many others don’t even know that freestanding ERs can offer a high-quality, convenient alternative to often overburdened, traditional hospital ERs. Some insurers, like Blue Cross Blue Shield have recognized the problem and have created educational materials to create this awareness.
  • Policy: Many state regulations ban ambulances from taking patients to a freestanding ER, even if it is closer, better equipped and is likely to take care of the patient with a higher satisfaction and with less wait times.

While there may be a long way to go, Adeptus Health is a good example of an organization that’s successfully disrupting emergency medical care – something that is urgently needed to address the nation’s problem regarding patient access. The right prescription to solve the problem involves using a combination of innovative commercial operators, education and awareness, policies, and the right set of incentives. We’re looking forward to seeing what’s to come in the freestanding ER space and, in turn, are hopeful that this new model can make a nationwide impact on saving lives.


Vijay Govindarajan is the Coxe Distinguished Professor at Dartmouth’s Tuck School of Business and a Marvin Bower Fellow at Harvard Business School. He is the author of Three Box Solution: A Strategy for Leading Innovation, HBR Press, April 2016.

Srikanth Srinivas is the CEO of Rapid i2i, a company that helps employers reduce healthcare and workers compensation costs.

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