and to “push people upstairs if necessary.” They also created a red and yellow alert system to expedite discharges. In addition, Parkland established 11 community clinics to provide medical homes for patients and encourage them to seek primary care in places other than the ED. This has resulted in decreased ED use and has saved hundreds of thousands of dollars inneonatal intensive care unit costs as a result of increased prenatal care, Anderson said. However, the clinics themselves still lose $2 million per year per clinic.

To further reduce workload within the ED, the hospital incentivized radiology, pathology, consultative services, “and everybody else” to stop working up patients there. This had become common practice because it is easier to obtain diagnostic tests in the ED than in other parts of the hospital. Parkland also adopted a “pod system” from Detroit Receiving Hospital to increase productivity. Faculty M.D. supervisory time was increased from 68 to 96 hours/day.

The hospital’s goal is to reduce dwell times for patients going home to 4 hours, and 8 hours for those who are admitted. However, Anderson said they would need additional capacity, probably 200 more beds, in order to achieve the latter objective.

Anderson characterized Parkland’s reform effort as systematic and multidimensional. It did not just involve the ED staff, because “[ED crowding] has got to be owned by everybody.” The key is to have the right expectations, set them from the top, and then hold people accountable, including top executives. These tools have allowed them to change what they believed was a very good ED into an even better ED.

REGIONALIZATION AND QUALITY HEALTH CARE

Susan Nedza, vice president of clinical quality and patient safety at the American Medical Association (AMA), said the purpose of regionalization is to improve the quality, safety, and efficiency of care provided in communities. However, this approach has its trade-offs. Regionalization is typically framed in terms of specific disease states, such as stroke. However, focusing only on stroke patients—or on trauma patients—means that other types of patients, such as the elderly woman with undifferentiated disease sitting in the ED waiting room, will not receive the same level of attention. Nedza said we need to think more broadly in terms of community health priorities because these are sometimes different than acute health priorities.

Nedza observed that acute care providers typically focus on individual patients when making decisions about resource allocation. But she said there are also broader considerations that involve the health of the whole community. For example, ambulance bypass protocols that direct heart patients to select hospitals may improve quality for individual patients (for those patients who reach the hospital), but have a negative impact on the



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