How Great Emergency Nurses Impact Patient Experience

Emergency Nurse

It’s been quite a year for nurses working in emergency departments (EDs) across the country. From the opioid epidemic to the mental health crisis, emergency nurses have had to confront more than their fair share of difficulty. And they do it all while exceeding the high expectations placed upon them by the healthcare industry and the community in which they serve.

The responsibility faced by emergency nurses is immense. They not only have to perform lifesaving procedures on a daily basis, emergency nurses also have to ensure each patient that walks through the door has the best experience possible.

As we celebrate Emergency Nurses Week, it’s important for ED leaders to realize just how instrumental these team members are to the patient experience. How exactly do they do it?

Nurses Lower Stress While Juggling Multiple Patients

Especially noteworthy is how emergency nurses are able to make a positive impact on the lives of patients and their families during stressful times.

The ED isn’t a place most people enjoy or even plan to visit. Visits are often unexpected and can be a great cause of stress for patients and their loved ones. So for emergency nurses to be able to enhance the patient experience given these circumstances — also while caring for multiple patients suffering from varying conditions and all with different personalities and needs — says a lot about the skills theses nurses have at their disposal.  

They Are Master Communicators

For emergency nurses, the ability to communicate effectively is increasingly important and for many, the most important tool. It’s truly the key to a positive patient experience.Effective communication is much more than telling a patient what to do to regarding treatment. It’s being able to listen and connect with patients to understand their concerns, no matter how trivial, and to put them and their loved ones at ease as best one can. Empathy and compassion are important components of effective communication and are invaluable when it comes to making the ED experience one where patients are empowered to have a voice in their care.

Emergency Nurses Manage Expectations

Nurses also play a pivotal role when it comes to helping patients anticipate what to expect. Expectations that aren’t met or grounded in reality given the situation are likely to have a negative effect on a patient’s experience in the ED. This is especially true across the board in stressful situations.

Communication comes into play here again — nurses understand better than most what patients can expect during their visit. When they are able to relay this information in a kind and compassionate way, it will often counter the impact of an extended stay or crowded waiting room.

And for emergency nurses, managing expectations isn’t solely limited to those of the patient, they often play an important role in managing expectations of everyone who enters the ED, from family members to EMTs, all of which shape the patient experience.

In closing, emergency nurses deserve all the recognition and celebration that comes their way this week and beyond. This week should also be a reminder for ED leaders, doctors, patients and their families of just how critical emergency nurses are. They help to provide a positive experience for everyone who walks through the doors of an emergency department. What do you think are some of the qualities that make a great ED nurse? How are you celebrating Emergency Nurses Week? How do you recognize the nurses in your life? Share your ideas and plans below.

Why Higher HCAHPS Scores Don’t Always Mean Improved Quality of Care

Filling in questionnaire.
Man filling in a medical questionnaire.

The most satisfied patients aren’t always the ones receiving the highest quality of care. It may seem counterintuitive, but recent studies and news articles suggest that a patient’s level of satisfaction doesn’t strictly correlate with the quality of care they receive.  

Since the inception of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which measures patient satisfaction and influences Medicare reimbursements to hospitals, healthcare providers have placed extra emphasis on their patients’ happiness. Some hospitals have gone as far as implementing valet service, hiring door greeters and even adopting loyalty programs, all in an effort to please their patients. While a nice touch, these added “amenities” offer little when it comes to actual quality of care. 

Hospitals will soon begin to measure satisfaction among patients within their emergency department with the Emergency Department Patient Experiences with Care (EDPEC) Survey. And just as with their inpatient population, hospitals will face financial repercussions if their ED patients are left unsatisfied. 

When it comes to this new survey, emergency departments will find the greatest cause for concern in regards to their patients’ perception of pain management. Specifically, these three questions:

• During this emergency room visit, did the doctors and nurses try to help reduce your pain?
• During this emergency room visit, did you get medicine for pain?
• Before giving you pain medicine, did the doctors and nurses describe possible side effects in a way you could understand?

If the inpatient experience is any indicator, patients suffering from acute and chronic pain may be disappointed to find that the pain medication they believe they urgently need will be prescribed sparingly or withheld altogether. 

With the growing opioid crisis in the country, many EDs are instituting strict guidelines when it comes to prescribing these narcotic pain medications. They’re turning to alternative therapies, such as acupuncture and even laughing gas, which have proven effective and have less dangerous side effects—think addiction, overdose and death. 

Even with alternatives some patients are set on receiving pain medication, regardless of the consequences. And if they don’t receive them, or are prescribed a limited quantity, the likelihood they’ll express their dissatisfaction in the EDPEC survey will be great. 

In many cases related to the management of pain, quality of care will come at the expense of patient satisfaction. When it comes down to it, the patient’s perception of the quality of care they receive isn’t as important as the reality of the care they receive. However, Medicare reimbursements may be in jeopardy as a result. 

I believe this short quote from The Atlantic sums up the dilemma hospital and ED leaders face:

"Patients can be very satisfied and be dead an hour later."

What do you think? What strategies have you implemented to increase patient satisfaction? Are you confident these strategies aren’t undermining the quality of care your ED provides? I’d love to hear your experience. Feel free to comment, send a message or email me directly at cmd@constancedonovan.com.


Sources:  
The Atlantic: “The Problem With Satisfied Patients.”

AMA Journal of Ethics: “Patient Satisfaction Reporting and Its Implications for Patient Care.”

What Is HCAHPS? Why Is It Important?

WhatIsHCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) usually refers to a survey created by the federal government. It is designed to measure how well hospitals are performing in the eyes of its patients. Generally speaking, it measures patient satisfaction. It’s pronounced “H-caps.”

This year marks the 10th anniversary of public reporting of HCAHPS scores. To celebrate, let’s answer some common questions about it with help from the Centers for Medicare and Medicaid Services’ (CMS) website as our source.

Why Do HCAHPS Scores Matter?

How patients rate hospitals can impact the hospital’s bottom line. Of the things hospitals are measured on, they can face financial incentives or penalties (up to 2 percentage points of their annual payment update) based on whether they report results and how they score in 10 areas. Also, in the new era of hospital Value-Based Purchasing, how hospitals do on the survey accounts for how well they perform in the patient experience of care domain.

What Are Hospitals Measured on?

According to CMS:
■ Nurse Communication (Question 1, Q2, Q3)
■ Doctor Communication (Q5, Q6, Q7)
■ Responsiveness of Hospital Staff (Q4, Q11)
■ Pain Management (Q13, Q14)
■ Communication About Medicines (Q16, Q17)
■ Discharge Information (Q19, Q20)
■ Cleanliness of Hospital Environment (Q8)
■ Quietness of Hospital Environment (Q9)
■ Overall Rating of Hospital (Q21)
■ Willingness to Recommend Hospital (Q22)

How Does the HCAHPS Survey Take Place?

Patients are surveyed by mail or phone. Hospitals can conduct the surveys themselves or hire an outside group to do it for them. The information is collected monthly and reported quarterly. 

How Can I Find Out How Well My Hospital Scores?

You can look up the HCAHPS scores of your local hospital and compare its performance to how hospitals are performing across your state and the country on the Hospital Compare website: http://www.hospitalcompare.hhs.gov 

How HCAHPS Holds Hospitals Accountable

The HCAHPS survey value lies in that it is a standardized measurement tool that makes it easy to compare one hospital to another and because the results are publically available. This type of transparency holds hospitals accountable.

To create the survey CMS partnered with the Agency for Healthcare Research and Quality (AHRQ).

According to them, there were three main goals for creating it were to:

1) “Produce comparable data on patients' perspectives of care that allows objective and meaningful comparisons among hospitals on topics that are important to consumers”

2) “Create incentives for hospitals to improve quality of care” because the results are available publicly

3) “Increase transparency and increase public accountability” because of public reporting

New for 2016

Medicare and Medicaid reimbursements have been influenced about how hospitals score on HCAHPS as a whole for inpatients. This year hospitals will also be held accountable for how well their emergency departments are performing. These scores will begin to affect reimbursements.

If you’d like more information on HCAHPS or talk about ways to help boost your Emergency Department’s scores, contact Donovan & Partners today. We bring to bear more than 20 years of experience in helping emergency departments assess opportunities and set up efficient and cost-effective processes to deliver quality care.

SOURCES:
Centers for Medicare and Medicaid Services: “HCAHPS: Patients' Perspectives of Care Survey,”

“The HCAHPS Survey - Frequently Asked Questions.”

Tips to Set the Scene for Open Patient Communication

We’ve all heard the saying, “There is no such thing as a stupid question.” But how good of a job is your emergency department nursing and medical staff at making patients truly feel that way? Your patient satisfaction and HCAHPs scores are riding on it.

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Healthcare has become consumer driven. Patient satisfaction surveys ask patients if nurses and doctors care about them, if they were given the information they needed to get well, and whether they are likely to recommend your hospital to someone else. Reimbursement is dependent on the effectiveness of our communication and the effectiveness of our treatment.

Here are some tips to help your team in their communication with patients.

1) Make Eye Contact. To engage the patients and families try being mindful to look them in the eye and listen with a caring and warm attitude.  Recognize this first step is the most important in establishing a rapport and this rapport will most likely set flow for the patient’s entire experience.  

2) Use Your Senses. You want to develop a communication style that is adaptive to the situation and patient you’re working with. Look, listen and feel to understand what is being said and not being said. Empathy and acknowledging the patient’s well-being and comfort demonstrate respect.

3) Anticipate. When you listen to understand your patients and their families it helps you anticipate concerns they may have. This can be very comforting. Anticipating involves knowing customarily what, when, why care is a certain way (process) and then thinking about questions the patient might have about the process but be too intimidated to ask. Try making thoughtful remarks such as “Many patients what to know when the doctor will see you”. Then acknowledge that the doctor has several patients and follow-up with information on how quickly the doctor will see them.

4) Try a Different Delivery Style. Think about creating a relationship where patients feel comfortable talking to us. You can create this type of relationship if you understand how to initiate conversations using techniques called “appreciative inquiry or welcoming questions.” These open channels of communication between patients and caregivers. That’s so important because patients have information that is crucial to helping them get better.

Appreciative inquiry involves framing questions in a way that helps you gather relevant information, foster a give and take in communication, and encourage positive action as a result

Rather than just communicating in short questions or commands, it involves asking an open ended question around the topic you want to address. Then you can guide to conversation to impart important information.

This might be a communication tactic which is different than the informative caregiver mode of communication that you’re used to. It’s no secret nurses and doctors are busy caregivers, we often need to make “a long story short” -- get to the point quickly and with technical accuracy. But while that is perfectly OK and actually important in communication between one shift of nurses to the next or between nurses and doctors or PAs, this hospital-speak is sometimes lost on patients.

In addition to being confusing, it often doesn’t create relationships with patients and family that inspire open and effective communication. Patients can become intimidated and are reluctant to ask questions because their nurse or doctor has such urgency.

How to Use Appreciative Inquiry
Here’s an example you might use when talking to a patient before discharge:

“We have a lot of patients that come to the ED for migraines. Have you sought out help for them from the emergency department before?”

This sets the scene in an empathetic way. You appreciate their problem -- the migraine. You set them at ease by letting them know they are not alone in seeking help for their type of problem and don’t feel scolded for it.

If they answer “Yes, twice before,” you can share information that will direct them toward taking positive action going forward. For example, you could then say: “We know about this clinic where you can get help managing your migraines.”

5) Be patient. Keep in mind that when you try this type of approach you may get more questions from patients. For example, a question about how long they can expect their recovery to take might be something you automatically know. But with patients you can’t take for granted that this is common knowledge. Patients and family don’t know what they don’t know, and need guidance to help them ask the right questions and establish expectations.

Remember, there are no stupid questions. Questions are a good thing. It means the patient is tuned in. Asking questions can help them better understand what role they need to take in recovering. Having an ongoing conversation can help you provide the best care.

Being composed, acknowledging, listening to understand, being responsive, knowing, and caring has the potential to engage and create a rapport with the patient and their family which impacts their overall experience. Interestingly, these approaches to communication can increase understanding, focus and efficiency too.

If you’re interested in talking more about communication techniques or making appreciative inquiry something you practice in your ED, drop me a message. I’m happy to talk more about it with you.

Create a Culture of Carefulness and Communication

Last week I mentioned two ways you can boost your patient satisfaction scores. Here's one doctor's perspective on how upping her communication game helps her provide quality care to the patients he sees. It's a good read.

Create a Culture of Carefulness and Communication.jpg

Communication is another area that you can focus on to boost scores. Solid communication among emergency department staff is so important. It influences patients' care and perception of that care.

As she talks about, establishing solid communication at shift changes is key. She also offers his personal tips and tricks for how to do it. Additionally, I love the shout-outs to the nursing staff. Do you have any things that have helped you create a "culture of carefulness and communication" in your emergency department?

This blog has got me thinking. In my next post we'll take a deeper dive into polishing up communication in the emergency department.

How to Decode and Fix Low Patient Satisfaction Scores

Patients have an uncanny ability to pick up on underlying areas that need improvement in your hospital. Do you know how to translate what they’re saying? Learning how to interpret patient satisfaction results is becoming even more crucial because of upcoming changes to Centers for Medicare & Medicaid Services (CMS) scoring.

How to Decode and Fix Low Patient Satisfaction Scores.jpg

Starting next year, your hospital’s overall reimbursement score will be impacted by how well your emergency department does on patient satisfaction surveys. It could cost your hospital a percent of your Medicaid reimbursement.

Here is how to translate some patient satisfaction results into changes for good.

Low score on: Attentiveness of nursing staff

Take a look at: Your staffing ratios and scheduling and rounding procedures

Nurses that don’t have time to spend with patients and satisfaction scores reflect that. Patients report less empathetic nurses when the nurses are harried and pressed for time.

In California, safe staffing laws have stated the appropriate staffing ratio in emergency departments is four patients to every nurse. The closer you are to that ideal the more time nurses have to talk with patients and provide quality care. Not only do patient satisfaction scores rise but outcomes can too.

If you feel you can’t afford new hires, take a look at how you’re doing scheduling. Maybe you can rebalance how staffed up your emergency department is so you’re making the most of the staff you do have and are balancing your staff to workload ratio appropriately.

Another way to boost scores in this arena: take a look at rounding. Are patients being checked on every hour by staff? When you provide scripting for allied health professionals when they complete rounds it makes it easier for the staff and ensures that patients are being listened to and their basic needs are being cared for.

Low score on: Delays in care

Take a look at: Operational efficiencies

How is patient triage upon arrival? Does your staff have processes in place to rapidly assess whether a patient is suffering from a heart attack or sore throat and get them the proper care? Develop processes to provide the right service with the right provider at the right cost. This approach requires developing clear procedures for routing patients efficiently and effectively to the appropriate treatment area and for diagnostics, e.g. x-rays.  Putting specific processes in place creates efficiencies and cuts down on the possibility of a patient languishing in one area and long throughput times.

For more insights into what your patient satisfaction scores are trying to tell you, reach out to me. I am happy to help your emergency department with an assessment that uncovers opportunities for improvement and outlines recommended actions.

Pay Attention to Safety and Caring and Patient Satisfaction Scores Will Rise

Four Areas to Target Including One Surprise

Patient satisfaction can seem like an ephemeral thing. Is there anything tangible you can focus on to boost it?

Pay Attention to Safety and Caring and Patient Satisfaction Scores Will Rise.jpg

Several studies have indicated that yes, yes there is. It is all about getting back to the basics. It appears that by focusing on things that improve safety and caring, patient satisfaction scores will rise as well.

A review published in the British Medical Journal in 2013 looked at 55 studies that measured care and patient satisfaction in several types of healthcare settings. The idea for the review came about in an effort to answer the question: should patient satisfaction even be used as a measure to rate hospitals?

The review found that, higher patient satisfaction scores were often linked to higher safety and clinical efficiency scores.

“Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations,” said the authors.

If patient satisfaction scores were high, the same hospital was likely to have high patient safety and patient experience scores as well.

Results from a Patient Safety and Quality Care survey of studies in 2008 speculated that this might be because the same things that help prevent serious complications, patient identification errors, infections, medication errors and falls also happen to improve patient satisfaction.

What Steps Can Your Emergency Department Take to Improve Safety, Caring and Satisfaction?

There are many things you can do and I am happy to talk to you about a unique plan for your hospital but for the purpose of this post, we’ll take a look at four biggies.

1) Take a look at communications. Make sure you have procedures in place to make communication of patient information easy. Areas to look at? Transfer of information between caregivers, shifts and different departments within your hospital. Looking at your procedures for intake and discharge can be especially effective.

Nursing leaders, you can reinforce the importance of communication in your rounding and bedside reporting to oncoming nursing staff. Modelling this behavior yourself -- leading by example -- can help ensure the whole nursing staff adopts this approach.

2) Make sure staffing coverage meets the demand for patient care.AHRQ’s Patient Safety Network has concluded what most of us know -- nurses are critical in ensuring patient safety. So let’s help set them up for success. Staff that aren’t pressed for time and stressed running from one emergency to the next has the time to provide quality care. Appropriate coverage also minimizes mistakes.

So how can you make this a reality? Experienced nursing leadership knows the wisdom of a data-driven staffing and scheduling approach. You can use healthcare analytics to understand demand and your functional capacity to solve your staffing challenges.

3) Encourage an environment of trust and non-judgmental for reporting errors. Staff is less likely to report errors or perform well when there is a “blame game” type of atmosphere. Patient safety and satisfaction suffer. Fostering the right culture can help remedy this.

A “just culture” -- one that strikes the right balance between openness and accountability -- improves safety without being arbitrarily punitive. The Leapfrog Group, a circle of large employers focused on improving health care safety, has recognized the importance of a fair and just culture in improving safety.

There is a methodology and algorithm you can apply to help you implement this type of culture and spell out guidelines for appropriate actions when errors are made.

 

4) Limit noises to promote healing and focus. This one may come as a bit of a surprise. Patient satisfaction surveys tell us patients are not as happy in loud environments. Studies have found that noise hinders healing, causes sleep deprivation, and increases pain.

So upon a second look -- it also makes sense that chaotic unscripted emergency department noise can compromise safety. Researchers have found that louder healthcare environments produce more medical mistakes. It makes it hard to concentrate, may desensitize staff to important alarms, and interferes with the effective communication between caregivers. The Joint Commission made a National Patient Safety Goal on managing clinical alarms systems in 2014. They recognized that if they are not properly managed, they can compromise patient safety.

To take control of noise you need to understand it. Every interaction, every piece of equipment, every medical alarm, every emergency page, and every phone creates noise. Even patients, visitors and others add to it.  

To solve this multi-faceted problem, engage everyone in pinpointing sources of noise and taking personal responsibility to limit it. Sometimes changes to the physical environment can help too.

So Why Does Improving Safety Yield Other Benefits?

None of the study authors pinpointed the whys behind the link between good safety scores and high patient satisfaction. Perhaps emergency departments that rate well on patient satisfaction measures are also paying more attention to safety rules too.

Or maybe it is because people go to emergency departments to get better. When adverse events are kept to a minimum and safety is a priority, people are more likely to improve and heal. It’s natural that those patients will be more satisfied.

What I do know for sure is that when you invest in improving processes and communication to improve safety and care it can yield a double-win!

If you need help examining safety protocols or your patient satisfaction survey results and finding ways to improve, I can help. Contact me. I’d love to talk over your emergency department’s unique situation with you.

SOURCES:

Patient Safety and Quality Healthcare: “Safety and Satisfaction: Where are the Connections?”

BMJ Open: “A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.”

AHRQ PSNet: “Nursing and Patient Safety.”

Hospitals and Health Network: “Runaway Noise in the Hospital.”

New England Journal of Medicine: “Balancing "no blame" with accountability in patient safety.” Wachter RM, 2009.

The Joint Commission: “The Joint Commission Announces 2014 National Patient Safety Goal.”

How to Boost Emergency Patient Satisfaction and Lower Costs

Happier patients and a better budget? It’s not too good to be true. Whether it’s long wait times or something else dragging down your patient satisfaction scores, you can take steps to give people a better experience. Chances are these moves can be good for your bottom-line too.

1) Slow Down and Listen

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Encourage doctors and other staff to take their time when they talk with patients. This may sound counterintuitive. Slow down when things get stressful and busy? When health care providers keep patients up to date on what they are thinking in their decision making process, patients report a better experience. It can also encourage patients to share information that may help doctors make the right diagnosis and only order necessary tests, saving everyone money. This is especially the case because, by at least one estimate from the Centers for Medicare & Medicaid Services, nearly half of all emergency department (ED) bills go unpaid.

2) Provide Patients With Follow-Up Instructions and Make Nurse Calls

When your hospital staff has information they easily can pass along to patients about how to care for themselves and take prescriptions, it improves the chances of recovery. One study found a link between whether patients get better and their satisfaction. It makes sense. They went to the emergency department to get fixed. Did you help them make that happen? It not, they may wind up in your emergency department again. Repeat visits add costs. This can be especially costly if they are uninsured and unable to pay.

Older patients and people who live alone may benefit from a follow-up call from a patient navigator. These nurses can make sure that patients are following their aftercare instructions. They can also encourage them to seek follow-up care with their primary care doctor or give them information on other places where they can find medical care on an ongoing basis.

3) Develop a Plan to Cut Crowding

This is often the number-one problem emergency departments face. It causes long wait times for patients to be seen and before they can get discharged. That’s often a top patient complaint. Crowding can also compromise quality of care, according to the US Department of Health and Human Services. It also puts strain on the staff.

The best way to tackle the issue of crowding is to make a plan. It’s likely that you can make improvements in a few areas and yield budget savings too by creating efficiencies.

The Agency for Healthcare Research and Quality suggests that you form a patient flow team to examine the whole patient experience process from check-in to discharge. The team should ideally include members from across the hospital. Doing that makes sure no part of the process is left out. Plus, it creates buy-in. When people are involved in the planning, they are better at communicating changes and more likely to follow them.

Once the team is formed, you'll work together to focus on the areas that need fixing and putting your plan into action. Ways to measure if goals are being met and celebration of successes are key to making these plans pay off.

4) Know Your Patients and Hire Allied Health Professionals

Mid Level medical staff members can help patients have a better experience. When an ED is staffed up properly, Physician’s Assistants and Nurse Practitioners can provide timely patient screening and develop a rapport with the patients.

These allied health professionals are especially helpful to evaluate incoming emergency patients and triage them for emergency or minor care. You want to be able to quickly figure out what your patients need and match them with the right providers for the right service. They can also be the ones to provide care for less complicated cases.

Remember that if you do need to make new hires, another bonus is that these health professionals are more affordable than doctors. If you don't feel equipped to make the case for extra staff, you can look to outside consultants to help you pull the right data and produce justification reports. Sometimes spending some money upfront can make savings down the road. Consultants can also help create a patient flow plan.

5) Develop Short-Stay Clinical Services

Not all patients who come in to the ED need to admitted to wait for lab results or stay in a bed to be observed. When it's not necessary, it can feel awkward for the patient and be expensive for them, their insurance company (if they have one), and your hospital.

Under the new healthcare law, Medicare can reduce or cut reimbursements for unneeded stays. Admitting these patients can also take up valuable bed space from someone in the waiting room who really needs it.

Instead, you may want to create two types of waiting areas for patients who have been evaluated but don’t need to be admitted. One can be as simple as a nice waiting room with reclining chairs. Some people call this a results waiting room. Patients who don’t need a bed but are waiting on things like X-ray results can wait here.

The second type is an observational unit or clinical decision unit. Patients who would go here are also waiting on results but may need a little bit of treatment and a bed. However, they don’t need to be admitted upstairs. Patients who need to be watched for things like low-risk chest pain, asthma, or dehydration can stay there and keep costs down.

For more ideas on how to improve patient experience while helping your budget, reach out to us. We'd love to talk about how we can help.


SOURCES:

ECI Healthcare Partners: “How to Cut Emergency Costs Without Compromising Quality of Care,” “Boost Your Patient Satisfaction Scores.”

American Academy of Family Physicians: “What Do We Really Know About Patient Satisfaction.”

Agency for Research Quality and Assurance: “Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals.”

The Centers for Medicare & Medicaid Services: “Reducing Nonurgent Use of Emergency Departments and Improving Appropriate Care in Appropriate Settings.”

Beth Israel Deaconess Medical Center: “Observation Medicine - Clinical Decision Unit.”

University of Maryland Medical Center

The Commonwealth Fund: “Achieving Efficiency: Lessons from Four Top-Performing Hospitals.”

RINPR: “No Easy Task: "Reinventing" Medicaid To Improve Health, Contain Costs.”

American College of Emergency Physicians: “Emergency Department Observation Services.”

The Hospitalist: “Pros and Cons of Clinical Observation Units.”