Quick turnover of physician groups raises red flags for ED managers

Strong communication, planning can help ensure group continuity

That was quick . . . In late November 2004, Methodist Hospital in St. Louis Park, MN, replaced its existing emergency physician staffing group, Emergency Physicians Professional Association (EPPA), with EmCare, a Dallas-based corporation providing services to more than 300 hospitals in 37 states. On Jan. 20, 2005 — a mere 61 days later — Methodist announced it was re-establishing its relationship with EPPA.

The short but event-filled reign of EmCare involved problems with inadequate staffing, according to Methodist in a press release announcing the EPPA re-hiring, and a lawsuit against Methodist. The lawsuit was brought by the Milwaukee-based American Academy of Emergency Medicine (AAEM), which claimed corporate entities such as EmCare violate state law.

The reasons for the initial dismissal of EPPA are less clear, with the parties directly involved reluctant to talk now that EPPA is back on board. However, sources have told ED Management that Methodist was seeking to move to an all-employee staffing model.

As for why EPPA was brought back, "My understanding is the most compelling reason cited by the hospital for reentering negotiations with the original group was that after the original group left, insufficient numbers of board-certified emergency physicians were credentialed to provide for the needs of the emergency department," notes Robert E. Suter, DO, MHA, FACEP, current president of the Irving, TX-based American College of Emergency Physicians (ACEP).

Regardless, the implications for ED managers extend far beyond one hospital in Minnesota. For one thing, observers note a growing trend toward providing physician services with larger corporate entities such as EmCare. The use of all contracted services, especially physician services, has implications for ED managers and ED medical directors. The short stay of EmCare also points to the potential volatility of changing groups, which can affect not only job security and morale, but quality of care as well — if adequate staffing is not maintained.

ED management experts agree that contract service failures, such as the one in Minnesota, can be avoided if physician and nurse managers maintain clear communication.

"I’d have to say the biggest issue in changing contracts from a nurse director’s perspective is clearly the lack of communication. The hospital and the physicians were not in agreement on the overall goals and objective, or the goals were unrealistic," says Diana S. Contino, RN, MBA, a consultant for MedAmerica, a Laguna Hills, CA-based emergency physician management company. "To a physician’s group, the hospital is a customer, and if they really pay attention to what the hospital needs and wants for the patients, they have a better chance for longevity," she explains.

Suter agrees. "If you are in an existing [contract] situation, the best strategy is prevention," he advises. "Maintain a good dialogue with the hospital, and make sure the members of your physician group participate to the extent that your group is indispensable to the overall success of the hospital." (ACEP has a document available on how small groups can get and retain contracts. See the resources, below, for information.)

Transitions are never easy

From the point of view of the physician or nurse managing an ED, continuity of staffing almost always is preferable, Suter says. "These transitions are always difficult, always stressful," he notes. "It’s not an experience you want to go through."

From Contino’s perspective as a former nurse director, all of this can be averted if the nurse director/hospital executive team and the medical director have open and honest communication and work effectively as a team, she says. "If you agree on the performance criteria the hospital has chosen, and if you work together, oftentimes, you do not end up with unplanned loss of contract issues," Contino says.

More and more, she adds, nurse directors are gaining a voice in the contract process. "CEOs, COOs, and vice presidents trust the input and suggestions of a results-oriented and effective department director," Contino asserts.

It’s important to do all you can to maintain continuity; changes made in an atmosphere of divided loyalties can have a lasting impact on an ED, Suter explains.

The people who stay may not be very happy about the fact that the contract turned over, he notes. "For example, the nursing staff may be mad at the new group because their favorite doctor’s not there anymore," Suter says. These changes are so difficult that they should never be entered into lightly, he says. "You should try work to through your problems and work with the group that you have."

The reality, of course, is that, ultimately, it is the hospital administration’s decision; the ED manager, however, must deal with the consequences. "If the hospital is very clearly moving in a certain direction, try to work with this as much as possible," Suter advises. "You could try to convince the hospital [administrators] that this is not what they really want to do; but if you can’t, then at least shake out any goals you see as incompatible [with optimal ED operations.]"

Another element of which you should be keenly aware, he says, is the time of year the turnover is occurring. "It’s never as easy to staff an ED with physicians as you think it will be, especially if you have short lead time, and especially in winter," he notes. "The reality is there are not many emergency physicians who tend to move in the middle of the school year."

If your hospital has made an absolute determination to turn its ED physician contract over, "you want to do it in July and make sure whoever is going to staff your ED has at least six months to move," Suter asserts. "Most people they bring in will be straight out of residency, and there’s a good chance they have kids [who] they do not want to take out of school."

In other words, he concludes, "you should choose precisely when your contract will turn over."

Suter’s advice to nurse managers or staff ED managers? "Make your CEO aware of [the importance of timing]," he says. "Get on your knees and beg them not to do it in the winter."


For more information on ED contract turnover, contact:

  • Diana S. Contino, RN, MBA, Consultant, MedAmerica, Laguna Hills, CA. Phone: (949) 461-5200. E-mail: ContinoD@MedAmerica.com. Web: www.medamerica.com.
  • Robert E. Suter, DO, MHA, FACEP, President, American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038-2522. Phone: (800) 798-1822. E-mail: rsuter@acep.org.

For a free copy of the American College of Emergency Physicians (ACEP’s) Obtaining, Maintaining and Retaining an Emergency Department Contract, go to ACEP’s web site: www.acep.org. In the "search" box, type "obtaining, maintaining contracts." Then click on the link, "Obtaining, Maintaining, and Retaining an Emergency Department Contract."