11 Performance-Based Compensation for Emergency Physicians Improves Adherence to Interventions Focused on Reducing Emergency Department Length of Stay

Abstract

Study Objective: Process flow mapping identified the interval from completion of the emergency physician evaluation to the time a patient leaves the emergency department (ED) as a significant contributor to ED length of stay (LOS) and boarding at our institution. In an attempt to shorten this period and decrease overall LOS, we evaluated the effect of an intervention whereby emergency physicians entered holding orders for stable adult inpatient medicine patients following discussion with the appropriate admitting service. While use of the holding orders resulted in a 60-minute reduction in ED LOS, emergency physician utilization of the holding orders was only 9.4% during the first 11 months of availability. We hypothesized that implementation of a performance-based compensation measure evaluating holding order utilization would motivate physician behavior change in this area. The aim of this study was to assess the effect of the implementation of a performance-based compensation measure on the rate of physician adherence to holding order utilization. Methods: For this prospective, observational study, the rate of holding order set usage was evaluated pre-and post implementation of the performance-based compensation measure. Emergency physicians at an academic tertiary care referral center ED were educated regarding the new compensation measure via electronic mail and at a scheduled faculty meeting. Written performance feedback for individual physicians was also provided. Utilization rates were compared using the chi-squared test and pre-and post implementation median times for patients who did and did not receive ED-based holding orders were compared using Mood's median test. Results: During the 12-month study period, 10,462 adult admitted patients were eligible for emergency physician-initiated holding orders, 9498 prior to and 964 following implementation of the compensation measure. ED-based holding orders were used in 895/9498 (9.4%) cases in the pre-implementation phase and in 152/964 (15.8%) cases during the post-implementation period, χ2=38.42, df=1, p<0.001. The median time from completion of the emergency physician evaluation to placement of an admitting bed order was 37 minutes (IQR 18, 72) for those patients receiving ED-based holding orders and 87 minutes (IQR 49, 135) for those without holding orders, p<0.001. In addition, the median ED LOS for holding orders patients (459 minutes; IQR 330, 538) was significantly shorter than the median LOS for patients without holding orders (500 minutes; IQR 340, 570), p<0.001. Conclusion: In this population, adherence to emergency department-based quality improvement interventions was more effective following the implementation of individual performance-based compensation metrics. We observed increased utilization of relevant ED-based holding orders, a reduction in the median time to bed order placement, and a reduction in overall length of stay following implementation of this performance-based compensation measure. We conclude that performance-based compensation can effectively augment ED-based quality improvement strategies focused on improving patient throughput.