Celebrating 40 Years





As I see it





Thomas Zguris


Progress is defined as "the process of improving something over time." Over the last century, mankind has certainly made staggering progress in just about every aspect of our lives. But lately, the lines between actual progress and change for the sake of making or saving money seem blurred. Remember, it is not really progress if the sole purpose is money.

Consider water. Throughout time, mankind has struggled to maintain a source of drinkable water. This often meant carrying it long distances. Today, in developed countries, water is available virtually everywhere with the simple twist of a faucet handle. What do we do in response? We bottle the water, carry it with us and discard the plastic bottle when finished. Progress?

Consider coffee. Historically coffee was one of the most inexpensive pleasures of mankind. It literally cost pennies per cup. What did we do? We elevated it to a status worthy of $3-$4 per cup. Then, we put it in little plastic disposable pods which cost $0.40 per cup versus $0.09 if brewed in a pot. Of course these pods find their way into the same landfills as the water bottles. Progress?

These are just two examples that represent changes in many products that have not made them better. Rather, they have just made someone very rich while damaging our environment. Consider healthcare. We have a network of emergency departments across the country staffed by exceptionally welltrained physicians and nurses and equipped with state of the art technology. Yet, because of high costs, we are looking for alternatives to this model.


Alternatives such as "Minute Clinics" and telemedicine solutions are popping up everywhere. Is this progress?

Some argue that the cost of an ED visit is too high. They are wrong. The cost of seeing one more earache or one more sprained ankle is marginal because everything required for that visit is already there. The lights are on, the doctor and nurse are already on duty and the otoscope or X-ray machine are sitting idle. There is little to no additional cost to take care of these patients. So where is the problem? It's not the cost, but the charges when compared to alternatives. In 1996, a former colleague of mine, Robert M. Williams, M.D., DrPH, wrote an article in the New England Journal of Medicine entitled "The Costs of Visits to Emergency Departments". This article predated alternatives like telemedicine or clinics based in retail pharmacies. Yet the article made the same point. Actual savings from using alternatives to the ED may not be as significant as widely believed.

So, for those of us on the leading edge of Emergency Medicine today, do we accept and even embrace alternatives to the ED? Or do we adjust our delivery model to offer the same excellent care that we already provide but at a more competitive price? The answer probably lies somewhere in between and will inevitably require collaboration with hospitals. Ultimately, the consumer will decide-and patients seem to prefer full-service EDs, as opposed to stand-alone clinics. In this case, perhaps progress is not just in improving something, but especially in protecting something that is already great.



Recipe for Quality

Recipe for Quality How does an emergency department management group like NES Health change the face of an emergency department or the quality outcomes? It's a question that comes up every time we talk with our current hospital partners, sit down for new business development presentations, or when developing strategic plans in the quality department.

When we look across the country at the over 4,000 emergency departments, we would like to think that much of what we do is separated by significant differences in employees, process, and culture. In reality, it's the subtlest differences in measurement that change the entire outcome. My wife once grabbed a container of salt instead of sugar when making muffins for our kids. This may not have been the slightest change in recipe; nonetheless the outcome was completely different than what was expected. Not to mention that my children and their friends held nothing back when declaring how horrible the muffins were, and will tell the story for years to come.

I use this example because I so often compare the practices in hospitals with that of restaurants. I did this often in a prior position during orientation sessions to new employees in order to drive home the concept of service excellence in a way in which people could relate. The good and bad in healthcare is a personal and memorable experience quite similar to the meals we eat. The great dish prepared by your grandmother or the worst meal you've ever had at your hometown eatery create permanent memories, in some ways as much as the birth of a child or the death of a loved one.

This concept was made real to me a couple of years ago when I read an article in The New Yorker magazine titled "Big Med" by Dr. Atul Gawande. It compared the Cheesecake Factory restaurant chain to how we do things in the field of healthcare. It discussed how, if we could model an efficient business aimed at affordable costs and consistent quality, we would get it all right. While I believe this to be true-and have embraced lean methodology, improved efficiency, and customer service along with the rest of the country-it is the right mixture at the right time that yields the looked-for outcome.


While the concept of modeling a successful restaurant or even a successful emergency department should be within reach, the variables that occur from entrance to exit can quickly become staggering. The difference between serving a dish of cold Fettuccine Alfredo or a 7-hour wait for discharge instructions can be but one process out of 1,000 failing, in either example.

Going back to the original question, how does NES Health help to deliver quality outcomes? I don't think I could say that we should model one specific business or restaurant in order to get it right. We do, however, have the right pieces in place to ensure we aren't getting it wrong. The ability to deliver key metrics to both our providers and hospital administrators is crucial to delivering quality in each of our staffed emergency departments. Here are some of the quality ingredients we use at NES Health.

List of Ingredients

1. Client IQ
Each of our emergency departments utilize Client IQ, which is real-time survey software deployed on touchscreen tablets. This provides immediate data on all of our physicians/advanced practice professionals, nurses they work with, the environment, and overall satisfaction of the hospital. This has recently been improved so that we can receive all of this through an app on smartphones or any of our mobile devices.

2. ActionCue
Our data analytics program, ActionCue, provides data to all of our site medical directors, physicians/advanced practice professionals, hospital administrators and the operations staff at NES Health. Some of the benefit of this tool is looking at throughput times and working with staff to ensure they are meeting benchmarks or working on established goals desired by the leaders at our hospitals.

3. Performance Improvement Teams
At the heart of our success, is the process of creating performance improvement (PI) teams made up of physicians and nurses to ensure a means by which to implement best practices at each staffed ED. The creation of a successful PI team is an avenue through which to have frontline staff decide what most needs attention in the ED, and then consistently making improvements. Improvement is always an ongoing, neverending process.

Every one of our emergency departments may have a different menu, different theme, and use a different model to put "an amazing meal on the table," so to speak. We do, however, have the same expectations for each and every ED: To always strive to be better than the national averages set forth by standards of care, and to continuously improve, to consistently follow best practices, to provide superb customer service, and to do it in ways that are affordable to our patients.
Read Dr. Atul Gawande's referenced article, "Big Med" here: http://www.newyorker.com/magazine/2012/08/13/big-med

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Themes from Medical Malpractice Lawsuits in 2014

Keri Gardner By Keri Gardner, M.D., MPH,
FACEP
National Director of Quality
& Patient Safety, Regional
Medical Director

As we closed out 2014, we looked back on our medical malpractice lawsuit experiences and saw that there were definitely some common themes. Troponins and TPA have been prominent in this year's malpractice claims. I will share three practice pearls with you so that this knowledge may help you avoid one of these distressing events in the new year. They include: 1) Evaluation of chest pain, 2) Stroke treatment and TPA, and 3) Imaging of injuries.

Evaluation of Chest Pain

With the advent of the ultrasensitive troponin, our evaluation of patients with chest pain is changing-but the literature is way behind practice, and let's face it, coronary artery disease is still a major disease in the American population. A full-time emergency physician is seeing hundreds of patients with chest pain a year, so even if the rate of missed MI is 1% or less, you have tremendous exposure on this complaint. A risk proof practice of medicine in this regards means understanding which troponin your lab is using, and partnering with your local cardiology group to establish which rule-out protocol they are using and then following it. What if you don't have a local cardiologist to work with? No problem. Develop your own protocol for your group in conjunction with your hospitalist group and other admitting physicians. We see so many patients with chest pain and studies show some of them are going to infarct and die in the next 48 hours. Whether you are doing 2-hour delta troponins, or 6-hour repeat troponins, or a troponin 8 hours after their pain started, make sure that you are following some protocol you can reference-and ensure that their EKGs have no changes from normal or from their prior EKG. When you send them home, consider starting a daily aspirin and recommend follow up within 1-2 days.








Stroke Treatment and TPA

Any controversial element of medicine is a gift to attorneys that keeps on giving because no matter what you do, someone will argue that you are wrong and have literature to back them up. Does this mean that we throw up our hands and say that it is hopeless? No! We just have to be at least as clever and savvy as the attorneys that are going to look at the case long after the medical record leaves our hands. Let's consider the case of ischemic stroke. Since stroke can be a devastating disease, make sure that you evaluate any neurologic complaints completely and document a thorough neurologic exam. When stroke is suspected, cover all your bases. First base: Get the labs and head CT done immediately. Second base: Establish a time of onset with the patient and family and document it. Third base: Count the number of hours since onset, see if you are in a 3 or 6 hour window, and do all the currently recommended therapy for stroke that is not controversial (aspirin, etc.) Home plate: Discuss the TPA options with the patient and family. Share your recommendations with them and share the opinion of whomever is the closest neurologist that you get on the phone-and then document the decision and why.

Imaging of Injuries

My last pearl of 2014 regards imaging studies of injuries. Just when everyone is telling us to do fewer studies, I am going to recommend that you may need to do more. Have a low threshold for imaging lacerations. If it was a kitchen knife that sliced the pad of a finger, then an X-ray is unlikely to be helpful. But a chainsaw tearing into a hand may have caused a bony injury or a jagged laceration to the leg from falling in the woods may contain a foreign body-both are examples of good injuries to X-ray. And when you finish suturing, make sure you pick up all your sharps, lest you find yourself in the position of having a patient show up a few days later with a suture needle that mysteriously appeared in the wound. In this winter season of giving gifts, I hope that you will give one to your future self by having your charts reflect the excellent care and decision-making that go into each of your patient encounters. Doing so doesn't just help you defend your care before a jury, it stops attorneys from being willing to take the case at all.

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Jennifer Moore

At NES Health we value our providers. We also understand and appreciate how hectic life becomes working long shifts in busy emergency departments on a schedule that doesn't allow for communicating during "normal business hours." For that reason, we have partnered with Schedule 360 ( http://www.schedule360.com ) to help you manage your work schedule more efficiently and communicate with NES Health in a simple, hassle-free and streamlined manner.

Schedule 360 (commonly referred to at NES Health as "360") has been dedicated to developing web-based scheduling applications that simplify the scheduling process for the past fifteen years. In fact, S360 is the most comprehensive, flexible and adaptable scheduling solution available. That flexibility is what made this tool the right choice for NES Health--where no two Emergency Departments are alike. S360 allows us to configure the tool to the unique needs of each individual site.

Using a blend of technologies including the web, mobile applications, text messaging and email, S360 empowers proactive scheduling and efficient communication. Leading organizations that utilize S360 on a daily basis include Kaiser Permanente, Spectrum Healthcare Resources and a number of large healthcare delivery systems.


Currently, NES Health is utilizing this tool for payroll processing, transmission to ADP for direct deposit and other physician time management features. In 2015, we will be rolling out additional features designed to improve the efficiency of the scheduling process and improve communication with all NES Health providers.

For example, S360 will allow every NES Health provider the option to:
  1. Receive schedules via any mobile device;
  2. Submit scheduling preferences (availability/non-availability);
  3. Swap shifts with colleagues;
  4. Receive immediate notification of any unfilled shifts;
  5. Collaborate and communicate as a facility and group in real time--whether on or off shift.
  6. Receive immediate posts via electronic message board and/or texts; and
  7. Gain access to a library of educational materials.
The rollout of these features will be conducted for each site individually, and will be performed with direct oversight and guidance of: 1) the Site Medical Director; 2) Jocelyn Bowman, NES Health's EVP of Operations; and 3) the respective NES Health regional staff.

Our hope is that each NES Health provider will embrace this technology to simplify their work lives. However, this technology is merely an additional way for us to communicate. It is not intended to replace the valuable one-on-one communication that our regional staff has relied on to build great relationships with NES Health providers over the past 40 years. Look for updates about S360 coming your way in early 2015!
NES Health Supports Medical Mission Volunteers

What if you had the opportunity to step out of your everyday life-and be a hero in a world where basic medical care is often out of reach?

NES Health is covering the travel costs for four physicians and mid-level providers to travel to Ethiopia with The Medical Brigade--a group of clinical and non-clinical volunteers who provide vital medical care to the children of Korah, a small and impoverished village on the outskirts of Addis Ababa. The Medical Brigade is sponsored by Out of the Ashes, a nonprofit organization.
On one of its biannual medical missions last summer, The Medical Brigade:

- Saw more than 400 patients for afflictions ranging from simple earaches to severe meningitis.
- Held multiple clinics, went on house calls for homebound patients, and performed a life saving surgical procedure for one little boy.
- Supplied local providers with much-needed
supplies, equipment, and medication.

These volunteers will soon embark on the adventure of a lifetime and provide hope and healing to those who desperately need it. In the next issue of Inside NES Health, we will chronicle their medical mission trip.

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New Technologies

In 2014, NES Health announced the use of new software technologies to solve one of the biggest challenges in emergency departments today: eliminating variability in the delivery of emergency care. The company's new programs for educating staff in best practices, and monitoring their performance in real-time, use new computer technologies to eliminate variability and thereby improve quality, patient safety and patient satisfaction.

At each of its client hospitals, NES Health is using software platforms developed by Qualitick, an analytics technology provider based in Tampa, Florida, and Prista Corporation based in Austin, Texas. Thomas Zguris, MD, MBA, FACEP, President and CEO of NES Health, said, "High quality care means delivering the finest patient experiences using evidence-based practices, and resource management using performance analytics that are as close to real-time as possible. These two technology partners provide us with valuable tools that have been unavailable until now."

Dr. Zguris stated, "We have found that the enemy of quality is variability. Through the new
programs we have developed for our emergency department staff, we educate everyone to use best practice standards and also utilize new computer technologies to monitor clinician performance in real-time. By so doing, we can eliminate much variability in care and patient experience, and thereby improve not only quality and safety, but patient satisfaction, as well."

Emergency departments are seen as "the front door" to every hospital, and patients often choose which hospital to frequent based on their personal experiences in them. Keri Gardner, MD, MPH, FACEP, NES Health's National Director of Quality and Patient Safety said, "The emergency department is a highly visible part of hospitals. Everything touches emergency medicine, and emergency medicine touches everything else."

Added Chris Pepin, RN, CEN, CCRN, NES Health's National Director of Quality, "These new technologies make rapid, consistent improvements in emergency care a reachable goal for emergency departments of all sizes, whether rural or urban, and are tools which every hospital will need and demand."


Keri Gardner

Keri Gardner, M.D., MPH, FACEP, has been promoted to fill the role of Regional Medical Director to lead initiatives to maintain and develop high performance practices of emergency departments at client hospitals in Alaska, Washington, and Arizona. She will support local Medical Directors in the successful, long-term management of their emergency departments.

Dr. Gardner will continue to function as National Director of Quality and Patient Safety for NES Health. She is also the Medical Director of Emergency Medicine at Alice Hyde Medical Center in Malone, New York.




Gil Palmer

Gil Palmer, M.D., FAEP, has joined NES Health's leadership team as a Regional Medical Director. Dr. Palmer will lead initiatives to maintain high quality standards and patient satisfaction in emergency departments at client hospitals throughout Ohio. He will support local Medical Directors at client hospitals in the successful, long-term management of their emergency departments.

Dr. Palmer is currently Medical Director of the Department of Emergency Medicine and also Associate Chief Medical Officer at Mercy Regional Medical Center in Lorain, Ohio. Both are roles in which he will continue.


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By Thomas C. Zguris, M.D., MBA, FACEP
President & CEO


For most physicians, residency follows a somewhat predictable path: three to five years followed by licensing and board certification, and then private practice or a staff role.

But for NES Health Regional Medical Director Dr. Paul Thomas ("Tom") Brizendine, things did not go quite as planned. While doing his residency in Wichita, Kansas in 1968 - the thick of the Vietnam War - Brizendine was called to active duty by the U.S. Air Force. This two-year stint included working as a general surgeon alongside Vietnamese physicians at a small provincial hospital just north of Saigon. "In terms of a learning experience, it was the best professional year of my life," he says. "I gained a tremendous amount of confidence."

After the war, Brizendine settled into private surgery practice in rural eastern Kentucky, which at the time had two small, aging hospitals with no surgical services. When a larger, modern facility was built in Louisa in 1974, Brizendine seemed like a natural choice to run its ED. He had already worked weekend shifts in the ED while at Maxwell Air Force Base in Alabama, and felt drawn to the field.

"I was the only surgeon out of eight or ten actively practicing physicians," Dr. Brizendine says. "And frankly, no one else wanted to do it! Plus, emergency medicine fit my personality and style of practice. I loved the immediacy of it; the need to be fast and accurate with your decision-making."

As Medical Director of the ED at what is now Three Rivers Medical Center, Brizendine had a heavy hand in recruiting physicians. The field of emergency medicine was becoming a specialty in its own right by the mid-1970s, but was still in its infancy. It didn't take long for Brizendine to realize that area hospitals had a genuine need for emergency staffing and management guidance - a realization that led him to create his own company, Whitaker Emergency Services.

"Tom began with one hospital contract, then grew that to two or three, and then suddenly we had 15 hospital



contracts in a four-state area," explains Frank Poschinger, who was Whitaker Emergency Services' business manager and COO. "It was really the birth of the ED contract management field; no one else was doing it at the time. Tom has always been full of ideas and energy; he inspired me to leave my career and become an entrepreneur myself."

The fact that he was already wearing multiple hats did not dampen Brizendine's entrepreneurial spirit. Poschinger recalls driving home with the doctor one afternoon after a meeting in Louisville. "I was reading an American Medical Association journal and saw an ad for the first free-standing emergency center in the U.S. So I turned to Tom and said, 'You know what? We're going to set up our own.' And he was immediately on board."

Within one year, the two men had established the first "immediate care center" in suburban Louisville with the help of investor-partners. Four more centers followed over a two-year period, until Brizendine decided to shift his focus back to his ED staffing and management company.

By 1990, Whitaker Emergency Services had reached a total of 22 contracts, garnering the interest of NES Health founder Dr. Allan Rappaport. Brizendine sensed a synergistic match, "so we got engaged and got married." Whitaker Emergency Services joined NES in 1992 to become Whitaker National, a wholly owned subsidiary. Whitaker had its own embedded billing company that today is known as ProBill, NES Health's coding and billing division. After the acquisition, Brizendine remained with NES Health as a site medical director for most of his contracts and became Regional Medical Director for the central, western, and southern regions.

Brizendine has since narrowed his territory and now oversees smaller clients in Kentucky and West Virginia, working with hospital administrators on staffing issues and providing seasoned guidance to NES Health physicians. He also collaborates closely with the NES leadership team on the company's business development.

"Tom has a long history with us and is a great ambassador for the company," says Dr. Tom Zguris, current President and CEO of NES Health. "He has a real command of the

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business and clinical issues we face on a daily basis, which makes him a key part of our clinical leadership team. Beyond that, Tom is just a really great guy - genuine, caring, and compassionate. I think the world of him and so do our hospital clients, who literally hug him when he visits. He has truly made an impact."

Adds fellow Regional Medical Director, Dr. Steven Wexler: "'Briz' is what we call a 'senior statesman' at NES. He brings calm maturity to the organization and his great personality and sense of humor make working with him enjoyable. In the last couple of years, Briz has taken a lead role in analyzing deficiencies in medical coding and documentation. He has really helped our physicians and medical directors improve in this area from both a medical-legal and financial perspective."
After a 40-plus-year career, Brizendine is slowing down a bit. His wife, four children, and seven grandchildren - not to mention the occasional golf game - provide plenty of incentive to spend time away from the ED.

But retirement is not in his sights just yet. In addition to working with NES Health, Brizendine is still an active ED physician at a small hospital in western Missouri, where his son also practices. And July marks Brizendine's 40th year as Medical Director for Three Rivers Medical Center.

"I don't know what I'd do if I weren't working," he admits. "Emergency medicine is what motivates me and gets me going each day. As long as I'm healthy and having a good time, I'm going to keep doing what I'm doing."
Stipend Program In mid-December 2014, NES Health announced the development and launch of its new Stipend Program for Emergency Physicians in Training. The Stipend Program will financially assist promising emergency medicine residents and fellows in the nation while they learn, and encourage these physicians to work at the company's client hospitals after completing their training.

"Having a robust supply of well-trained emergency physicians in the pipeline is critical to the health of our country's hospitals," says Thomas Zguris, MD, MBA, FACEP, President and CEO of NES Health. "I'm pleased we can offer young physicians help at a time when they need it most, and also offer them a way to get to know our great company."

"This unique program offers a great opportunity for newly-trained emergency physicians to make a difference at some of the most underserved hospital emergency departments in the U.S.," states Steve Wexler, MD, FAAEM, Chairman of the Stipend Program. "Our program not only pays generous monthly stipends, it also offers clinical lectures for residents and fellows, mentorship by practicing emergency physicians, and short-term training opportunities at emergency departments around the nation."
Entrance to NES Health's Stipend Program is gained by application. Emergency medicine residents, fellows, and training program directors can learn more by calling the program's Coordinator, Ruth Ann Sheets, at 1-800-394-6376. Adds Chris Pepin, RN, CEN, CCRN, NES Health's Director of the Stipend Program, "Our program offers a truly distinctive learning experience. We want to hear from every emergency resident and fellow who is interested in receiving a financial boost during their training and securing a job in a high-performance emergency department once their training is complete."


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Jennifer Moore Promoted

Jennifer Moore Jennifer Moore, CPA, MBA, MHA, has been appointed as the NES Health's Chief Administrative Officer/Chief Financial Officer (CAO/CFO) effective January 1, 2015. Ms. Moore previously served solely as the organization's Chief Financial Officer.

"As CAO/CFO, Jennifer will play an important role in ensuring policies are in place and approving budgets, as well as leading our finance, human resources, information technology, building management, and revenue cycle functions," said Thomas Zguris, MD, MBA, FACEP, President and CEO of NES Health. "Her proven leadership abilities, professional integrity, solid decision-making skills, and depth of experience, are qualities that will strengthen our company's standing as a foremost healthcare solutions company for hospitals."

"I am pleased to accept the position of CAO/CFO," said Ms. Moore. "I look forward to continuing to work with our executive leadership team, affiliated clinicians and managerial teams to strengthen NES Health's level of service quality, productivity and financial accomplishment."

After earning her MBA and MHA at the University of Florida in Gainesville, Jennifer worked for HCA's North Florida Regional Medical Center. Subsequently, she worked for the Main Line Health System in Pennsylvania. She completed her BS in accounting at Bentley College in Waltham, Massachusetts and is a licensed CPA. Jennifer began her career working for Arthur Andersen's healthcare division (now Andersen Worldwide). She subsequently worked in various financial and operational capacities for several health care organizations, including a previous term with NES as Controller.


Contact Information
NES Health Expands - New Jersey

NES Health expanded its emergency medicine staffing and management services with a new contract in Elizabeth, New Jersey. Trinitas Regional Medical Center has chosen NES Health as its business partner for emergency physician staffing and management services beginning on January 1, 2015.

Trinitas Regional Medical Center is a full-service teaching hospital serving those who live and work in Eastern and Central Union County. Every year, their physicians and staff treat over 70,000 emergency patients, 17,000 inpatients, and several hundred thousand outpatients.

"NES Health's strength as a national organization dedicated to the highest quality will enhance care for emergency patients at Trinitas, which has one of the busiest Emergency Departments in the State," said Gary S. Horan, FACHE, President and Chief Executive Officer, Trinitas Regional Medical Center. "A further step toward augmenting care at Trinitas is the recent launch of an $18 million construction/renovation program that will double the treatment capacity of our Emergency Department and streamline care for emergency patients."

A Catholic teaching hospital, Trinitas Regional Medical Center is sponsored by the Sisters of Charity of Saint Elizabeth in partnership with Elizabethtown Healthcare Foundation. Utilizing a full spectrum of sophisticated inpatient, outpatient and longterm care services, Trinitas Regional Medical Center is proud to have forged a lifelong partnership with families, physicians and communities to provide the best care in a supportive and caring environment.

NES Health is pleased to welcome Trinitas Regional Medical Center as our newest client. It is clear that we share a common vision to provide the highest quality care possible. This will be an excellent partnership that will help Trinitas reach higher levels of quality, safety and patient care," said Thomas Zguris, M.D., MBA, FACEP, President and Chief Executive Officer of NES Health.

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