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Raising Standards to a Higher Plateau

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LEXINGTON, KY The year was 1997. Two young doctors, James Foster, MD, and John Mullins, MD, were working for various large, national staffing companies in emergency rooms at small community hospitals throughout Central and Southeastern Kentucky. Both had attended medical school at the University of Kentucky, College of Medicine and at the time, one was on a career path to orthopedic surgery and the other was interested in general surgery.

Mullins recalls being hired over the telephone by a non-clinical person working in St. Louis, Missouri. “I was hired. I showed up. I worked. I went home. I was paid. The companies I worked for provided no management of the department or feedback on my performance. To them, I was truly a ‘warm body.’”

In September 1999, Foster and Mullins started a two man group practice. Mullins recalls, “I think we can do this better.”

Fast forward to 2013. Those same two doctors, Mullins and Foster, founders of MESA Medical Group (MESA), now employ more than 300 emergency medicine and hospital medicine physicians, 100 advanced practice providers and over 100 support staff, in addition to managing emergency and hospital medicine programs at over 30 hospitals throughout Kentucky, Ohio, and West Virginia.

Neither Mullins nor Foster anticipated MESA growing into a regional or multi-state EM/HM powerhouse. “We grew because there is an unlimited need for what we know how to do and hospitals keep hiring us,” says Mullins. “Our growth was born out of our commitment to providing quality patient care. Our guiding principles of integrity and accountability along with our passion for healthcare and raising standards resonated to our hospital partners.”

Hospitals were unable to fill their emergency room schedules while holding the doctors accountable to their performance. According to Foster, “The ER climate in Kentucky was very fragmented at the time.” Staff members were spending extraordinary amounts of time trying to find qualified emergency medicine physicians which placed undue stress on administration and staff members at the hospitals.

“We took the approach that everybody, including ourselves, will work their fair share of nights, weekends, and holidays. We hired doctors who were like-minded, and many of those that disagreed left. The situation improved immediately for both the hospitals and the physicians,” says Foster.

Familiarity, Feedback, and Passion

MESA is committed to maintaining the culture of a small group practice. “Even though we now have over 400 providers in our group,” Mullins exclaims, “we talk regularly about the desire to maintain the flavor of our vision to remember our past as we embrace the future. I am on a first name basis with each member of our group and I am available to anyone 24/7.”

“If anyone calls us a staffing company, I correct them. We are a group practice!” emphasizes Mullins.

Rarely do hospitals contact MESA when their ER is running smoothly, so MESA’s expertise is in the turnarounds of under-performing emergency departments. When entering a new hospital operating agreement, Mullins and Foster do the evaluation themselves. They typically walk into situations that have been mismanaged by other groups in geographical areas that are difficult to recruit to. “Although a complete turnaround can take several months,” Foster is confident in the organization’s proven ability to vastly improve the hospitals overall performance. “We’ve done it so many times we know what to look for and how to fix it. That’s what sets us apart,” says Foster.

Accountability for performance and outcome is both the carrot and the stick for emergency medicine physicians where speed and quality patient care often conflict. MESA providers are held to higher standards of care that have been developed by Foster and Mullins over their years of firsthand experience and learning from other emergency medicine groups. “We focus on performance metrics that are 100% aligned with the hospitals. The time it takes for the patient to see the doctor after arrival and the time it takes for the patient to be discharged from the department or admitted to the hospital are closely tracked,” says Foster. “These indicators are very important factors in patient satisfaction. We give our physicians quantifiable and objective feedback, both good and bad, to improve performance and enhance the patient experience.”

Hospital administrators now know that the emergency room is their front door and the path to more admissions, although that has not always been the case. According to Foster, traditionally, the ER was the “red-headed stepchild” of the hospital that continually lost money. MESA raises the emergency room experience and physician’s accountability to a higher standard by calling every single patient that is discharged from their hospitals to conduct a patent satisfaction survey. “We have a hospital specific survey, a team of interviewers, and a reporting system that give us immediate feedback from the patients that we share with our hospital partners and providers. It’s enormous, a monumental task, but we do it for the feedback and because it’s the right thing to do,” says Foster.

The patient surveys fuel the physician feedback machine. All MESA doctors receive a monthly and a quarterly “physician scorecard.” “We want our fellow physicians to know how they are doing,” says Mullins. “What does it mean to be a good doctor? I can tell you that being smart isn’t the biggest measuring stick. Are you compassionate? Are you efficient? Do your patients feel satisfied with their care? Do you meet the standards of the profession?”

Mullins believes passion cannot be forced, and it is the key ingredient both he and Foster share and also look for when bringing new physicians into the MESA organization. “What we do, we do without notes or a business plan. We do what we do because we passionately believe that patients deserve the best.”

Mesa Adds Hospital Medicine

Hospital medicine is the flip side of the same coin of hospital-based patient care. It was only natural that MESA developed a hospital medicine program in October 2008 when TJ Richardson, MD, joined the group as Chief Medical Officer for Hospital Medicine. Richardson was a founding partner of Central Kentucky Medical Group, an internal medicine practice in Lexington. He was familiar with MESA partners Foster and Mullins through their work at common hospital emergency department locations.

“I realized that my passion was for inpatient care,” says Richardson of his decision to head up MESA’s hospital medicine program. “I knew that John and Jimmy were committed to quality patient care. They were sound physicians, and I was impressed with their high energy and commitment to the highest standards. And I like that MESA is an independent group. Independence is a good thing.”

Richardson and MESA now oversee 12 hospitalist programs in Kentucky and one in Ohio with 40 physicians under his supervision and tutelage. Richardson says he demonstrates the MESA Best Practice strategies of raising standards of patient care by providing in-patient care that is timely, efficient, caring and scientifically proven with peer review, patient satisfaction surveys, and MESA’s unprecedented patient call back program after discharge by trained medical assistants. “Listening to patient feedback is a major part of what we do,” says Richardson.

Aside from the challenge of providing quality patient care, Richardson acknowledges that physician retention and preventing burnout are his top priorities. MESA addresses each issue head on with “sustainable scheduling and a commitment to our doctor’s mental and physical health,” says Richardson. The standard MESA hospitalist works seven 12-hour days followed by seven off days. This schedule allows the group’s hospitalist physicians their important time-off to enjoy life and their families. Additionally, “Our size and physician pool allows us to create even more flexible scheduling when necessary.”

It is often beneficial for hospital administrators to partner with MESA for both emergency and hospital medicine programs. Mullins expressed that the natural synergy and efficiencies are obvious “because ER doctors want to admit patients through the path of least resistance, so admitting a patient to your colleague is more efficient.”

Mullins believes that MESA “not only saves hospitals money, but we make them money when we manage both the emergency and hospital medicine programs. Hospitals save by only paying a subsidy to one group rather than two competing groups. If having EM and HM doctors talking to each other can reduce hospital stays beyond what’s necessary by even half a day, it saves money. Plus increasing ER visits, which MESA does, is additive to hospital admissions.”

Mullins confidently states, “There’s no doubt, we can document it. Hospitals are proven to be more profitable because of our efficiencies, our performance based outcomes, and our accountability.”

Physician Recruitment

Director of Physician Recruitment, Doug Smith, MD, serves as the physician liaison for MESA Medical Group’s recruitment team. He credits MESA’s recruitment department for “consistently doing a fantastic job. They are matchmakers, not salespeople.” Smith claims his role in meeting with potential MESA physicians is to understand what is important to the physician, such as proper support staff and coverage in the hospital or a flexible schedule that allows providers to determine where and how much they work and the ability to have a balanced lifestyle and pursue outside interests.

The physician shortage makes finding the best suited matches imperative to the stability and growth of MESA, which Smith believes is what sets them apart from their competitors. “MESA’s commitment is to make our physicians happy. Every physician matters to us.”

Maintaining physicians’ work schedules “is like working a Rubik’s Cube,” according to Smith. “Changing a physicians schedule will impact another physician’s schedule, maybe more, but we have the ability to match a provider with the hospital they want to work at and the schedule they want to work. Our schedulers work tirelessly to accommodate the individual physician’s needs.”

When recruiting physicians to join the organization, Smith points out that MESA is a physician-friendly group that is designed from a physician’s viewpoint. They do not have non-compete clauses, and physicians have the option to work part-time, full-time, or be an independent contractor. Smith advised, “Our ultimate goal is to have providers who want to live and work in the community where they practice.”

Smith graduated medical school from the University of Cincinnati College of Medicine and completed his residency in emergency medicine at the University of Kentucky. Before joining MESA in 2005, he served as a Naval Flight Surgeon with the US Marine Corps based at Camp Lejeune.

Future Growth Fueled by Need

The ever-changing landscape of today’s healthcare reform initiatives will continue to impact the delivery of patient care. Rapid changes in coverage criteria and limits have a direct influence in the way hospitals and physicians deal with the financial challenges of patients. This is no more acute than in a hospital’s emergency department.

There is a very large population of underinsured and uninsured people in this area. “Many of these patients go to the emergency room for their care because they have nowhere else to go. I strongly feel that this situation is underappreciated,” says Foster. “The economic situation is very challenging and will be more difficult in the future.”

In October 2011, MESA made the proactive decision to invest in additional executive leadership to manage the challenges of their continued growth. MESA brought in its first Chief Executive Officer to oversee the organization’s operations and growth throughout Kentucky, Tennessee, West Virginia, and Ohio. Larry Kraska came on board with 25-years of executive level healthcare experience and is an expert in extensive large physician group management and hospital administration. Kraska understands the key to MESA’s success will be geographic density and a core group of cross-credentialed physicians.

Kraska describes why a regional emergency and hospital medicine group like MESA is needed because it solves two major challenges. “One is the imbalance in the supply and demand equation of a physician shortage. The second is the increasing demand for ER and hospitalist services as the result of the Patient Protection and Affordable Care Act.”

“Clearly, MESA Medical Group is the leading provider group in Kentucky because of our unique approach to raising standards,” Kraska continues. “It’s due in large part, to the strength of our physician and executive leadership team and to our mission of constantly enhancing the ways we recruit the best emergency and hospital medicine physicians, along with the results-focused contract services we offer our hospital partners. Doing so ultimately leads to better patient care—and that’s job one for all of us.”