key strategies for improving patient ˜ow success · the american society of nuclear cardiology...

September 2012

Key strategies for improving patient �ow in today’s competitive, consumer-driven

health care environment.

Plus, the latest movement to get ahead of the technological curve.

SUCCESSIn the E.D.

September 2012

2 I EmPress!ons – the newsletter for EmCare® health care professionals

ContentsEffects of Caffeine and Xanthine on Pharmacologic Stress ................................................1 A look at how drugs affect pharmacologic stress, Myocardial Perfusion Imaging (MPI) with Adenosine (Adenoscan) and Regadenoson (Lexiscan).

EmCare’s Jolly Good Fellows ............................................................................................2 EmCare offers physicians plenty of opportunity to become physician leaders. Learn about some of the administrative activities and specialties available through the fellowship program.

Success in the Emergency Department ............................................................................3 Key strategies for improving patient flow in today’s competitive, consumer-driven health care environment. Learn strategies for optimizing throughput rates, increasing patient satisfactory scores and balancing budgets.

Visions for Vietnam ........................................................................................................5 Emergency medicine doesn’t exist as a specialty in Vietnam – yet. But with the efforts and visits of James Ramseier, M.D. that could soon change. Find out about his remarkable overseas mission.

MOPP-ing Up ..................................................................................................................8 An EmCare regional medical director shares his successful formula for Management of Patient Perceptions (MOPP) and improving patient satisfaction scores.

Congratulations, Awards and Accolades .........................................................................10 EmCare Radiology executives draw crowds at a national convention for imaging managers, while an EmCare physician becomes an officially-recognized “superstar.”

Innovation Task Force ...................................................................................................11 Technology is always advancing, and so is EmCare. Find out about the latest movement to get ahead of the curve.

New Look, New Home for a New Decade ........................................................................12 To celebrate the fortieth anniversary of EmCare, the company is celebrating with some new branding, some new names and some new offices! Find out about the name changes and fresh new logos for our venerable company.

Acknowledgments .......................................................................................................12

From the EditorEmPress!ons offers EmCare-affiliated clinicians a regular source for information on best practices, thought leadership, emerging legislative and regulatory issues,

as well as risk management. This newsletter includes regular columns from EmCare leaders throughout the country. It also informs readers about EmCare providers’ volunteer and mission work, professional achievements and honors.

EmCare has evolved through the years – and EmPress!ons is adapting to meet the needs of the company’s more diverse clinical audience by adding medical editors from all five specialties – EmCare Emergency Medicine, EmCare Hospital Medicine, EmCare Acute Care Surgery, EmCare Anesthesiology Services and EmCare Radiology Services. In upcoming issues we will publish articles on issues dealing with important topics in those areas.

To help us meet your need for information, we welcome your ideas for articles. We will offer regular features representing all of the medical specialties EmCare represents and I encourage you to consider writing on topics of interest to you and your colleagues. And be sure to notify us of your professional activities and achievements.

To submit an article, ask a question, or update your e-mail address, contact Jennifer Whitus, EmCare’s Marketing Communications Manager at [email protected] or (214) 712-2793.

I look forward to your comments and contributions.

Sincerely,

Russell Harris MD, MMM, CPE, FACEP CEO EmCare – North Division Managing Editor, EmPress!ons

mailto:[email protected]

September 2012


Effects of Caffeine and Xanthine

on Pharmacologic Stress Drug Interactions with Pharmacologic Stress Myocardial Perfusion Imaging (MPI)

with Adenosine (Adenoscan) and Regadenoson (Lexiscan)

by: PRADEEP JACOB, mdEmCare Radiology Services

BACKGROUNDMyocardial Perfusion Imaging (MPI) is a common

noninvasive imaging method of detection and risk stratification of coronary artery disease. MPI is utilized extensively in the emergency department setting along with 12-lead EKG, serum cardiac enzymes for the assessment and stratification of patients presenting with chest pain.

Under stress, coronary artery vasodilatation occurs resulting in increased myocardial blood flow (MBF). Normal coronary arteries undergo dilatation whereas diseased (atherosclerotic) coronary arteries do not. Uptake of radiopharmaceuticals by the myocardium is directly proportional to MBF. The difference in MBF between normal and diseased coronary arteries results in differential tracer perfusion between normal and abnormal coronary artery tissue beds and differential uptake by the myocardium. Therefore there is less uptake of the radiopharmaceutical in tissue bed supplied by diseased coronary arteries. The differential uptake can then be detected using single photon emission computed tomography (SPECT).

MPI is typically performed using treadmill exercise which results in coronary vasodilatation at peak exercise – at least 85 percent of maximum predicted heart rate (MPHR). In patients unable to perform vigorous exercise (unable to sustain 85 percent of MPHR) or have a left bundle branch block (LBBB), pharmacologic stress may be utilized to mimic exercise. The pharmacologic agents are either chonotropic/inotropic (dobutamine, which results in pharmacologically induced tachycardia, increased

myocardial contractility and vasodilation), or coronary vasodilators (dipyridamole, adenosine, regadenoson).

PHARMACOLOGIC AGENTS

AdenosineAdenosine is endogenously produced in small

quantities and acts as a non-selective agonist on adenosine receptors. There are at least four types of adenosine receptors, A1, A2a, A2b and A3. These receptors are located in the sinoatrial node, atrioventricular node, atrial and ventricular myocytes, vascular smooth muscle cells (particularly coronary arteries). Activation of A2a receptors mediates an increase in MBF. Stimulation of A1 receptors causes negative chronotropic, inotropic and dromotropic effects. Stimulation of A3 and A2b receptors results in mast cell degranulation and bronchoconstriction.

Adenosine is administered as a weight-based continuous infusion and has a rapid onset of action (within two minutes of starting infusion) and short half life of less than ten seconds, allowing return to baseline within two minutes of terminating infusion.

Some of the side effects of adenosine infusion include mild increase in heart rate and decrease in systolic and diastolic blood pressure and bronchoconstriction (particularly in asthmatic patients). The vasoactive effects of adenosine are inhibited by competetive adenosine receptor antagonists, methylxanthine compounds such as caffeine and theophylline.

RegadenosonRegadenoson is a selective A2a adenosine receptor

agonist with very low affinity for the A1, A2b and A3 adenosine receptors. Therefore, side effects such as bronchoconstriction are reduced. Regadenoson is administered as a rapid bolus administration and has a rapid onset of action with increase in MBF to greater than twice that of baseline by 30 seconds and short sustained duration with a return to baseline by 10 minutes. Some of the side effects of regadenoson infusion include mild increase in heart rate, and decrease in systolic and diastolic blood pressure.

DipyridamoleDipyridamole inhibits the degradation and

reuptake of adenosine and, thereby, increases tissue levels of adenosine. It has a slower onset of action and longer sustained action. Dipyridamole is no longer commonly used for stress MPI.

DRUG INTERACTIONSMethylxanthine compounds such as caffeine and

theophylline are non-specific adenosine receptor antagonists and interfere with the bioactivity of adenosine and regadenoson. By inhibiting and antagonizing the activity of adenosine and regadenoson, methylxanthine compounds result in preventing maximum coronary vasodilatation and an increase in MBF. This prevents differential uptake of the radiopharmaceutical between normal and diseased coronary artery tissue beds, significantly

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September 2012


reduces the sensitivity of MPI in detecting coronary artery disease and may lead to a false negative result.

Aminophylline may be used to attenuate or reverse the activity of adenosine and regadenoson and treat symptoms related to their side effects.

Dipyridamole can potentiate the effects of adenosine and regadenoson, thereby precluding the use of the latter agents in patients who have taken oral dipyridamole within the past 48 hours.

GUIDELINESThe American Society of Nuclear Cardiology

(ASNC) guidelines suggest that dipyridamole and dipyridamole containing medications be withheld for 48 hours prior to MPI. They suggest that aminophylline containing medication be withheld for 24 hours and caffeine products and chocolates be avoided for 12 hours prior to MPI. These products include coffee, tea (including decaf coffee and tea - a Starbucks Venti

decaf coffee contains 20 mg of caffeine!), soft drinks, energy drinks, and other caffeinated products.

Some practitioners advocate titrating the effects of caffeine by waiting specified periods of time based on the specific amount a patient has consumed to allow metabolism of caffeine to occur. This practice should be avoided as the metabolism of caffeine is variable and establishing the exact amount of caffeine ingested may not be accurate.

Although there are anecdotal reports that suggest that the effect of caffeine on regadenoson (as opposed to adenosine) may not be as significant, there are no large clinical trials to support this.

TABLE-1. PATIENT INSTRUCTIONSWithhold prior to MPI:

Caffeinated products 12 hoursAminophylline medications 24 hoursDipyridamole 48 hours

The performance of MPI as a screening test should not be taken lightly. Severe complications such as myocardial infarction and death from MPI are rare but possible and the costs of administering the test are significant. Administration of radiopharmaceuticals exposes the patient to ionizing radiation. Therefore, optimizing the test is critical in order to reduce false negative and false positive exams and produce reliable results. Pradeep K. Jacob, MD is an EmCare Radiology Services physician and Section Chief of Nuclear Medicine in the Department of Radiology at Erlanger Health System, Chattanooga, Tenn. He has also served as Vice Chief of Erlanger’s Department of Radiology and an Assistant Clinical Professor in the Department of Radiology at the University of Tennessee College of Medicine, also in Chattanooga, Tenn.

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Administrative Fellowship Program Nurtures Physician Leaders for EmCare

by: KERRY SILVER

As Chair and Emergency Department Medical Director of Advocate Trinity Hospital, an inner-city hospital on Chicago’s South Side, Rebecca Parker, MD, FACEP had a challenge. She needed to attract bright physicians to work in the E.D. at Advocate, but the high cost of doing business – in particular, low reimbursement rates and high malpractice costs – meant she was competing for talented doctors against large urban hospitals. Dr. Parker, who is now an Executive Vice President for EmCare’s North Division, needed to find a non-monetary incentive for talented physicians to join her team.

At the same time, Christine Bishof, MD, MPH was serving as Chief Resident at Cook County Hospital. For many doctors, the first couple of years after completing residency can be a challenging transition. However, Dr. Bishof was immediately comfortable with the role of attending physician and was interested in growing her leadership skills. One of the faculty members at Cook introduced Dr. Bishof to Dr. Parker because she

thought they had similar styles.The meeting between Drs. Parker and Bishof was

the catalyst to creating the Administrative Fellowship Program at EmCare. “I was their prototype,” she explained. “[Cook County Emergency Medicine Residency Program] prepared me for the challenges of emergency medicine, and I was ready to do more.”

And so the EmCare Administrative Fellowship Program was born. Dr. Parker felt the opportunity was ripe to provide a leadership track at EmCare. Dr. Bishof was anxious to hone her skills under the guidance of Dr. Parker while participating in a formal leadership program.

Through EmCare’s two year Administrative Fellowship, Dr. Bishof was exposed to a wide array of learning opportunities within the practice of emergency medicine, included in hospital leadership initiatives, introduced to physician leaders throughout EmCare, and invited to participate in all the activities of a medical director, including attendance at EmCare’s

annual leadership conference for medical directors, committee meetings, and workshops.

“I felt a part of the team. I was able to look behind the curtain and see how to run a department,” Dr. Bishof explained. She had the opportunities to meet many of EmCare’s physician leaders, including Dighton Packard, MD, EmCare’s chief medical officer and David Mendelson, MD, an EmCare executive vice president of medical affairs. During those meetings, she gained insights into the leadership path at EmCare.

Dr. Parker was understandably pleased with Dr. Bishof’s experience in the Administrative Fellowship program. “Christine was the emergency physician representative and chaired the Performance Improvement Committee (PIC) at Advocate Trinity. Through her leadership, the hospital was able to decrease the amount of time it took to move patients from the E.D. to the cath lab. She was very successful,


September 2012


Achieving Success in an Increasingly Complicated Environment: Key Strategies to Improving E.D. Patient Flow

by: KIRK JENSEN, md Chief Medical Officer, BestPractices

Executive Vice President, EmCare

Success in an emergency department (E.D.) is no longer defined simply by the delivery of timely and high-quality care that saves life and limb. In today’s competitive, consumer-driven environment, we are now assessed by our Boards and our patients on such things as optimal throughput rates and patient satisfaction scores.

Indeed, the long list of issues demanding E.D. and hospital administrators’ attention means the juggling of priorities and resources. Where do we focus already limited assets to produce the most benefits? After 25 years of work in emergency medicine management and clinical care, the approach that I am convinced is of fundamental importance to success – and the one that I have made my specialty – is smooth patient flow.

It is no secret to the readers of this newsletter that smooth and efficient patient flow through the entire continuum of care is a key factor for E.D. and hospital success. Avoiding over-crowding and the host of problems it can create leads to a better experience and quality of care for patients and their loved ones, health care workers and everyone else involved. It can also mean a more profitable institution – with less money lost due to time spent on diversion, and fewer patients leaving without being seen.

The benefits of ensuring that E.D. operations flow smoothly from the very beginning of the patient visit has a huge impact on subsequent steps in the system. While there is no magical solution to E.D. flow problems, through my experiences as Chair of the Institute for Healthcare Improvement’s

Improving Flow Through Acute Care Settings team and partner to hospitals with BestPractices, there are a few key strategies that I convey to E.D. and hospital administrators:

Understand Your Demand and CapacityThe first step is to understand and track your

demand and service capacities. By examining and understanding demand and capacity data, hospitals may be able to assess the following: how many patients are entering the system, when, where, and why they are doing this, what resources are required to treat them, and whether the capacity exists to do this effectively. Without this fundamental information, one can better understand of the situation and how to optimize patient flow. After all, as the old adage goes, you can’t manage what you don’t measure.

Develop a Realistic Strategic Vision for Your Emergency Department

In trying to be all things to all people, many of our nation’s E.D.s have lost sight of what mission they really are on and what they can realistically accomplish. Sometimes, the unfortunate truth is that, with limited resources and other operational impediments, an institution will never be able to succeed in all desired areas of performance at all times. In these cases, trade-offs must sometimes be made to ensure that the care being delivered is safe, efficient and high-quality.

Thus, as part of any improvement process, it is important that E.D. leadership step back and develop a clear “strategic vision” by asking two critical questions: what is our mission as a department? And how can we succeed at this mission with the resources available to us? Using the answers to guide your work, a shared strategic vision lays out clear and realistic outcomes behind which you can unite your team and institution.

Triage is a Process, Not a PlaceOver the years, we have witnessed the role of

E.D. triage burdened with a variety of new functions


September 2012



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and responsibilities. The result is that what once was a simple and value-added screening point for patient intake has been effectively transformed into a complicated bottleneck and point of inefficiency in the E.D. I would argue that most of these changes add little value to the triage process and can be performed better and more appropriately at other points during the patient’s visit.

Examining and reworking the triage system to remove these add-on functions is an important step in improving patient flow. The triage process is like a flywheel, setting the pace of patient flow throughout the institution. It should serve as a driver of the patient and processes along the continuum of care rather than an impediment to smooth operations. An ideal triage process should do nothing more than identify patient needs and disease/injury severity in four to five questions, so that patients can be segmented into diagnostic and treatment lines and matched to resources (space, staff, supplies, and services) within the institution.

This isn’t an unknown concept to hospitals – in fact, many already practice some form of patient flow segmentation through triage procedures, such as identifying “critical care” or “fast-track” patients. What few hospitals and E.D.s have is a proven, standardized assessment model with clear and reliable system practices to support it.

The most efficient and effective model for patient segmentation is the five-level Emergency Severity Index (ESI) system (or the Canadian equivalent – the CTAS system). Assessing and segmenting patients into one of five streams ranging from a Level-1 patient requiring critical, life-saving care to a Level-5 patient with far less urgent needs is recommended because it is easy to understand, implement and teach to E.D. teams. Once in place, it can be easily applied to all clinical situations, and allows for efficient patient processing and treatment.

It is not enough, however, to simply assess a patient and put him or her back in the queue. Standard operational procedures and processes to manage segmented patient flows after triage is performed must be established to keep the system operating efficiently. Currently, the purpose of most segmentation style front-end E.D. practices is to determine how long a patient can safely wait before he or she moves through the system. In order for this

to work, assessed patients must be ushered to and through the next steps in their journey in a timely manner.

A good segmentation system should be supported by a fully staffed and smoothly functioning “fast track” system that can quickly handle non-urgent patients. This allows the rest of your E.D. to be optimally focused, operate more efficiently, reduce wait times and limit waiting room overcrowding. Reworking your triage practices and patient intake by implementing a patient flow segmentation model will give you a best-in-class intake system that is built to support smooth patient flow.

Remember: Change Takes Time, Effort and Innovative Strategies

The ability to develop and implement interventions that perfect operations is something at which the U.S. health care system has always been good. From fast-track triage to always-ready catheterization labs, we have done a fantastic job at tackling the myriad of problems that affect E.D. patient care. The result is the potential for a modern emergency care system that we can be proud of and comfortably rely upon – not just for our patients, but also for our own family and friends.

Sometimes lost in this innovation, however, is the understanding that achieving improvement in areas like patient flow takes time, effort and innovative strategies. If there were quick and easy solutions to these problems, E.D.s nationwide would have already implemented them. Tackling system change is a fundamental, long-term undertaking that will require sustained commitment from everyone involved. But, as I have witnessed over the years, by utilizing the strategies outlined here and sustaining execution over time, hospitals can successfully achieve smooth patient flow. Kirk Jensen, MD, Chief Medical Officer for BestPractices, Chair of the Institute for Health Improvement “Improving Flow through Acute Care Settings” team, Chair of the IHI Operational and Clinical Improvement in Emergency Department team, Rocky Mount, N.C.


September 2012


Dr. James Ramseier Brings Personal Passion for Emergency Medicine to Vietnam

by: KERRY SILVER

Emergency medicine doesn’t exist as a specialty in Vietnam. But it will in the future with the continued efforts of James Ramseier, M.D. and the volunteer organization with which he works. Since 2007, Dr. Ramseier has worked with Good Samaritans Medical and Dental Ministry to pave the way for a desperately-needed emergency medicine program in Vietnam –and they are making great progress.

Dr. Ramseier’s love for the people and culture of Vietnam began in 2002. While most medical residents are focused on completing their programs so they can move on to the next phase of their medical careers, Dr. Ramseier chose a somewhat different path. During his emergency medicine residency at Mercy St. Vincent Medical Center in Toledo, Dr. Ramseier did a one-month elective in international emergency medicine at Cho Ray Medical Center in Ho Chi Minh City, Vietnam. The experience was transformational.

Dr. Ramseier, who now works in Las Vegas, Nev., described the environment he encountered in Vietnam. “Cho Ray was the equivalent of a Level I trauma center in the U.S. – very busy with lots of high acuity patients, many of which were trauma-related. Since Vietnamese doctors receive no formal training in emergency medicine, care is provided by surgeons,

internists and physicians right out of medical school. The patients are triaged then moved to the emergency room (literally one large room) where treatment is initiated. A patient with tuberculosis could be lying next to a patient that is gastroenteritis who in turn could be lying next to a patient in cardiopulmonary arrest. With family members milling around, helping take care of their loved ones, it looked like organized chaos.”

The doctors in the emergency room at Cho Ray were eager to learn from Dr. Ramseier as he worked alongside them in an incredibly busy E.D. In turn, Dr. Ramseier learned a lot from them about how the Vietnamese practice medicine. He also fell in love with the Vietnamese culture. “Ho Chi Minh City is a beehive of activity. Eighty percent of the 9+ million people own at least one motorcycle. The food is amazing and ranges from simple (pho and rice dishes) to exotic (snake and dog.) But what struck me most was how friendly everyone was. The E.R. physicians that I worked with took me in as one of their own.”

When asked how medicine differs in Vietnam, he explained, “The disease processes are different and the available diagnostic and therapeutic equipment is often limited.” He went on to list some of the infectious diseases he dealt with, including malaria, various parasitic infections, and Dengue fever. He

also reflected on the number of head injuries and orthopedic injuries he saw.

“There were quite a few more traumatic injuries than I was used to seeing. Imagine almost everyone in Los Angeles County riding a motorcycle. Factor in that no one is wearing a helmet and that Ho Chi Minh City is less than half the size of LA County and the reasons become clear.” He went on to describe the turmoil. “I’ve


September 2012



ridden motorcycles for most of my life, and yet I would say that riding a motorcycle in Ho Chi Minh City for the month I was there was one of the craziest things I’ve ever done. Furthermore, it wasn’t uncommon to see a motorcycle – the equivalent of a Honda 90 – with the father driving, the mother sitting behind him holding an infant in her arms, and an older child sitting in front of the father holding on to the handlebars. If that wasn’t enough to catch your attention, that’s right, none of them were wearing helmets!”

He went on to explain that in 2002 no one was required to wear helmets and people considered them an inconvenience. In 2007, the central government mandated that all adults were required to wear a helmet. To this day, there still are no requirements for children to wear them.

Dr. Ramseier was so impressed with how eager his fellow physicians were to learn more about emergency medicine, that at the end of the month-long rotation, he considered staying in Ho Chi Minh City and delaying the completion of his residency. After much deliberation, he decided to return to the U.S. to finish his residency and vowed to return to Vietnam to find a way to give back to a people and a culture he had grown to love.

When asked what drove his desire to help in Vietnam, he replied, “A lot of the decisions anyone makes are shaped by one’s family and by ones experiences growing up. My parents moved to Africa when I was three, and I grew up in Rwanda, Burundi and Kenya. My mother was a nurse and my father was a teacher/administrator. They made a life-long commitment to serve others. That’s where I get it.” Because his family lived in so many places during his childhood, it was natural for Dr. Ramseier to look outside the U.S. for some way to make a difference.

In 2007, Dr. Ramseier had an opportunity to return to Vietnam – this time with the organization Good Samaritans Medical and Dental Ministry. After recognizing the enormous need for emergency medicine training among doctors in Vietnam, this group began holding an annual emergency medicine

conference at Hue College of Medicine and Pharmacy in the city of Hue, in central Vietnam. Dr. Ramseier has returned for the conference each of the last five years. Further, he is currently assisting with the creation of Vietnam’s first EM Residency program in Hue. Interestingly, fewer than five to ten percent of all medical school graduates in Hue are able to enter a residency program of any kind.

Through the years, a small group of dedicated physicians has seen their efforts grow tremendously. In 2010, approximately 200 Vietnamese physicians attended the conference. Prominent emergency medicine physicians from the U.S., Australia, Europe and Africa have presented at the conference, including Robert Suter (former ACEP and IFEM president), Richard Stennes (former ACEP president), Peter Cameron (president of IFEM), Howard Blumstein (president of AAEM), and Joe Lex who has been instrumental in leading the academic faculty and programs for the last three years.

The 2012 conference will be held in Hanoi. “Hanoi is a beautiful city – like Paris in the 1930s. It is very

scenic and is known for its lakes and its food. Nearby Halong Bay is a World Heritage Site not to be missed, and north of Hanoi is the beautiful mountainous Sapa region, home to several minority ethnic groups.”

Similar to the past two years, in 2012 there will be four different conferences running during the week.

The first will be the Emergency Medicine Symposium chaired by Dr. Joseph Lex with keynote speaker Dr. Judith Tintinelli, author of one of the leading textbooks in Emergency Medicine. The second is the Leadership Conference chaired by Dr.s Terry Mulligan and Nguyen Dat Anh which will be geared towards the country’s medical leaders with representation from key hospitals, medical

schools and government. That conference will focus primarily on the development of emergency medicine as its own specialty. The third conference will focus on the development of a country-wide EMS model as part of the development of emergency medicine. Finally, the fourth conference will be the Nursing Conference chaired by Michel Guerrero, RN with keynote speaker AnnMarie Papa, RN, president of the Emergency Nursing Association.

For residents interested in a month-long international EM rotation or participating in a teaching sabbatical, the Good Samaritan organization is currently making a fully furnished house in Hue available for rent. Good Samaritan can also assist with all other necessary arrangements. To learn more about the emergency medicine program through Good Samaritans, contact Dr. Ramseier at [email protected] or go to http://vietnamem.org/em/index.htm.


http://vietnamem.org/em/index.htm

September 2012


and the hospital was thrilled with the outcome and engaging a new physician leader. The benefit to her was the hands-on experience.”

Dr. Bishof cautions those interested in this program, “Be forewarned that with each new activity [in this program] it will be hard to let go of the one before. Each committee is so interesting and I wanted to continue. I even ended up creating a new one after participating on the cardiology and STEMI committees. One of the nurses recognized the need for a trauma committee and needed physician support. They appreciated my presence.”

Resident Elective in AdministrationUsing the Administrative Fellowship template,

the EmCare North Division also initiated a month – long elective in administration for emergency medicine residents. The first to take advantage of this program was Nathan Deal, MD, chief resident at the University of Chicago’s Department of Emergency Medicine. Like Dr. Bishof, Dr. Deal expressed an early interest in the administrative aspects of emergency medicine. During this month-long elective, he had the opportunity to be exposed to some of the features of a one to two-year fellowship.

Dr. Deal described his experience. “I wanted the chance to understand the unique challenges of a smaller community hospital. During the elective, I had the opportunity to better appreciate the logistics of running an E.D., including the challenges of staffing, recruiting, retention and credentialing.”

“For any resident who is interested in a career path in administration, this month with EmCare is a perfect jumping-off point.” Dr. Deal went on to explain, “I was exposed to things that are not part of a typical residency program and it was a great learning experience.”

EmCare’s Administrative Fellowship TodayDuring EmCare’s two-year Administrative

Fellowship program, participants act as assistant medical director at a site while participating in a variety of hospital functions. They have onsite clinical and administrative duties. Through the various rotations, participants learn about committee structures, medical structures and the collaborative approach to emergency medicine. Dr. Parker emphasized how important it is for the hospital to be

EmCare’s partner in offering this kind of program.“EmCare now offers the Administrative Fellowship

at three hospital systems. These all have strong physician leaders and a commitment to education and development of their physicians,” Dr. Parker explained. They include:• Lake Health, a multi-hospital system in the

Cleveland, Ohio area• Jersey Shore University Medical Center in

Neptune, New Jersey• Sinai Hospital in Baltimore, Maryland

EmCare plans to expand the program nationally as qualified candidates apply for the program and are matched with physician leaders who can serve as mentors.

Administrative Fellowship Activities and Rotations

The Administrative Fellowship program features an increase in responsibility as the participant develops skills. Throughout the program, the participants are directly involved in a variety of projects and committee work. The fellowship emphasizes leadership, and the overall objective of the program is to develop an effective director capable of managing all aspects of an emergency department. Each of these rotations includes specific activities and reading.• General: Throughout the fellowship, the

participant attends events hosted by ACEP, EmCare and the Studer Group.

• Quality: This includes two six-month rotations. It covers monitoring core measures, participating in performance improvement, six sigma and lean sessions, learning regulatory requirements, leading a quality committee peer review session and either a mock or scheduled Joint Commission survey.

• Customer Satisfaction & Service: This rotation includes attending Studer Group training, participating in patient satisfaction committee and, during the second year, handling complaints independently, and AIDET and rounding implementation.

• Corporate Operations: This rotation is one month during the first year and two months during the second year. It includes visiting EmCare’s offices in Horsham or Chicago and Dallas to shadow staff responsible for scheduling,

recruiting, credentialing, analysis of budget, staffing and service planning.

• Physician Executive: This activity is ongoing, and includes visiting EmCare’s headquarters in Dallas and shadowing various divisional leaders.

• Risk Management: This is a two-month rotation that include, participation in case preparation, undertaking an on-site risk project (to assess department for risk, and implement of a resolution), chart review on high risk diagnoses, fail-safe program implementation and participation in a Risk Claims Assessment (RCA) as it occurs. In the second year, it includes ongoing assessment for risk and chart reviews.

• Hospital Administration: During this one-month rotation, the participant will attend medical staff meetings, hospital administration meetings and department meetings (such as ICU, radiology and hospital medicine (H.M.)) and have the opportunity to participate on hospital throughput committees.

• Coding & Billing: This two-month rotation includes a two-day trip to Philadelphia to meet with Reimbursement Technologies, Inc. (RTI), EmCare’s –H.M. billing company. As part of this rotation, the participant will gain a deeper understanding of coding and billing, denials, collections and revenue capture opportunities.

• EMS: During this month-long rotation, the participant will participate in departmental activities for EMS, participate in EMS administration and attend an EMS operations committee meeting.

• Advocacy and Organized Medicine: During this ongoing activity, the participant will attend organized medicine meetings and participate in advocacy efforts through the local, state or national organization of choice. They will learn how these organized medical groups are structured and interact while learning about the process by which they influence state and federal legislation and regulation.

To learn more about the EmCare Administrative Fellowship Program, please contact Craig Bleiler at [email protected] or 800-247-8060 ext. 25165 or [email protected] or 800-247-8060 ext. 25035.




September 2012


“MOPP”-ing Up: Improving Patient Satisfaction Scores by Managing Patient Perceptions

by: KERRY SILVER

These days, medical providers can’t escape the barrage of messages about quality care and patient satisfaction. While medical providers focus on The Joint Commission definition of quality of care – hich addresses appropriateness, availability, continuity, effectiveness, efficacy, safety and timeliness – our patients may have very different concepts of what it means to receive quality care.

We can never lose sight of the fact that our patients’ perceptions are as essential to our success as the clinical standards to which we hold ourselves. A patient’s perception of whether he or she received quality care is very subjective and often based on factors that are very different from either JCAHCO or a medical provider’s definition of quality care.

As Regional Medical Educator for EmCare’s Southeast Division, Michael A. LoGuidice Sr., DO, MBA , FACOEP and his team developed a plan to help patients understand what was happening throughout their emergency department visit and, accordingly, to improve their satisfaction with the E.D. experience.

“Instead of trying to meet expectations, we should be trying to manage patient’s perceptions,” Dr. LoGuidice explained. “By using an action plan focused on shaping patient perceptions, I believed we could improve the Emergency Department’s patient satisfaction scores. We developed a strategy called Management of Patient Perceptions – or MOPP –designed to do that.”

Shaping Patient ExpectationsResearch shows that there is often a gap between

patients’ perceptions of their care and the actual care they received. Patient satisfaction (or dissatisfaction) is determined by a variety of closely linked elements that, when combined, influence the patients’ overall perceptions of their care experience. To understand the patient’s E.D. experience, Dr. LoGuidice and his team separated the patient visit into multiple stages. For each stage, they identified focal points they

believed would help improve patient satisfactions scores. Those stages are:• Pre-treatment Stage• Emergency Department Stage• Disposition Stage

The following graphic depicts these three stages and the activities that influence patient perceptions in each stage.

Setting Expectations in the Pre-treatment Stage

The team developed several important strategies during this stage, from the moment the patient arrives until they are through triage. Those strategies include:• Wait time in the pre-treatment area: Lengthy

wait time is typically the primary patient complaint. Patients are more tolerant of waits when they have realistic expectations of the wait times. To maintain high patient satisfaction scores in the midst of delays, provide updated, honest information in a timely manner. Whenever possible, patients should be assigned an available bed for bedside triage. The patients’ perception of wait time is influenced by the manner in which they are treated by the staff in the pre-treatment area. Physicians and nursing staff often underestimate the length of time a patient will have to wait.

Patients often overestimate their wait times, especially when they are not expecting a delay.

• Signage in pre-treatment area: Signs in the waiting area help manage patient’s expectations in the E.D. LoGuidice recommends two signs:• Anatomy of an Emergency Department

Visit: Describes anticipated wait times for an E.D. patient. It should include the following

elements:• 15 Minutes to physician exam• 1 hour for lab & basic X-ray results• 2 hours for CT scans or ultrasound results• 30 minutes to discharge after instructions complete• Triage Education: Explains that patients will be taken in order of severity of condition.• Clinical greeter in pre-treatment area: A medical technician in the lobby offers several advantages: he or she can monitor the pre-treatment area, help patients into

the E.D., assist the triage nurse, and recheck vital signs. The medical technician provides another layer of patient service to enhance the patient’s overall perception.

Setting Expectations During the Emergency Department Stage

The team developed several important strategies during this stage – from the time the patient arrives until they are ready for disposition. Those strategies include:

• Wait time in the treatment area: This includes waiting for the nurse or medical assistant to obtain and chart information about the patient’s symptoms or condition, waiting for the healthcare provider to enter the room, waiting for diagnostic studies such as labs or x-rays, waiting for the provider to come back with results, and waiting for discharge instructions. Two additional factors


IMMEDIATE BED PLACEMENT

EDUCATION SIGNAGE

CLINICAL GREETER

GREAT COMMUNICATION

DOOR TO DOC TIME:

15 MINUTES

PROVIDER ROUNDING

COMFORT MEASURES

NURSE ROUNDING

BEDSIDE TRIAGE

BEDSIDE REGISTRATION

GREAT COMMUNICATION

GREAT COMMUNICATION

HERE’S MY CARD

PRIMARY CARE CONSULT

CALL BACKS

M A N A G E M E N T O F P A T I E N T P E R C E P T I O N S

PRE-TREATMENT I EMERGENCY DEPARTMENT I DISPOSITION

September 2012


that affect patient satisfaction include:• Explanation provided for an extended

wait: Patients need to be kept informed about delays. When wait times are explained to patients, delays are more tolerable — especially when the explanation apprises the patient of progress.

• Total wait time in treatment room: The patient’s mental clock for timely medical care starts from the moment he or she enters the treatment room. Long unexplained waits detract from the patient’s overall satisfaction.

• Communication: The perceived quality of the patient’s care is directly related to the quality of communication with the patient and among the medical professionals who come in contact with the patient. Health care providers must consider the patient’s education, background and primary language to assure complete and accurate understanding. Two essential components of the patient’s perception of quality are:• Patient’s first impression of the provider:

The following elements are essential to establish the perception of quality:• Greeting, including a friendly smile, firm

handshake (for everyone in the room), and a soft tone

• A congenial introduction, such as “I’m Doctor Smith and I’ll be taking care of you today.”

• If an MLP or NP are assisting in treating the patient, include an introduction of them and an explanation of their role.

• Provider’s explanation of the medical problem: The healthcare provider must explain complex clinical information in clear ways using:• Understandable terminology• Visual aids• Adequate time for the explanation• Invitation to ask questions

• Provider’s explanation of tests and procedures: Patients need to be informed of the rationale and logistics associated with any procedures and tests. The more information you can give a patient about a test, the more they can mentally prepare for and reduce their anxiety about it.

• Communication between doctor and

staff: Patients can sense when there is lack of teamwork among healthcare providers and staff. This is usually due to a lack of communication. If communication difficulties persist, scripting may be necessary.

• Communication before room placement: Patients become exasperated when they are asked to repeat information about their chief complaint over and over again. Demonstrating good communication between the staff and doctor can be as easy as repeating your understanding of information documented in the chart. For example, “Nurse Linda told me that your pain started yesterday.”

• Communication during the visit: To ensure seamless flow of information, the team must share information about the patient’s questions, lab work, and other tests.

• Doctor’s willingness to listen: Patients can discern when the doctor isn’t fully engaged and this lack of full attention will affect the patient’s perception of the level or care he or she has received. It is important to be an active listener by maintaining eye contact and paraphrasing to ensure you clearly understand what the patient has said without appearing to be rushing.

• Physician rounding: Physician rounding logs should be submitted daily to the medical director. A physician will evaluate and examine all admitted patients who were cared for by a midlevel provider. Physicians also greet and interact with 5 discharged patients per shift who were cared for by a midlevel provider.

• Informed consent: Obtaining informed consent requires a physician to explain the treatment to be rendered, the risks and benefits of the proposed treatment, alternatives to the treatment, risks and benefits of alternative treatments, and the risks and benefits of doing nothing. The information must be explained clearly in vocabulary anyone can understand. The patient should have the opportunity to ask questions.

• Comfort measures: These make the patient feel more comfortable, including allowing

family members to stay at the patient’s bed side and providing chairs for family members. The temperature of the room should be comfortable, and a team member should offer a blanket, pillow, water and, if appropriate, food. If the patient has a physician relationship, the team member should offer to call the patient’s preferred doctor.

Disposition StageThe team developed a few additional strategies

during this final stage – once the patient is ready to either be admitted or discharged. Those strategies include:• Provider’s explanation of prescribed

medications: It is important to explain prescriptions to the patient in the clearest terms possible, including the reason for taking it, how and when to take it, what side effects and adverse reactions may occur and what to do if they occur.

• Communication after the visit: Sometimes the patient has a question or expresses an opinion to a staff member after the visit. It is important to communicate this information to the provider, especially if it reveals a misunderstanding that can be cleared up before the patient departs the Emergency Department.

• “Here’s my card” initiative: ED providers should give their business cards to patients upon discharge or admission. The cards have the provider’s name, hospital address and ED phone number.

• Callbacks: Twenty percent of discharged patients should be contacted after their discharge. These calls should include all AMA patients and LWOT patients.

• Primary care consultants: During normal office hours, the E.D. providers were required to contact the patient’s primary care doctor.

ResultsUsing an action plan that was focused on patient’s

perceptions during the different stages of their ED visit, LoGuidice’s team evaluated how effective this approach was in improving patient satisfaction scores. Press Gainey Patient Satisfaction Surveys were



September 2012

1 0 I EmPress!ons – the newsletter for EmCare® health care professionals

used to evaluate progress. They also collected real-time satisfaction surveys with the Client IQ Qualitick program. Press Gainey surveys are conducted by phone several days after the E.D. visit. The Qual-tick program collected data at time of service. Random patients were directed to the Qual-tick terminal in the E.D. to complete the survey.

The team showed a significant improvement in the E.D. satisfaction scores, as well as an improvement in the physician satisfaction scores.

Qual-tick DataVery satisfied 83%

Satisfied 12%

Dissatisfied 5%

The E.D. team focused on improving patient and team communication. The Press Gainey scores didn’t capture a good sample of the E.D. population. LoGuidice went on, “Although these scores were improved, they did not reflect the success we achieved with this program. The Qual-Tick program measured significantly higher patient satisfaction scores.”

He went on to explain that initially the E.D. team was highly motivated to ask patients to complete patient satisfaction surveys at the time of service. However, over time, the team didn’t collect as many patient surveys. The lower number of surveys makes it difficult to compare the Press-Gainey results to the Qual -Tick results.

“If we would have generated more patient satisfaction surveys, I believe that the Qual-Tick program would have proven more effective to measure patient satisfaction than the Press-Gainey survey. If I were to do this study over again, I would try to find a better way to keep the ED staff motivated to do the Qual-tick surveys.”

Michael A. LoGuidice Sr., DO, MBA , FACOEP currently serves as Medical Director of Hernando County Emergency Services in Brooksville, Florida. If you have questions about this article, email Dr. LoGuidice at [email protected].


Radiology CEO, COO Present at AHRA

EmCare Radiology Services’ CEO, Phil Heckendorn, and COO, David Walker, were selected to present at the 2012 Association for Medical Imaging Management (AHRA) Convention in Orlando, Fla. Their session was called “Picture It! The Radiology Department of the Future,” and impressed upon attendees the vital importance of combining on-site and off-site components with updated technology, such as EmCare’s SuperPACS system.

Heckendorn and Walker told a packed house about changing expectations, increasing demands and evolving technologies that are shifting the landscape of radiology in hospitals. As patient satisfaction becomes the leading financial benchmark for hospitals

and health care facilities, the demand for 24-hour Radiology performance is becoming the norm – leading to evolution in technology and a wider use of teleradiology for overnight and weekend reads in order to keep pace. The radiology duo examined trends and factors that are changing how radiology is traditionally delivered and who is delivering it, as well as the things hospitals can do to keep their radiology departments ahead of the game.

This was the second time this year that Heckendorn and Walker were asked to make this presentation at a national convention. They also spoke at the Becker’s Review Annual Meeting in Chicago last May.

EmCare Physician Can Now Add

“Superstar” to Her CVCongratulations to Dr. Maria Aurora R. Soriano,

MD, for winning the 2012 Faculty Superstar Award from the Department of Pediatrics at Sinai Hospital of Baltimore. This award is given each year for Excellence in Teaching, Scholarship, Clinical Care and Departmental Stewardship. Dr. Soriano is the EmCare Director of Pediatric Emergency Services at Sinai Hospital in Baltimore, Maryland.

Picture - left, Joseph Wiley, MD, Chief, The Children’s Hospital at Sinai and right, Maria Aurora R. Soriano, MD, Director of Pediatric Emergency Services at Sinai Hospital of Baltimore

The North Division would like to thank Dr. Soriano and the entire Pediatric E.D. Faculty for their dedication and commitment to resident education, teaching and scholarly activity.

DAVID WALKER Chief Operations Officer

EmCare Radiology Services

PHIL HECKENDORN Chief Executive Officer

EmCare Radiology Services


September 2012


EmCare’s Big Push for Innovation

by: JOSEPH TWANMOH, MD, MBA, FACEP Director of Health Systems Innovation, EmCare North Division Site Medical Director, Saint Agnes Medical Center Emergency Department, Baltimore, MD

You meet with your chief medical officer or CEO who tells you that the emergency department patient satisfaction scores are below the hospital target. You and your team must do something to raise the scores within the next six months.

Your chief medical officer or CEO is unhappy with the amount of time that patients are waiting in your emergency department. She believes that you need to hire “faster” physicians. If the physicians could only see patients faster there would not be any waits.

Your emergency department is in gridlock because you are boarding multiple admissions. Your CEO wants to know why you are on ambulance diversion and why there are all those patients in the waiting room.

Do any of these situations sound familiar to you?Many of us face the same problems every day

in each of our departments and each day we are individually trying to solve those same problems. Rather than reinvent the wheel, isn’t there something that we can do as a company to help solve these problems? Fortunately, common solutions exist.

Common solutions for common problems; this is the idea behind the Innovation Task Force, which was formed several months ago in EmCare’s North Division. Right now, many of you are working on innovative solutions to problems that each of us face, as emergency physicians or medical directors. Wouldn’t it be great if there were a repository of information available at your fingertips at any time

of the day or night? Soon that may become a reality.The Innovation Task Force is chaired by myself,

Joe Twanmoh. Members include Russ Harris, Al Sacchetti, Darius Starosta, and Becky Parker. Recently, our Studer partners, Gina Shoup and Julie Kennedy, have joined the group. The goals of task force are to create a repository of information, provide a means of communication to keep you abreast of cutting-

edge issues and connect you with your colleagues that have successfully implemented change in their departments.

Innovation is not just about coming up with creative ideas. It is about the successful implementation of those ideas. Steve Jobs is considered a great innovator. Apple wasn’t the first to come up with the idea of an MP3 player, smart phone, and or a tablet. But, arguably, the iPod, iPhone, and iPad are the best in class. Steve Jobs’ real genius was his ability to bring those ideas to market successfully

Initially the task force will focus on three specific areas:

1. Clinical 2. Throughput and operations3. Patient satisfactionFor the clinical initiative, the task force is already

working on a web-based repository of training videos. Many of you have seen the work of Al Sacchetti and his team where simple, short videos show clinicians how to do procedures such as pacemaker insertion, paracentesis, or how to purse string a bleeding AV fistula. In literally two minutes, one can get up to speed on a procedure that one hasn’t done in years.

Patient throughput and operations are challenges that we face on a daily basis. While many of our emergency departments are overcrowded, effective solutions exist and been implemented in Emcare contracted facilities. We plan to have a collection of proven best practices available to you and also on the Web. More importantly, we plan to be able to

JOSEPH TWANMOH, MD, MBA, FACEP EmCare Medical Director

St. Agnes Hospital, Baltimore, MD


September 2012


EmCare – Celebrating 40 years with a hot new look and cool new digs

It was 1972. Sanford & Son premiered on NBC, Wilt Chamberlain scored his 30,000th point in the NBA, the first-ever mobile phone call was placed, Mark Spitz won seven gold medals in swimming at the Olympic games, the Dow Jones Stock Exchange closed above 1,000 for the first time ever and a small group of Dallas emergency medicine physicians launched a new physician practice management company they called “EmCare.”

Forty years later, Big Bang Theory rules the airwaves, the Miami Heat won the NBA championship, the iPhone and iPad are all the rage, swimmer Michael Phelps has become the most highly decorated Olympic athlete, the Dow has surpassed 13,000 and EmCare dominates as the largest physician practice management company in the nation.

A landmark anniversary such as EmCare’s 40th warrants some excitement and recognition, and EmCare won’t disappoint. The company has introduced new names, logos and taglines for its affiliated service lines. It has also moved into new corporate headquarters in Dallas.

A landmark anniversary such as 40 years warrants big change and EmCare won’t disappoint. The company is introducing new names, logos and taglines for its affiliated service lines. It is also moving into new corporate headquarters in Dallas.

Re-BrandingOver the past two years, EmCare has conducted a

thorough assessment of its brands. With enhanced brand recognition and increased sales as its goals, the company has changed the names of a number of its affiliated entities.

• The parent company remains EmCare, Inc. and a new tagline has been adopted … Making Health Care Work Better.™

• The company’s emergency medicine service is now EmCare® Emergency Medicine.

• EmCare Inpatient Services is EmCare® Hospital

Medicine.• Anesthesia Care, Milford Anesthesia, Pinnacle

Mid-Atlantic and North PinellasAnesthesia have been unified into EmCare® Anesthesia Services.

• RadCare is now called “EmCare® Radiology Services.”

• EmCare’s new surgery affiliate, Acute Surgical, is now EmCare® Acute Care Surgery.

• No changes will be made to EmCare’s endorsed brands – BestPractices and Affilion.

This “fully branded house” branding architecture will help to ensure that EmCare achieves even greater brand recognition. Along with the new names come new taglines, each of which represents the goals, attitudes and commitments of our services. EmCare Emergency Medicine (EEM) has two taglines: Emergency Medicine, Customer Driven for sales initiatives and Making Health Care Work Better for recruiting. The tagline for EmCare Hospital Medicine (EHM) is Changing the Horizon of Health Care. EmCare Anesthesia Service’s (EAS) will be represented by the tagline The Complete Anesthesia Solution, while EmCare Acute Care Surgery (EACS) will utilize Emergency and Trauma Surgeons. EmCare Radiology Services (ERS) will be bolstered by the tagline Partners in Radiology & Teleradiology.

EmCare’s Marketing Department worked for months to develop a contemporary new look for EmCare and its service lines, a look that will be apparent in everything from business cards to websites and advertisements to trade show exhibits. The new look retains the EmCare green and adds a rich gold accent against a clean white background.

The sleek design will help to position EmCare in the minds of its various constituents as the nearly $2 billion industry leader that it truly is.

Re-LocationFor many years now, EmCare’s corporate offices

have been on the 51st through 53rd stories of a

connect you with others that have already successfully implemented these innovations, eliminating the need for you to have to reinvent the wheel at your hospital.

With HCAHPS looming on the horizon, there is hardly a hospital CEO in the country who isn’t concerned about patient satisfaction. Fortunately, improving patient satisfaction isn’t a mystery. With our Studer engagement, the roadmap to improve patient satisfaction is well laid out. We plan to show you what works best and who has done it before.

Lastly, we will be launching the Innovation Cup at the North Division leadership meeting in Philadelphia this November. Modeled after the Genesis Cup, individuals may submit their innovations for review. The team with the best innovation gets recognition at the division meeting, the Innovation Cup to take home and bragging rights for a year. This year’s Innovation Cup theme will be “Value-Based Purchasing.”

We hope to see you in Philadelphia!

Joseph Twanmoh, MD, MBA, FACEP is the Director of Health Systems Innovation for EmCare and the Site Medical Director for Saint Agnes Medical Center in Baltimore, chairing their emergency medicine department. He earned a BS in Biology from Tufts University, his medical degree from the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, and his MBA from The Johns Hopkins University – Carey Business School. Dr. Twanmoh is the immediate past president of the Maryland Chapter of the American College of Emergency Physicians (ACEP) and an assistant professor at the University of Maryland School of Medicine. He is also trained in LEAN and LEAN Sigma.



September 2012


downtown Dallas high rise (shown left). On August 3, those offices were moved to a 16 story mid-rise in North Dallas’ Galleria area. EmCare and its affiliates will occupy the 13th through 16th stories of that building, nearly 83,000 square feet of space. The building will feature state-of-the-art technology and will have room for EmCare Radiology Services, EmCare Hospital Medicine, EmCare Acute Care Surgery and EmCare Anesthesia Services, the latter of which will relocate in 2013.

Re-MixForty years, and EmCare is just getting started.

Looking ahead, one can only imagine the many ways each of us at EmCare will be … Making Health Care Work Better.


EmCare’s New Look

Business Cards Tradeshow Booths

Sales Brochures

ML-021612-01 © 02/2012 EmCare, Inc. – All rights reserved.

Local Practice.Divisional Support.National Resources.™ · Leadership· Quality· E�ciency / Metrics· Flexibility· Synergy

Integrated Service Lines: · Emergency Medicine· Hospital Medicine· Acute Care Surgery· Anesthesiology· Radiology / Teleradiology

Making Health Care Work Better.™

September 2012

Special Thanks to:

EmPress!ons Medical EditorsDr. Nathan Goldfein – Hospital MedicineDr. William Hartenbach – AnesthesiologyDr. Kent Hutson – RadiologyDr. Rebecca Parker – Emergency MedicineDr. Tommy Verdone – AnesthesiologyDr. Kent Skipper – Acute Care Surgery

EmPress!ons Editorial Board MembersEllen AmblerDonna BiehlMark BruningDr. John DerdeynDotti DuboisDr. John FernandezGary GelbartMark HammDr. Russ HarrisPhil HeckendornDr. Michael HicksDeborah HilemanGreg Hufstatler

Submit Article Ideas To:Jennifer WhitusMarketing Communications [email protected](214) 712-2793


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