A midsize health system recognized a pattern in Serious Safety Events (SSE) occurring in its hospitals. Half of all SSE-1 (deaths) and SSE-2 (severe permanent harm) were attributed to delays in physician evaluation of patients admitted through the Emergency Department (ED).


The health system engaged stakeholders in a conversation initiated by an Admission Taskforce then brought to Clinical Performance Committees and Medical Executive Committees on each campus for standardization of expectations and enactment. The standard adopted is that a patient admitted from the ED should be evaluated in a timely manner: no later than 4 hours for intermediate care unit (IMU), floor, and observation patients and no later than 2 hours for intensive care unit (ICU) patients. To measure this provision, a metric was developed for hospitalists to pilot: Timely Evaluation of Emergently Admitted Patients (4-4-2).

Description: The 4-4-2 metric is incentivized for contracted hospitalists in the health system. To be compliant, a hospitalist must see and evaluate ED patients admitted to their care within the set standards, and an appropriate medical power plan (MPP) must be planned or initiated by a physician within 24 hours of admission. The physician-patient evaluation is captured by the completion of a “Physician at Bedside Attestation” embedded in the MPP. Admission MPPs planned or initiated by ED providers, residents, fellows, advanced practice providers, and nurses do not count. The target has been set at 85% to allow for unusual patient care situations.


Timely Evaluation of Emergently Admitted Patients is a unique metric, and data validation has revealed multiple workflow issues that are targeted for performance improvement. This metric should help ensure patient safety but will require culture change, staffing adjustments, and ongoing refinement to achieve its intended purpose.