EMRA Fellowship Guide, 3rd Edition

Administration/ED Operations/Patient Safety & Quality Improvement Fellowships

Author

Christina Brown, MD
Chair, EMRA Administration & Operations Committee
ChristianaCare

Faculty Reviewer

Thomas Spiegel, MD, MS, MBA
Medical Director, University of Chicago Mitchell Adult Emergency Department
Assistant Professor, University of Chicago Pritzker School of Medicine

Special thanks to our 2^nd edition author

Zach Jarou, MD

INTRODUCTION

Description of the specialty
Successful physicians have long known that the practice of medicine is equal parts art and science, but today’s physicians also must be knowledgeable about the business of medicine. Administrative and operations fellowships in emergency medicine were designed to prepare residency graduates with the administrative, quality, health policy, patient safety, research, and operational skills necessary to lead an emergency department, hospital, or health care system, and to research the best approaches to ED operations. At some academic medical centers, institution-wide fellowships focused solely on patient safety and quality improvement have also been created.

History of the specialty/fellowship pathway
The first administrative EM fellowship was created by EPMG in California in 1990 and was followed by two more in 1993, one in Chicago founded by EMSCO Management Service and another at Orlando Regional Medical Center co-sponsored by EmCare. These first three fellowships were described in a 1995 publication of Physician Executive by Dr. Byron Scott, one of the earliest graduates of Orlando’s Administrative Fellowship Program. Since that time, more than 30 EM administration and operations fellowships have come into existence, in addition to a dozen non-EM-specific patient safety fellowships. Also worth noting: In March 2023, the American Board of Medical Specialties (ABMS) approved the subspecialty of health care administration, leadership, and management for all specialties (details here).

Why residents choose to follow this career path
EM residency graduates interested in addressing patient care from a systems perspective, becoming a researcher in ED operations, and/or pursuing departmental or hospital-wide leadership roles may consider this career path.

Although a fellowship is not required to pursue this career path, fellowship training can lead to earlier opportunities to take ownership over impactful projects in an emergency department, creation of scholarship in this area, and mentorship to help cultivate your leadership and research skills. Fellowships may also help subsidize the cost of your graduate degree as a trade-off for the decreased salary you may make during your time as a fellow.

How do I know if this path is right for me?
If you see challenges as opportunities, if you enjoy thinking about the way patients flow through your department and how their care can be made more streamlined and safe, and if you are interested in the art and science of ED operations, then an administrative fellowship may be right for you.

Career options after fellowship
There are a number of career options available after fellowship, including medical director, patient safety and quality improvement officer, director of physician group practice, director of observation medicine, chief medical officer, payer leadership positions, health policy leadership positions, or research leadership positions, including the burgeoning field of healthcare delivery science.

Splitting time between departments
Unlike clinically based fellowships, splitting time between departments is not applicable for EM administrative fellows, however physicians with this skillset may have fewer clinical shifts in order to complete administrative projects and responsibilities.

Academic vs. community positions
Emergency departments need policies and protocols to run smoothly in both academic and community settings. The administrative and operational needs of each department will depend upon the patient population, local resource availability, and relationships between the emergency department and other services in the hospital. Fellowships exist in both settings; however, research-based fellowships are exclusively run out of academic medical centers.

Some fellowships are sponsored by local or regional groups of providers, while others are affiliated with large nationwide contract management groups. The clinical responsibilities, administrative responsibilities, and research requirements also vary among programs. Some fellowships are focused on operations at the department-level, while others also provide exposure to leading a hospital or health-care system.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
As of April 2023, there were more than 40 EM admin fellowship programs. Additionally, there are nearly a dozen patient safety & quality improvement fellowships available to EM residency graduates.

• EM-Specific Admin Fellowships at Academic Centers
  • Baylor College of Medicine
  • Baystate Medical Center
  • Beth Israel Lahey Health
  • Brigham and Women’s Hospital
  • Brown University
  • Case Western Reserve University/UH Cleveland
  • Columbia University (Dr Lorna M Breen Emergency Medicine Fellowship in Healthcare Administration)
  • Denver Health
  • Emory University School of Medicine
  • Florida Kendall Hospital
  • Fort Worth
  • George Washington University (Medical Leadership & Operations)
  • Harbor-UCLA
  • Indiana University
  • Keck School of Medicine
  • Maimonides
  • Massachusetts General Hospital
  • McGovern Medical School
  • Mount Sinai
  • New York Presbyterian Queens
  • New York Presbyterian-Weill Cornell
  • NYU Langone Health (Healthcare Leadership & Operations)
  • NYU Langone Health (Kenneth and JoAnn G. Wellner Fellowship in Emergency Department Safety and Quality)
  • Northwestern University
  • Oregon Health & Science University
  • Rush University (Emergency Medicine Administration and Health System Strategy)
  • Stanford University
  • Staten Island University Hospital
  • SUNY Downstate/Kings County
  • Temple University
  • The Ohio State University
  • University of Alabama, Birmingham
  • University of California, San Francisco
  • University of Chicago
  • University of Colorado
  • University of Florida
  • University of Kansas
  • University of Massachusetts
  • University of Missouri
  • University of North Carolina (Chapel Hill)
  • University of Pennsylvania
  • University of Pittsburgh
  • University of Wisconsin
  • Wake Forest Baptist Health
  • West Virginia University
  • Yale University
• EM-Specific Admin Fellowships with Contract Management Groups
  • ApolloMD (Georgia)
  • Emergent Medical Associates (Los Angeles Area)
  • Envision (Available at Various Sites Nationwide)
  • University of South Florida (TeamHealth)
• EM Hybrid (Academic/Community) Programs
  • ACEP/IES Administration, Quality, Informatics, and Policy Fellowship
  • UCLA - VEP Healthcare
  • UCLA - Antelope Valley Hospital
• Institution-Wide Admin Fellowships at Academic Centers
  • Jefferson Health
  • MedStar Health
  • Northwell Health
  • Vituity (Available at Various Sites Nationwide)
• Institution-Wide Patient Safety & Quality Improvement
  • Christiana Care
  • Health Careers Futures
  • Harvard Medical School
  • Institute for Healthcare Improvement
  • Kaiser Permanente Northern California
  • NorthShore University HealthSystem
  • Our Lady of the Lake
  • Regions Hospital/Health Partners
  • University of Florida College of Medicine–Jacksonville
  • University of Pennsylvania
  • University of Toledo
• VA Interprofessional Fellowship Program in Patient Safety (six sites)

Differences between programs
There are significant differences between programs advertised as administrative fellowships. Programs vary from a series of leadership lectures and hospital committee appointments offered by large contract management groups to traditional fellowship models at academic centers requiring peer-reviewed research and involvement with resident education.

Length of time required to complete fellowship
Fellowships vary in length from 1-2 years. Most 2-year fellowships will include a graduate degree such as a Master’s of Business Administration (MBA), Master’s of Health Administration (MHA), or a Master’s of Public Health (MPH), although some do not. Some fellowships may result in advanced-level work (PhD), particularly those that focus on the science of ED operations.

Skills acquired during fellowship
Fellows should gain training in quality improvement, research, patient safety, economics/finance, billing/coding/reimbursement, health policy, risk management, process improvement, leadership, operations, staffing, utilization management, patient satisfaction, and medical informatics, as well as other areas that may be relevant to their interests and capstone projects. Outside of the clinical environment, fellows participating in programs that offer advanced degrees, will have the opportunity to learn information specific to their degree. Students completing traditional MBA programs will typically have the opportunity to choose electives and will have the opportunity to be exposed to a wider breadth of topics compared to healthcare-specific or executive MBA programs.

Typical rotations/curriculum
Clinical responsibilities: Clinical responsibilities again vary across fellowships. Typically, the fellow will work as an attending physician in the clinical environment, either seeing patients primarily or supervising learners. It is important to balance protected time (not having a full clinical workload) to develop fellowship interests, but to work clinically enough to have a sense of operations and frontline staff. Fellows at most academic fellowship programs will work approximately 8 shifts per month.

Research responsibilities: Most academic programs require fellows to conduct one or more IRB-approved research projects for publication in a peer-reviewed journal as part of their fellowship completion requirements. Other scholarly work, such as authoring presentations or book chapters, is encouraged. Fellowships with contract management groups or community sites will also typically require completion of a capstone project, though there may be less emphasis on publication.

Obtaining advanced degree: The paradigm of department chairs and medical directors learning “the business side of medicine” on the job is over. Today’s physicians-in-training will most likely require an MD/MBA or equivalent training to become the next generation of physician leaders--prepared to create and manage the health systems of tomorrow. Contract management groups are often trying to create an internal leadership pipeline for their organizations, and if you stick with the group that trains you, obtaining an advanced degree may have no effect (positively or negatively) on your career trajectory. Most two-year academic administrative fellowships are coupled with completion of an MBA program, though some programs may also offer an MHA, MPA, or MPH. Generalized MBA programs will provide exposure to classmates from all industries and usually allow students more flexibility in choosing their courses, while executive or healthcare-specific MBA programs are less flexible and students may not have the opportunity to learn lessons from other industries that could potentially be applied to healthcare. MBA programs at top universities will typically require completion of the full MBA application used by general applicants, including the GMAT, while some MBA programs will automatically guarantee a spot to whomever is selected as the program’s administrative fellow. Most, but not all, fellowship programs with an affiliated advanced degree fully subsidize the cost of the degree.

Administrative responsibilities: These vary significantly from fellowship to fellowship, and it is vitally important to ask details about what your responsibilities will be. Be sure the fellowship’s area of focus, and the areas of expertise of the core fellowship faculty match your areas of interest.

Board certification afterwards?
Administrative, quality improvement/patient safety, and operations fellowships are non-ACGME accredited and there is no additional board certification. However, other advanced credentials are available, such as the American Association for Physician Leadership’s Certified Physician Executive (CPE) program or by becoming a Fellow of the American College of Healthcare Executives (FACHE) or the American College of Medical Quality (FACMQ).

Average salary during fellowship
Because of the wide variety of training formats, some programs at academic centers will pay on a PGY scale, while other academic programs may pay up to $100,000 per year in salary. Fellowships based at contract management groups may pay you an hourly attending rate for your clinical shifts, in addition to a leadership stipend. It is important to consider your moonlighting opportunities and/or free tuition, if pursuing an advanced degree, as part of your overall compensation.

PREPARING TO APPLY

How competitive is the fellowship application process?
As a non-ACGME fellowship that does not use a centralized application process, there is no data available regarding the competitiveness of administrative fellowships, however not all programs are filled each year.

Requirements to apply

• Letter of interest/intent
• Updated CV
• Completion of ABEM-certified EM residency program
• 3 letters of recommendation (program director, administrative mentor)
• Some programs may require a GMAT score (determine if this is a requirement at programs you are interested in early so that you have time to study and receive your score before the fellowship/MBA program application deadline)
• Ability to obtain a medical license in the state you would like to complete your fellowship

Research requirements
Research is generally not required to apply, but demonstrating some evidence of scholarship in the area is helpful for your application, particularly for research-focused operations fellowships.

Suggested elective rotations to take during residency
Many residency programs offer administrative or medico-legal rotations where residents can spend time with department/hospital leadership learning the nuts and bolts of how the hospital/department is run or with risk-management specialists to learn more about ways to reduce patient harm, as well as reduce your risk of future liability. Residents may also consider completing the Institute for Health Care Improvement’s Open School “Basic Certificate in Quality and Safety” course, which can be completed free of charge if your institution already has a subscription.

Suggestions on how to excel during these elective rotations
Several qualities are important for any administrative fellow. First, you must demonstrate leadership potential and the ability to manage change. Second, be sure that any projects you are involved in are executed fully. Delivering a polished final project is far more important than loose associations with many failed change efforts.

Should I complete an away rotation?
Away rotations are generally not necessary, especially given the length of time it takes to complete most administrative projects. That being said, if you have a fellowship that particularly interests you, see if you can visit or shadow for a couple of days.

What can I do to stand out from the crowd?
Demonstrate the ability to take an idea from conception to execution. This can be at the residency, department, or hospital level.

Should I join a hospital committee?
Any involvement with relevant administrative, research, quality, operations, IT, etc., is helpful. If you do join a committee, make sure to have an active role, and be able to describe your particular efforts for that committee.

Publications other than research
Any publication that shows that your contribution to a project or an area of expertise that you have is helpful.

How many recommendations should I get? Who should write these recommendations?
Most fellowship programs required 3 letters of recommendation. One letter should be from your residency program director and another should be from an administrative mentor.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, as long as you continue to demonstrate interests in relevant content areas.

What if I’m a DO applicant?
There are no barriers for DO applicants.

What if I am an international applicant?
Please contact individual programs regarding whether they accept international applicants. In general, international applicants are usually required to be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). You also must have a visa (traditionally a J-1).

APPLICATION PROCESS

How many applications should I submit?
As a non-ACGME fellowship that does not use a centralized application process, there is no data available regarding the competitiveness of administrative fellowships. Thus, it is hard for us to make recommendations about how many programs to which an applicant should apply. Our general advice is that you should only apply to programs that you would seriously consider accepting a fellowship offer from. Look also for programs that will best help you meet your future career goals.

The number of programs an applicant should apply to will be influenced by many factors, including geography and the areas you hope to gain expertise in during your fellowship training. For example, if you know you want to stay in a certain geographic area or stay on as faculty at a particular institution or there are only a few programs with an emphasis on what you would like to be your area of focus, your options are limited. If you’re open to relocating anywhere in the country and want to be on a fast track to becoming a medical director, you may consider applying more widely or looking at programs offered by contract management groups.

How do I pick the right program for me?
There are a number of questions that an applicant must answer before deciding which program is right for them, including whether they want to be academic faculty – teaching residents and publishing peer-reviewed research – or whether they want to work in the community as part of a private group.

Applicants with specific interests in patient satisfaction, research, health policy, patient flow, observation-medicine, clinical pathways, resource utilization may find that certain programs offer faculty expertise or mentorship in these areas.

Common mistakes during the application process
Common mistakes include not being aware of important application deadlines for each program, not having a clear idea of what you hope to gain by completing the fellowship program, and not understanding the differences between degree-granting and non-degree granting fellowship programs.

Application deadlines
Deadlines are highly variable by program. Applicants should begin researching programs at least 1 year prior to completing their training to identify programs they may be interested in, making note of each program’s application deadlines.

Tips for writing your personal statement
Be able to briefly explain your background, how it shaped you into the person you are today, what your future goals are, and how the program will help you get to where you hope to be.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
If you don’t obtain a position during your first attempt, get a job with a group that will allow you opportunities for early leadership within your department. Become involved with hospital committees.

Reach out to programs that you were interested in and ask what you could do to become more competitive in the future. Reapply during the next application cycle if you are still interested.

INTERVIEW PROCESS

How do I stand out from the crowd?
During your interview, stand out from the crowd by being able to highlight your ongoing interest in this field by providing concrete examples of your prior leadership and accomplishments in terms of projects completed and your specific contributions.

What types of questions are typically asked?
In addition to typical interview questions, expect to answer focused questions regarding your leadership style, conflict management, and your five-year plan.

How many interviews should I go on?
Similar to the number of programs you should apply to, consider where you are geographic and academic interests overlap. Since there is not a match process and many programs may offer rolling acceptances, start interviewing at places which you are most interested in first.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

• Crane JC, Noon C. The Definitive Guide to Emergency Department Operational Improvement. Boca Raton, FL: Productivity Press, 2011.
• Hall RW. Patient Flow: Reducing Delay in Healthcare Delivery. New York: Springer Publishing, 2013.
• Jensen K, Kirkpatrick DG. The Hospital Executive’s Guide to Emergency Department Management. Danvers, MA: HealthLeaders Media, 2014.
• Jensen K, Mayer TA. The Patient Flow Advantage: How Hardwiring Hospital-Wide Flow Drives Competitive Performance. Pensacola, FL: Fire Starter Publishing, 2015.
• Kayden S, et al. Emergency Department Leadership and Management: Best Principles and Practice. Cambridge: Cambridge University Press, 2015.
• Langley GJ, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass, 2009.
• Litvak E. Managing Patient Flow in Hospitals: Strategies and Solutions. Oakbrook Terrance, IL: Joint Commission Resources, 2010.
• Mayer TA, Jensen K. Hardwiring Flow: Systems and Processes for Seamless Patient Care. Gulf Breeze, FL, Fire Starter Publishing, 2009.
• Strauss RW, Mayer TA. Strauss & Mayer’s Emergency Department Management. New York: McGraw-Hill Education, 2014.

Important skills to practice while in residency to prepare for fellowship
The most important thing a resident can do to become a leader in any capacity is to become clinically excellent. Without this, you will not have credibility to be a leader in your department.

Take advantage of opportunities to become involved with resident process improvement projects. Demonstrate ongoing commitment and complete projects in a timely manner.

Tips on how to succeed as a fellow
As a new fellow, it is important to clarify expectations with your program director and other members of the leadership team early and often. Be proactive. Tackle areas of knowledge deficiency. Find a balance between doing things you’re good at and taking on projects from which you can learn.

CONCLUSION

Additional Resources

Journals

The American Journal of Medical Quality

BMJ Quality

BMJ Quality and Safety

Chicago Booth Review

Harvard Business Review

Health Affairs

Health Care: The Journal of Delivery Science and Innovation

Implementation Science

The International Journal of Quality in Health Care

The Joint Commission Journal on Quality and Patient Safety

Journal for Healthcare Quality

The Journal of Clinical Outcomes Management

Journal of Graduate Medical Education

The Journal of Healthcare Risk Management

Patient Safety and Quality Healthcare

Quality Management in Health Care

Podcasts

AAEM Podcasts

AAEM Podcasts: EM Operations Management

New Directions in Health Care by The Commonwealth Fund

Urgent Matters

WIHI – A Podcast from the Institute for Healthcare Improvement

X (formerly Twitter) Resources:

National organizations

American Association for Physician Leadership

American College of Emergency Physicians (ACEP)

ACEP EM Practice Management & Health Policy Section 

ACEP Freestanding Emergency Centers Section

ACEP Observation Medicine Section

ACEP Quality Improvement & Patient Safety Section

ACEP Committees

• CEDR - Clinical Emergency Data Registry Committee
• Clinical Policies Committee
• Coding & Nomenclature Advisory Committee
• Medical-Legal Committee
• Public Relations Committee
• Quality and Performance Committee
• Reimbursement Committee

ACEP 911 Network

American College of Healthcare Executives

American College of Medical Quality

Emergency Medicine Residents’ Association

Society for Academic Emergency Medicine

• Academy of Administrators in Academic Emergency Medicine
• Observational Medicine Interest Group
• Operations Interest Group
• Patient Safety Interest Group
• Medical Quality Management Interest Group

Conferences

• ACEP Scientific Assembly
• Emergency Department Directors Academy*
• Leadership & Advocacy Conference*
• Reimbursement and Coding Conferences
• ACMQ Medical Quality Meeting
• Emergency Department Practice Management Association (EDPMA) Solutions Summit*

• Institute for Healthcare Improvement Annual National Forum on Quality Improvement in Health Care
• The Academy for Emerging Leaders in Patient Safety: The Telluride Experience

*Travel scholarship available from EMRA

How to find a mentor
Residents should seek mentorship from their academic department chair or vice chair, medical directors of the departments where they work, and/or other research faculty and hospital administrators involved in emergency department operations, patient safety, quality improvement, clinical pathways, clinical decision support, observation, or other areas of mutual interest.