Improving rural emergency care through alignment in staffing

Rural hospital leaders aren’t strangers to the pressures of supporting physician coverage. Physician shortages are constant, and for most critical access hospitals, locum tenens coverage is part of the operating model.

The question most organizations focus on is whether there is enough coverage. It’s a necessary question – but it doesn’t always explain performance.

In many rural emergency departments, inconsistency shows up in quieter ways. A shift that runs smoothly one week feels disconnected the next. Workflows change slightly depending on who is on shift. Communication between physicians and nursing staff varies more than expected. Over time, those differences begin to affect patient experience.

These patterns are familiar, particularly in environments where employed clinicians and locum tenens providers are working side by side.

At Aspirus Keweenaw Hospital, a critical access hospital in Michigan’s Upper Peninsula, coverage was stable, but performance was not. Expectations were understood internally but inconsistently carried out each shift.

Leadership began to look more closely at how consistency could be built into the structure providers entered rather than relying on each clinician to adapt upon arrival.

Conditions rural hospitals are managing

The environment surrounding this work isn’t unique to one facility. Across rural health care, leaders are balancing:

• Persistent vacancies and ongoing reliance on locum tenens physicians
• Limited access to additional clinical or operational resources
• High workloads that contribute to fatigue and turnover
• Variability in patient experience and performance metrics
  
  

Over time, these pressures tend to show up operationally with fluctuating satisfaction scores, inconsistent workflows, and teams adjusting from shift to shift rather than working within a shared rhythm.

A different approach to alignment

Aspirus Keweenaw introduced a pay-for-performance model designed around these conditions. The structure was incorporated into existing operations rather than managed as separate initiatives.

Staffed and locum providers worked within the same expectations. Performance was tracked using a small set of indicators based on NRC Health data. Those expectations were introduced during onboarding and reinforced through scheduling and communication practices, shaping how physicians approached their work from the start of each assignment.

The model operated within the existing environment without requiring more administrative layers or complex infrastructure.

What the results showed over time

Between 2022 and 2024, the hospital reported measurable changes in the emergency department’s performance:

• ER patient satisfaction increased from 60 percent to 73 percent.
• Performance reached the top quartile across the Aspirus health system.
• Month-to-month variation in scores narrowed, reflecting stable performance.
  
  

Inside the department, the changes were more operational. Communication between physicians and nursing staff became more consistent. Expectations were carried more evenly across shifts, regardless of who was scheduled. Workflows held more steadily from one rotation to the next.

These gradual shifts influence how teams function over time and how consistent care is delivered.

Going beyond one facility

This example closely reflects the operating conditions for most rural hospitals. The approach worked within a mixed physician model, where employed physicians and locums were part of the same care team. It did not rely on more administrative capacity or innovative technology. The number of performance measures remained limited, and expectations were introduced early enough to influence day-to-day performance.

Hospital executive teams evaluating their own emergency department performance need to examine whether expectations are structured and applied consistently across all providers.

Evaluating your own organization

For leadership teams, this raises a set of practical considerations:

1. How are expectations communicated across both staff and locum physicians?
2. At what point are these expectations introduced?
3. How consistently are workflows carried across shifts?
4. When performance fluctuates, is the response focused on individuals or the conditions surrounding their work?
   
   

Getting these answers can help clarify whether inconsistency is being managed reactively or addressed more directly through operational design.

Emergency department performance is often discussed in terms of staffing levels, patient volume, or access to resources. Access is still essential. At the same time, consistency in how care is delivered shapes patient experience, team stability, and physician retention.

At Aspirus Keweenaw, aligning expectations across providers and incorporating them into daily operations was associated with more stable performance and more consistent patient experience. For hospitals working within similar constraints, that alignment is a practical area for evaluation.

Read the full Aspirus Keweenaw case study

NRHA adapted the above piece from Wapiti Medical Staffing, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.
 

Jen Lloyd joined Wapiti in January of 2018 after 20 years with Avera McKennan Hospital and Avera Medical Group, with her previous role as director of clinic & ancillary services. Jen has a wealth of experience with administrative and operations functions of health care spanning across multiple aspects of a health care facility. Her overarching roles focused on serving patients in Critical Access Hospitals and Clinics.