Expect Resistance and Prepare for It

sisyphus_detail_by_humblestudent-d38vzahBig changes invite even bigger resistance.

If you attempt a major transformation in your department, or even a small change, watch for resistance from where you least expect it.

Everyone talks about progress, but few tolerate change without any anxiety.

This post summarizes Step 8 in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments. It captures some of the issues we wrestled with. You will face different giants. Please add your thoughts in the comments!

Rally Around a Vision

Doctors and nurses make a two-horse chariot. They need to pull at the same speed, in the same direction.

Rally your team around a central vision.

“What’s best for patients?” worked well for our department. You need a target for your team to steer towards.

Some horses never learn to pull as a team. They kick, bite and chafe at the whole idea.

Get rid of them.

You need the right people on the bus, or you will not get anywhere.

Jim Collins, in the bestseller Good To Great: Why Some Companies Make the Leap…And Others Don’t, tells us to hire well.

Do not look for blind followers. Find people who intrinsically enjoy helping others.

If you need staff, do not hire out of desperation. You will regret it for years.

Expect Resistance

In Step 4, Redefine Nurse to Patient Ratios, we discussed concerns that nurses have with this approach to EM care. Docs have their own hang-ups:

Irregular shift start/stop times.

Eventually, physicians get comfortable estimating when they will get called in on a particular day.

Even so, uncertain start times drive some docs crazy. Physicians need to be totally convinced of how a flexible start time benefits patients and doctors, or they will hate it.

For 90% of the shifts, start times follow a predictable pattern.

Cancelled shifts.

Especially in the early days of a flexible schedule, some days will have more doctors scheduled than patient volumes warrant. If docs are not busy, then a shift might get cancelled towards the end of the day.

Eventually, doctors get used to this. They realize that, overall, it is better to be productive AND have short wait times than to have only one or the other.

Pressure to pay attention to flow

Some departments try to manage patient flow without giving any responsibility to the docs working that day. Asking docs to monitor and manage flow irks some physicians.

Either they get used to it, or they move to work somewhere else. Most end up staying because they appreciate the improved efficiency.


If you measure productivity, you invite competition. Groups need to spend time celebrating differences as a fact of life.

Equality does not exist in real life (no matter what the utopians say).

Loss of Superman/Saviour Identity

In a chronically backed-up ED, faster docs gain a reputation as ‘Saviours of the ED’.

They walk in and nurses say,

Oh thank God you are here! We’ve been drowning in patients with Dr. X and Dr. Y working. Please save us!

The new approach eliminates this kind of praise. All days have short waits. All docs work to the speed at which they can provide safe, high quality care.

Transparency of productivity

Many docs do not want to know how quickly, or slowly, they see patients. Short wait times and maximal efficiency demand that productivity is explicit.

Loss of control

Docs try to control what happens on their own shift. If they care about what happens to the whole department, they have to cede control for staffing to someone who takes responsibility for scheduling 24/7.

Some docs hate this. They want their Tuesday morning, just like they’ve always had for 20 years.

Teams for Their Own Sake

Build strong teams. Teams must see value in membership beyond any tangible benefit to the organization. Team members need to value being in the team simply for the sake of being in the team.

If leaders try to build teams only to get great metrics, staff will see through it and balk at being involved.

Change Pain

Many people hate change. They would rather cling to what ‘works’ in the past than try something new.

Teams criticize leaders for not being transparent. But leaders often do not know exactly how something will get done. They just have a vision of where the group should go.

Learn to Love Complaints

Celebrate great complaints. Bad complaints focus on safety. Jump to fix them ASAP.

Good complaints move up Maslow’s hierarchy and focus on staff’s inability to express themselves, or fully use their training.

Change attracts attention. Other departments will notice and try to shut you down.

For example, infection prevention and control pretends overcrowded waiting rooms do not exist.

But as soon as you start bringing the waiting room into your department, they show great interest in having a minimum number of square feet per patient, terminal cleans, and other nitpicking issues that they ignored in the old paradigm.

Nonsense Sound Bites

Some stupidity refuses to die. Be prepared to respond, with a smile, to nonsense repeated at the highest levels.

“Match demand with capacity”

People talk about building bigger EDs to match patient demand. No. Improve flow to match patient demand, first.

“Nurse-to-patient ratios promote great care.”

No. Rigid RN-Pt ratios guarantee that unscheduled patients will wait.

“The literature supports modern triage.”

The literature also supports using parachutes. Ideally, you should never need to use a parachute.

“Patients need stretchers.”

If patients can wait for hours in the waiting room on chairs, then they can sit in chairs while receiving treatment inside the ED.

“Low Acuity patients block the ED.”

This myth refuses to die. Sick, admitted patients block the ED. Low acuity patients take a few minutes to see and treat. They NEVER block the ED.

“Quality Care requires patients to wait.”

Over 400 articles, at last count, show how waiting harms patients.

“Quality care” for the one patient lucky enough to get inside, while 100s of patients wait, does not define quality.

For EM, time equals quality (see Step 1 – Revamp Triage).

This gives you a taste of what’s in Step 8. Please check out No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments for more.  Thank you!

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2 Replies to “Expect Resistance and Prepare for It”

  1. Wow – I lost count of how many paradigm shifts are embedded in this. No doubt there will be resistance initially as many staff at all levels struggle through mindset changes as well. But getting buy-in in the first place will probably be the biggest hurdle. I suspect the desired results will have to be evident early in the game so that more and more people come on board to make this work and be sustainable over the long haul. People get very comfortable in their established ways, even if those ways are not working well. If they can see the “what’s in it for me” it might be easier to get them to engage and make an honest effort.

    1. Thanks for taking time to share a comment, Valerie!

      You nailed it with your comment: “…desired results will have to be evident early in the game…” Our first major change was planned for 12 hours but worked so well that staff insisted we keep doing it. That helped get other things changed. It works the other way, too, unfortunately. Any change that fails – especially if it fails spectacularly – makes a team 10x more apprehensive about the next change. We experienced that. The opponents of change did not let us forget it for years. We ended up abandoning large changes and settled for smaller nibbles.

      Thanks again for reading and commenting!

      Best regards,


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