The Secret of Great Hospital Performance

MP900386070When you pull out to pass a car on the highway, what do you care about?
Do you care about speed or…
do you care about your gas pedal? 
We press on the gas pedal (input) in order to pass (output).
We focus on the job at hand, what we need to get done. We do not care about the gas pedal. We care about passing safely.

Healthcare focuses on the gas pedal.

  • How much will this cost?
  • How big is our budget deficit?
  • Where can we trim costs?
  • Why are costs going up so fast?

It’s understandable. Money grabs our time and attention in hospital leadership.  But, like the gas pedal, inputs should be secondary. Our biggest concern should be outputs, are we delivering great care?

Block funding for hospitals died years ago in most countries.  Unfortunately, block funding still thrives in many Canadian hospitals.

Block funding = stretch one pile of cash out for a whole year of hospital services.

  • No funding for growth.
  • No funding for acuity.
  • No incentives to deliver more care.
  • Focus on the budget; don’t spend a penny more…keep the gas pedal in focus.

Fortunately, most jurisdictions are starting to admit that block funding doesn’t make sense.

Focus on Outputs

The secret to great hospital performance = focus on outputs.  Focus on great service and outcomes for patients, first.

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7 Common Patient Waits & How to Fix Them

After supper, a friend told me healthcare gave terrible service.

Men Sitting at Table Drinking Espresso

As a senior management consultant for a well-known multi-national corporation, he spends his time helping companies run well.  In his opinion, healthcare runs poorly.

While full of wonderful, caring people, healthcare is inconvenient and inefficient.


7 Waits and How to Fix Them

1. Waiting for appointments with Family Practice – All family docs could offer same day visits.  Some physicians have been doing it for decades.  Their patients love it, and their practices remain profitable.  Some patients want appointments booked days in advance and that should continue.  Other patients want to be seen the same day and could be accommodated with on-site urgent-care clinics or advanced access booking.

Patients should never have to wait to see their family doc (or a physician in the practice group).

 2. Waiting in the waiting room for your physician This should be very rare.  When it happens every visit, it represents terrible practice management.  Physicians run 2-3 exam rooms to prevent patient waiting.  If physicians are double-booking because of patient no-shows, then they should collect no-show fines or consider firing patients  from their practice who continue to not attend for booked appointments.  If physicians are booking too many patients to see them promptly, they need to stop booking so heavily and spread out appointments.  They should stop fooling themselves and book a longer day at the office.  They are staying late anyways; they might as well do the courtesy of allowing their patients to arrive later instead of making them sit in the waiting room for hours.

Either way, it’s up to physicians to keep their own waiting rooms empty.

3. Waiting for blood-tests and X-Rays –  Lab tests can be processed in minutes to hours, but we make patients book separate visits to get blood-work and imagining, then we make them book another visit to discuss the results!  Basic blood-work and x-rays should be available same day for all patients.  This can be done by allowing advanced access at labs and imaging suites.  Digital images can be read off-site.

Patients could receive basic tests and results in the community just as they do in the ED without extra cost to labs and with great savings for patients.

4. Waiting to see specialists.  Ostensibly, wait times to see specialists are long because there aren’t enough specialists.  However, there’s a glut of unemployed specialists in many fields (e.g., orthopedic surgery, cardiac surgery, etc).  Most of the specialists are ‘unemployed’ because they can’t get operating room time.  If there really are too few specialists, why don’t they leverage family docs (or unemployed surgeons) in their clinics to screen through their consults and follow-ups?

I worked for a few years as an associate with our local vascular surgeon to churn through his office visits and minor procedures so he could focus on patients needing surgery.

5. Waiting in an ED waiting room –  We discuss how to close your waiting room in other posts.  It’s the right thing to do – get patients inside, get them seen, get them treated.

6. Waiting for an inpatient bed inside the hospital –  There is no reason to warehouse patients in emergency departments.  Unless hospitals make a conscious decision to get patients up to the wards, nurses and physicians will not change their behaviour and get patients upstairs.  Dozens of papers show that quality and patient satisfaction improve when patients wait in the halls on inpatient wards instead of waiting in the ED.  Furthermore, hospitals that send admitted patients up to the wards, when there are ‘no beds available’ on the ward, somehow find a way to put patients into rooms.  Staff find a way to discharge other patients to open up space.

Admitted patients should never be left in the ED to wait for an inpatient bed.

7. Waiting for surgery –  Patients wait because OR time is limited by OR closures or cancellation of surgery.  ORs need to be kept open – after hours if necessary – to treat patients.  Surgery must not be canceled because surgical beds are full of medical patients.

Let surgeons manage surgical beds; do not let medical flow issues shut down surgical flow.


1. If we remove waits, won’t demand go up? Won’t utilization increase?  Anxious patients who demand ‘unnecessary’ investigations receive those investigations in the current system.  Most average patients don’t want to give blood or get X-Rays and then wait around for results unless they really have to.  Average patients would continue to pursue investigations only on advice from their physicians.

2. Wouldn’t MDs start ordering too many tests if they knew they could get same-day results?  Sure, more family docs might order blood-work and X-Rays for patients that they presently send to the ED preventing a few ED visits.  Same day service would still require hours of waiting for patients; hardly a convenience all patients would want.  The current technology for blood-work and x-rays still dissuades frivolous testing because of the time and effort required. Until investigations become as quick and convenient as a medical scan on Star Trek, we won’t see a giant spike in investigations.

Canadians wait politely, and they should not.  There’s no need for most of it.

We need to challenge the old way of doing things: waiting for appointments, waiting in waiting rooms, waiting for labs, waiting for x-rays, waiting to discuss results, etc, etc…

We need to adopt a ‘get it done now’ approach all across healthcare.

If you agree, feel free to leave a comment by clicking on leave a reply or # of replies.


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112 Patient Flow Solutions for Emergency Departments

This list should get us started…  Please add your ideas in the comment section at the end!

  1. Close your waiting room – bring patients straight inside to chairs if no beds open
  2. Use triage to enhance flow: triage = sorting and nothing else
  3. Limit the number of nurses at triage – 1 nurse can SORT 200 patients per day easily
  4. Have patients self triage
  5. Use on-line triage
  6. Use Bedside registration
  7. “Quick Reg” – limited registration; just enough to create a chart
  8. Have patients use self registration
  9. Offer pre-registration on line
  10. Post live wait times on-line to smooth patient volumes
  11. Use patient passports – patient education hand-outs at front door
  12. Educate the community to arrive in ‘slow’ hours (e.g., before 11am Tues – Fri)
  13. Educate community to avoid the surges on Sunday evening/all day Monday
  14. Limit 1 visitor per patient
  15. Encourage patients to bring med lists with them
  16. Encourage community MDs to send in referral notes
  17. Have on-call MDs
  18. Have flexible start and stop times for MDs
  19. Get MDs to take responsibility for flow in real time
  20. Have on call RNs
  21. Shorten nursing documentation (1-2 pages max)
  22. Use combined triage & nursing secondary assessment form
  23. Use physician scribes/navigators
  24. De-zone – move staff to where need is greatest; don’t leave a zone overstaffed
  25. Use advanced directives
  26. Use pre printed orders
  27. Measure and reward MD performance
  28. Measure consultant response times
  29. Insist on in-house consultant coverage for internal medicine, anesthesia, pediatrics…
  30. De-unionize – flow will improve
  31. Have nurses only do nursing tasks (carry out orders, give medications), not clerical work
  32. Track RN break times – insist on accountability
  33. Reward RN extra effort (staying late, skipping breaks, going the extra mile)
  34. Match RN staffing to patient volumes by hour
  35. Match MD staffing to patient volumes by hour
  36. Never allow MDs to go home if waits are long
  37. Staff extra MD and RN shifts on known high volume days (Mondays, holidays)
  38. Encourage MDs/RNs to work in teams and hand over readily
  39. Stagger RN shift changes
  40. Have dedicated ED X-Ray
  41. Have U/S (and tech) in the ED
  42. Use techs for lab draws and ECGs
  43. Stat labs
  44. Prioritize ED lab and DI
  45. Don’t batch
  46. Dedicated porters (RN/tech should porter if porters overwhelmed)
  47. Track DI and lab turn-around times
  48. Get a great EDIS (ED information system)
  49. Create meaningful alerts on EDIS to identify LOS, reassessments, etc
  50. Have a modern EMR linked to the EDIS
  51. Retire outdated EMRs – an old, slow EMR might be worse than none at all
  52. Consider a real time locating system (e.g., RFID)
  53. Consider EMR on tablets for each MD
  54. Computer terminal in each room
  55. Link ED EMRs with community EHRs
  56. Have forms available on-line
  57. Bypass ED for STEMI identified by EMS (straight to PCI)
  58. Eliminate phone calls for CT, etc
  59. Extend CT hours of operation
  60. Encourage the hospital to work on a 24-7 service model (at least a 7 day service model!)
  61. Do not schedule big surgical cases on Monday
  62. Track admits and discharges by time of day and day of week
  63. Eliminate day-day variations of admits/discharges
  64. Perform nurse handover on the ward; not by phone from the ED
  65. Get admitted patients straight up to the ward before a bed becomes available
  66. Use a visual bed management system for inpatient flow admitted patients leave promptly
  67. Use patient flow navigators
  68. Create robust medicine clinic follow-up clinics (next day)
  69. Do not allow consultants to ‘send patients to the ED’ and see them there
  70. Teach residents about quality and efficiency as paramount in their education
  71. Use PO instead of IM, and IM instead of IV treatments if possible
  72. Position EMS off-load in-front of the main nursing station – not hidden away where patients can languish
  73. Form psychiatric patients promptly as needed
  74. Do not perform an internal medicine ‘ward’ work-up in the ED
  75. Order all tests and treatments on the first touch
  76. Plan on disposition from the first encounter
  77. Have Multi-use rooms (eliminate bottle-necks)
  78. Establish procedures to sedate patients in any room
  79. Partner with volunteers – they can help a ton!
  80. Establish CDUs on in-patient wards – do consultations there
  81. Give every MD, RT and Consultants a phone to carry
  82. Do not scale down services over holidays when demand always goes up!
  83. Encourage same day, out-patient cardiac diagnostics and consultation
  84. Establish direct referrals to cardiology (not internal med, NP, cardiology, etc)
  85. Have everything needed for work in every area (don’t make staff walk to the ‘tube system’)
  86. Use pre-printed prescriptions
  87. Have the chief call in 2-3 times per day to monitor flow
  88. Create an internal, real-time ED surge plan
  89. Create a hospital wide surge plan and link it to the ED surge plan
  90. Give admin on call authority to move admitted patients out the ED
  91. Have back on-call to support internal medicine consults
  92. Do not allow surgeons to be on-call to the ED on their OR day
  93. Teach all nurses to apply splints and/or casts
  94. Use ‘just in time’ approach to patient movement – don’t stock-pile patients by loading rooms
  95. Avoid batching
  96. Assign patients to areas; not rooms
  97. Use overhead paging liberally – don’t walk around looking for patients
  98. Improve patient signage
  99. Use patient instruction sheets
  100. Use a re-assessment check-list so MDs aren’t called to reassess prematurely
  101. Build a minor treatment area (aka fast track)
  102. Get rid of as many stretchers as possible (limits holding admitted patients)
  103. Use exam tables where-ever possible
  104. Use some chairs instead of stretchers in the acute area for telemetry patients
  105. Get rid of walls – use curtains to divide most rooms
  106. Eliminate sequential processing
  107. Insist on parallel processing
  108. Look for bottlenecks – theory of constraints
  109. Learn queuing theory and how it applies to your department
  110. Learn and love LEAN
  111. Employ an unlimited capacity mindset – don’t limit flow for lack of ‘rooms’
  112. Adopt a ‘get it done NOW‘ attitude across the organization!

More ideas?  Questions?  Feedback?  Click on leave a reply or # replies below:

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Physician Scheduling Extreme – Interview with Dr. Marko Duic

Imagine a schedule where you could work any day you wanted, see as many (or few) patients as you wanted, and take as many holidays as you wanted.

Sound unbelievable?

Dr. Marko Duic has honed a physician scheduling system that delivers MD choice, MD control and a perfect fit between physician speed and patient volumes.  He shares how he does it:

Welcome, Marko.  You’ve figured out a way to give physicians choice, control and as many holidays as they want.  Is that true?

For individual physicians, it’s true.  The only restriction is that a few physicians need to stick around to keep the emerg going–so not everyone can take off at the same time.  This might be an issue if everyone in the department wants to go to the same conference. But if an individual physician wants to go off for 3-6 months, to, say, cycle from Cairo to Capetown, it’s not a problem.

How long have you been doing this for?  

Since 2001

How do the physicians like it?  

They state that it’s a major reason why they’d never go to another ED to work.

How do patients like it – what results do you achieve?

The most important patient satisfaction correlate is their time to see the doctor (Physician Initial Assessment time).  Well, the two hospitals in Ontario that use this system are often number 1 and number 2 in PIA times, and one of them is definitely a leader in satisfaction among peers.

What do the nurses think of this system?

At first, not that pleased that we could muster up ANY number of physicians ANY time, and they would get stuck with a pile of orders.  They had to see that a pile of orders is better than a pile of unseen patients.  At least with the patients having been seen by MDs, nurses could be asked to do the most urgent orders first.   What the nurses like about his system is that there are always enough doctors to see the patients, so they never have to get abused by impatient patients.  There’s never a day when three slow physicians work back to back and the place explodes.

Could this system work anywhere; do you think you could teach others to do it?

Of course it could work anywhere.  It’s how patients would schedule doctors, if patients were allowed to schedule us. 

Most emergency departments schedule a fixed number of shifts every single day, but you don’t.  Why?

Each physician has a number of patients per shift that he’s most comfortable seeing.  It could be 15, could be 30, could be 45, could be 60.  And each emergency department has a number of patients that they see any given day.  So for example, in one of our departments, we see 300 on Sundays and Mondays and 270 the other five days.  So I have to schedule enough physicians that their combined capacity to see patients adds up to the number of patients I’m expecting.  So if all the fast guys go on a conference together, the slow remaining guys have to be scheduled in larger numbers–maybe 9 or 10 of them in a given day to see that many patients.  If the slow guys go on a conference, I might only need five or six of the remaining fast guys to see the patients.  If everyone’s in town, and I alternate fast and slow guys, I might need 7 or 8 physicians.  If the physicians are different speeds, how can you expect to have the same number of them per day?

So, how do you determine exactly how fast each MD works?  

I have stats, but they don’t really work that well.  So I do it by trial & error repetition and intuition.

But what if more patients arrive on a particular day?  

Shifts start when patient waits get up to a certain level.  Physicians call each other to figure out when the next one needs to show up.  If the day’s busier, it becomes evident in the conversations.  Physicians come in early, and stay late, and if needed, call an extra physician.

And what if you need another physician to help?

We use our on-call funds to pay one of them to show up.  We call in turn, alphabetically, and change the order by one physician each time, so everyone gets a chance.

Who decides if more MDs are needed on any given day?

The physicians who are working in the department at the time.  If they risk running over the target patient waiting time, they call extra help in.

What if the physicians working that day do NOT call for extra help?

Then the times go over, this is a disaster, and they need to explain why they don’t.

What are your thoughts on the provincial Hospital On-Call funding system?

It’s good to have money to pay physicians to come in to serve patients.  Especially in the ED, where volumes and acuities are unpredictable, and where timely access to care is what’s held out to the public in the name EMERGENCY DEPARTMENT that’s posted on the door.

Are there times when you have scheduled too many MDs on one day?  What happens then?

They either shorten all the shifts, or cancel one of them, or both.  They come to an agreement that suits them all.

Okay, let’s focus on the mechanics of schedule creation.  How do physicians ‘pick their shifts’?

They submit a selection form that shows me when they want to work, when they can work, when they would prefer not to work, and when they can’t work.  I use all the physicians’ forms to give everyone a schedule that’s almost entirely made up of shifts they want or can do.

Is it completely different every month?

Basically, yes.  Some patterns repeat–some guys like nights; other guys like Wednesday mornings; some people can never work Friday evenings.  But overall, it’s different every month.

What happens if there are too many shifts requested by the group?

Everyone gets a bit less than they asked for.

What happens if you can’t provide enough coverage to meet the expected volumes on a day?

Short term, everyone works a bit more than they would like.  Long term, hire more people.  But if it’s one day, and no one wants to work then, then there’s a lottery.

Can MDs take holidays?

Yes, any time, for any length of time.  We’ve had people take full-year sabbaticals or 4 to 6 months LOAs and come back to a full shift roster.  This system is totally flexible.  20 guys can cover the absence of 1-2 guys with minimal disruption for a long time.

What if everyone wants to take holidays at the same time?

Then we close the department.  No, seriously, there’s a max of about 1/3 of the department that can be on holidays for a longer period, or 1/2 the department for a few days, or 2/3 for a day or two, and it can still have full staffing.

What about Christmas, New Years and summer vacation – how do you handle those holiday requests?

In whatever way EPs want, but overall, some people always want to work them, and if there are not enough, then there’s always the record of who did it last year and the year before–those people get first dibs on taking them off this year.

Wow – this seems too good to be true, but it looks like the results prove it works.  Do you have any final comments?

Try it, you’ll like it.  More importantly, the physicians will love it and insist on always doing it this way.  Patients will love it too.

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Fix Patient Flow Bottlenecks – Forever

Patient flow seems impossible to fix in most hospitals.

Nearly every step in a patient’s journey can stop flow.  Even the most LEAN-ed processes require fanatical vigilance to guarantee patients don’t get stopped as they move through our hospitals.

Water Pouring from Bottle

Eli Goldratt popularized ‘bottleneck’ in his classic ‘The Goal‘ – a long narrative presentation of the Theory of Constraints.  A worthy read.

Bottlenecks decrease flow.

They cause havoc by showing up unplanned.  In industry, bottlenecks turn up as critical processing steps whose maximum speed determines the maximum speed of a whole production line.

In healthcare, bottlenecks change all the time.  In fact, a dozen different things could be the bottleneck – the rate limiting step – over 1 day in the ED.  During the morning, it’s lack of staff; during the afternoon, it’s lack of beds.  Despite this, most folks like to blame their favourite bottleneck:

 “If we only had more beds. If only we didn’t have admitted patients!”

“If only we didn’t have such slow docs!”

“If only we had more nurses (or faster nurses…)!”

“If only we had more space!”

If only…

Picking one bottleneck – usually out of our control – removes responsibility to address all the bottlenecks within our control.

In recent posts, we’ve been talking about closing the waiting room, bringing patients straight into the ED and cycling them from chairs to exam tables.  These steps bypass the ‘bed block’ excuse most EDs use for making patients wait for hours in the waiting room.  Once patients get ushered straight in, dozens of new bottlenecks show up: nursing shift change, waiting for porters, DI/Lab back-up, not enough MDs, patient reassessment delays…running out of patient gowns…

There’s only one way to guarantee a bottleneck will never slow flow in your ED.

Parallel processing

Like putting together an IKEA cabinet, some things need to be done in order.  Sequential processing means doing things one after the other – like a long train of boxcars.  However, insisting on sequential processing creates hundreds of potential bottlenecks.  Parallel processing unhitches the boxcars and lets them all run on separate tracks at the same time.  That way, if any process stops, all the others can continue.

Simple enough…

But, medicine loves process.  Many of the sacred cows in emergency medicine are core to sequential processing:

Triage followed by

Secondary Assessment followed by

MD assessments followed by

Lab and DI followed by




Most providers fight to keep care in a general order.  It’s what they’re used to.

A parallel approach looks like this:

Triage (sorting only…more in another post) followed by

Everything else

Easy, right?  It’s not.

If you truly adopt this thinking, you might have MDs assess and discharge a patient before the patient even sees an RN.  Or, you might have Lab/DI and discharge planning involved before an MD gets to a patient.  This requires huge flexibility for providers who’ve been bound by historical process.

But…but…what happens first?

After triage, everything else gets done ‘as soon as possible’.  Whoever can get to the patient first, gets started on their part of the process even if it means they can’t complete it before another provider arrives.  Get it done, now!  Sequential steps can never be tolerated as an excuse for making patients wait.

What bottlenecks are holding you back?  What’s holding you back from adopting a fully parallel approach?  Share your thoughts by clicking on ‘leave a reply’ or # replies below.

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Are Patients Always Right?


At one time, patients decided whether their problem was worth a visit to the doctor.

Patients were welcomed.  Minor concerns gave providers a chance to relax in an otherwise stressful day.

But, attitudes change.

Instead of welcoming all patients & all complaints, nurses and doctors get taught to judge whether patient complaints are deserving.

They learn that caring for patients with problems unsuited to their highly specialized skills should be done by someone else.

Anyone else.

Over time, providers develop strong opinions about who really needs their care.

Only the truly sick patients ‘deserve’ to be in the ED….except the very sickest of all….dying patients.  They shouldn’t have come to the ED in the first place.

Here are some of the flags nurses and doctors use to identify undeserving patients.

Undeserving patients –

1. Seek help for minor complaints that should have been handled at home.

2. Take poor care of themselves.

3. Attend the ED/clinic out of convenience.

4. Demand repeat investigations.

5. Should be seen by their family doc, or public health nurse, or not at all.

Otherwise really nice nurses and doctors adopt these attitudes.   They reason it’s all part of being a good steward of public funds and common sense.  They confuse a reasonable expectation to educate patients about options to access care – best done at discharge – with turning patients away.

 “Let’s face it: most patients don’t need to be seen.”

‘Undeserving’ patients don’t get great care.  EVER.

We need a new attitude.

We need –

to always let patients define whether their concern is legitimate.

to welcome all patients no matter how ‘minor’ their complaint.

to treat all patients as privileged – like family.

Nothing less than a new attitude, ideal and service standard will do.

If we want to change the way patients access care, we need to provide attractive options for patients.  We cannot provide few, inconvenient options for access and then train providers to hold a ‘send them away’ attitude.  This never promotes great service or care.

Changing minds will require changing incentives in our present system.  We need redesign at the highest level.  In the meantime, how are you going to change attitudes in your ED or clinic?

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ED Stretchers Boarding & Flow

Racing a patient through the emergency department on a stretcher makes exciting TV.

Physician and Nurse Pushing Gurney

But for most EDs, stretchers are the enemy, because stretchers crush patient flow.

Most patients walk into the emerg and walk home – less than 15% get admitted in Canada. There’s no need to force patients to lie on a stretcher unless absolutely necessary.

Patients sit for hours with serious or potentially life-threatening conditions in most waiting rooms.  It’s much safer to get them in and examine them on an exam table inside the ED even if it means they have to sit in chairs during investigation and treatment.

Sure, some patients need stretchers for the duration of their ED visit.  But for most patients, if they can walk, they can sit.  If they can sit, they do not need a stretcher.

Stretchers enable dysfunctional behaviour that makes patients wait.

Stretchers –

1. Attract admitted patients boarding them for days.

2. Act like real estate for ED patients.  Providers assign one ‘lot’ for each patient.

3. Make patients immobile even if they walked into the ED.

4. Allow providers to ‘tuck patients in’, rails up, safe and sound.

Exam tables increase flow by –

1. Removing a spot for admitted patients.  Exam tables are like OR tables:  OR tables are for surgery, not admission.

2. Providing a shared resource for all, not an assignment for one.

3. Getting patients to move, which fosters flow.  Exam tables don’t have wheels.

4. Keeping providers moving with patients.  Exam tables are unsafe without a provider present.  Patients spend minutes on an exam table instead of hours on a stretcher.

Dozens of patients cycle on and off one exam table, whereas one stretcher serves only a few patients per day.  If the average patient spends 6 hours in the ED, each stretcher can serve, at most, up to 4 patients per day and usually far less.

If you haven’t done so already, replace as many stretchers as possible with exam tables.  If exam tables are only found in the minor treatment area, you don’t have enough!

Like any change in historic process, providers realize how attached they are to stretchers when you start asking them to use exam tables instead.  But without building EDs twice the size, we cannot continue insisting that all patients, except the lowest acuity, get seen on stretchers.   Staff support exam tables once they see how much  flow improves; it’s the best way to get patients seen and treated promptly in today’s over-crowded EDs.

Stretchers ruin patient flow, function as a reservoir and promote dysfunctional behaviours. Get rid of them where ever you can!


Do admitted patients block your ED stretchers?  Do all your ED patients currently in stretchers actually need to be in one?  Are they blocking flow making other patients wait for care?  Why not replace some stretchers with exam tables?


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Patient Safety Requires Abundance

How much more can you work?

Finger Pressing Button on Calculator


Do you work too much already?


Emergencies demand MORE.


You risk patients’ health if you cannnot respond to increased demand.



Most departments run on a poverty mentality: serve as many patients as possible doing as little as possible for each.  Parsimony appears wise, even frugal, but it’s backward and unsafe.

A poverty mentality fosters a dysfunctional system with no resilience – nothing extra, no reserve for disaster, no teaching, no service excellence, no follow-up, only the bare minimum.

Abundance turns poverty on its head.  Why not do as much as you can for every patient?  Instead of sprinting through diagnosis and discharge, why not provide over-the-top care and service?  Why not welcome patients back if they can’t get great follow-up that works for them?

Abundance means treating all patients like they were privileged.  Privileged patients get all the extras without extending their stay.

Abundance provides outstanding patient experience AND builds resilience – the ability to flex; to increase services on demand – necessary to guarantee safe, quality care for the next wave of patients.  Poverty delivers second-rate care and jeopardizes emergency services for the whole community.


1.  “But great service will just increase volumes!”

2.  “Can’t most of the patients be seen in a clinic?”

3.  “Won’t abundance increase costs?”

Objection #1  This has to be the dumbest reason to not improve service.  If volumes increase because your service is great, so be it.  Hopefully, other EDs will improve, too.

Objection #2  True, emergency departments exist to care for the acutely sick and severely injured.  Emergency services require

I. Capacity to care for the acutely sick and severely injured,


II.  A dependable method to sort out patients who aren’t sick or injured.

I. Patient resuscitation for the acutely sick requires 3-4 nurses, at least one MD and a horde of other staff to attend immediately.  Ask ED staff:

Have you had 2 resuscitations at the same time?

How about 3?

Have you ever had 4 resus patients at the same time?

These scenarios are NOT rare.  While the answers depend on your annual visits, guaranteeing immediate care might demand up to 16 nurses, a team of allied health providers and a group of MDs.

II. No method can guarantee that patients sent away from an ED won’t come to harm.  All EM staff have seen patients triaged to a minor treatment area only to be admitted to the ICU or sent for emergency surgery.  Sore throats and back pain can turn out to be life-threatening epiglottitis or aortic dissection.  Why not see them in the ED?

Objection #3 “ED care costs too much.”

So, why don’t we send patients straight to a clinic where they’d be seen immediately?  A clinic could assess patients, perform routine investigations, get urgent access to x-rays and even provide IV treatment.”

Indeed.  And how would the costs differ?

Fixed costs for EDs are huge, but it costs very little to see one more low acuity patient – far less than a separate clinic.  And, low acuity patients NEVER block up the ED.


In Canada, EDs back up everything else – doctors’ offices, post-op clinics, imagining, consultant services, etc.  An abundance mentality guarantees that no matter what happens, patients will receive immediate, high-quality care.  EDs must create their own resilience with an abundance approach to service or risk emergency preparedness for their whole community.


How much more can you do – today – for patients in your ED?  Are you risking your community by fostering a poverty mentality?





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Saving time. Saving Lives

Guest post by Dr. Marko Duic MD

At a recent high-school career-night talk where I was invited to discuss medicine as an option, I asked the 11th and 12th grade students why they were possibly considering medicine.

“To save lives” came the unsurprising response.  What else would they say?

Later, when I described that my job is not only as an emergency physician but also a department chief—an administrator—they determined that I made less, not more money than I would if I were only an emergency physician, so they asked me why I do it.  My answer surprised even me, so I would like to share it.

When the students first told me they wanted to do medicine to “save lives”, I pointed out that we don’t do that in medicine.

Instead, we delay death. 

Everyone ends up dying anyway, which would not be the case if we really saved lives.  However, by doing our physician work well, we have a chance of giving patients useful time between whatever life-threatening emergency they presented with, and their inevitable later demise.

They asked for an example.

I pointed out that most potentially life-threatening causes of chest pain (MI, PE) are treated with “blood thinners”. But once in a blue moon, and only a few times in the average emergency physician’s career, the parade of usual chest pains for which we give life-prolonging blood thinners, is punctuated by a patient with a very similar but not identical chest pain for which blood thinners could be life-ending:  the aortic dissection. It is easy to miss such a patient if one is not paying attention, and if one did miss such a patient, the results could be grim.

So the story I told was of a 48 year old man I had seen six months previously who had had a 55 minute stay in our emergency—including triage, being examined, scanned and transferred to vascular surgery in another hospital.  His wife reported that he was discharged a week after surgery, which repaired his dissection that extended from the aortic root to the ileac bifurcation.  He was now doing well at home.

Had I saved his life?  No, he will die at some point.  But maybe he has 10 years until some other grievous atherosclerotic event does end his life.

10 years, 16 useful hours in a day:  about 60,000 hours of useful time for this patient, as a result of an excellent team, a great emergency department, and very fast and very careful doctoring.

WOW, the high school students said with admiration.  That’s really cool.  Or maybe the term was “wicked”.

At my hospital, by engaging the team to come up with a leaner flow process, we cut down the average wait for patients by about two hours.  The change was planned for months, then put into place overnight on 6 June 2011.  On 5 June, patients waited 4 hours at the 90th percentile, and on 6 June and thereafter, they waited 2 hours (posted on this site earlier).

Thus every patient (I told them to keep things simple, although the details are messier) saved 2 hours of useful time.

250 patients/day, 500 hours saved per day.  120 days—one quarter—60,000 hours of useful time have been saved.

Administration for physicians is not as dramatic as “saving a life” as a physician, and filled with much recrimination from all kinds of people with aversion to change, even though it’s clearly an improvement for patients.  Yet it’s deeply rewarding when one can “save lives” administratively—allow people who could go live in the community to stop wasting their lives in the waiting room.

As a physician, I can “save a life” once in a while.  As an administrator, I can save some life for each patient.


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Schedule 4 Patient Flow AND Efficiency

Schedulers think in LEGO blocks.  They guess how much work an average staff member can do, and then schedule enough staff to meet the average amount of work each day.

To build a schedule, they plug staff into a grid, like identical LEGO blocks, to meet the demands of an average day.

4 problems with LEGO block scheduling:

1. Nobody is average.

2. No day is average.

3. Under-staffing makes patients wait.

4. Over-staffing makes costs go up.

Average doesn’t exist in clinical medicine.

Treatment protocols can be standardized, but the core of clinical medicine – history taking and physical examination – remains messy, relational and often intuitive.  Ask any emergency nurse: every doctor works at a different speed – same goes for the nurses.

Discussing speed makes most providers squirm. Slow providers say fast ones are slipshod and careless; fast providers say slow ones are lazy or talk too much.

Schedulers run from this time bomb.  It’s safer to assume average work speed, and hope that patients won’t wait, and costs won’t soar.

But patients wait… and costs soar.

How can this be resolved?

Let’s look at physician schedules.  First, we must re-frame provider ‘speed’ – defuse the time bomb. Dr. Marko Duic put it something like this:

“Every physician has a number stamped on his forehead that states the number of patients he can safely see per hour. Everyone can see the number, but no one can see his own number. Ask any nurse how many patients a physician sees in an hour, and they will tell you as accurately as reading a number off the doctor’s forehead.”

We can’t change the speed people work, and we must welcome every worker onto the schedule regardless of how fast or slow they work.

How can we build a schedule that minimizes patient waits AND maximizes staff efficiency?  Furthermore, how can you get staff to want such a schedule?

If you want to schedule for waits AND efficiency:

1. You must match demand with productivity.  You should know how many patients attend your ED per hour.  You know how fast your docs work.  Schedule enough MDs, based on their individual work speeds, to meet the average patient volumes by hour.  Some days you may need twice as many doctors, if they all happen to be slower on one day.

2. You need hour to hour flexibility.  Physicians must stay late, arrive early, go home early or call in more MDs for help when patient volumes warrant.  Let the physicians on duty control these decisions, and keep them accountable for the outcomes.

3.  You should let physicians chose whatever shifts they want.  Choice makes doctors happy.  Collect their shift preferences and have them indicate 50% more shifts than they want for whatever time frame you are scheduling (e.g., 1 month).  Juggle the MD lineup each day based on #1 above.

We will interview the provincial guru on MD scheduling, Dr. Marko Duic, in one of the next posts to bring out the details.


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