Patient Safety Requires Abundance

How much more can you work?

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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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Patient Waits Drop if Waiting Room Closed

See what happened to our wait times from the first day we closed our waiting room, without spending a penny:

On June 6th, 2011, patient waits plummeted from over 4 hours at the 90th percentile to just over 2 hours when we closed our waiting room.  90th percentile = how long 9 of 10 patients have to wait; it presents the worst case scenario.  Today, patients wait less than 60 minutes on average to see a physician – one of the shortest in Ontario.  

Physician Initial Assessment includes a complete history and physical examination; not just shaking hands in the corridor or having an alternate care provider see patients.

From day one, the left-without-being-seen rate crashed from 3-4% down to 0.4%.

Hoarding patients in the waiting room – like boarding admitted patients in the ED – prevents patients from receiving the care and treatment they need.  If you remove the waiting room reservoir and bring patients straight into the ED, they get seen, diagnosed and treated.

6 keys to success:

1. You need an outstanding team of nurses, physicians, allied health and administrative staff willing to try something new.  This can’t be overstated!

2. You need nurses willing to accept working differently.  Sometimes there will be crowds of patients; other times there will be none.  RNs will need to work together to move patients through when volumes surge instead of moving patients through when the nursing schedule allows.  Schedules must match patient volumes by time of day; not the time of day when stretchers open up.

3. Physicians must be willing and able to increase staffing to meet surges in patient volume.  MDs must arrive early, stay late or call in their peers for help if patient waiting threatens to exceed targets.

4. Wherever possible, replace stretchers with exam tables.  Ambulatory patients can be seen on exam tables and wait in chairs.  Stretchers attract admitted patients; stretchers kill patient flow.

5. You need an unlimited capacity mindset.  Every patient needs to come inside.

6. Physicians have to get comfortable moving/directing patients into exam rooms and back out into chairs.

We’ll dig into all these points in later posts.

For now, what’s holding you back?  Why wouldn’t you want to decrease patient waiting by closing your waiting room?


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Reservoirs Kill Patient Flow

Reservoirs often show up as extra capacity, and who wouldn’t welcome that?  Shiny new clinical space gets first place on hospital tours, center stage in photo shoots and prominent mention in ad covers.

We find reservoirs all over healthcare: special inpatient wards, waiting rooms, bigger clinics, bigger emergency departments…extra capacity.

But, mindlessly expanding capacity decreases patient flow – increases patient waiting – if we don’t guard against forming reservoirs.


5 features of reservoirs in healthcare:


 1. Reservoirs slow patient flow.  Like giant, hydro-electric dams, they convert high flow, hard-to-manage situations into low flow, contained events.


2. Reservoirs allow us to meter out patients – for example,
we trickle them in from the waiting room into the ED, or trickle them up to the inpatient wards – when we are ready to see them.


3. We find reservoirs familiar; a common solution to high flow demands. They’re socially acceptable.  In fact, most institutions pride themselves on the size of their reservoirs.


4. Reservoirs decrease chaos and make us feel safe, but patients feel just as scared and unsafe while parked in a reservoir.


5. Reservoirs fill easily.  They attract contents.  Reservoirs might empty now and then, but they tend to promote filling and storage (waiting).


Waiting rooms, gigantic emergency departments or even special inpatient wards are reservoirs, and patients do not benefit from them if they exist only to slow patient flow.

These fat areas in the stream of patient flow end up grinding flow to a halt without extreme vigilance to keep patients moving.

We have to match patient volumes with flow; not capacity.  Sure, we always need more beds, but we need increased flow more.   Flow doesn’t just mean flow out of the hospital; it means flow in, too.  We often blame long term care or families for not taking patients home, as though there’d be no waiting if there were no alternate level of care patients (ALC; patients who need long term care) in the hospital. Or, we blame the inpatient wards for not taking patients out of our EDs sooner.

Truth is: we didn’t have an ALC problem years ago, but we still had admitted patients in the ED.  ALC represents one (major) factor impeding flow, but it’s not the only issue.

In the same way, patients crowded ED waiting rooms long before holding admitted patients in the ED became such a problem.


Until we develop a culture of taking every patient in – in to the ED and up to the wards – when they present, and not just when we are ready for them, we will never get rid of reservoirs and crush patient waiting.


How can we balance maximal patient flow and institutional capacity?  Is bigger better?  How can we avoid building reservoirs?



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Why build waiting rooms? For patients or providers?

Every emergency department has a waiting room that probably gets used more than any other room in the ED.

Did a patient group meet and declare they wanted waiting rooms?

Of course not.  Patients come to the ED to get help; not sit in a waiting room.

“Well, patients need to be able to wait somewhere before they get inside the ED.”


Why can’t we bring all the patients straight inside the ED?


Only someone painfully unaware of modern ED struggles could ask such a silly question.

“We don’t bring patients inside the ED because we don’t have enough resources to care for them.”

It’s all about stretchers and ratios.  We decide the ED is full when all our stretchers are full.  We decide the number of stretchers by how many nurses we have working based on a ratio of 4 stretchers to 1 nurse.

Stretchers and ratios keep everything neat and orderly inside the ED.

So, to maintain order inside the ED, we build waiting rooms to house all the patients that we don’t feel ready or able to help.  No matter how many patients pile up in the waiting room, we stick to our stretchers and ratios.

Providers want waiting rooms; waiting rooms benefit providers not patients.  Patients want to come straight inside the ED.

Why don’t we bring all patients inside?  What could be worse for patients than leaving them for hours in the waiting room?


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Waiting harms patients – A novel idea?

A room full of unbelieving faces stared back at me.  I had just finished presenting a brief review of the negative clinical impacts of patient waiting.

They didn’t buy it.  My medical colleagues flatly rejected overwhelming evidence.


It’s been said that every idea must pass through 4 stages:

 1. Critics scoff at your new idea because it’s novel and lacks supporting data.

2. After gathering data, critics say it lacks significance or is biased.

3. Eventually, your idea catches public interest.  It gains popular support.

4. Finally, everyone accepts your idea, and the critics tell how your idea was theirs from the start.


Despite hundreds of papers clearly demonstrating harm for patients due to waiting, we will never see improvement without popular support.

We need to engage the public – educate them – on the risks to their health when they wait in crowded emergency departments.  We need hospital leaders and governments to understand that waiting harms patients.

We need to challenge our cherished clinical processes that have been designed to benefit providers, but actually add harmful waiting to patients’ experiences.

We need to share solutions – brave innovations – that strip all the useless, harmful waiting out of our patients’ time in our institutions.

At which stage are you in realizing that waiting harms patients? What needs to be done to recruit you, and others, as champions to help STOP Patient Waiting?


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