Author: Shawn Whatley

Big 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.

Competition/productivity

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!

You should get upset when your hospital gloats about great average wait times in the emergency department.

Average means nothing to patients stuck on the right end of the curve, the ones who waited longer than average.

In Scheduling to Meet Patient Needs, we introduced the idea that average harms patients.

This post describes an alternative to ‘average’, and a way to get admitted patients out of your ED, from the book: No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

Real-Time Data

Average wait times from yesterday will never improve wait times today, right now. Administrators nudge average waits in the right direction with process change, over many days.

But it’s not enough.

If you want to improve waits for patients that sit in your emergency department, you must make process changes on the spot, using real-time data.

In Step 6, Give MDs Responsibility, we discussed letting doctors control patient flow. Docs can adjust every hour to changes in patient volumes and acuity.

Doctors need live data to manage patient flow.

At our hospital, the charge nurse would show the charge physician a printout of all the patients waiting, with wait times in minutes.

Every hour, the charge physician would write his/her action plan, for example, ‘Call next doc in early’, and sign the sheet.

Just asking doctors to ‘Keep and eye on the tracking board’ will not work.

Again, you need live data in minutes; not averages in hours from 10:00 and 2:00 the day before.

No one would approve the average number of life vests, or an average number of parachutes. Emergency services must guarantee resources for the worst case scenario.

Metrics That Don’t Budge

Sometimes, departments perform quite well at baseline. ED teams need a vision, something aspirational, to keep them pushing for excellence, when they have already out-performed their peers.

Find a vision that works for your group. We chose “Treat patients like family.”

But some metrics barely move, no matter what you do.

Many measures, like total length of stay, rely on other departments. For example, you have little control over lab and DI turnaround times, but you can still influence them.

• Stay focused on what you can control, and improve it.
• Then, encourage other departments to post their performance.
• Challenge them to improve as much as your team does.
• Find top results from other hospitals to push them along.
• If you can inspire even one other department, you create an alliance to change others.

Senior hospital leaders need to help drive performance that crosses multiple departments.

Full Capacity Protocol

EDs would be safer without admitted patients filling all the stretchers. Hospitals choose to leave admitted patients in emergency departments. They could choose otherwise. Patients could be moved upstairs.

Dr. Peter Viccellio first described the Full Capacity Protocol. I think of it like this:

Imagine 10 lifeboats. Pretend that each lifeboat can hold 10 people.

Now imagine 9 of the lifeboats filled with 12 passengers, and one filled with 16. One boat is dangerously overloaded.

Which boat should pick up the next drowning passenger? One of the boats with 12 people, or the one with 16?

Hospitals choose to put every new patient into the most overcrowded department in the whole hospital. Emergency departments work at 150% capacity or more, while the inpatient wards complain about working at 105% capacity.

The Full Capacity Protocol works by sending 1-2 admitted patients to each ward, twice each day.

At a certain point of ED overcrowding, say 115%, all new admissions go up to the wards. Ten inpatient wards each take 1 or 2 patients at 10:00 and 14:00.

But hospital leaders choose to ignore the Full Capacity Protocol. They would rather listen to one department whining about overcrowding than fight with 10 departments at the same time.

Who’s in Charge?

Hospitals leaders do not have authority to operate as they think best. They have to please too many stakeholders: unions, physicians, regional health authorities, ministries of health, patient groups, and individual politicians.

Hospital leaders have been handed a governance mush and they deliver mushy results. Boards settle for trying not to stand out, trying not to change things too much.

It takes a very special group of Hospital leaders to make meaningful change to patient flow in our current system.

This gives you a taste of Step 7 from No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments. Check out the book for more. Thank you!

Patients will always wait, if emergency departments (EDs) insist on rigid staff schedules.

In the last post, Scheduling to Meet Patient Needs, we discussed how to build a flexible schedule.

Now, let’s look at how to make it work in Step 6 of No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

EDs need hour-to-hour flexibility in the number of physicians working, if you want great patient wait times.

Give MDs Responsibility for Flow

1. Assign approximate start and stop times for each shift.

2. Identify the most recently arrived physician as the charge physician responsible for patient flow and wait times.

3. The next MD on the schedule must call and speak with the charge position a few hours before the next shift starts.

4. If wait times or patient volumes increase, the charge physician will ask the next physician on duty to arrive early and ask the doctors currently in the department to stay late. Or if it looks really busy, the charge physician activates the on-call system.

5. On slow days, the charge physician will delay the arrival of the next physician on duty, send doctors home a bit early, or even cancel a shift. Shift cancellation is rare. It happens at the end of the day a few times per year.

No More Bogus On-Call Systems

Physicians must be eager to be on call. They must be excited to go to the hospital, at any hour, to see patients when they were not scheduled to work.

If physicians would rather ignore a page, you have a useless call system.

One person on call is marginally better than no call system. You need to rally 1, 2, or even 6 extra docs in to the ED, within 1 hour of activating the on-call system.

Physicians should be upset if they were not called, and someone else got to respond instead. Figure out a way to make coming into the ED more attractive than staying at home. Find the tipping point.

Trauma teams often get paid to be on standby. Plus, they get paid for most, or all, of their shift just for showing up to the hospital, even if a case gets cancelled after the team arrived. They get overtime, double time, and other perks to guarantee patient care.

Expect to pay similar rates for physicians to be excited about being on call. You might start by paying at least twice the amount that MDs would make on a full evening shift just for showing up to the hospital while on call.

Be ready to prevent abuse.  You need to build incentives to prevent over- and under-use of the system.

Consider applying the unused portion of your on-call funding to the night shifts. But keep people accountable for their performance during the day or else they might never activate the system and try to ’save’ the on-call funding for the nights.

It requires a delicate balance to build a solid on-call system.

Statistical Aside

For those of you who enjoy stats, we can think of the difference between doctors and nurses in terms of discrete versus continuous variables.

Doctors behave like discrete variables. Even large EDs have only 2-4 doctors working at any one time. MD resources come in “chunks”.

Nursing resources tend to behave like continuous variables. EDs often have 10 – 15 nurses working at one time.  A department can instantly add 1.5 hours of nursing by asking 6 nurses to skip a 15-minute break.

Although flexible scheduling would help match RN resources to patient volumes, EDs can build resilience into the RN staff with other approaches, for instance, flexible ratios and teamwork.

Use Patient Navigators

In Canada, hospitals save money by forcing non-medical work onto doctors. In the old days, hospitals used to hire people to help doctors focus on patient care. Not anymore.

Hire patient navigators (PNs) to do all the non-medical work that physicians do now. Doctors can pay for PNs out of their own pockets.

PNs direct patient flow, find charts, check to see if labs are completed, find information, answer pages and telephone calls, and generally do everything else that physicians waste their time doing outside of patient care.

PNs improve patient experience, ED efficiency, and team communication.

PNs improve MD efficiency by at least 20% and return joy to emergency medicine.

This gives you a taste of what’s in Step 6 of No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

Thanks for checking this out!

Photo credit: www.hindustantimes.com