Category: No More Lethal Waits

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

Nobody is average. No day is average.

A statistician drowned walking across a river with an average depth of 2 feet.

Average harms patients.

When emergency departments are understaffed, patients wait. When departments are overstaffed, costs go up.

This post touches on material in Step 5 from No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments.

In Step 2, we said to Close the Waiting Room; bring everybody inside. If EDs do this, staff will feel every surge in patient volumes.

It will create chaos, if you do not match physician scheduling to hourly changes in patient volumes. Staffing levels need to swing up and down with changes in patient volume.

High-end restaurants solved this long ago. If an evening gets busy, restaurants call in more staff. If it is slow, waiters go home early. Restaurants schedule staff based on how fast each waiter works.

To use this thinking in the ED, schedulers have to tackle clinical speed and the traditional LEGO block approach to scheduling. Check out Schedule 4 Patient Flow and Efficiency to see how.

 Schedule Trilemma

Scheduling frustrates some of the smartest people, when they ignore the schedule trilemma.

A trilemma offers 3 options such that only 2 of the 3 can be true at the same time.

One classic trilemma asks you to pick 2 of the following 3 options: better, faster, cheaper. If you want better and faster, then it won’t be cheaper. If you want faster and cheaper, then it won’t be better. And so on…

A humourous Soviet era trilemma asks you to pick 2 of the following 3: communist, honest, smart. You can be communist and honest, but you won’t be smart. And so on….

The schedule trilemma asks us to pick 2 of the following: efficiency/MD productivity, short patient waits, rigid shifts.

If you want to keep physicians productive and have rigid start and stop times for your shifts, then patients must always be waiting so that physicians are never idle.

If you want short wait times and rigid shifts, then you need to over-staff your department so that there’s always an MD ready to see patients, even during the biggest surge in patient volumes.

But if you want efficiency and short patient waits, then you must not have rigid shifts; you need flexible start and stop times.

We need flexible shifts to maximize efficiency and decrease patient waits.

Scheduling to Meet Patient Needs

1. Determine the speed each physician works

2. Estimate total volumes

3. Let physicians pick their shifts

4. Each MD should choose 50% more shifts than they want to work

5. Use number 1 – 3 to create the schedule

6. Assign approximate start and stop times

We’ll look at how to operationalize this in the next post.

Check out this interview with Dr. Marko Duic, the brains behind this scheduling approach.   The interview touches on the mechanics which we will expand in the next post: Step 6 – Give MDs Responsibility for Flow and Hire Patient Navigators.

I hope this gives you a little taste of the process advice from the book. Check out No More Lethal Waits for more.