Quality in Healthcare, Patient Wait Times, & MD Arrogance

Physicians believe that:

Anyone who delivers care in less time than me must be cutting corners and providing low quality care. Same goes for clinics, hospitals, emergency departments…

Do physicians believe, then, that taking longer would improve quality? Does more time equal more quality?

Deep down, many physicians believe that:

The highest quality care happens at precisely the speed at which I provide it, or could provide it, if I chose to work at my top speed.

This could just be physicians resisting change for their own reasons. But I think there’s more…

Outcomes & Quality in Healthcare

Patients believe compassion equals quality, and rightly so: quality care must be compassionate.

But patients also want great outcomes.

Time determines outcome for most EM care (ICES Quality Report, 22 of 48 indicators are time based).

Many papers show ways to decrease waste for patients: see articles on LEAN and time in emergency care.

EM associations teach ways to increase speed without decreasing quality (Physician Efficiency, Canadian Journal of Emergency Medicine; Doing Things Faster Without Sacrificing Quality, ACEP), and many report ways to speed up care (Speed it up from Stanford 2013; ERs Move to Speed Care, WSJ 2011).

Time equals quality in emergency care. There is no evidence that patient waiting or taking-a-long-time-to-provide-care equals quality.

Humility can help to improve performance. Are we willing to look for ways to improve based on others’ success?

Patient Flow into Buckets or Patient Flow into a Funnel?

Nurses and doctors think patients belong in buckets.

Not literal buckets; buckets of care: primary care bucket, emergency medicine bucket, inpatient bucket…

How do we know providers believe in a bucket concept of care?

They tell patients they’re in the wrong bucket!

They tell patients to get out of the bucket!

They tell patients to go to a different bucket next time they need care.

Hilton hotels suggests staff should be empowered to handle ANY issue that arises for guests during their stay.

What happens in healthcare?

Sorry, ma’am. You’ll have to go somewhere else for that.

Sorry, sir. I don’t have time to discuss that with you. The ED isn’t the place for that kind of problem.

Subtitle: And don’t come back next time!

Funnel of Care

Patients should seek care where THEY choose. How they choose and how we can help them make a great choice will be discussed in another post. For now, once patients present with a concern – no matter where they present – we should be prepared to help to whatever extent we can. Sending them away with a dismissive, “This isn’t an emergency” is unacceptable.

The funnel starts where patients choose to access care. The funnel continues to more and more specialized care until patients get what they need.

With bucket-thinking, we expect patients to make their own clinical judgment. Then, we berate them for poor clinical judgment:

“Why didn’t you go see the family-doc/walk-in-clinic/anywhere-else?”

But without clear, available access, patients are forced to attend the ED. EDs refer patients to their family docs for follow-up far more than family doctors refer to the ED. Referral patterns have reversed. We could make the ED a referral only facility like an ICU – no entry without a referral letter. Family Docs and clinics would need advanced access, longer office hours, basic resuscitation equipment…

System issues force patients to seek care wherever they can get it. It’s our job to help them when they get there; not send them away.

What do you think? Would you want your family to be sent away from the ED? Is that safe? Is it good customer service? Click Leave a Reply or # of Replies below.

See How Patient Flow Improved: Mini-Trial of RN-MD Triage

Early Success!

We tried a nurse-physician team with 3 stretchers in our old (empty) waiting room. We did not change our old process; just added a parallel process out front.

An RN met all ambulatory arrivals at the front door for a quick look as before (pre-triage). Ambulance patients came in through a separate process. We ran the parallel RN-MD trial from 10:00 – 13:00.

Process

Patient arrives to see an RN screener/sorter/pre-triage.

Patient directed to an RN-MD team with 3 beds in the waiting room.

Patient sent to registration.

Patient sent home or to appropriate clinical area.

If RN-MD process overwhelmed, patient sent to traditional triage.

At any point, patient sent to acute room as indicated.

Results for 3 hour trial:

30 ambulatory patients seen (less than average volumes?)

Time to see MD = 0 minutes for 27 patients (< 3 minutes from RN screener).

3 patients direct to acute room by RN screener.

5 patients (17%) seen and discharged home by the MD-RN team

3 exam spots added (6% additional capacity) at ZERO cost.

0 left without being seen

0 patients required traditional triage

Reflection

We identified a number of things to improve for our relaunch next week.

Staff who had strongly opposed the trial turned optimistic.

As a team, we had become overly anxious to try new things after a major change ‘failed’ in 2012 (we tried something for 2 1/2 days that didn’t work as hoped). We got a boost today.

We’ll share process detail and performance data as we gain more experience.

Have you tried something like this? Share your thoughts by clicking on Leave a Reply or # replies below.