Patient Safety Requires Abundance

How much more can you work?

10%?…25%?…50%?

Do you work too much already?

Emergencies demand MORE.

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

Abundance

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.

Objections:

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,

AND

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?

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 11^th and 12^th 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 90^th 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.

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/her forehead that states the number of patients he/she can safely see per hour. Everyone can see the number, but no one can see his/her 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.