03 February 2008

Performance Improvement, part 2

I wrote yesterthread about the operational crisis that we experienced in our ER in the early part of this decade. I'd like to pick up the threads of that story and continue on by writing about some of the changes we made.

Of course, I can't provide a comprehensive list of the elements of the turn-around. There were too many people involved, doing too many things. So I'll briefly summarize the major themes and deal with them in more detail individually. By the way, I'm not an MBA and have never taken a management course, so if there are any professionals out there, please don't cringe if I misuse a buzzword, mis-categorize an intervention, or just generally treat the most obvious facts as stunning insights. I'm probably a pretty typical doctor in that the most basic concepts from management 101 are earth-shattering revelations to me. But then, that's part of the problem, isn't it? We have all these physicians out there playing amateur manager without a clue, re-inventing the wheel as we go along. So here we go:

Process Analysis
When nothing is working, it's hard to look at the process without feeling overwhelmed. Where to even begin? We looked at the choke points and the patient flow to see what worked, what didn't work, and where we could find efficiencies. For us, the initial problem seemed to be the waiting room -- it was always full! This was in fact caused by various bottlenecks at triage, bed placement, MD assignment, disposition decision, and admission to the hospital. Eliminating (or at least reducing) the bottlenecks was undertaken in sequence, during which we had to deal with cascading consequences -- for example, getting patients in beds faster resulted in physicians being overwhelmed by the influx, which slowed discharges, etc.

Institutional Support
The biggest conceptual change was that the ER's gridlock was not an ER problem, but a hospital problem. Nurses and doctors on the floor could not shrug it off as "somebody elses's problem" but were obligated to take ownership and contribute solutions. Other service lines were also involved.

Management Practices
While the fundamental problem was identified -- dissatisfied patients -- there was no clear understanding of exactly which factors determine patient satisfaction. Furthermore, the ED was a data-poor environment, with limited ability to track patient flow. The physicians historically had been managed via a policy of "benign neglect," and there was substantial variation in the docs' operational capacities.

New Resources
It is hard to bootstrap yourself up without increased resources. Every ER Director has a wish list a mile long of the things they would like. In an environment of limited resources, we had to choose the few areas in which we could get the most 'bang for the buck.'

Culture Change
It sounds like fluff, but this is incredibly important. Working in a county-ER type setting, with a lot of uninsured/welfare patients, there's a temptation to view patients as parasites, or burdens, or anything other than customers. To rebuild the concept of customer service as the core mission of the ER, to instill it into the staff within the ER, and to communicate that it was not "show" but a real and sustained focus of the organization was a very difficult endeavor. To do this while at the same time empowering the nursing staff and improving morale was exceedingly difficult. Leadership is an interesting phenomenon, and the investment from the top leadership in the hospital as well as the ER nursing leadership was the key to driving much of the culture change.

This sort of change did not come overnight. In fact, since the seminal events that instigated our performance improvement plan, the time elapsed has been several years (longer than the existence of this blog). Staying power, continued focus, an emphasis on long-term trends instead of short-term oscillations in data, and the patience required to effect the change and see it sustained over time were required. Notions of an overnight turnaround or abrupt changes would have been unrealistic and probably would have poisoned the relationship between management and the ER staff.

Starting tomorrow, I will break down each of these categories into more detail. Stay tuned!


  1. I find it interesting when the things written in a management book get applied independent of that book and work. I think you might find Good to Great by Jim Collins a fascinating read in that many of the things you describe as effecting change in your organization are the same things that differentiate good companies from great companies.

  2. If your ER is like mine then you got the same problem: a facility that was built to handle the needs of your county and not HOARDS of ILLEGALS with ingrown toenails and sniffles. We have more translators some nights then Paramedics (patient care techs). I went to get a soda the other night in the lobby and saw an immigant lady with a 3 year-old granddaughter. It HAD to be her granddaughter because she looked well past menapause. She was looking out the window while her granddaughter was licking the leg of the bench. I walked over to her and in my limited spanish told her that this was a hospital (we see well over 120K cases a year) and that there are viruses and bacteria living on the leg of the chair and the child should go and wash her hands. The lady GASPED and said "really, virus y bacteria"... I almost fell over; mind you it was 11 PM on a weeknight and what do you think she was at the ER for? A TOOTHACHE! And why do you think she brought this little girl? "for company". I wanted to get the girl home as I was outraged that she brought a "pet" to the ER and brought her back to the discharge desk. I got the translator and looked in her mouth and did a quick ENT exam, wrote her and antibiotic, 16 IBP 800's and 6 APAP 5/500 and she was given the "dental referral clinic" page and instructions. BAM I had her in and out in 7 min and had the translater lecture her on innapropriate use of the ER and poor child welfare. She (translator) told her that if she saw the child coming in for no reason in the middle of the night she will contact the police and DCF. The rest of the night I saw 2 ingrown toenails, diaper rash at 4AM, sore throat and a caugh; I would wager that the names were fake and the clientelle illegal. We actually have one TV set in English and the other in Spanish. I have NOTHING against our friends to the South but I dont understand why 8 people accompany one cousin to the ER for a rash! I think that triage should put anyone with out US idendification or a visa without life threatining illness to the back of the line. I think word will spread that they are not going to tax our ER. THAT my friends is why our service is loosing $$$$$$$$.

  3. Rant, rant, rant...

    Here's the opposite comment: you have a new reader... and I think you have a book here. Be careful how much you blog. :-)


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