30 January 2008

Movin' Meat: Door to Doc

A comment I made drew some disbelieving attention over at Crayzee Central. I didn't give it much thought initially, but it's probably worth a post. What I said was that Door-to-doc time at our facility is down around twenty-five minutes. It's true, and not because we are some "cushy" palace of a private hospital with lots of empty beds and nurses sitting down with nothing to do. It's been a long, hard slog for us to get where we are, and it might be informative to write about how this came about, and why.

First of all, a disclaimer. I am the administrator for our professional corporation. I am not involved directly in ED operations or hospital administration. So while I have a place and a voice at the table where the decisions are made, I am not a decision-maker, nor am I responsible for implementation. I will use the phrase "we" in describing our accomplishments, and I feel a great sense of pride at the progress, but I cannot take credit and do not want to be seen as doing so. We have a great team -- the CEO, the ED Medical Director, the Nursing leadership, etc. If our hospital's ED management were a baseball team, I would not be the star pitcher or slugger. Maybe a good utility infielder. So I will take the opportunity to brag, but don't label me as too egotistical.

In order for this journey to make any sense, context and perspective are needed. In order to see how far we've come, you need to know where we started.

Our facility is a very large, private charity-based hospital in an economically depressed urban/suburban community. We see over 100,000 patients annually, which is as about a big as ER as I have ever heard of without a major academic affiliation. Our hospital's physical plant is very old and the ED has not had anything but cosmetic renovations in two decades. It is very small, with fewer than 50 beds in the ER, though the hospital does have several hundred inpatient beds. The hospital administration has some financial resources, but due to a very marginal payer mix departmental budgets are quite restricted. (Part of the reason budgets are restricted is the hospital is running a profit margin necessary to assure the bond markets we are credit-worthy in order to build this.)

A necessary element of success is the leadership. Our hospital C's - the CEO, CFO, COO, and CFO - are excellent. Reasonable, visionary, and exacting. They are somewhat new to this institution, and bring with them a commitment to the mission of being the premier medical center in the region. They understand that when our performance in the ED fails to meet standards that it is often due to factors not under our control, and they do not personally blame us. Neither do they give us a free pass. Every identified "improvement opportunity" must have an action plan. Sometimes it seems a Sisyphean challenge -- we are tasked to do the impossible with inadequate resources -- but the result when we fail is that we just have to begin anew. The consequence, after several years' relationship with this administrative team, is that we know they will hold our feet to the fire, and we know expectations are high, but we also know that as long as we share their vision, as long as we keep working towards the shared goal and making incremental progress, we don't need to fear them.

A few years ago, our ER was truly in crisis. The wait times were in measured in hours. The walk-away rate approached 9% at its worst. The nurses were burnt out -- understaffed and overwhelmed, they routinely called in sick, taking "mental health days," leaving the ER even more short-staffed. Patient care suffered. There were, I believe, a number of preventable adverse outcomes due to the chaos in the ED. Physicians resigned, citing an unsafe environment and excessive stress. It didn't all happen at once. Like the story of the frog boiled alive in a gradually heated pot of water, life in a busy and inefficient ER slowly got worse over a period of years, with a variety of causes. We rushed about, putting out fires here and there, and rarely paused to look at the big picture. The wake-up call came when Press-ganey changed its methodology of ranking patient satisfaction scores. We had always had low-ish scores, but under the new method, we ranked at the 1st percentile.

That got some attention. It's hard to be told that you are the worst ER in the nation and not respond with denial, disbelief, with excuses -- especially when it is due to a change in the "scorecard." But there it was, staring us in the face: 99% of American ERs had patients who were happier with their care. This put us down with inner-city hell-holes like King-Harbor in LA. The message was heard loud and clear up and down the organization: improving the performance of the ER is of the highest priority, and every department, every service line that impacted the ER would be expected to contribute.

This is going to be a long story, so I'll break off here for today, with the observation that the last sentence is the most critical component of our organizational turnaround. Hospitals that view ER performance as an ER problem routinely fail to solve their problems. The ER is largely dependent on the institution for its success or failure, and without an institution-wide performance improvement plan, the prospects for meaningful reform are bleak.


  1. Still think it's cushy.

    My standard of cushy is low though...having an open bed for an acute patient without having to play "who REALLY doesn't need this monitor?" to me is like a dirty fantasy I dare not think about without feeling guilty.

    Twenty-five minute waits implies there are---gasp---open beds and---GASP!!!---someone to staff said bed and there are adequate triage nurses in the lobby even. Dude. Cushy. Don't get all liberal on me and be embarrassed that your work is at the very least more efficient and the staff are probably not dreading coming to work like they used to.

  2. Why on earth would you think SF is embarrassed that his workplace is more efficient? Should he be embittered, or in any way disdainful of his work the way you seem to be?

    "Cushy" in my mind implies work that is not difficult. As SF writes, the change was the result of a thoughtful process that has required tremendous work on all levels. They can now move over 100,000 patients a year, AND have decreased wait times dramatically. However in your mind, it seems, "cushy" means "anything that is not as dreadful as my own situation." I'm so sorry that no one understands you, Nurse K. I know a good therapist if you need one.

  3. You're an odd person, Matlatzinca. Take a deep breath. It will make the tingling go away.

    I'm more joking about what we as ER staff consider "cushy". Our ratio is 15 beds to 46K visits/year. We, like most ERs in the world, are screwed 6 ways to Hell no matter how efficient we are. It is what it is.

  4. Shadowfax, how lucky you are to work in a facility where administration 'get's it.' If the ER ain't working it's a facility wide problem, not just the ER's.

  5. Shadowfax- well done.

    To wit-

    "In order for this journey to make any sense, context and perspective are needed. In order to see how far we've come, you need to know where we started."

    Perfect. Future vision requires understanding of the past. Easier said than done- I think you're on the right track.

    Nurse K- I try to understand your issues, and they all seem personal. I'm sure you try very hard at your job and I like to believe you are effective at what you do. Your job is not an easy one. However, please don't mix up the daily battle with the overall war. Your complaints are legitimate- and common. If your administrator does not address them, then go higher- or move on.

    Sisyphus is an interesting euphemism- this from wikipedia:

    n the essay, Camus introduces his philosophy of the absurd: man's futile search for meaning, unity and clarity in the face of an unintelligible world devoid of God and eternity. Does the realization of the absurd require suicide? Camus answers: "No. It requires revolt."

    Best, Chris

  6. NK - Ah, I see. It was humor that I was misinterpreting. My humor chip must have been offline.

    You are right about one thing, though: I am odd. Still, if my workplace didn't seem to be a satisfying place to work, I would change it. Make it better, or move on.

  7. We have 20 beds for c120,000 /year. I guess, despite theoretically being a leading, University Teaching Hospital affiliated ED, this makes us really small. Or maybe it's true about you guys doing everything bigger?

  8. I'd say unequivocally that Dr. Shroom wins the prize for this round of "who is more royally screwed", but it's hard to do that when the healthcare system one is involved in rations care by forcing people to wait and, among other things, outright denying treatments to people. Already 120K people/year come to a 20-bed ER which is likely so overcrowded that it's perpetual chaos, so the long wait times will keep at least some of the subacute patients away so the government doesn't have to reimburse at ER rates.

    Achieving one of the goals of cost control in socialized medicine (rationing care by waiting)=getting screwed. If you're not screwed over enough, your socialized medical system is probably caving in due to cost or has killed everyone already.

    Hm. Wait. The UK screws you over with long wait times AND is caving in due to high costs? Oh, okay.


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