Patient Flow Enewsletter
Volume 2, Issue 2
Thursday, April 7, 2005
Even the titans of industry might not be able to figure out the problems of the modern emergency department (ED). Any patient with any need can present at any time of day or night and expect to receive timely, accurate and expert care. Yet the facility is fixed, ebbs and flows are unpredictable, the financial margins are minimal or even negative and the technical complexity is enormous. The staffing is short. Financial investment in expansion and growth would yield uncertain return. Improving the ED might even hurt the organization by bringing unprofitable patients. It is a recipe for disaster.
Quite frankly, formulating a system to provide timely, high quality emergency care violates all currently held rules for constructing a sound business model. But we're not the first to be faced with such a monumental task. Other businesses have already achieved what leaders in other sectors perceived as impossible tasks. McDonalds achieved worldwide growth by delivering a consistent product. Federal Express delivered packages anywhere in the world in 24 hours or less through logistical expertise and a clear mission. Toyota revolutionized quality by measuring it from every angle, fixing the small details and improving every day. The airlines have virtually eliminated aviation error, enabling safe flight around the globe. Nuclear power plants can essentially guarantee that there will never be an error in their operation. The business world is littered with countless stories of successful operations, thriving against seemingly insurmountable odds.
So why are we all so reluctant to look at the lessons learned? The answer to that question lies in understanding how healthcare workers perceive themselves. Because healthcare professionals perceive their contributions as literally being the difference between life or death, they perceive looking at the efficiency models used to merely produce an automobile, for example, as not only inappropriate, but in fact as insulting to our profession. However, if we're truly dealing with life and death, shouldn't we be eager to look at innovations from any other organization that could potentially help us improve ED care?
All of us in healthcare spend hours in meetings where we talk about system enhancements, but we need to recognize that design and analysis of efficient systems are not our purview; they exist in the engineering realm. Yes, physicians follow similar principles in medicine, but the medical model is best applied to making medical decisions at the individual patient care level. If we want to talk as experts about improving system efficiency and technical quality, we need to look at engineering principles and examples from other sectors.
Take any industry with high efficiency and a low error rate - hotels, automobiles, airlines, etc. - and you'll discover several common denominators:
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Because of isolation and lack of competition, the healthcare industry has never been forced to adopt these principles. But new pressures are pushing us to look at technical and service industries to see how we can improve throughput and improve on the margins while still providing the highest quality of care to our patients.
At Northwestern Memorial Hospital, we've been increasingly looking at ED efficiency with an engineer's eye. We recognize that there are certain skills that we do not have, and process methodologies that we have not been taught, that likely hold keys to improving our ED.
In our department, we began by determining reliable measures to track data to understand our efficiency. Increasingly, hospitals are now hiring process, industrial or production management engineers - or consultants with an MBA - to help them design output-oriented processes. We believe this approach can work for anyone who is open to learning from industrial sectors that have been forced to optimize their operations because of competitive market forces.
From our experience, we know that tracking different data points provides a clearer understanding of the problems that need to be corrected. For example, we measure breakdown of throughput at specific intervals: arrival to triage; triage to room; room to disposition decision; admit decision to departure. Thorough analysis of these data points is helping to move us from an understanding of "what" the problem is, to a better appreciation of "why" it is actually happening. Understanding why problems are occurring is critically important and helps the ED make an evidence-based articulation to colleagues against what we call "proximity bias," whereby those closest to the problem get blamed, even though the causes may rest elsewhere in the hospital (ED overcrowding being a wonderful example of such a phenomenon).
One key lesson for us, so far, is that we need to focus our staff resources much more tightly - just as a hotel or an airline does - with people assigned specific job functions that build upon each other. Too many job descriptions are written based on what people in the ED actually do (descriptive model), rather than what they should do (normative model) to maximize efficiency.
We discovered that as physicians, we end up getting pulled away to complete tasks that have nothing to do with efficient hospital care: logging into the computer, clicking through 10 screens in order to work on staff charts - dozens of things other than treating patients. We want frontline workers like us to care for patients and then have other staff work on the systems to support the actual patient care providers - people who are trained to do so.
Too often, doctors and charge nurses in a busy ED environment are required to reprioritize their focus away from patient care and toward correcting the system that was originally intended to support the care of patients. We've learned that someone with different training can perform these process control and management tasks allowing healthcare providers to focus on providing healthcare. We've also found that process managers who have no primary patient care responsibilities do a better job of optimizing the system because they can focus on the macroscopic level, allowing health care providers to focus on the essential task of optimizing the individual patient's care. This model parallels the roles played by pilots and air traffic controllers in the airline industry.
Maybe someday we'll all be hiring former air traffic controllers or assembly line engineers to smooth out our EDs and keep things running efficiently throughout the hospital. In the meantime, a small investment in time, engineering talent and discipline can produce tools and generate ideas to help us run our hospitals like the pros.
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James Adams, M.D.
Professor and Chair, Department of Emergency Medicine
Northwestern Memorial Hospital and Northwestern University
Chicago, IL
Contributing authors to this article include Peter Pang, M.D., and Martin Lucenti, M.D., Ph.D., Emergency Medicine at Northwestern Memorial Hospital and Northwestern University.
