Effecting change is a battle of minds and hearts. The battle of the mind is one of working smarter, not just harder. This is where the tools of Lean and Six Sigma are valuable, bringing science and methodology to reengineering patient flow. An in-depth review of Lean and Six Sigma principles is beyond the scope of this chapter (for a detailed view, see Mayer and Jensen, Hardwiring Flow),1 and managing change is discussed in Chapter 3. However, a few points are worth mentioning here. When creating change, an ED should follow the steps outlined in Table 35-1.
The battle of the heart is more difficult. Humans by nature are not fond of change. There are entire MBA courses and curricula devoted to change management and strategy. One of the most difficult tasks is to get a group of highly skilled individuals (eg, doctors and nurses) to move in the same direction, at the same time.
Many conceptual models exist on change management and implementation. A popular model of change management is called ADKAR, which is a mnemonic for awareness, desire, knowledge, ability, and reinforcement (Figure 35-5).2 It is necessary to address each step sequentially to effectively change culture and attitude.
First, an awareness of a need for change must occur. Many frontline ED staff members are unaware of basic ED operational metrics such as door-to-doctor times, patients who leave without being seen, and length of stay. Many cannot articulate clearly what metric goals they are trying to achieve and why. If the staff is unaware, then how can they be expected to change?
Once awareness occurs, there must be desire or motivation to change. Healthcare providers are often aware of better ways and may even complain about the current inadequate processes, but have no motivation to change. Some providers would rather just continue doing what they are currently doing.
Knowledge, Ability, and Reinforcement
After awareness and desire occur, then one can apply Lean and Six Sigma as tools to provide knowledge (how to make changes), enhance ability (proper information and training), and give reinforcement (monitoring and feedback). However, without awareness on the part of the staff (why change is needed) and desire (motivation to change), any reengineering efforts are doomed to fail.
Creating Vision: Sharing the “Why”
Doctors and nurses are professionals, who will generally do what is in the best interests of their patients, and what is in their own best interests, as well. In the absence of information demonstrating how their actions affect their patients, they will gravitate toward making their own lives easier. The challenge for ED leaders is to
- Create an urgent motivation for change
- Inspire staff to place their patients' needs above their own
- Demonstrate how the change is in the best interests of their patients
- Show staff that they are integral to that change
Consider and compare the effectiveness of the following 2 statements shared with staff.
- “We have to reduce ambulance diversion hours because it's costing the hospital admissions.”
- “We have to improve the system to make it easier for us to take of our patients, some of whom are our own loved ones and neighbors.”
Implementing change may require ED leaders to confront some staff members with performance or attitudinal challenges and then initiate disciplinary processes, including termination if necessary. The Studer Group describes ranking employees into high, middle, and low performers.3 Studer recommends that ED leaders retain high performers; engage and improve middle performers; and manage up or manage out the low performers. This is not a new concept. Jack Welch during his tenure at General Electric had his employees ranked annually. The lowest performers were given their notice. He credited this with making GE one of the best performing companies in the world at that time.
While this concept may seem harsh and not practical for an ED, the problem with low performers is that they drag everyone else down. They are like an anchor. The high performers have difficultly excelling while pulling along this anchor. The middle performers, who tend to follow the pack, may sink to the level of the low performers rather than rise to the top. Low performers can be vocal skeptics and influence their peers. Their negativity will thwart change initiatives in a department. Certainly ED leaders should give low performers an opportunity to change. But if after being given a chance to improve, they demonstrate an inability to join the team and improve, it is time to cut losses.
Rounding with a purpose is another valuable Studer tactic to manage change and improve physician-to-disposition decision time.3 No one knows the barriers, bottlenecks, and delays better than the staff that works in the ED days, nights, and weekends. Rounding with a purpose consists of asking specific questions of each staff member. Simultaneously, the ED leader establishes/enhances personal connections during rounding. This process can yield valuable information, by consistently asking the frontline staff critical questions such as
- What is working (processes)?
- What is not working (processes)?
- What equipment or resources are necessary to help reduce throughput times?
- Who is doing a great job that can be recognized for best practice and great performance in quick throughput times?
- What can I realistically do for you now that will make a difference?
At the end of each rounding session, effective ED leaders keep track of the items that the staff identifies as obstacles to effective throughput. Those items become the list of actionable items to be addressed. Further, when the members of the ED staff see leadership addressing issues that affect their ability to provide safe, efficient, quality care to their patients, those staff members are encouraged to continue to improve.
Creating clinical teams is an effective way to simultaneously change culture and address throughput. While it is common for nurses to have assignments within specific parts of the department, physicians generally do not. This occurs because some ED work teams are organized in a way that the provider has no “ownership” of the patient until he/she signs up for that patient and begins an evaluation. For example, in an ED, in which there are 3 providers working at the same time and many patients waiting to be seen, no one provider may feel any sense of urgency to see the next new patient. The reasons for this mind-set are varied with a net effect of longer patient waits and slower throughput. A physician may feel that he or she
- Has more patients than the other(s)
- Has sicker patients requiring more time
- Has just picked up the last chart
When physicians and nurses are placed on teams with direct responsibility for the patients in a specific location, several positive things happen.
The communication between nurses and physicians improves. The nurses know which physician is caring for which patient, and vice versa.
The size of physician's area of responsibility is reduced—meaning less walking to and from the nurses' station to each patient room.
The physician now has specific responsibility for specific patients in those rooms even before signing up for and evaluating them.
One hospital has taken this one step further and assigns patients to one of 3 teams while the patient is still in the waiting room. In Lean terms, this is a classic work cell redesign (Figure 35-6).
A Lean work cell redesign: (a): typical work cell; (b) work cell redesigned.
Work cell redesign with specific assignments works particularly well in large departments, in which multiple providers are working at the same time. Variations of this redesign process are the implementations of fast tracks, pediatric areas, and provider triage. In effect, these specialized areas of the ED allow a dedicated staff to work in a smaller area to care for a specific type of patient.
Because the physician-to-disposition decision stage begins with the physician evaluation and ends with the physician reevaluation and determination, adequate physician staffing is critical. An arbitrary standard of 2.5 patients per physician hour has been used for over 20 years. Much has changed in that time. Patients are sicker. Patients with conditions that would have led to admission years ago are now more aggressively managed in the ED and then discharged. More patients come to the ED and fewer inpatient beds are available. Psychiatric services are less and less available.
Little has been published regarding current optimal staffing, but an informal, unpublished survey of busy Baltimore community hospitals found ideal provider staffing ratios of between 1.6 and 1.8 patients per hour per provider. Prior to addressing delays with increased staff, the redesign team should make sure that an inefficient system is not wasting physician and staff time on non-value-added activities.
Making Efficient Use of Time and Resources
Physicians are the most expensive human resource in the ED. Improving physician-to-disposition decision time requires liberating them from non-value-added activities so that they can efficiently evaluate patients and safely make the appropriate disposition decisions. Identifying wasted activities is key to this efficiency. Searching for hemoccult cards or developer, applicators, or pillows, for example, are not efficient uses of physicians' time and represents waste in Lean methodology. Thus, it is important to make physicians as efficient as possible.
If a department is disorganized and cluttered, the redesign should start with what is known in Lean jargon as a 5S project (Box 35-1). In simple terms, the redesign team should clean house and organize the department. The team should get rid of equipment and supplies that are not used and ensure that those that are used are easily accessible. Frequently used supplies, such as sutures, that are not proximal to the location where they are used, can result in hundreds of wasted steps for staff and providers. Multiplied by several poorly placed articles of equipment and supplies, this form of waste can lead to miles of walking and hours of wasted time in a single day.
Examples of 5S include the following:
- Central line mobile carts that include everything needed for central line placement and are located near the patient beds where central lines are routinely inserted.
- Rooms are adequately and consistently stocked with the appropriate supplies to minimize the need to go elsewhere for those supplies; the locations of the supplies are clearly labeled. There are adequate and accurate par levels.
- Frequently used forms are kept in a consistently organized visually accessible manner in the physicians' charting area.
Once the department is well organized and well stocked, a thorough workflow analysis with good data on interval or sub-cycle times will identify the biggest bottlenecks.
Diagnostic testing, that is, lab and imaging, commonly affect physician-to-disposition decision time. It is beneficial to obtain baseline data on high-frequency tests and to establish cycle-time standards. For instance, how long should a CXR take from order to result? The assessment team should factor in the number or percentage of patients who will be affected by an intervention. For instance, an abdominal CT with contrast can take hours from order to result, but only a relatively small percentage of patients receive that test. Does saving an hour on each patient who gets an abdominal CT provide more benefit than saving 15 minutes on each patient who gets a chest x-ray or receives laboratory testing?
The answer depends on the number (percentage) of patients getting those tests and the determination of whether the test is rate limiting for disposition. In general, the team should choose a project large enough to make a meaningful impact, but not so large and complex that it becomes unmanageable. Inadequate staffing levels of the diagnostic testing personnel are another related demand capacity problem that frequently has an impact on throughput times. As with ED physician and nursing staffs, it is necessary to align diagnostic testing staffing capacity with patient demand.
The electronic medical record (EMR) is a double-edged sword. While providing many documentation and ordering (CPOE) advantages, EMR use in its current state can be difficult and create inefficiencies. Anecdotally, many EDs have experienced slower patient throughput because of skill deficit, mandatory system requirements, and equipment and system crashes. Several of the enterprise systems do not adequately address ED needs in an efficient manner. Some groups have addressed this inefficiency by employing scribes to enhance physician productivity.
Creating computer/electronic tracking board prompts and alarms can alert practitioners when a patient has been in a department for a certain period of time. These prompts can create cognitive triggers and increase the sense of urgency among providers to make a disposition decision.
Creating a Positive Perception of the ED
The ED may be perceived negatively within the hospital. The reasons include that the ED
- Has multiple unplanned admissions
- Requests inpatient beds at all hours of the day and night
- Demands that its patients get all their tests done stat
- Wants its patients to go upstairs immediately after being admitted
- Costs the hospital money, when it goes on ambulance diversion
- Places pressure on almost all hospital departments
Prior to change, ED leaders must be seen as effective and collaborative. They must listen to and address the issues of other departments in order to have others listen to and address their needs.