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“Excellence is what we strive for, but consistency is what we demand.”

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Baruch Spinoza1

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All emergency departments (EDs) seek to deliver the best possible results for the patients whose care is entrusted to them. Quality of care no longer means simply delivering appropriate clinical care, but also now includes delivering care across the dimensions of “service quality” including at a minimum, adherence to evidence-based guidelines, outcomes measures, patient satisfaction, and patient safety.

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EDs are complex adaptive systems, involving professionals and nonprofessionals with varying backgrounds and degrees of education and training, all of whom must come together as a team to deliver the best-possible care for their patients. In order to do this, EDs must engage and align the providers to work in an accountable fashion with the common goal of serving the patients, their families, the medical staff, hospital leadership and, of course, each other. It is important to recognize that those who serve patients well also serve their teammates well, as will be demonstrated in more detail later.

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Change in healthcare has often been described by the metaphor of rafting down a river, in which there were “Class V whitewater rapids” of change, requiring nimble skill to navigate those turbulent waters. But there were also long, placid stretches of calm water, during which the changes could be assimilated into the culture of the organization. While proceeding in those calm waters, whether all the oarsmen were pulling in precisely the same direction was of less importance. However, the current healthcare environment is one of perpetual whitewater, and of dizzying change, driven by a deep commitment to becoming the high-quality, low cost-provider of care. These treacherous waters simply cannot accommodate team members who are not on board and not paddling in a consistent and coordinated fashion. “Paddling in the same direction” is therefore an essential requirement skill for success in the current environment.

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This chapter delineates the process by which success is defined and measured and then provides several approaches to ensure that those who are consistently excellent—the “champions”—are rewarded. This chapter also provides strategies for dealing with the “stragglers,” those who cannot adequately participate in the delivery of the promises of hardwiring excellence that we have made to our patients and our team.

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Rewarding ED champions simply recognizes the adage that, “What gets rewarded gets repeated.” While intrinsic motivation is the key to meaningful and lasting change (as discussed in detail in Chapter 1), very few people are immune from the genuine expression of appreciation for a job well done under difficult circumstances. In addition, a culture of appreciation accelerates the pace of change toward developing further champions.2,3

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With regard to those who straggle behind, the figurative term “corral the stragglers” actually means that the leaders will separate them from the group and spend time with them to meaningfully ...

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