Change at Frederick Memorial Hospital, or, Looking for Brown Ferns

The last time our emergency medicine group took over management of a new emergency department, at Bristol Hospital in Connecticut, my colleague Noah Keller wrote a post about how we try to instill our unique brand of company culture within the first days and weeks of taking over. Rather than memorizing protocols, we are memorizing people’s names, he wrote.

On September 3, we formally took over management of the Emergency Department at Frederick Memorial Hospital. Part of instilling that culture that Dr. Keller wrote about means encouraging everyone here to continually improve. At a new Emergency Department, that means looking for what I call brown ferns.

The story of the brown fern goes like this:

Imagine you have been working at company for a few years. You have a nice office, a clean desk, and everything is in its place. One day your wife or husband comes in and gives you a beautiful plant, a fern, to liven up your office. It looks very healthy over in the corner. You water it and nurture it and it adds just a little brightness to your work day. Then you go on vacation, and when you come back it’s a little brown from lack of watering. But you have a lot of work to catch up on, and you begin to neglect it. Every day it begins to die just a little bit more. Now, because it’s been in your office a year, the fern is brown and dead. But you don’t notice it, because it’s been there so long it’s now just a part of the scenery. Then one day your old friend from college comes to your office to visit, and the brown fern is the first thing they notice. Whereas you just breezed over it because it’s been there so long, your college friend sees it for what it is, a big ugly thing sticking right out in the corner of your office.

The first time I told this story was in 2005 at St. Mary’s Hospital in Maryland. I was Chairman for the first time in my career and I was hiring and mentoring a lot of new providers. I gave them each little books to put in their pocket, and told them to write it down every time they saw something they considered to be a brown fern, those little (or big) problems in the ER that are there but for whatever reason have been neglected or ignored.

I also put a brown fern box in the ER, and I told them to just fill it up. Periodically I would empty the box, put everything into a list, print it, and share it with everyone by posting it in the ER so they could see the brown fern they had identified was acknowledged. Then I designated different people to fix the various brown ferns. Slowly but surely, things would get checked off the list.

The past few weeks at Frederick Memorial Hospital we have been following a similar process, except instead of notebooks, pens, and printers (our technology has progressed a little), we are using a shared Basecamp to-do list. Whenever a provider sees a brown fern, they bring up the Basecamp app on their phone and add it to the list. If you don’t add it to the list right when you see it or think of it, then very soon it will become your brown fern, something you stop noticing because it’s just always been there.

We’ve divided the Basecamp to-dos into several categories, including Scheduling/Productivity, Patient Flow, EMR Issues, Meds/Supplies, and Operations. Basically the nuts and bolts of running an ER. Problems range from the easily fixable (need Keurig coffee machine for staff, new keyboards for computers) to the systemic (admission process clunky, lab turnarounds long). Most of these brown ferns will get divided into three categories: short-term goals, medium-term goals, and long-term goals.

Short-term goals can easily be taken care of, meaning the Emergency Department will get an immediate boost from the sense that things are changing for the better. This critical momentum can be harnessed to start tackling the more complex goals, while new providers and existing ones can take the lead on leading change processes, developing their leadership and management skills, and making their Emergency Department a more efficient, better place to work, and ultimately a superior place to receive emergency care. If you’re good enough, in time you’ll train yourself to recognize your own brown ferns.