During my career as an emergency physician, I have worked in several different emergency departments. Going back to residency, I had shifts in numerous ER’s in Chicago, from inner city locales and large teaching hospitals to smaller community based hospitals in the surrounding suburbs. There are many differences in facilities and processes even within the same market yet they are all tasked with providing the same high quality outcomes for the patients.
Some of these differences are understandable as the tertiary teaching hospitals have more resources and specialists, so they accept transfers from outlying hospitals. Some hospitals have service lines that others do not such as trauma or neurosurgery. From a patient’s perspective however, when they are wheeled through the ER doors they expect to receive high quality care for the emergency that they are experiencing at that moment.
So why do hospitals have such different processes to accomplish the same goal? First, there are many differences in facilities from size and ED design to outside forces that may affect patient volume. St. Vincent’s Hospital in Manhattan recently closed which can have a profound effect on surrounding hospitals that have to assimilate the displaced patients.
The population in St. Mary’s County, Maryland where I practice has grown quite a bit in the last 5-10 years and much of it is due to the local Patuxent Naval Air Station which brings military and civilian jobs to the area. We have had to make many changes in the 5 years I have been here to adapt to this growth.
With the new healthcare legislation, I think most would agree emergency department volumes will continue to climb in the foreseeable future. Much of this will be due to shortages in primary care that will continue. The newly insured patients may be more willing to seek care earlier but will have difficulty finding primary care physicians accepting new patients and will end up in the emergency department. With the economy straining hospital budgets, there will not be the ability to suddenly and on a nationwide scale increase the number of emergency department beds. In fact, ED beds have been declining nationwide. Add to this, the increasing numbers of Baby Boomers that will require significant medical care and you can see the coming tidal wave of patients on the horizon.
Will you be ready? The only way to handle increased growth without increasing your physical plant is to increase virtual capacity by improving efficiency. This is a very broad topic as efficiency can relate to pre-hospital EMS, your triage process, efficiencies in ancillary services (lab, radiology), your hospital’s admission and discharge process and your physician and nursing staff speed. In order to make significant new capacity in the system, you will likely need to look at everything in a stepwise fashion.
Some of these issues are not under your direct control which presents a unique challenge well known to Medical Directors in emergency departments. It is very beneficial to have strong relationships with your nursing and hospital administration to get these tasks accomplished in a collaborative fashion. For this blog entry, I will focus on something for which I have more control, the providers.
My company monitors provider data religiously in an effort to improve our speed, efficiency and quality. We provide coaching and mentoring to our doctors and midlevel providers to assist them in reaching their full potential. We provide educational opportunities and hold peer review meetings regularly to improve our utilization so we are not performing unnecessary testing which further prolongs patient throughput. We hold regular department meetings and LISTEN to the providers as to how to improve their ability to practice efficiently. It can be something as simple as “please move the PACS monitor closer to the docs workstation so I don’t have to make 20 trips across the ED to look at an x-ray.”
One small improvement like this can have a significant impact on a provider. Talk to your providers to see what they think is important and what will help them reach their goals. You may find some simple solutions and quick fixes that will improve your throughput. Even one to two extra patients per shift per provider can have a significant effect on overall efficiency of the department.
I have found great success in making sure we hire the best quality providers, giving them the tools to perform well in their jobs, providing and accepting feedback to continuously improve ourselves, and keeping providers and staff happy. Happy providers make for happy patients but I will elaborate on that more next time when I talk about patient satisfaction, another passion of mine.