Sunday, November 22, 2009

What can we learn about ED Capacity and Patient Flow from Funnels?

This is part of the support material for the ER Overcrowding Solutions Presentation at the bottom of this Post...


As it has been shown time and time again, an Emergency Department that doubles its bed capacity never ends up seeing double the amount of patients before it requires another expansion. Why is that? The reason is simple. When a Hospital doubles ED physical capacity, it never doubles inpatient capacity nor doubles the number of radiologists, consultants, lab techs, analyzers, transporters, etc. As such, even a modest increase in ED volumes puts significant strain on all the ancillary departments we need to help us service demand and the inpatient units we need to unload admitted ED patients to. This markedly increases variability in system interfaces and increases the time patients actually spend idle in ED beds.

To illustrate this, close your eyes and imagine we are pouring sand into a three-dimensional funnel. As we pour sand on the top of the funnel some sand makes it to the bottom opening and exits the funnel but, if we pour sand more briskly, the funnel will eventually fill up as sand is being poured in faster than it can exit. The sand that spills over the top (because it does no longer fits in the funnel), represents patients accumulating in the ED waiting room and hallways.

Now, let’s imagine we obtain a much larger funnel but this funnel has an even smaller opening to let the sand out. We will now be able to pour more sand initially into the funnel entrance and pack more sand within the inside of the funnel. Nevertheless sand is getting out more slowly. As we pour more sand, each individual grain of sand has a far longer and congested distance to travel from the top to the bottom and is also competing with far more grains of sand to get through the bottom opening. When this funnel eventually spills, the mess will be far greater. That is what happens to Emergency Departments that just expand…

By contrast, eliminating variability is the equivalent of widening the bottom exit of the funnel. The more variability we eliminate, the wider we make that exit. Now, when we pour sand on the top, it travels much faster towards the bottom exit and the funnel is less likely to spill.

If we were able to eliminate all variability, the bottom opening would widen to the same diameter that the top opening making in effect an open cylinder. In such a perfect system, the same amount of sand being poured at the top would swiftly exit the bottom no matter how much is poured into it and could never be saturated even if the overall size of the cylinder was very small indeed.

Unfortunately, such a perfect non-variable system is unattainable when we talk about patient flow. All we can do is to strive to open the bottom of the funnel as much as possible by decreasing and eliminating as much variability in the system as we can. The take home message is that decreasing variability is by far, the most significant, cost-effective, logical and fastest thing we can do to increase ED efficiency, improve asset utilization and free-up functional capacity. Anything else…including ED expansion, is doomed to fail…

Acute ED Decompression Plans

An important management element to consider whenever we attempt to improve ED operations is the implementation of acute ED decompression plans. This involves the design of pro-active strategies that are aimed to facilitate prompt movement of ED admitted patients and/or Holdovers to non-typical or underutilized areas of the Hospital which may be able to take care of these patients at the time. The purpose is to avoid ED overcrowding by promptly redistributing a limited number of patients across several areas of the Hospital without overwhelming any particular unit involved.

Even though operationally efficient Emergency Departments can manage and control the flow of about 80% of their daily patient load, they are still at the mercy of inpatient capacity for the other 20%. As such, even the best managed Emergency Departments can occasionally run into trouble if inpatient capacity is fully maxed out or floor processes are misaligned with the acute needs of the ED. That’s why these Acute ED Decompression Plans are necessary.

Now…just as the ED has underutilized areas than can be tapped to promote ED patient flow, all Hospitals tend to have untapped capacity that could be allocated to support the ED on an occasional basis at particular hours of the day. For example…a limited number of stable ED admitted patients waiting for telemetry beds might be able to be divided between the unused capacity of a PACU and a Cath Lab Recovery Unit during the early operational hours of these areas. A limited number of ED admitted patients waiting for a Med-Surg bed might be able to be divided between the unused capacity of an Endoscopy Recovery Unit, an Ambulatory Care Center, a Maternity unit, and even a Pediatric inpatient unit during particular times of the day...and so forth…

Regardless of which of those areas or services may or may not be available at your Hospital, you are always bound to find some similar staffed areas which can be used to acutely decompress ED admitted patients. The problem is not usually finding them but rather, creating a viable plan that can be executed “on-a-dime” whenever the need arises. I am going to now describe some of the general steps necessary to come up with such a plan…

1st…We need to identify the thresholds for activation. This is obviously going to depend on the size of your ED, the extent of the boarding problem you are experiencing and the capacity of your institution. For the sake of argument, let’s say you have a large ED and your thresholds for activation will be having more than 24 holdovers in the ED at any time and any location. Your team might also consider activating the plan, regardless of the number or holdovers, if all beds in the Main ED are occupied or expected to be soon all occupied based on the number of expected ambulances.

2nd…Your team needs to identify the specific Units or areas that could help decompress the ED including …the types of ED patients each of those individual areas can take care of…the hours during which each of these areas could safely receive those kinds of patients…the number of patients each individual Unit or area could potentially absorb and; the limits beyond which each unit or area should never go over.

3rd…Your team needs to declare who will be allowed to identify the need to activate the ED Decompression Plan and who they need to contact next. These Activators might include the ED Charge Nurse, the ED Nurse Manager, the ED Case Manager…etc. After these “activators” have been identified, your team needs to also identify the people that will facilitate and manage the execution of the plan. These facilitators might include your Inpatient Flow Coordinator or Bed Czar, the inpatient nurse managers, the Director of Inpatient Case Management…etc.

4th…Your team needs to solidify the procedures, protocols and managerial elements of the plan including all the anticipatory steps that must be undertaken every day to prepare the institution in case the plan might need to be activated. For example…your institution might have your Patient Flow Coordinator review the OR schedule, and the expected utilization of all the areas involved in the plan every morning and communicate to all the activators and facilitators which of these areas can be expected to have available capacity in case the ED meets the thresholds for plan activation. In addition, other housekeeping elements and requirements of the plan need to be spelled out. For instance…your team might require that before any ED patients can be moved to a decompression area a verbal “Hand-Off” of care between an ED Provider and the admitting MD still occurs; that a nurse to nurse report take place, that the patient arrives to the decompression area with at least basic admission orders documented, that only patients deemed clinically stable be sent to any of the acute decompression areas…etc…etc.

One of the things that should be evident is than an acute ED Decompression plan must be orderly and unhurried in its execution…not a “knee-jerk” reaction. That’s why it is called a decompression plan instead of a surge capacity plan. In fact, a properly implemented ED Decompression plan (pro-actively activated whenever threshold is met and deactivated after the ED goes back under threshold) can obviate the need for reactionary and resource consuming institutional surge capacity plans from having to be activated as often.

Most of the time…all an Emergency Department needs to regain control of patient flow is to be able to turnover just a few beds within a short period of time before the next bolus of demand presents for service. Institutional Surge Capacity Plans, which are mostly reactionary and move at glacial speed, cannot provide this ability. By the time the bed meeting is accomplished, the Surge Capacity Plan is approved to be activated, the institution receives communication that the Hospital is in surge mode; and some capacity is starting to be freed up…the ED is so far down into the weeds that all these reactionary institutional efforts are basically powerless in arresting ED overcrowding. In contrast, Acute ED Decompression strategies are designed to meet the needs of the ED in almost “real-time” and decrease the need for the institution to implement highly disruptive, resource intensive and even unpopular surge capacity plans and actions…

To illustrate this point, one of the things some of our clients find surprising when they first meet us is the fact that we don’t advocate sending admitted ED patients to the inpatient hallways unlike many consultants and Emergency Medicine Societies currently suggest. These people base their recommendations on the typical model most Emergency Departments operate under, nevertheless…the asset utilization, turnover, efficiency and increased functional capacity that is achieved through operational transformation strategies provides a significant operational cushion against overcrowding and reduces the extent of decompression the ED might require to avoid patient flow issues. As such, whenever a hospital implements these strategies they find that the ED can still operate efficiently with a number of ED admitted patients and holdovers that would have crippled ED flow and cause significant overcrowding in the past.

In other words, the threshold whereby the ED can get into trouble becomes much higher than before and the number of ED admitted patients the inpatient side will need to absorb to prevent ED operational decay becomes much lower. Most find that the simple Acute ED Decompression strategies we just mentioned usually suffice and that the institution doesn’t need to go into surge capacity mode as often. In fact, we have been involved with institutions that prior to our arrival were either thinking or already placing ED admitted patients into their inpatient hallways yet; after changing their patient flow processes, they haven’t found much use for this.

Strategic ED Staffing Plans

Very few Emergency departments and ancillary support interfaces adjust their staffing patterns to have more resources or most efficient members working the days of the week the ED is expected to have more demand. In addition, all departments have what is known as “fatal staff combinations” that should never be allowed to form. For example…having your slowest ED Physicians, your most inexperienced midlevel providers, your less effective charge nurse, your most novice ED techs and the least efficient X-ray Techs all working together a Monday afternoon is hardly a sound strategic choice. Unfortunately, these fatal combinations are allowed to form often and repeatedly in most Emergency Departments.

One reason most Emergency Department Managers cite for not approaching their schedule strategically is because of a shortage of staff members or too much variability in staff skill sets and capabilities. Although these reasons are valid sometimes, in most instances they just represent a “cop-out” for having to actually deal with the backlash that will inevitably ensue when the staffing preferences of some staff members are changed or from having to explain to some staff members why they cannot work on certain days or in certain areas of the ED.

Another barrier is that it takes a lot of time and effort for an ED Manager to create a strategic schedule that takes into account the whole department rather than just a particular group of people. For example, having a true strategic schedule would require that the person in charge of the nursing and Tech schedule and the person involved in the Physician and midlevel provider schedule both coordinate their staffing efforts to prevent fatal staff combinations from happening. The larger the Emergency Department, the more difficult implementing a strategic schedule becomes.

Nevertheless, the fruits of this endeavor can be very beneficial to the ED system and even the ED staff due to smoother system workloads and functional operations. All efficient enterprises adjust their staffing to cover more effectively their busier or seasonal demand days and try to prevent inefficient employees or managers from being scheduled together as much as possible. This is just common-sense.

Another reason strategic scheduling is so rare in Emergency Departments is that, in the typical overcrowded ED, the inefficiencies of some staff members are less visible amidst the chaos and idle time these departments must endure. Nevertheless, as a Department revamps operations and becomes more efficient, the effect that these fatal combinations and ad-hoc staffing approach has on the system become immediately visible. As such, Emergency Departments working on an operationally efficient model can identify these issues more easily and address them conclusively to reach the full performance potential the new operational model is designed to achieve…

Now...this is what must be done step by step...

1. Identify the busiest days and shifts and the lowest demand days and shifts of the ED based on historical data.

2. Adjust the staffing ratios so that you take some resources from the slowest days and transfer them to the busier days in a budget neutral way.

3. Classify all staff members (doctors, midlevel providers, nurses, techs, nursing assistants, X-ray techs, phlebotomists…etc…) as either A, B, C, or D players in the system based on their historical performance and capabilities.

4. Eliminate the D players as soon as possible (they shouldn’t be working in the system any way).

5. Make the schedule by taking your busiest days first and loading them mostly with A and B player across the boards. Afterwards, fill the rest of the schedule by keeping an almost equal proportion of A, B, and C players except in those areas that require a higher level of efficiency. If, due to staffing constraints, you must have a higher proportion of C players scheduled, try to only do this on the historical slowest days and shifts.

As a rule of thumb, never put two C players together if it can be avoided for obvious reasons. Also try to not put A with C players together but rather combine As with Bs and Bs with Cs. The reason for this is as follows:
When you put an A player together with a C player the C player knows he can’t keep up no matter what he does and will not attempt to make any adjustments in their performance. Meanwhile, the A player will tend to adjust his or her performance down partly due in reaction to the C players lack of productivity…Even worse, when you frequently combine A players with C players you will soon demoralize the A players and reduce their performance even more.

Now…when you combine As and Bs the dynamic changes as B players tend to adjust their performance up to more closely mirror that of the A player. When you combine a B player with a C player the dynamic is also different as the C players don’t usually see the performance of the B player as being out of reach and will thus adjust performance to more closely mirror that of the B player.

What I just discussed is based on numerous business productivity studies and is also very evident in sports performance. We all probably have witnessed this dynamic in action with major sport upsets in which a more gifted athlete is beaten by someone considered to be inferior. The usual reason for these upsets is that the gifted athlete adjusted his performance down and this allowed the inferior athlete to be more competitive.

Sunday, February 1, 2009

The Dark Side of Hospital Staff Empowerment

Now... before someone starts crying out...

We are all for staff empowerment. In fact, it is intrinsically woven into everything we do and help our clients accomplish. So much so that three of our clients submitted the patient flow transformational initiatives we helped them implement as their Nursing Magnet Status accreditation projects and all of them received that coveted certification.

Needless to say, a well executed staff empowerment initiative is critical to true Hospital transformational change and the key to sustainable long term results.

Having said that...

A poorly executed staff empowerment program can be extremely detrimental to staff culture and can set an organization behind for several years.

The purpose of this post is to illustrate the perils of an ill-conceived empowerment program and enumerate the elements necessary to be successful in this endeavor...

Saying your staff is empowered does not make it so...

I’ve never heard a senior Hospital executive say they do not wish their operational staff be empowered or that they do not currently encourage this throughout their organization.

Why is it then that so many hospitals have staff that feel disenfranchised?

Simple...true staff empowerment requires a protean effort and support from senior management to be implemented. In fact, the main reason to empower the staff is to encourage innovation and rapid cycle changes at the grassroots operational staff levels of the organization. By definition, this involves eliminating a lot of the bureaucratic, political, conceptual, and budgetary constraints to change that traditional Hospital administrators feel comfortable within. It also involves creating all the necessary supervisory interfaces to prevent “rogue” actions by the staff without stifling them into inaction or despondence.

All this is obviously easier said than done within the highly structured and hierarchical managerial framework of most hospitals. In fact, most hospitals have clearly defined vertical reporting mechanisms and well demarcated departmental silos which tend to shield “sacred cows” and detrimental processes from scrutiny. Meanwhile, most of the changes necessary for these empowered staff teams to enact true system transformation run horizontally across departmental boundary lines.

Bottom line...paying “lip service” to staff empowerment just won’t cut it unless all these issues are addressed in the empowerment strategy.

Full empowerment versus graduated empowerment...which is better?

Sometimes well-meaning senior Hospital Administrators attempt to empower their staff “cold-turkey” without any preliminary training or facilitation...one day they have little say in administrative matters and the next...they are supposed to change and manage their work environment and their cross-functional interdepartmental interfaces without a hitch.

This is as perfect a recipe for disaster and staff alienation as can be conceived.

First, a little known secret...most of the formerly disenfranchised operational staff couldn’t care less about being “empowered” and will actually fear what this might mean. From their perspective, this sudden “empowerment” looks and feels more like an abdication of managerial duties by administration and gives the impression that administration feels that their problems are so pervasive that they are basically saying...you guys fix it...

In fact, rather than welcoming “empowerment”, most operational staff members avoid it. To obtain their commitment they need to be reassured, and fully informed that they will be supported, mentored, supervised and protected by administration during this transition. They will also find comfort if they know there will be strict parameters and guidelines within which they will be expected to work and clear communication channels with administration whenever they reach an impasse or encounter an institutional barrier they cannot circumvent.

Thursday, January 29, 2009

Common Myths and Misconceptions About Operationally Efficient ERs

Efficient ED-Myths & Misconceptions


Misconception # 1

Operationally efficient EDs see patients faster.

Many confuse faster care with timely service when in fact, they are different. The pressure to work faster happens when departments develop patient backlogs and get overcrowded. In this setting, staff needs to rush patient care and dispositions to bring waiting patients and avoid getting farther behind.

In contrast, operationally efficient departments see patients as they present without major effort. This prevents patient backlogs and also creates an unhurried work environment. This is actually achieved through well-planned patient flow redirection, reallocation of resources and optimization of ancillary services response times rather than by making staff work faster or changing clinical practice patterns.

Misconception # 2

Operationally efficient EDs compromise quality of care.

Skeptics clamor high service efficiency is incompatible with quality patient care. Nevertheless, in all measurable quality benchmarks, "30-Minute" EDs outperform traditional departments. Because they control patient flow and prevent overcrowding, these departments easily meet time sensitive quality measures and minimize the errors of omission that occur in departments where staff is overstressed.

The ability to provide timely service also decreases several other liabilities. In fact, operationally efficient departments have almost no patients leaving without being seen and dispense with waiting room mishaps, both of which represent troublesome medico-legal risks for emergency departments.

Misconception # 3

These EDs have more efficient staff.

Some think that these departments must have exceptional staff to meet a 30-minute service goal in a consistent manner. The truth is that in all departments, whether operationally efficient or not, the staff will have varying levels of skills and competence. Therefore, operationally efficient departments must be systems driven. In other words, to achieve consistency, operational guidelines must drive the processes that allow control of patient flow, rather than any given person or combination thereof.

To illustrate, in most of our client implementations the staff working prior to conversion is almost the same staff working after. Since the only thing that changed was the way patient flow was processed it can only be concluded that institution of a system that allowed them to work to the full extent of their capabilities was the main reason for the improvement.

This has implications for independent groups under threat of takeover. Because of pressure on administrators to find solutions to ED problems, they are induced to turnover the contract to whoever promises higher quality and efficiency through "better" staffing. As explained above, it is not the staff that needs changing but rather the traditional system hindering their ability to perform.

Misconception # 4

"30-Minute" EDs mostly increase "walk-in" volumes.

Although these departments increase "walk-in" volumes due to the convenience of the service they provide, this is only a "by-product" of their efficiency and marketability. In fact, the most significant and immediate effect of these departments is their ability to immediately bed most ambulances and decrease ambulance diversions. This increases inpatient admissions even before marketing starts.

Not only is this due to the fact that the department stops loosing ambulance patients to diversion but is also driven by sudden realization by the EMS community that they can now unload their patients immediately and enjoy some of the “down-time” built-in between their runs. This is an important determinant of EMS satisfaction and a powerful incentive to favor bringing unassigned patients. Since about 41% of ambulances get admitted a department that prevents EMS diversion and attracts more ambulance volumes, can become the most important and effective driver of inpatient revenue.

Misconception # 5

"30-Minute" EDs are a marketing gimmick and a passing fad.

Since operationally efficient departments provide an exceptional and consistent service some of them advertise a time to service guarantee. This has drawn criticism by some members of the emergency medicine community that contend these guarantees are a gimmick to attract market share and might lead to over utilization and trivialization of emergency department services. The truth of the matter is that these departments have a service with strong market appeal and competitive advantage. From a business perspective, it would then be na├»ve for them not to exploit this “first-to-market” status to its full potential before other operationally efficient departments become more ubiquitous in their area.

Misconception # 6

Emergency Department market share cannot be shifted.

Think about the Department of Motor Vehicles (DMV). Similar to emergency departments, DMVs do not have a compelling or discernible service difference and as such, people go to them based on geographic convenience. In essence, they are all positioned in the mind of customers within the same category. Now imagine one decided to apply the principles of operational efficiency and advertise service within minutes of arrival. In the customer's mind, this particular DMV has decisively positioned itself as the place to go if they do not want to spend the day waiting. As a result, this department will have a surge in visits from communities beyond their typical geographic catchment area some of which will be firmly entrenched within the service areas of other DMVs. This extended area is limited only to the time a customer is willing to travel to enjoy the more convenient service.

This is similar to what happens when a traditional department converts into an operationally efficient model and changes the service paradigm. Their efficiency allows them to not only reclaim patients from surrounding Urgent Care Centers but also siphon patients from other ED waiting rooms whenever they get overcrowded and receive their ambulances whenever they go on diversion. In our experience, this effect is felt even if the competing institution is more than half an hour away.


Although other misconceptions probably exist, these are the most common we have encountered so far. At this time, fear and resistance to these new and competitive services is natural and expected amongst traditional departments. Nevertheless, as operationally efficient departments become more common and more people are exposed to them, the impetus for change will inevitably increase and the need for logical discussions like the one above will become more evident. We hope this post contributes to the overall rational understanding of how these departments truly operate.

Hospital Change Management

Most hospitals approach operational improvement as something that should be tackled by the internal resources already in place in each departmental silo. They also expect each department to address their problems and come up with solutions within their budget. This might be right for daily operations and non-disruptive incremental improvements but...fatal when change must occur at a fundamental level to reach new performance heights across an organization. In fact, most hospitals do not possess the internal change management skills set and methodological understanding to accomplish major operations redesign.

With that in mind…consider the DICE score.
The DICE score is a useful tool to address the most significant shortcomings in a change management strategy. This score was developed by the Boston Consulting Group as an objective assessment of an organization’s capabilities to tackle change and was validated in over 229 organizations. To read more about it, log on to the Harvard Business Review website at www.hbr.org or to www.bcg.com/DICE to use the available online tools.

The beauty of the DICE score is that it can objectively measure the probability of success of an initiative prior to implementation. DICE stands for the Duration of a project and the frequency in which milestones are reviewed, the Integrity and overall capabilities of the implementation team, the Commitment of the senior administrative branch (C1) and operational level employees (C2) and finally; the amount of Effort and workload increase expected to be perceived by all the people involved in the change. For each of those parameters a value, based on a predetermined scoring system, must be given and applied to the formula below:

D+(Ix2)+(C1x2)+C2+E

The score goes from 7 to 28 and the lower the number the better. In fact, those projects with a score from 7 to 13 have a high statistical probability of being implemented successfully while those with scores from 19 to 28 are almost guaranteed to fail. Those with scores from 14 to 18 need to be improved to have a better chance. The scoring values to be given to each variable are thoroughly explained in the resources mentioned above.

As a matter of perspective, this tool implies that a short departmental project led by a cohesive, highly skilled team; championed by senior management; and implemented in an area where the staff is receptive to change would have a score of 7 and be guaranteed to succeed. On the other side, a multidepartmental initiative without clearly defined milestones; led by an unskilled team; with lukewarm senior management support, and implemented in areas where the staff is resistant to change would have a score of 28 and be guaranteed to fail.

As an objective measure of the organization’s capability to implement change, the DICE score helps galvanize support by forcing administrators to face reality. In fact, most hospitals attempting to implement this change have scores over 23. Confronted with that, the discussion naturally progresses towards how to improve this.

On that note…we have the effort conundrum.
In reality, organizations attempting to implement a “30-Minute” ED can’t lower DICE scores to 7 because the professional ED staff will have particular views about how much effort they are willing to put forth for an imposed initiative. Whenever effort is perceived to be more than 10%, resistance rises and the score reflects it.
The above implies that, to lower the scores to an acceptable range, implementers have to concentrate inordinately on the other variables, namely the DIC aspects.

Having said that, there are ways to preempt and manipulate the perception of effort of the staff to lessen the damage that resistors would otherwise accomplish.
Which brings us to...physician and nursing buy-in.

Since the initial amount of perceived effort by the staff will be high, regardless of the benefits in patient flow and satisfaction, preempted “buy-in” from a majority of physicians and nurses is critical to prevent active or passive sabotage right after implementation. Unfortunately, their support is difficult to gain, as they tend to view organizational change as an imposition on their professional rights. Nevertheless, they do respond to open communication and may in fact, demand it.

Disclosing and explaining the following can facilitate this process:

1. What we are trying to achieve.
2. Why we are trying to achieve it.
3. The consequences of keeping the Status Quo.
4. How the changes will look and feel.
5. The things that will benefit them.
6. The things that will be needed from them.
7. What the organization will provide to ensure success.
8. The changes that will come next.
9. When they will hear more about it.

The message above must be repeated over and over again and implementers must prepare to have their message challenged on several occasions. As part of this open communication, a formal mechanism must be instituted to allow these professionals the chance to contribute ideas, challenge controversial decisions, and be able to exert some influence on the final outcomes. This process helps manage unrealistic staff expectations by ensuring that rational, unbiased and logical debate actually takes place. This also helps diminish false “rumors” and arm supporters with the right knowledge base to disarm resistors trying to capitalize on disinformation.

But…you must actually paint two pictures.
The most important part of the buy-in process above is describing how the new changes will look and feel in the most realistic and descriptive way possible. In essence, to paint a clear picture of how things will be without any “sugar-coating” or hyperbole. Otherwise the staff will feel they are being “sold” an inaccurate picture with a hidden agenda. In fact, two different scenarios must be conveyed. The first one involves the immediate post-implementation period and the second, the long-term picture after the changes have been fully internalized.

The first picture is uninviting. The staff must be told that they will need to adjust to an entirely new work dynamic and that many will feel uncomfortable initially. That some will want to “regress” to old ways. That unproductive members will no longer be able to hide amidst former inefficiencies and their displeasure will be vocal; and finally, that some disgruntled members might threaten to quit although, in the end, few actually do.

Concomitant to that first picture, the staff must also see how things will be once they surpass the learning curve of the new system. The staff must understand that after the “dust settles”, they will be working in a more controlled environment. They must be told the clear benefits this system will provide to their patients, how much it will facilitate care and how much having no patients in the waiting room will decrease their liabilities. Finally, they must be exposed to the fact that most of the staff currently working in backlog-free operationally efficient departments states universally that they would never like to revert to the old ways.

Although the first picture seems brutally honest, it needs to be to serve its purpose. This effectively makes the staff understand that the scope of change is significant and that they should not expect an entirely smooth transition. This also sends the message that change is hard and that the implementers acknowledge this. It also establishes that implementers have a clear idea of the expected difficulties and will try to minimize the impact.

This is a lesson learned the hard way. Invariably most implementers take the position that they must shield the staff from the “unpleasant” aspects of change. Nevertheless, doing that only makes them irate when their expectations of a “trouble-free” transition do not materialize as sold. In the end, honest communication and debate go a long way to establish the rationale of the change, diminish anxiety and prevent resistors from negatively influencing the staff whenever process “breakdowns” occur during the initial stages of change.

Another thing that helps them buy-in… fixing “broken windows”
Criminal psychology experiments have shown that seemingly trivial crimes like graffiti, broken windows, aggressive panhandling and public disorder can invite and create the environmental context for other major crimes to occur. When a broken window is not repaired others are subsequently broken and a sense of anarchy spreads sending a signal that no one is in charge and that there are no repercussions for negative actions.

Similarly, trivial deficiencies and oversights can invite inefficiency and defeatism amongst the ED staff. As an example, with one client we identified that seemingly inconsequential problems, like a noisy air intake in the waiting room, lack of a water cooler for patients, lack of security at the doors and other minor oversights were demoralizing the staff in charge of greeting patients thus lowering their efficiency and inclination for customer oriented behavior. To them, these were major issues no one cared about solving. Similarly, many of these easy to fix “broken windows” negatively influence the behavior of physicians, nurses, techs and virtually everyone that interacts with or within the emergency department on a daily basis. This fact actually represents a wealth of opportunity to help garnish support and momentum for the change initiative. In fact, there are two advantages:

First, when the staff sees these “broken windows” being fixed, a sense of being finally heard starts to develop. In addition, each problem fixed represents a very specific victory for a particular faction of the ED staff. When several “victories” accumulate, the staff starts to acknowledge the perception that the upcoming change initiative is exerting a positive effect on the organization. The end-result is that they start to fear it less.

Second, the sense of order accomplished by this philosophy can improve productivity before the new system changes are fully implemented. By removing these perceptual barriers to performance you allow more productive behavior to come through while taking away the particular excuses used to justify prior deficiencies.

Basically fixing “broken-windows” establishes early on the fact, that the change initiative has “teeth” and can deliver positive relevant results if allowed to take course. Nevertheless, fixing these perceptual problems by itself is not enough to support major change or modify behaviors substantially. It is just an adjunct that can facilitate the buy-in process and transition of the staff in conjunction with the other elements discussed before.

And…what about ED “culture” change?
Many ask-how can I change the culture of the staff to work efficiently and provide customer oriented service? The fact is that you cannot change the culture; the culture must change itself with time. Remember we are not dealing with skilled laborers on an assembly line. We are talking about highly trained professionals, most of which have years of experience practicing their craft. Asking them to change their work habits and patterns is almost as difficult as asking them to change their religious beliefs or political affiliations. It just doesn’t happen.

When you develop an operationally efficient emergency department you automatically provide the staff with the controlled work environment and support systems necessary to leverage their intrinsic performance. This context is a powerful change agent all by itself. Basically, when the staff adapts to process patient clusters rather than allow incremental backlogs, they eventually realize they can have more “downtime” if they strive to process a cluster efficiently before the next one presents. This realization becomes so powerful that the “peer pressure” to service patients in a timely manner even collates down to the most unproductive staff members.

Unfortunately, this is a mute point for traditional departments because the incremental backlogs they form during the day do not allow them to catch up with patient loads until the late night or early morning. In comparison, operationally efficient departments catch up many times a day and keep waiting rooms empty during peak hours. This ability to catch-up and have “down-time” provides the most powerful incentive to work efficiently in an ED. When the staff actively pursues this on a shift-by-shift basis, the culture has changed.

Now…how do you also get all stakeholders and other departments to buy-in?
Unfortunately, many changes necessary to accomplish the objectives are not under direct influence or control of the ED but of stakeholders with few incentives to cooperate. In fact, managing the interactions of all the stakeholders required for the change is the most difficult aspect of trying to implement this kind of initiative. Nevertheless, it can be done if stakeholders are made part of cross-functional teams accountable to deliver results within a strictly defined period of time. The following explains the steps of this management approach:

1. Form Heavyweight Teams. These “multidepartmental” units are formed temporarily for the purpose of developing the process changes necessary to achieve the necessary capabilities and operational efficiencies. They must have representation from both, administrative and operational factions and be broadly integrated. These teams must also be accountable and fully empowered to take all actions necessary to execute the strategy.

2. Place them in a Fishbowl. This ensures that all these stakeholders with differing agendas work together with a common mandate for operational efficiency. The “Fishbowl” is basically a meeting process specifically engineered to make any action or inaction immediately visible to the entire organization. This diminishes dissent and establishes an unrelenting pressure to deliver results within a strictly defined period of time. The “Fishbowl”, is very important to manage change strategically. Once in it, there should be no escape to scrutiny.

3. Follow a strict Project Management format. Even though the “Fishbowl” is a powerful agent of change, if the strategy is viewed as undoable, it will not be enough to save it. To ensure compliance with bold initiatives the change process itself must be broken down into non-threatening elements easy for each decision maker to act upon within a scheduled amount of time. Since far-reaching change will invariably be overwhelming when initially stated, this structured project management approach is necessary to avoid initial “shock” and resistance.

Although simple in principle, this is logistically difficult to accomplish in the hierarchical hospital environment. Because of strongly defined clinical and administrative departmental lines, establishing the format above requires significant amount of time, effort and facilitation. That also explains why the ED cannot be the owner of the initiative and why visible senior management support is so important to overcome organizational inertia.

But…we have a multidepartmental patient flow committee…what’s the difference?
Plenty. Although having a multidepartmental Patient Flow Task Force seems like the institution is going in the right direction, the reality is otherwise. The truth is that these “teams” do not usually have all the influencers, resources, budgetary leeway, and empowerment to establish changes in a rapid fashion. In addition, they are not placed in a strictly enforced project management schedule and their inactions are not immediately accountable to the organization. In short, these teams do not act like “Heavyweight” teams in a “Fishbowl” and are a liability because of a tendency to analyze, report and suggest rather than take decisive relevant actions.

Besides, most of these teams do not have the change management skills and experience to design or implement a “30-Minute” ED strategy. If they did, most departments would be operationally efficient by now. Although they have value when attempting to improve services incrementally, they are mostly powerless when the objective is to transform the department into an operationally efficient entity with an entirely new service format.

Should we conduct trials before fully committing?
No. For starters, “trials” mostly test the system in an artificial environment that does not accurately depict the synergies and interactions the system will ultimately require to be consistent. Second, trials carry a connotation of noncommittal and open the door for a vocal minority of resistors to influence the outcome. Therefore, to tip the scales in favor of change, the strategy has to be implemented in a committed, almost grandiose way, without any hesitation and under a strict timeline. In fact, the administrative support must be “in-your-face”.

In Summary:

If an organization decides to proceed without a change management strategy that accounts for all potential shortcomings, they run the risk of “spinning their wheels” for a long period of time. I know institutions that between performing “trials” and trying to put together all elements necessary to obtain synergy and support have wasted significant amounts of effort, time, and money to be nowhere near completion.

Furthermore, the first mistake is to make the emergency department primarily responsible to carry these changes. Due to the multidepartmental scope of these initiatives, the ED resources do not have the internal credibility and project management skills to establish change cohesively. Stakeholders tend to default to a departmental silo mentality and must be in fact, coerced to work cross-functionally and review milestones frequently. The emergency department is just not influential enough for this. The lesson of this is that becoming a “30-Minute” ED cannot be another departmental improvement initiative but rather an organization-wide strategic pursuit.

That is why implementers should use the DICE score to assess how well the hard-elements required for change have been addressed and the chances that their particular combination of factors will culminate in successful implementation. In fact, in organizations that cannot seem to understand the scope of commitment needed for this kind of change, presenting them with their DICE scores might be all that is needed to garnish support.

Following the change management strategies discussed in this post will help lower the DICE score into the right range and help implementers reach the critical tipping point for change in the most effective, timely and painless way possible. Otherwise…wheels might keep on spinning and spinning.