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 or to 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:


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.