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 naïve 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.
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