ER Efficiency-Principles and Pitfalls

Devising the Operationally Efficient ED: Principles and Pitfalls


Principle 1: Insist on realism

Let's face it, if converting into an operationally efficient emergency department were easy, most departments would have found a way to do it already. The fact is that emergency departments have been under pressure for a while to find solutions but most organizations do not know where to start. Operational efficiency and productivity have not been part of the lexicon of emergency department management and many hospital administrators even avoid speaking in these "business-like" terms. Furthermore, since some believe emergency departments loose revenue on outpatients but drive inpatient admissions, many hospitals approach the ED as a "Loss Leader" (a service not intrinsically profitable but that provides exposure to profitable ones). Therefore, development of emergency department services is mostly reactionary to capacity and PR issues rather than strategically focused.

In addition, some hospitals have medical staff members that can quickly adapt to change while others have a staff that will be suspicious and clamor quality of care will suffer. Some members might also have interests in urgent care and ambulatory clinics in the area and will view an efficient and marketable emergency department as a threat to their own bottom line. Resistance will come from many angles and implementers must be realistic about the organization’s capability to execute change.

Principle 2: “Home Grow” your strategy

Operationally efficient EDs can be set-up in different ways and success is not dependent on any particular method but rather on the metrics that must be attained. Therefore, trying to copy a successful set-up from another institution can be counterproductive as each organization has divergent requirements and capabilities. Implementers must then have a good handle on their particular organizational idiosyncrasies and adapt the strategy accordingly. The following case study illustrates this point.

CASE STUDY: Strategy Design

Medical Center-University affiliated
80,000 yearly ED volumes pre-engagement/almost 100K currently

Because of population growth this large emergency department started to develop problems with overcrowding, lengthy waiting times and ambulance diversions. Therefore we were contacted to help establish an operationally efficient system based on a provider intake methodology. The client had vested their hopes in such a format and was truly interested in exploring that option. Nevertheless, during discovery we identified the department did not have the right capabilities and culture to support provider intake. First, physicians typically do not have the aptitude for the “intake” function so most successful provider intake set-ups utilize mid-level providers which are more comfortable in this setting. Although the department already used mid-levels, their scope of practice was limited and they were not allowed to work independently. This made the provider intake function impossible for them to perform. In addition, they had only a few full-time mid-level providers which meant several would have to be hired and those already in the staff would have to be re-trained.

Contrary to the mid-level situation, this department was well staffed with physicians and had a good pool of nurses. Because the department had a Fast-Track, there was also space available to redirect patient flow. Therefore, a decision was made to use an RN Rapid Screening format and utilize clinician resources more effectively. The Fast-Track was converted into a staging area and the former triage area was turned into several rapid screening spaces. After implementation, the department was able to redirect 53% of the daily patient load through these areas allowing the main pods to immediately bed most ambulances. Door to Provider time decreased by 67%.

This example illustrates the potential perils of attempting to devise or copy a strategy. Any other methodology than the one utilized would most likely have failed. Therefore, successful strategy design and execution is based on the ability to fit the major process and system changes within the current capabilities and culture of the organization. Furthermore, deciding between Intake methodologies is actually the easy part. The hard part is to identify the process changes required from all ancillary departments, stakeholders and the organization as a whole and being able to incorporate them in the overall design of the strategy.

As an update...this Department continued to work hard on developing the capabilities necessary to establish a viable Provider Intake system and improved Hospital interfaces. In fact, their metrics have continued to improve in spite of a significant volume increase...Their current Door to Provider time is only 19 minutes and over 40% of their entire daily patient volume load is discharged from the ED in under 120 minutes.(NOW...THAT'S EFFICIENT)

Principle 3: Have a change management strategy

In any organization there are influential and charismatic individuals that can either positively or negatively influence your initiative. They might be executives, middle managers or staff employees that seem to carry the pulse of the organization and can effectively influence the masses. These people should be identified and placed in a structured environment to work together with a common focus and mandate for operational efficiency. This environment must make any action or inaction immediately visible to the entire organization to diminish dissent and establish peer-pressure to act. In addition, the change process must be broken down into non-threatening elements easy for each decision maker to act upon within a scheduled amount of time. This project management approach is necessary to establish an environment conducive for stakeholder decision-making and compliance.

Principle 4: Address the masses

Even if you follow all principles in this article, everything will fail if your operational level staff feels in any way disenfranchised from the process. To prevent this, anyone affected by change must be allowed to participate in the restructuring process by creating mechanisms to allow discussions, exchange of ideas and interactions with decision-makers. The staff must be given the chance to provide suggestions, debate controversial decisions and to come up with their own solutions. After everyone has been engaged in the change process and the rationale of major decisions has been explained, all people involved must understand clearly what is expected of them in the new system. Therefore very detailed and specific operational guidelines must be developed for the staff to follow.

Principle 5: Think in “Operating Guidelines” terms

As alluded to above, deciding on a particular methodology is just the “backbone” against which all the other myriad of process changes will be developed around. Make no mistake; there will be hundreds of inefficient processes to identify, revamp and delete along with numerous better ones to develop. This can become unwieldy if a repository of information and instructions is not created along the way. Developing the operating guidelines for your system is therefore the most important principle to follow in order to successfully implement change. These guidelines will essentially be the “marching orders” for all to follow and become the main communication instrument for self-directed learning. All questions about the way patient flow is processed in the department, along with any surge protocols required to address particular situations, must be part of these guidelines. In addition, a formal protocol to add, change or delete any guideline must be developed and enforced to prevent resistors from using their own personal criteria to the detriment of the new system.

This is actually the main difference between operationally efficient and regular emergency departments. Although all have clinical protocols to follow, most emergency departments do not possess guidelines to define how patient flow will be processed and establish clear expectations for all the stakeholders involved in the process. This deficiency arises from the mistaken perception that clinical protocols and operating guidelines are equivalent when in fact, they have nothing to do with one another. The former is for clinicians and nurses to follow already established “best-practices” with a focus on evidence based medical practice. The latter addresses how patients are processed from point A to point B and has nothing to do with the way clinicians perform their clinical decisions or interact with their patients. In other words, operating guidelines do not dictate or suggest how clinicians practice medicine but rather define how the patients will get to the point that those clinical decisions can be made and how they will be supported along the way.

In fact, the ability to create proper operational guidelines cannot be understated. All successful business enterprises spend significant time and effort developing them without exception. From a business perspective, they are necessary to prevent degradation of performance and deliver a consistent service. The reality of the situation is that an emergency department without operating guidelines is in essence a dysfunctional multi-million dollar enterprise left without direction.

Principle 6: Consider an outside agent of change

Proper planning, project management, staff education and meticulous follow-up are required to implement an operationally efficient emergency care model. Conflict resolution between departments along with constant redirection of individuals falling behind schedule must also occur. Although the principles described in this post increase the chances for a strategy to be successfully devised and implemented, many organizations lack the right resources to develop and execute this kind of strategy from within. In addition, since hospitals tend to follow hierarchical reporting mechanisms and promote departmental silos resistant to change, minor opposition from medical staff members, other stakeholders or the ED staff itself can derail the resolve of the institution. In this situation a contractual agreement with a third-party might be needed to galvanize organizational commitment. Furthermore, where overcrowding is common, the staff might be conditioned to be suspicious and cynical about the resolve of the hospital administration to improve their working environment. Under these circumstances the staff might also transition more easily if they perceive that an objective third-party, rather than the hospital administration, is driving the change process.

Principle 7: Disrupt the Status Quo

With major initiatives, the chances of coalitions being formed against change are more likely if resistors have time to organize. Coalitions against change should be expected because operational deficiencies will be unveiled and discussed for the first time in the open and some might view this as an impugnation of their capabilities. Therefore, organizational restructuring must happen in a relatively swift way to prevent resistors from obtaining a significant support base. If change is only incremental and does not disrupt the status quo, resistors will invariably have the motives and the means to try creating instability in the transition process. To prevent this, the strategy for converting into an operationally efficient ED should be executed in six to nine months. This allows enough time to change the main processes appropriately while preventing resistors from influencing the outcome negatively.

Principle 8: Manage the “Neutral Zone”

After restructuring, there is a period where the staff is internalizing new processes and feels uncomfortable with the new system. There might even be a kind of nostalgic longing for the old ways due to the fact that the staff felt more competent then. During this time some of the staff might try to regress to old familiar processes and interactions and use their own criteria rather than follow the operating guidelines. This can jeopardize long-term success if mechanisms to diminish feelings of inadequacy are not accounted for. Information and constant clarification is therefore necessary to diminish anxiety. In addition, the staff will not immediately see the benefits the new system confers to them and their patients because they are still going through a learning curve. During this time, the fact they are able to provide timely service will look more like an imposition than a benefit.

Implementers must also be aware that other forces might also be at play. Even though the system will immediately leverage the majority of the staff to produce consistent and extraordinary results, operational efficiency promptly unmasks the shortcomings of the most unproductive staff. In other words, in a chaotic and overcrowded environment it is easy to hide deficiencies and some of the staff might actually depend on this. When the new system starts this “fail-safe” is eliminated and affected members will attempt to discredit the process in a last ditch effort to derail change. This is a fact of life for any enterprise that obtains operational efficiency and implementers must anticipate this.

Having said that, this is also the most prolific time period of the conversion. Until the new system goes live, most of it exist conceptually only on paper. As such, the majority of the “fine-tuning” required will happen during this pilot stage. In fact, a significant amount of what will eventually end up as part of the operating guidelines of the system will be developed over the next several months. This is to be expected as it would be naïve to assume that the implementers have been able to account for all the new interactions and process synergies required prior to seeing the system in action. Notwithstanding the fact that the new system should be in use within six to nine months from the start of the change initiative, in our experience, the entire conversion process will take about two years of constant revisions before reaching an operationally efficient “steady-state”.


This post represents an attempt to provide a realistic view of the scope of organizational restructuring required for establishing a “30-Minute” ED and the pitfalls to avoid. Our purpose is not to discourage potential implementers but to actually increase their chances for success by describing all the elements necessary for change from our experienced and objective viewpoint.