Patients are waiting? There are delays? In my ED? I’m shocked, shocked! – Part 1

But are you? As patient volume climbs and primary care providers and consultants become ever less available, waiting in the ED stretches on forever, or seems to if we listen to our patients’ complaints or review the results of recent satisfaction surveys. You have heard this, haven’t you? Hasn’t your administrator brought you recent results of the hospital’s patient satisfaction survey from the winter just past and wasn’t ED waiting time one of the hospital’s lowest rated measures?

For over one year now I’ve been encouraging you, gentle reader, to measure various facets of what goes on in your ED. Patient time in the ED is only one measure, but one very much on the minds of your patients and your administration. As I described two months ago in the April 2001 column, patients are “demanding excellent, speedy, available convenient health care.” Your administration, which is actively competing with nearby hospitals, is looking for the same.

Measuring the patient’s “registered time in the ED,” “waiting time” or “throughput interval” is the first step towards addressing it? How are you measuring and reporting this parameter at your hospital? Unfortunately, many of you, with the poor quality tools available can only measure pretty broadly—for example from patient arrival until patient discharge. You may not be able to group patients by disposition in our measurements and most assuredly you don’t measure and report patient time in the ED in percentiles, but more likely only as an average. Reported as an average, this measure is not merely insufficient, but misleading, but is often all that’s available from your systems.

Why should you measure and report your “throughput interval” in percentiles rather than as an average registered patient time in the ED? Because averages assume a uniform “bell-shaped” distribution and we all know that some ED patients spend unusually long periods in the ED, in fact we call them “outliers.” Percentile reporting permits the acknowledgement of outliers yet allows for tracking and management of service performance.

For example, most of you can recall when going to the bank meant choosing a teller’s line, getting into it and immediately regretting that you had not chosen a different line. About 15-20 years ago many banks began implementing a single queue for all waiting customers and as a result, we all got to the front of the line faster than if we had chosen a “slow teller” but perhaps not as fast as if we had luckily chosen a “fast teller.” What does this observation have to do with measuring ED patients’ “throughput interval?” Well, your bank has a standard for customer waiting time in line and the people who work in that branch know at what point in the queue the standard will be breached. The bank has set a customer service standard for example (this may not be true for your bank) that 85% customers will get to a teller in 10 minutes or less and the branch manager knows at what point on the queue that standard will be breached. Typically, the branch manager or teller supervisor will open another teller window as the waiting line of customers approaches that point.

Ah you say, now I understand, if only the airlines operated that way. Well, they do, they just set their standard much lower, perhaps as low as 70% of customers waiting 20 minutes or less.

Getting and analyzing data in this way is easy with an ED information system, but difficult if the only automation you have is the hospital registration system. Of course, measuring patients’ registered time in the ED does nothing to get at the causes for it.

Another way of getting at the same idea is to look at preset intervals. Some hospitals have learned to report this interval in multi-hour “chunks.” Intervals of less than two hours, two-to-four hours, four-to-six hours and over six hours are often used. One can then describe the fraction of the total patient volume (percentage of patients) whose registered time in the ED falls into each of these tracking periods. This is the approach to reporting at the QI Project® for registered patient time in the ED.

If you’ve been reading my column over the past year, you’ll recall that I’ve extolled “base-lining” and discouraged benchmarking. So why do I point you to the QI Project®, a benchmarking site? Mostly so that you can consider adopting the definition they use and also so that you can determine if your hospital is one of the 1500 or so hospitals that report data to this consortium. If so, it will make your measurements, the first step to improvement, easier.

In the examples of the bank and the airline counter I describe different standards. Setting standards is a rather foolish way to operate. It is what your administration does when without consultation with you and consideration of the ED’s capacity to adhere to the standard, your administration advertises, for example, that all patients will be seen by a physician within 30 minutes of arriving at the ED. Here, the standard is that 100% of patients will have a waiting time of 30 minutes or less to see the physician. Is that achievable? Yes, but not unless your ED has the capacity to perform at this level and few do, though many can be improved—over the course of years—to meet or even exceed this level of performance. Knowing where you stand today is the first step and one well worth undertaking for it tells your administration that you intend to actively manage this measure of quality-of-service.

Next month I’ll address what some hospitals have accomplished in reducing the patient “throughput interval.” In the meantime, you might determine if your hospital shares data with the QI Project® or belongs to the Advisory Board Company, a research and consulting organization to which about half of the hospitals in the country belong.

Teamwork or Why Did You Come to Work Today?

Times are tough in our Emergency Departments and not likely to improve for a while. We’re all doing too much with too little, too many patients waiting too long for some portion of their care in too crowded spaces while too few professionals try to keep the patients “safe” and family and friends informed. Every winter, this past one included, the local and national press seems to discover just how crowded our EDs have become and just how stressed we who work in them feel.

Recent predictions of a worsening shortage of nurses trumpeted by the general press seem laughable to those of us who have been working in EDs that have had vacant nursing positions for more than two years. Overtime hours for our nursing staff, short-staffing and “coverage” by agency nurses in an effort to fill that gap just add to the stress. Emergency physician practices are seeing shrinking income for many reasons including insurers denying claims, even when submitted with a copy of the chart, because despite state level “prudent patient” laws and regulations if the insurer holds onto the money longer, they benefit from the “float” and perhaps you won’t appeal because of the cost in your time and billing expense. Reduced practice income translates into physicians working longer hours in order to maintain income or holding off adding an additional physician to the group, even though growth in patient volume may warrant it.

Most EDs in the country are staffed with hospital-employed nurses, clerical and technical personnel. Outside of the Northeast and academic health science center hospitals, most emergency physicians work for themselves or for a contract group that may staff one or hundreds of hospital EDs. It’s been said by some that, “Nurses run the ED, physicians just work there.” Still others have pointed out, “Emergency Physicians enjoy a truly collaborative practice and this is what drew many of us into our field.” What are you as the leader doing to support your entire team?

In 1994 I began working with the Institute for Healthcare Improvement Inter-disciplinary Professional Education Collaborative, and despite 19 years of emergency medicine experience as a resident and attending physician, I came to learn for the first time the true nature of an inter-disciplinary team and inter-disciplinary collaboration. Few readers will have the same opportunity, yet all of you reading this, practice collaboratively to some degree in your ED. How can you improve upon the collaboration—the interdisciplinary team—that currently exists for the benefit of both your patients and yourselves?

In my October 2000 column I urged cooperation with your ED nurse manager in refining the details of documentation, both physician and nursing, that would support appropriate billing of ambulatory payment classifications (APC) for hospital payment for ED services. More recently, we’ve all enhanced our assessment and management of pain for all patients, an effort that required collaboration among all ED staffers.

These opportunities for collaboration are a continuing reality in our professional lives and they provide the opportunity to go beyond bedside collaboration to a true inter-disciplinary team building effort in which mutual respect and support are the goals. These opportunities allow us to “walk a mile in the other’s moccasins” not so that we can learn what it takes to perform nursing duties, but rather so we learn how truly different and difficult those nursing duties are and therefore why we must partner with nurses.

Nursing is not practicing medicine and as a physician, you and I intelligent, well educated and medically trained as we may be simply do not know what goes on in both the training and acculturation of a nurse anymore than a nurse understands these same experiences and perspectives in a physician’s life. Oh, there are always exceptions: nurse-physician couples with exceptionally good communication skills and receptivity to one another’s viewpoint or the rare colleague who practiced as an emergency nurse before going to medical school and who now practices as an emergency physician. And while I won’t discuss it further, the same issues pertain among all specialized employment groups that work in your ED including clerical staff, tech staff, pharmacy staff, environmental services staff and others.

Step one to building an inter-disciplinary team is truly acknowledging nurse to physician and physician to nurse, out loud and in public, that neither truly understands the other’s training, practice culture, legal and regulatory concerns among many other issues. Why out loud and in public? Because once stated in this way, there’s no going back to the old way of doing business. Once stated this way, you’ve essentially agreed that you each must engage the other in addressing your issues because you’ve agreed that you need the other’s “take,” i.e., viewpoint on whatever it is you’re addressing. From this foundation a new relationship can develop if you will work at it. Would alternative management structures help? Certainly, but ultimately success here rests on person-to-person relationship building. In the ED where care of patients is our agenda, building that effective relationship—the interdisciplinary team—must be on our agenda.

Ideally, the respective physician and nursing leaders should make the statement together and to a joint gathering, reinforcing the position by on subsequent occasions and individually, slowing the rush to complete a project until the other is engaged. For example, discussion at a physician staff meeting to start shifts 30 minutes earlier to facilitate morning commuting could bring up the comment from the meeting leader, “I’ve no problem with that, but perhaps we should engage the nurses before we commit to the change.” Then engage in a meeting—not merely “on the fly”—the nurse manager, the evening or night shift charge nurse or both and staff nurses so as to get the widest range of opinion. Meeting with the physicians and nurses together is better, yet, but usually entails involving representatives of the groups rather than the whole staff.

Inter-disciplinary teamwork begins by acknowledging the expertise and necessity of the “other” and builds through engagement in progressively more complex problem solving. While in the main, physicians give treatment orders and nurses implement them, smooth operations in the ED come not only from each knowing their role, but also from successful, trust-building work that acknowledges one another’s unique expertise and culture. Achieving those successes in a structured, non-clinical setting will carry-over to the patient’s bedside.

Public Accountability and the McDonaldization of Your Emergency Department

Controversy is useful when it leads to learning and useful changes, less so when engendered merely for its own sake. My title this month coupled with my opening sentence probably has alerted you that what follows in the body of this column may be provocative. I seek neither your concurrence nor your disdain publicly expressed; rather, I encourage you to discuss what I raise here with your colleagues if you are so inclined, for it is most likely through that discussion that learning and change, hopefully useful, may follow. Remember too, the aphorism attributed to Walter Lippmann, a great newspaper writer, “When all think alike, no one thinks very much. “

Last month, in writing about the “Emergency Medicine Continuous Certification (EMCC)” program of the American Board of Emergency Medicine, I went on to discuss lifelong learning but only after acknowledging the development of the EMCC program as at least in part a consequence of the public’s demand for physician accountability. This month I thought to extend the idea of public accountability to the “McDonaldization” of the ED, a topic recently raised on the emed-l mailing list (subscribe by sending “SUB EMED-L your name” without the quotes to or go to the subscription page at NCEMI.

A physician, whose contributions to the list have been frequent and valuable, broached the topic by reporting a radio news story about an ED that offered movie tickets to any patient who was not seen within 30 minutes of arrival. This list correspondent then went on to discuss his concern that quality was now being assessed by hospital administrators through “speed-of-service” first and “quality-of-medical-care” second. Over the ensuing five days more than two-dozen additional postings by generally indignant emergency physicians mostly agreeing with, adding anecdotes of their own and extending the arguments of the initial poster were added to the list.

I was astonished. This outpouring of emotion over a legitimate effort at improving the competitive position of a hospital surprised me. Aside from failing to recognize that competition for patients among hospitals is very much the norm in any community with more than one hospital, it seemed to me that these emergency physicians had forgotten that our specialty developed consequent to public demand for just the service that had precipitated the passion: readily available quality medical care. In the late 1970’s, many of our leaders who were seeking the sanction of organized medicine for our specialty were proud to assert public demand as measured by increasing numbers of ED visits as evidence of need for our specialty.

The debate is long over and both quality-of-medical-care and speed-of-service have won, but relying solely on the former and ignoring the later will assure that you as a provider or your group practice as a contractor will not long succeed in the current and likely future environment of practice for emergency medicine. Setting this false dichotomy in place is a diversion that will in the long run reduce your credibility in your hospital.

For nearly a decade now I’ve been troubled by what I was told by one of the former (now discredited) leaders of my former employer, the Allegheny Health, Education and Research Foundation. He said, “Steve, the chefs don’t run McDonalds.” in response to my question as to the opportunities for physician-leadership of operations inside our healthcare system. He pointed to an example, nearly identical to the one I recount above, demonstrating that physicians insist upon setting quality-of-care and quality-of-service at odds with one another rather than embracing both as legitimate measures, each insufficient without the other.

The debate is long over because reliable measurement of quality-of-care remains elusive, while quality-of-service measurement has become codified for the ED through the institutionalization of patient satisfaction surveys and measurement of patient throughput intervals. The assumption on the part of hospital administrators has become that quality-of-care is a given, it is what it is and it is sufficient. Yet, quality-of-service matters because among the public, quality-of-service distinguishes one ED from another. Lamenting this state of affairs won’t change it. The pronouncements by study groups based on limited findings of clinical superiority of trained and/or board certified emergency physicians won’t change the view of hospital administrators, even though you and I may believe the conclusion.

No, I don’t propose giving up, taking my ball and going home to lament our fate. Rather, I urge you to undertake the effort described exactly one year ago in my first column: measure operations performance in your own ED as a first step to improving it.

My professional activities for most of the last decade have been a living rejoinder (at least in my mind) to the administrator who rebuffed my interest in operations leadership nearly a decade ago. So too, your active participation in solving the problems that plague your hospital today will gain you the power to influence your hospital administrator’s agendas. Dismissing your administrator’s concerns about competitiveness, market share and revenue growth as ludicrous, insulting or trivializing of emergency physician’s professional services will only add to the barriers between your hospital and you while empowering the corporate staffing companies which understand these concerns and often partner effectively with hospital administrators in addressing them.

Few emergency physicians add to their professional agendas both the management and improvement of quality-of-service in the ED. Whether the time is volunteered (unlikely) or compensated (usually at less than the clinical service rate) working alongside the hospital administration in improving quality-of-service without setting this effort against quality-of-care is essential to gaining an opportunity for participation in setting your hospital’s marketing and advertising agenda.

Hospital administrators today have just begun to acknowledge the same public demand our specialty’s founders heard more than three decades ago. The public began demanding excellent, speedy, available convenient health care decades ago as I learned on entering emergency medicine residency in 1975. I was told that success in emergency medicine would be conditioned on achieving “four-A’s” and that both my chosen field of emergency medicine and I would succeed through “availability, affability, alacrity and ability” in that order. My experience over the past quarter century has born out the wisdom of my teacher.

Lifelong Learning, the Key to “Preserving the Passion”

I’ve been hearing from colleagues who have asked me about the “Emergency Medicine Continuous Certification” program of the American Board of Emergency Medicine, which was announced in the Fall/Winter 2000-2001 issue of the ABEM Memo a publication mailed to all ABEM diplomates and others associated with the ABEM. The Board’s early sharing of information and the detailed description of the proposed process, along with candid acknowledgements of methods yet to be developed and work yet to be done gives me confidence that standards are being upheld, yet the impact of this new process on diplomates has been and will continue to be considered.[1] Questions about specifics of the program and your comments are best addressed to the ABEM, either by letter or by email. (The details of the EMCC program have been updated since original publication of this piece.)

The EMCC will entail annual self-assessment testing following review of “Board-selected literature on specific topics in the specialty.” I suppose all of us certified by ABEM will find ourselves engaging in review of the same content more-or-less at the same time, whereas presently we pick and choose among many formal and informal CME content providers. Unquestionably, the real and growing public concern about physician knowledge and skills is appropriately enhancing attention to physician accountability both as directly transmitted to the ABEM and as manifested by other components of medicine’s private self-regulating specialty structure. Yet, most of us have managed to stay current without the encouragement of EMCC. While I support this pending and timely implementation of EMCC, I can’t help but admire my many colleagues who continuously strive for excellence by engaging in their own “lifelong learning” plan.

In conversations with colleagues prompted by the ABEM newsletter, we have frequently moved into discussions about “keeping up.” For those of us in academic centers or regularly engaged in teaching residents and students, keeping up is part of our daily work and daily challenge and motivation is regularly provided by the bright, aggressive resident who wants to demonstrate that s/he can “out knowledge” us. But as I speak to those of you practicing in the majority of EDs across the country, I’m constantly humbled by the efforts you undertake in “keeping up.”

Marcus Reidenberg, an internist and clinical-pharmacologist who taught clinical correlation sessions during my pharmacology course in medical school, recommended a three-part approach to keeping up with new pharmaceutical developments: a medicine text, a pharmacology text and a subscription to The Medical Letter. With ever more therapeutic agents available, it has been challenging even in hospitals with a strong formulary system where one only has to learn a single H2-blocker or third-generation cephalosporin and while I’ve stopped buying the two textbooks, for more than 25 years now I’ve subscribed to The Medical Letter. Arriving in it’s usual 4-8 page (rarely more) format every two weeks, I can honestly say it is about the only publication that doesn’t get “stacked” before it gets read, and mostly I read it cover-to-cover. With The Medical Letter and a drug database in my Palm™ I seldom am taken by surprise by a new drug.

As I’ve become more of a physician-executive and less of a clinician-educator, I’ve found my time for reading the medical literature more and more limited; or maybe it’s the recent requirement for reading glasses that has driven me to replace music on the audio tape/CD player with audiotape based CME. I won’t tout any particular provider of audiotape programs, but I’ve found these tapes to be a wonderful way to spend time during my regular train commutes between Philadelphia and New York.

On summer vacations and other longer trips, when the occasional opportunity to read presents itself far from the stack of journals in the corner, what do you read? Over the past 20 years I’ve become accustomed to carrying The Yearbook of Emergency Medicine in my bag.[2] Whatever works for you, it is certainly useful to have a single volume to carry on a longer trip that can be read in “small bites.”

Does everyone in your group keep current or do you as the group leader cast about for ways to help your colleagues keep learning? Medical Staff CME requirements are a potent inducement for gaining minimal compliance, but are your colleagues really learning what will be most useful to them in their own practice? Probably not if their CME is devoted to only one or two trips to courses or symposia; probably yes if they add to this general learning reading and study about the difficult clinical problems they have faced in giving care in the ED. Research, which examined the daily practices of exceptional physicians, has identified the combination of general topic CME with patient-oriented study as leading to the best results in “keeping up.”[3]

The addition of this “practice-based CME” whether formally recognized for credit or not; though practiced as a student and resident by most of us is only variably carried on by practitioners. Too rare is the practice, common in sports, of inviting observation of even simple commonplace activities such as performing a physical examination or eliciting a patient’s history. Yet every great sports figure is supported by coaches who commonly drill those they train in the fundamentals. As Manning and DeBakey point out, “The things that human beings do best they do every day. You will therefore practice better medicine if you engage in daily study and daily evaluation of your performance.”[4]

Just as many of you have adopted computer technology creatively to enhance your learning and patient care, so too must all of us who practice medicine adopt learning and evaluation strategies that give the public confidence that our intent to do good for our patients is supported by expert knowledge and skill.

[1] Disclosure: I’m a senior director of ABEM. Which means in English that I was a director (1986-95). I currently do oral exams for the board. I was trained in EM finishing in 1978, first certified by ABEM in 1980 and recertified in 1990 and 1999.

[2] Disclosure: I was an Associate Editor of the Yearbook of Emergency Medicine from 1980 through 1999 and received royalties based on sales during that period. Former colleagues of mine presently edit the publication.

[3] Manning PR & DeBakey L: Medicine-Preserving the Passion. Springer-Verlag, New York, 1987.

[4] ibid, page 276

Emergency Medicine and Internet Technology: Here Today, More Coming Tomorrow

Technology has always fascinated me. I built Heathkits in my early teens and received my amateur radio license before I was 14. But I’m not you and many of you tell me that you’ve only just come into using a family computer to browse the web and only rarely do you check your e-mail. At a recent gathering one long-time colleague confided that he had only recently decided that computers were not just a fad and that he was going to have to learn to live with them.

In this space in the June 2000 issue, I presented an overview of some issues relevant to selecting an ED information system. I don’t intend to reprise that here; rather, I thought I’d share some of the sites that I’ve learned from in recent months or used as a clinical reference both in delivering care and in case review. If I’ve not included your favorite site please don’t “flame[1]” me.

The National Center for Emergency Medicine Informatics is the one site I suggest everyone in emergency medicine explore first. This site is a wonderful “home page”[2] for your favorite workstation in your ED if you don’t already have a standardized home page. Among the many fine tools on the page, “MedBot” a search tool focused on a dozen or so medicine sites pops up a friendly window for your search terms while keeping the main page visible. Another area of page offers “Medical E-tools and Calculators” including algorithms to compute GI bleed complication risk, hypernatremia treatment, and hyponatremia treatment along with a bradycardia treatment algorithm and a rash diagnosis algorithm.

When away from the ED and direct clinical care the NCEMI site still holds my interest for both its daily and weekly educational and amusing nuggets including aphorisms, eponyms, cartoons, phobias and questions. The overview of the current literature relevant to emergency medicine through the “Daily Sample” column frequently prompts me to start reading an article that I then finish in the journal that had been sitting on the pile by my desk. Many other features may appeal to individual users including the ability to customize the NCEMI homepage with your most used links.

Jeff Mann in his “Site Philosophy” describes his EM guidemaps as “quick-to-read” references that can help neophyte emergency physicians optimize their clinical practice of emergency medicine. Doctor Mann explains that, “My EM guidemaps should be seen as a supplementary informational tool – specifically designed to help you manage acute clinical problems in the ED setting. They are based on a combination of my evidence-based medical knowledge and my personal experience, and they reflect my problem-solving approach to acute medical emergencies. These ready references provide a pared down how to get through the night quick hit of practical wisdom. Don’t confuse these few dozen screens that cover selected ACLS, medical, toxicological, neuro-opthalmological and trauma topics with a comprehensive text, but when you find yourself with a hole in your brain for the evaluation of a patient with for example, diplopia, Jeff Mann ’s guidemap will help you care for the patient with just a quick read of his site.

One of the external sites that we in the Maimonides Medical Center ED use extensively is the emergency medicine on-line text, Emedicine. This commercially supported site (multi-million dollar investments by pharmaceutical and health-care advertising firms) is the home of multiple texts in many areas in medicine, but the emergency medicine text was the first one. The text chapters are well organized with a front-page folder screen allowing easy selection of top-level topic (Allergy and Immunology, Cardiovascular, Dermatology, etc.) and a frame down the left had side of the screen for sub-topic: Aneurysm, Angina, Aortic Regurgitation, etc. The chapters include prominent notice of date and time last updated. Many of the chapters I recently browsed had been updated within 8 weeks of the time I am writing this column.

Another site, EMedHome offers regularly updated content, free CME and has recently implemented a relatively inexpensive CME program in support of the ABEM Life-Long Learning and Self-Assessment program of the Emergency Medicine Continuous Certification program now required of all diplomates. The longstanding, regularly updated “database” of Adobe Acrobat documents described as Protocols, Algorithms, Sample Orders, and Guidelines remains available for download, printing, and distribution. This site has some advertiser support but explicitly asserts its editorial independence.

What if you don’t have Internet access in your ED? While wireless alternatives are available, your hospital should be importuned to support Internet connectivity from your ED as a matter of patient care. Looking up references in the hospital library, no matter how nearby is not the same thing as pondering the advice from any of these sites with the chart in your hand and the patient visible across the ED. Almost certainly you have one or more computers in the ED that could have a web browser installed and a network connection upgraded to include Internet access for negligible expense. Build a coalition of your colleagues, including nursing staff, before you approach hospital administration with your request. Point to this article as describing current practice and request basic Internet connectivity as a tool for patient care.

Today, access to clinical references over the web as described above is the routine in many emergency departments. As hospitals, even small hospitals, implement electronic medical records through the web the Internet and the web browser will likely become important tools for organizing, tracking and documenting care delivered.[3] Applications supporting scheduling and tracking of residents’ hours and demographic, education, evaluation and procedure databases have already come to the web at for example GME Toolkit from Dataharbor.

The Internet and computers are not a fad. Those of us in leadership positions who’ve yet to embrace the web, should begin exploring it at once. I’m proud of my colleagues at Maimonides who have bought home computers and typing tutor programs and have begun learning their way around the web. Just as they learned to read head CT scans long after residency, so too are they learning to navigate the web. When will you?

1 To send an offensive email message or newsgroup posting, especially one containing strong language and personal insults. Compact American Dictionary of Computer Words. Copyright © 1995, 1998 by Houghton Mifflin Company.

2 For a Web user, the home page is the first Web page that is displayed after starting a Web browser like Netscape’s Navigator or Microsoft’s Internet Explorer. The browser is usually preset so that the home page is the first page of the browser manufacturer. However, you can set it to open to any Web site. For example, you can specify that “” or “” is your home page. You can also specify that there be no home page (a blank space will be displayed) in which case you choose the first page from your bookmark list or enter a Web address. Compact American Dictionary of Computer Words. Copyright © 1995, 1998 by Houghton Mifflin Company.

3 An application service provider (ASP) is a company that offers individuals or enterprises access over the Internet to application programs and related services that would otherwise have to be located in their own personal or enterprise computers. Sometimes referred to as “apps-on-tap,” ASP services are expected to become an important alternative, especially for smaller companies with low budgets for information technology. Definition copyright © 1996-99 by Inc.

Community Engagement

I’ve asserted that “all emergency departments are local” and that among other attributes, leadership entails involvement with your community. Several months ago in discussing the concept of the pareto optimum, I briefly discussed, but didn’t detail, engagement with the community you serve. Engaging your community goes beyond the minimum of delivering excellent clinical care in your ED, it is a value-added service that helps you demonstrate to hospital administrators that you think in terms of the big picture and not narrowly, only in your own financial interest. Of course, contributing to the quality of the relationship between your hospital and your community is very much in your self-interest.

Regardless of whether your ED is in competition with nearby hospitals or yours is the only ED in town we know that while the expression might be a cliché, the ED is truly the bridge between the community and the hospital. How can you as an emergency physician support that bridge? The key is becoming known for your support of your community’s agenda both within and outside of your hospital.

Most folks are preoccupied by the details of their life. They don’t spend a lot of time thinking about your hospital, your ED or your staff. Only in time of need do they think of the hospital, the ED and you. Engagement is essentially a political function. You are seeking to place your ED in a favorable light in the minds of your community members. You do this by meeting them on their “turf” and addressing their interests.

Every community hosts school and religious institutions. Many include volunteer ambulance corps as well. All of these locations and organizations provide opportunities for your engagement. Seek them out whether or not they seek you out. Use the hospital’s public relations staff if they are available, but even if they are not, make the calls yourself.

Prepare yourself before you call by finding out about the organization from hospital resources such as your public relations or development office. Learn about the number of members or participants and how broadly the organization or school affects the community. Clearly the only high school in the region has a different influence within the community than one high school out of a dozen in the town. Prepare by seeking the help of your public relations, development or printing department in the creation of both publicity materials such as posters and “leave behinds” a handout that will serve to remind both those who attend and those who don’t that you’ve visited and you represent the hospital, the ED and emergency medicine physicians. A standard drape for a podium and a table showing your hospital ED’s logo along with your practice’s if you have one is useful. Don’t rely on the standard hospital table drape; insist upon one that clearly touts the ED, even if you have to pay for it yourself. Remember you are representing the ED to the community and you want to emphasize that association.

Prepare a presentation that will be relevant to the audience. Speaking from your heart about alcohol related motor vehicle crashes that have killed or injured teen-agers in your community, whether high school students or those off at college will have still greater impact if done as a brief presentation and discussion. Engaging another point of view can be helpful as well. I recall that some years ago several of my colleagues participated in “Doctor-Lawyer” presentations at high schools on the topic of drinking and driving. Even absent physical injury, the legal impact of underage alcohol use can catch an audience’s attention.

Tragedy is not the only “hook” for an audience and might better be reserved for a time when you’ve already become known as a supporter of community groups. Speaking to the gardening society about how to handle pesticides, fertilizers and herbicides—in other words hazardous materials disposal which you can prepare for by getting the information from your community’s trash disposal department or service will have much more impact coming from you and the hospital ED then any bill-stuffer or reminder slipped through a mail slot. While this or other topics of interest to a community group may at first blush seem “out of your field” in speaking to a lay audience, it’s more important for the topic to be of interest to the group than that it is of interest to you. Then too remember that your community organizations are pleased to have your interest and participation, so while you may not practice environmental toxicology, you already know more, including how to prepare to speak on the topic, than does any member of your audience. Selecting topics of interest and organizations to approach is easily done by attending to the news in your community. Weekly community newspaper(s), school, church or association newsletters are good sources of topics of interest.

Along with speaking to outside organizations where you facilitate the introduction and the contact with the organization, you want to make yourself available to hospital personnel who have need for hospital spokespersons. Set up an appointment with whoever handles hospital public relations. Offer to speak to them on background when issues come up elsewhere in the hospital. Tout your expertise as a generalist who will take the time, even if the cardiologist won’t to explain what angioplasty means and why having it available at your hospital—or not—matters in your community. Then take the telephone calls that are sure to come and do your best to answer the questions. Pretty soon you’ll find that your name will get out to local reporters who need background information on a medical story or who are looking for a local twist on a national or regional story. Since all of this contact with the press is intended to bring your hospital and ED to the favorable attention of your community, more than it’s intended to advance personal recognition, be sure to talk about the hospital and ED and refer the press back to hospital contacts.

Building community relationships begins with serving the community through excellent medical care, but includes communicating more broadly with the many “micro-communities” in every town.

When Bad Things Happen to Good People

This column is dedicated to the memory of Richard C. Wuerz, MD who in life reminded me of the joys of teaching and in whose death reminds me of the subject of this column. Still early on in a career as an Emergency physician academic, read the final report of his work with the Emergency Severity Index and for those with access to Academic Emergency Medicine[1], his legacy is summarized in Ron Walls’ superb editorial about the emergency severity index.

All of us practicing in emergency medicine have experienced death in our practice. This month, I’d like to briefly describe a useful resource for helping all ED staff manage the aftermath of a patient death, but then I’d like to go on and discuss Critical Incident Stress Debriefing (CISD) and its role when death strikes closer to home.

Patients die in the emergency department or before arriving and we perform in the role of the “failed” healer and announce to those assembled that indeed their family member or friend has died. In this role, more akin to that of the ancient Roman “temple priest” who led the worship of Aesculapius than to Hippocrates who founded scientific medicine, we physicians struggle to inform the patient’s loved ones and yet move on to care for others in our busy emergency departments.

I’ve recently had the chance to view some of Ken Iserson’s materials published under the imprint of Galen Press. Ken, a faculty member at the University of Arizona Emergency Medicine Residency Program, and Director of the University’s Bioethics Program has produced favorably reviewed texts, videos and training programs that are useful in teaching death notification to physicians. He also now includes a pocket guide that is convenient memory jogging device to carry in your white coat pocket—or waist pack—during a shift. If you or your staff has ever struggled with death notification—and who has not—some formal training is useful and if all are trained to a single approach, then you will have more confidence in accomplishing the difficult, but necessary and timeless ritual.

Sometimes though, death and clinical crises strike closer to home. In the past six-months in our emergency department we experienced the sudden unexpected death of one nurse found in her bed by her teenage son, the near-death of another nurse in a motor vehicle crash on her way to work, the motorcycle crash death—observed by his wife—of the son-in-law of one of our emergency physicians followed shortly thereafter by that physician’s hospitalization with unstable angina and most recently the hospitalization for pneumonia with mild hypoxia of one of our patient care technicians that turned into an ICU stay when he developed respiratory failure from which he has fortunately recovered.

These events, drop into our lives as just one more stressor in what all of you know is already a stressful time for all of us in emergency medicine. Every hospital confronts fiscal uncertainty and emergency department volume continues to grow, adding the sudden unexpected death of a colleague, co-worker and oft-time friend can cause even the most “normal” of people to collapse or respond abnormally in the crisis. As a leader, how might you respond?

In a well written piece on the Prehospital Perspective site and supported by an extensive bibliography of scientific evidence on his own website, Bryan E. Bledsoe, DO, FACEP, EMT-P debunks critical incident stress management in a rationale that resonates for me.

Critical Incident Stress Debriefing (CISD) is a technique that has increasingly been deployed in the EMS community over the course of the past decade. Many community EMS providers are aware of trained CISD practitioners in or nearby to your community. Oft-times, EMS providers themselves have been trained. I first became involved in the early practice of CISD while I was Philadelphia’s EMS Medical Director in the 1980’s. At that time, in this fire department based service, the death of a firefighter while on duty was a near apocalyptic event marked with all sorts of elaborate, formal ritual. Yet, little beyond the ritual was offered to the members of the fire company who may have worked alongside the one who perished. “Survivor guilt” was common and was manifested at times in a variety of inappropriate and personally destructive means. My first exposure came when a firefighter on-duty died from a medical catastrophe in a firehouse that housed a paramedic squad, which had tried, but failed to save their colleague’s life. Was that ever a bleak time in that firehouse. At a closed meeting, I sat in the firehouse kitchen along with the rest of the company and discussed the events, the hopelessness of the resuscitation efforts and yet confirmed the appropriateness of the efforts. I’ve since met firefighters, years later, who remember the debriefing and thank me for it.

The Critical Incident Stress Debriefing (CISD), developed by Jeffrey T. Mitchell, Ph.D.[2], , is a group meeting or discussion about a distressing critical incident. A critical incident is any event, which has a stressful impact sufficient enough to overwhelm the usually effective coping skills of either an individual or a group. Providing crisis intervention and education, the CISD meeting (lasting approximately one-to-three hours) may reduce the impact of a critical incident.

Critical Incident Stress Debriefing as described by D. G. Mitnick.:

· Is not therapy or substitute for therapy

· Should be applied only by those who have been specifically trained in its uses

· Is a group process, group meeting, or discussion designed to reduce stress and enhance recovery from stress. It is based on principles of crisis intervention and education.

· May not solve all the problems presented during the brief time frame available. Sometimes it may be necessary to refer individuals for treatment after a debriefing.

· May accelerate the rate of “normal recovery, in normal people, who are having normal reactions to abnormal events.”

Following the motor vehicle crash which nearly took the life of one our nursing staff—she was resuscitated and stabilized at our emergency department—we held CISD meetings for the staff taking advantage of the CISD team that was staffed in part by members of one of our community’s volunteer ambulance services. Separately, we had also supported the ethnic rituals of co-workers and friends of the nurse who had died earlier in the year.

Perhaps because I’m in mid-life and these events pile on me more frequently than ever before, I’m ever more aware of the effect on my colleagues and myself. Inevitably, we aging baby-boomers will experience these losses ourselves, not just with our patients. As a leader, you can yourself learn and then teach the best ways to notify others about the death of a loved one and reach out for help for yourself, colleagues and ED staff when that moment comes into your own lives.

[1]Walls RM: Dr. Richard Wuerz’s Emergency Severity Index. Acad Emerg Med 2001 8: 183-184.
[2]Mitchell, J.T. & Everly, G.S. (1995). Critical incident stress debriefing: An operations manual for the prevention of trauma among emergency service and disaster workers. (2nd ed.). Baltimore, MD: Chevron.

Leading Beyond the Bottom Line: Part 2 (updated)

Last month I introduced the conceptual model of the Pareto Optimum espoused in Leading Beyond the Bottom Line. I explored how that model might provide a philosophical basis for recasting our relationship with our hospitals. As a reminder, LBBL suggests that as physicians act evermore like managers, focusing solely on the bottom line, they’ve foregone the physician-manager’s unique opportunity in healthcare. The physician-executive authors of the LBBL approach assert that rather than only assure an operating margin, the physician-manager can assist the health care entity in reaching the Pareto Optimum among: Patient Care, Financial Health, Employee Well-being and Community Commitment.

This month I’d like to take up the far thornier—and closer to home—challenge of discussing how emergency physician leaders who embrace the LBBL approach could strengthen their practice itself and, perhaps, help us in emergency medicine emerge from the dichotomizing rhetoric of the past half-decade in our specialty’s ranks.

Before explaining this difficult thesis, I must digress and explain some of the concepts I will use below, particularly that of the “zero-sum game.” Theorists describe a zero-sum game as any circumstance in which the balance gained and lost among any number of “game players” (read this as negotiators, warriors or doctors and hospitals) adds up to zero. Wins and losses add to zero for the group as whole. We’re also familiar with the metaphor of “growing the pie” consequent to which all that “play” gain, even though holding only a constant portion of a growing endeavor.

Nonetheless, moving the LBBL concept from the macro level down to our own practice, whether salaried, fee-for-service or an amalgam of both entails a parallel description of the apparently “competing goods or objectives” that we might strive to balance within our practice, even as LBBL offers a model for use by the hospital and the communitarian movement[1] proposes a particular model of balance for our greater society.

As always, our patients are the reason we strive for the Pareto Optimum in our practice. Our personal and economic well being parallels the need for the hospital’s financial security and engagement with our hospital both at the general medical staff level and with administrative leadership parallels the hospital’s engagement with its broader community. Lastly, engagement with both physician colleagues in our practice and those who work along-side us in our emergency departments identifies the fourth component of our practice environment’s Pareto Optimum.

Few of us have consciously addressed the competing interests in our personal and professional lives at a conceptual level. Most of us make tradeoffs between personal and professional commitments that compete for our time and attention, but few of us do so within an explicit framework. Self-help books abound and it’s not my intention to fit one into this month’s column. Rather, just as I asserted in July 2000 when I wrote about the pyramid of medical staff development, leadership requires making that which is implicit, explicit for your colleagues. Thus, the open, but structured discussion of how well—or poorly—you as a group are succeeding in meeting competing objectives broadly grouped in the four categories I’ve described above, can begin building a new, strengthened group purpose.

So, how can we actually strengthen our practice team and reduce the din of the argument among us while re-affirming our leadership within medicine as publicly concerned caregivers and safety net providers? I recommend open, structured discussion as the first step.

How to begin? Just as last month I suggested you share the LBBL article with your administration, so too you should share it with your physician colleagues. At a subsequent staff meeting raise one issue that is current within your group. Perhaps it is turnover or income or conflict with members of another hospital department—or perhaps it is restiveness over the administrative charge paid from practitioner earnings to your management group. Whatever it may be, raise it and make it explicit to all and proceed to characterize it within one or more of the four categories.

As an example, the resentment of some group members over what appears as apparently confiscatory administrative charges might be mitigated by the complete neglect by those same staff members of participation on medical staff or hospital committees or project task forces. If all of that work falls on the group leaders, should they work the same clinical hours in order to maintain income? Here we see that within the group the balance between individual economic well being and “community participation” may be out of kilter. Conversely, arbitrary disciplinary actions taken by the group manager against a staff member ostensibly engendered by an effort “to save the contract” suggest that collegial support and economic performance are similarly unbalanced.

I’m not denying that throughout the history of emergency medicine, charlatans and thieves have harmed patients, colleagues, hospitals and communities. Undoubtedly malefactors among emergency physicians, both practitioners and managers, continue thriving parasitically upon some emergency physicians today. Yet, I’m equally certain that the cause of resentments and conflict in the average group practice is more often the failure to explicitly address the apparent conflict and competition among the four components of the LBBL model.

Few practice leaders have management training and believing themselves smart—probably correctly—and while wanting “to do the right thing,” most have little knowledge and still less experience in balancing competing human interests beyond clinical work during a busy ED shift. Consequently, just as most humans avoid confronting difficult tasks, it’s natural for a practice leader to avoid confronting colleagues with the process of striving for balance. Particularly so since once undertaken, striving for the Pareto Optimum becomes a continuous effort, much as physiological systems depend upon continuous homeostasis for balance, so too will the gathering of colleagues known as “the practice” require continuous effort to maintain the Pareto Optimum.

Explicitly seeking your group’s Pareto Optimum among patient care, personal financial security, engagement in our hospital and medical staff community and engagement with colleagues and co-workers presents the opportunity of including not only those who depend upon us in our personal lives but also those dependent upon our medical safety net services even as we enhance the quality of our professional lives in the process of reaching our own Pareto Optimum.

[1] The communitarian movement, attempts to address a just society’s dual need for both social order and individual autonomy. Their concepts also inform my view; although, I assure you I’ve not embraced that particular movement and neither do I have the space, the inclination or my editor’s permission to discuss political theory in this column.

Leading Beyond the Bottom Line (updated)

It’s a philosophy refreshing and thought-provoking on the larger scale of hospitals and health care delivery systems and on the more parochial level of emergency medicine. Presented in July-August issue of The Physician Executive (pp. 6-11) published by the American College of Physician Executives (ACPE, not to be confused with ACEP), Leading Beyond the Bottom Line was followed by an online cyber forum during August.

Leading Beyond the Bottom Line is a concept that suggests that physicians who act more like managers is a failed approach that vitiates the physician’s unique role in health care. The physician-executive authors of this approach assert that rather than ensure profit, the health care entity must reach a Pareto optimum among financial health, patient care, employee well-being, and community commitment. The Pareto optimum is named for Wilfred Pareto, who first articulated the optimum as a socioeconomic concept of balancing competing and cooperating interests. Balancing these interconnected objectives goes beyond conducting a “stakeholder analysis” or the 360° assessment that Leading Beyond the Bottom Line articulates as a philosophy for guiding action.

Because I’d like to take this month’s column to discuss how the Leading Beyond the Bottom Line concept might apply in emergency medicine, I don’t have sufficient space to detail the thesis. Read the entire series on the ACPE website.

I believe that the philosophy inherent in Leading Beyond the Bottom Line connects to us in emergency medicine very directly. My hope is that it may provide a philosophical basis for recasting our engagement with our hospitals while also leading us out of the dichotomizing rhetoric of the past half-decade within our specialty’s ranks. This month I’ll address only the potential for recasting your interaction with your hospital.

Adopting this philosophy can facilitate the creation of a shared mission for your hospital and emergency physician group, and the process will develop your communication and negotiation skills. Yet, confronting the need for the struggle and then entering into it with people on the “other side” with whom you have “history” may be a daunting challenge.

Begin by engaging hospital representatives. Sharing a copy of this article with almost any hospital administrator is a good way to start. The nursing administrator for the ED may be the most accessible representative of the hospital and a good person with whom to start. However, there’s no need to limit your approach to a single individual, and indeed approaching as many of the hospital managers as you can may generate momentum and at the least will stimulate some interest among your hospital administrators that can facilitate opening the dialogue.

Entering upon an effort to recast your “working” (notice I’ve said nothing about your contractual) relationship with your hospital with nothing new in your approach will doom the effort to certain failure. The Leading Beyond the Bottom Line philosophy as a starting point can only succeed if you sit down and talk together. Your quiet insistence about the importance of meeting coupled with your equanimity when denied can go a long way to bringing even the most contrary hospital manager to the discussion table. Confrontation is not about fighting with your administration; it’s about addressing squarely — face to face — the issues before the respective groups. Rehearsing your approach, words, and facial expressions in the mirror, trite though it may sound, will make it easier for you to stay focused if baited by the “opposition.”

Once engaged in dialogue, the most important task entails moving beyond philosophy to successfully making something real happen through the use of the framework. The arrival of the ambulatory payment classification (APC) method for outpatient prospective payment provides an almost ideal focus. Although implementation began in August, by the time you read this, it’s likely that you will have heard from your administration in one form or another about the negative effect on hospital revenues the implementation of APCs has wrought.

Challenge any demand from a hospital administrator by calmly stating how unproductive such a demand is to the improvement they seek and the dialogue essential to gain the improvement. Point to the copy of the Leading Beyond the Bottom Line article you’ve sent around. Suggest that calm dialogue about the hospital and practice’s concerns will more likely reach a useful resolution for both.

Lastly, point out that pitting the hospital against the practice assumes a “zero-sum game” in which for one to “win” the other must “lose,” and that you’re confident that neither the hospital, the particular administrator nor the practice wants to “lose.” Suggest that finding the Pareto optimum for the practice and the hospital around the larger objectives noted will benefit everyone. Advise the particular administrator that he has nothing to lose and everything to gain by entering into the work with you because of the consequences of effective teamwork: better and more consistent results requiring less continuing attention as working together becomes more the usual way of doing business.

Your ace in the hole is that facility billing with APCs is entirely dependent upon the quality of the documentation. Either physician or nursing documentation must support medical necessity and document the delivery of the services. This is another reason to involve the ED nurse administrator because documentation that isn’t present in the physician note entails more reliance upon nursing notes for proper coding. Yet, a well-written physician note can suffice for the facility’s coding purposes as well as the practice’s.

In this endeavor, the physician group and the nursing staff are natural allies in meeting the needs of the process, and cooperation with nursing provides leverage in bringing the hospital financial administrators — and by extension operating administrators — to the table for direct confrontation on the issue. Are you and your administration together leading beyond the bottom line?

Residents, Recruiting and Retention

Today, as I write, the “R” of September prompts me to contemplate not oysters, but the three “R’s” of residents, recruiting and retention. The upcoming ACEP meeting in October coincides with the beginning of the recruiting season for senior emergency medicine residents and that too spurs me to offer a few thoughts about these aspects of an emergency physician leader’s job. The specialty’s publications, including Emergency Medicine News, see a spurt in positions offered advertising and the recruiters will be out in force looking to collect the curricula vitae of as many senior residents as they can. Ah, the sound of the whirring fax machine as it spits out all those pages of accomplishments into your and my in bins.

I’m addressing you who are recruiting or as is equally likely, hoping to retain the fine physicians who are already among your staff and colleagues. How well does the annual position chase serve your needs? Does this annual rite of autumn bring you concern that your some or many (!?) among your staff are searching for greener pastures? What can you do about it? What can you do about it now?

Retention begins during recruitment, by not over-promising nor failing to address the real questions of the candidates you interview. But, today you are contemplating the possibility that you will be one or two physicians short of full staffing in just a few months and you’re wondering if you can or should forestall their departures. Well, I’ve learned from sad experience that in the main a leader should not counter-offer or negotiate with a staff member who has already announced his/her resignation. It’s unlikely to really re-engage the departing physician and those that remain are likely to suspect that a “special arrangement” not available to them has been negotiated. As a consequence, you may receive other “resignations” intended to extract a “special arrangement.”

Nonetheless, talking to a restive colleague or staff member to learn why he or she is unhappy or looking elsewhere is a useful undertaking. The long-standing member of the group may simply be reassessing his or her value in the greater world of emergency medicine or seeking to learn more about a fundamentally different type of clinical practice: rural or urban, academic or community, urgent care or other sub-specialty. Staff members seeking to move to different geography or practice type deserve your best assistance. Introductions to colleagues elsewhere or referrals for informational interviews through the network of other directors and leaders you may know gives evidence of your support for the individual physician and enhances the likelihood that the departing physician will speak well of your practice. Assisting those individuals who are determined to leave also demonstrates to those who remain that you are interested in their individual careers. And, that’s the key to retention: Support the individual physician and his/her unique career aspirations.

Many resident graduates who you have recruited will need individualized attention if you wish to retain them on your staff. Much has been said in other venues about whether or not newly graduated residents are worth recruiting and I don’t intend to discuss the pros and cons here. Suffice it to say that after more than 20 years of preparing residents to go out into the world, I also actively recruit both our own graduates and graduates of other residency programs, but I’ve learned that newly minted residency trained emergency physicians do require additional effort on the part of practice leaders. That practice is not like residency seems obvious, but for the residency graduate who enters practice in a different environment, the experience may be more unsettling than is initially apparent.

So, starting today and regardless of your past failings, set aside the time to meet with individual staff members and learn their aspirations. For those physicians who tell you they only want to come to work and make a living, consider enumerating the opportunities available in your local environment, through professional associations at the state or national level or in sub-specialty niches. I’ve listed just a few of the many niche opportunities in Table 1.

Consider breaking down the problems you face into “bite-sized” pieces and sharing them with your restive staff members, along with your support and hand-holding to get the problem solved. It may take you longer, but you will have developed a new level of interest and commitment. For still others, you may wish to encourage exploration of the competitive landscape with the request that you want to know what they learn so that you can maintain your practice’s competitive position.

A theme mentioned several months ago: the pyramid of medical staff development also provides a tool to re-engage restive staff members. Begin by articulating a consistent set of expectations for practice members, but move to evaluation in light of those expectations quickly for those most restive. Your goal here is not truly to evaluate, but rather within the structure of your clearly articulated expectations, shore up the understanding of those expectations and allow for the most restive—and perhaps outspoken—to share their misgivings and concerns. The goal is personal attention to the individual and creation of an opportunity to turn inward looking staff members into engaged colleagues, concerned, as all should be, for the well being of the practice, hospital and the community. When staff members are engaged in improving the well being of the practice, the hospital and the community served, retention comes naturally.

Lastly, fair compensation and benefit arrangements accompanied by humane working conditions with sufficient staffing, the opportunity for meal breaks and arrangements for call-in staffing when overwhelmed can go a long way to assuring your staff and colleagues that you want them with you for the long-haul.

Table 1: Niche opportunities in emergency medicine

Air Medical Transport
Emergency Medical Informatics
Continuous Quality Improvement
Critical Care Medicine
Cruise Ship & Maritime Medicine
Disaster Medicine
Emergency Medical Services
Emergency Medicine Practice Mgmt and Health Policy
Emergency Medicine Research
Emergency Ultrasound
Hyper-baric Medicine
Injury Prevention and Control
International Emergency Medicine
Pediatric Emergency Medicine
Rural Emergency Medicine
Short-Term Observation Services
Sports Medicine