Better Results in Hospital Emergency Departments

Agamedes goes shopping for a better ED solution.

Do you need new -- lateral -- thinking for your own problems? email nick leth at gmail dot com. Need solutions? No worries. Now.

How often do you just sit at your standard-sized desk in a shared space in a noisy open office area and think, "There is so much work to do... If only someone would order me to work harder... I would then pull my finger out, stop malingering, grow to love my work and get twice as much done every day. All I need is the order from a remote manager and I will work so much faster."

How often do you think that?

Never?

I wonder why the Health Department thinks that an order to work faster is such a good idea in hospital emergency departments...

Good lessons from the shop floor

Do some shopping in The Herdsman, watch the checkout section. The Herdsman is a food shop. I'll describe what I see. You will see the same in plenty of other shops.

Two or three cash registers are in operation. There is a small queue at each. A call goes out... Another checkout operator appears, opens another till. The checkout queues adjust, customers are served, the queues disappear. Checkout operators close tills and go away.

What has just happened?

There are employees at The Herdsman who can operate the checkout counters. When they are not needed at checkout -- they help in other areas of the shop. If one checkout operator has no customers, they will move to be a bag-packer at another till. If the checkout area is very quiet, idle operators will find work in other areas of the shop.

Here are the key ideas:

• The shop knows -- roughly -- which are the busy times for checkout. But customers come and go as they please... Customer numbers vary over time.
  
• The shop employs enough checkout operators to provide an efficient checkout service to customers. They will employ more operators at known busy times.
  
• Checkout operators help each other to provide good service to customers.
  
• In quiet times times at the checkout area, checkout operators work somewhere else.
  
• At all times, each checkout operator gives highest priority to working in the checkout area.
  

I don't know what checkout operators do when they are not in the checkout area. Perhaps they just sit out back with a cup of tea... though I doubt it. Whatever it is that they do, I suspect that it is useful for the shop. Sure, they may have to go back to checkout at a moment's notice... Meanwhile, they are providing some support in the shop. Rather than just sitting around, feeling useless.

Apply this answer to ED

Is ED -- the hospital Emergency Department -- like a shop? In some ways, it is:

• The hospital knows -- roughly -- which are the busy times for ED. But patients come and go as they please and as they must... Patient numbers vary over time.
  
• The hospital can employ enough ED staff to provide an efficient ED service to patients. The hospital employs more staff at known busy times.
  
• ED staff help each other to provide good service to patients.
  
• In quiet times times in ED, ED staff can work somewhere else.
  
• At all times, each member of the ED team gives highest priority to working in the ED area.
  

This is the obvious benefit: The hospital can employ more ED staff than the absolute minimum. In quiet times, "spare" staff will be helping patients in other areas of the hospital. In busy times, there will be enough available staff to cope.

Yes, there are potential problems:

• Specialist ED staff may not want to work anywhere else. So talk with them... Discuss the problems, look for solutions. There's probably a real need for a core of dedicated ED experts. This core of experts can be supported by other staff with more flexible training.
  
• Other hospital wards may not appreciate staff suddenly disappearing back to ED. Look on the bright side: While they were in the ward, they helped.
  
• Not every non-ED task can be dropped every time ED needs more of its staff. Be very clear about the type of work that an ED staff member can do in a non-ED ward. Make sure that it can be dropped at short notice. Avoid work which is either time-dependent or time-consuming and non-interruptible. Work with ward managers to make it work.
  
• With staff coming and going from wards, how do we know what's going on? Patient notes and other work records are really important. Keep them accurate and up-to-date.
  
• It takes time to get back to ED... Inventory managers will tell you to build "lead time" into your call for ED staff to return to ED: See the patient numbers building up and call back your ED staff before patient numbers reach crisis point.
  
• I'm sure there are lots of other problems. So what? Identify the problems -- and solve them.
  

In Western Australian hospitals, ED staff are being ordered to be more efficient. More efficiency may not be possible. Evidence suggests that giving the order is not helping. See, for example, "Hospitals fail to meet waiting time targets" in The West Australian, 6 August 2010.

We can improve the effectiveness of ED with a better staffing model. Shops around the world provide the example, I see it in action at my local food shop. It works.

We can make it work in our hospitals.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com