What is the most important result -- outcome -- preferably measurable -- from the ED, Emergency Department, of a major public hospital? Why does that ED exist at all? What -- if it failed -- would mean that the entire ED was failing... that ED was "not a success" ?
I asked my wife. Feel free, reader, to ask yourself that same question. Take a short break for thinking. Then read on...
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The most important result for a hospital Emergency Department is, that as many patients as possible come out "cured".
If the ED were not "curing" -- fixing, repairing, keeping alive and passing on for further treatment -- then why would that ED exist? Filling a bit of spare space in a large building? Providing a coffee service for idle ambulance drivers? Providing storage space for unused hospital equipment?
Don't be ridiculous.
The Emergency Department of a major public hospital exists *solely* in order to keep people alive, to deal rapidly and effectively with people who would otherwise die, to keep them alive -- and perhaps even improve their state of health -- until the patient's medical emergency has been stabilised. Either the patient is dead, or they are medically ready to be passed on to a less emergency oriented department of the hospital. For further -- non-emergency -- care.
It would be "nice" if the emergency patient were able to walk out of ED and directly back to a medically healthy life. But really, that is *not* the key aim of ED. ED exists to keep a patient alive and to stabilise their condition so that the patient can be sent elsewhere for further treatment.
All of that is absolutely wrong.
Wrong, that is, if you believe Paul Murray's report in The West on 9th Sep (Public service in crosshairs). He quotes from a Service Priority Review from Public Sector Commissioner Mal Wauchope.
"There does not appear to be evidence that outcomes ... are better in WA than in other Australian jurisdictions..." Okay, does not sound good. The quote continues, "... despite the higher cost of many service areas."
Hang on! What does *cost* have to do with ED outcomes? Isn't ED about *keeping people alive*?! If we want to keep people *alive* then cost is ... just... cost. Either we want to keep people alive -- or we do not.
If we do want to keep people alive then the important result -- the vital outcome -- is that we keep people alive!
Yes, money is (in practical terms) limited. Cost cannot be ignored. But the important measure of ED *success* is: How many people -- how many incoming emergency patients -- are kept alive and successfully passed on -- by the Emergency Department.
If we are not satisfied with that *sensible* measure of success then we have several options. More resources. More staff. Better processes. Better equipment. Any of these may require extra money. If we are not willing or not able to provide extra money -- we may have to adjust our measure of acceptable ED success. Perhaps drop a target that 80% of patients survive, to 70%. Count 70% of patients being "cured" as a sign of the success of ED. We can still plan for a future of 80% or more... Meanwhile we accept that the higher rate of success is dependent on currently unavailable ... resources.
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But then the report gets even worse.
"... only 65% of emergency department patients were seen on time". Good grief. Even worse, this report considers that this is even worse because it is "compared with 74% nationally." So?! Or even, WTF?!
So, nationally, 74% of ED patients were "seen on time". How many of these patients actually *lived*? Any?
How many of WA's ED patients survived the extra delay? Yes, delays in emergency treatment seem very likely to reduce the odds of surviving the ED experience. But did they??
What if 74% of ED patients are seen "on time" -- within an arbitrary time set by a politician -- and 99% of those patients die in ED? Is that "success"? Not by any sane measure.
What if "only" 65% of ED patients are seen "on time" -- yet 99% of those patients live to see another day? Live to get further treatment? Sounds like success to me.
[ I'll add a small example below. But, not to interrupt the flow: ]
Okay, I admit it, I have recently come through ED. I am really -- really -- pleased that I came out alive. Would I have exchanged treatment "on time" but sent out dead, for treatment which sent me out alive? No way.
ED *success* is measured by the percentages of patients who come in as an emergency -- and come out alive.
Forget the time. Forget the cost. Yes, remember that time and cost will affect that survival rate. But...
The only *sane* measure of ED success is, the number of emergency patients who actually survive the experience.
Get real. Measure real success. Accept some level that will be counted as, "as much success as we are currently able and willing to achieve." Then worry about whether or not we want to improve ED -- through cost, resources, people, whatever -- in order to -- over time, as and when we can -- in order to raise the level of real success that we really expect... demand... is to be achieved.
Why does the Emergency Department exist at all? To keep emergency patients alive so that they can be passed on -- alive -- for further, less urgent treatment.
Number of live exits from ED, that is the only sane measure of ED success. Accountants may measure cost. Politicians may measure time. The ED patient measures only continuing life. That "life after ED" is the one and only *sane* measure of ED success.
So set a real -- relevant to ED -- measure of success. Then measure it.
Look for ways to ensure that the "required" level of that measure of success.. is met. How? That is the real challenge. The rest is simply the means by which we attempt to reach that required level of actual ED success.
Ask the question, What level of actual success do we demand -- with the underlying question of, How will we provide the resources which will allow us to achieve that *real* success. "Real" success. Which delivers the results which ED actually exists to provide.
=== And here's a simple example. Of "time" being used -- wrongly -- as a measure of success:
I worked on a contract to provide IT support services to a major government utility. One measure of success was, that 90% of calls for help would get a help desk response within five minutes. (The numbers are from old memory, they may not have been 90% and 5 minutes. That is not relevant.)
The help desk was required -- with contract payment dependent on meeting the measure -- the help desk was required to: Respond to 90% of calls for help within five minutes.
So how did the help desk ensure that this target was met?
One person at the help desk had a very specific task: For every call that came to the help desk, that help desk employee would *call back* within five minutes. Absolute "success" against the required measure!
Of course the call-back was, essentially, useless.
Yes, we have received your call. No, we are not acting to resolve your problem. This is a call-back in order to satisfy the meaningless requirement of the contract. As far as solving your actual problem -- useless.
Was each caller entirely satisfied with this call-back? Would they, perhaps, have preferred to have had their problem actually fixed? The answer is obvious...
By setting a meaningless measure of success -- the contact ensured that "success" was meaningless. Tick... done... useless.
And that is the situation with Wauchope's measure of the "success" of ED: it is... well... *not* ticked... *not* done... absolutely useless. Yet it does take attention away from any sane measure of success.
What is the actual purpose of ED?
Identify that. Set a target. Then measure that target.
Only then can we claim that we know the level of "success" of our hospital Emergency Departments.
Get real.
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Oh, btw: My own treatment in ED was brilliant! Every single person was brilliant, dedicated, caring, experienced, expert. Well, as far as I can remember, anyway. I was unconscious for a lot of the process :-)
Best of all -- my personal measure of success: I came out alive.
Thank you.
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Now much more than a clever name for a holiday journal:
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Dr Nick Lethbridge / Consulting Dexitroboper
Agamedes Consulting / Problems ? Solved
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Dr Nick Lethbridge / Consulting Dexitroboper
Agamedes Consulting / Problems ? Solved
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"I have an above average QI." … per Ginger Meggs
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