Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Here’s the secret to emergency department efficiency

Phillip Stephens, DHSc, PA-C
Policy
June 5, 2019
961 Shares
Share
Tweet
Share

A gray-haired emergency medicine physician once provided the most succinct view of ED efficiency ever uttered. He said, “Sometimes they ask us to dig a ditch. Then they give us spoons with which to do the job.” Though cynical, it is the view of many. There really is only one problem and a single solution to ED efficiency. The problem is variation. The answer is scale.

Biologists understand variability best. Biologic variation is partly heritable and partly acquired. Variation is then passed through the system. Some days, the challenge in emergency departments is patient volume. The next day volume is low with fewer people, but acuity is high with sicker people. On another day, boarding is an issue. Hospital beds are full due to high volume or acuity on previous days. Another day staffing is a problem.

EDs aren’t killed by a single bullet. EDs die by a thousand cuts. Hospitals then make two mistakes: They either chase yesterday’s problem today or search for a universal solution where none exists.

Author Malcolm Gladwell often tells the story about Harvard trained psychophysicist Dr. Howard Moskowitz. In a TED talk, Gladwell explains how a cola company asked Howard to determine the perfect cola sweetness. Moskowitz tested different formulas on thousands of people to determine the perfect level of sweetness. Instead of a bell curve, the data was all over the place. Why wasn’t there a perfect cola everyone liked?

Instead of dismissing the fact that figuring out what people think about cola may not be easy, Howard thought a lot about the problem. Suddenly, he realized rather than looking for the perfect cola; he should have been looking for the perfect colas. But just like understanding ED variation, few understood Howard’s epiphany.

Sometime later, rather than finding the perfect pickle, he helped a company develop more pickle varieties because in his view there wasn’t a perfect pickle. There were only perfect pickles. People preferred different types of pickles and really didn’t even know what they liked until given an option. Spaghetti sauce varieties are also credited to Howard.

Understanding variation was revolutionary to the food industry that had always looked for universal truths. Ultimately, there wasn’t a single best cola. There were only perfect colas. It’s an important distinction for ED’s to understand.

A different causation for ED inefficiency arises each day. Hospitals search for a sole cause. But in actuality, there isn’t a cause. There are only causes. Hospitals have little control over variables such as geographic location or socioeconomic factors that impact efficiency. Hospitals do control factors such as staffing or resources to varying degrees.

The only constant is that efficiency barriers vary widely then permeate the system. Many are controllable, and some are not. Managing efficiency becomes more a matter of understanding the range of variation a specific ED faces rather than chasing yesterday’s problem. To do otherwise is simply treating the symptom and not the disease. Understanding variation prevents ED’s from being reactive. The solution is non-reactive as well because the solution is scale.

The term “capacity over demand” was coined by researchers who have studied this problem. It is defined as staffing and resources able to handle over 100% of expected variation whether it’s volume, acuity or other input issues.

It’s a great term and gets closer to an efficiency solution than others that have been attempted. The challenge is capacity over demand solutions require a larger budget than most hospitals can expend. Efficiency experts have applied manufacturing solutions to EDs with varying success. The problem, though, has always been variation. Inputs can be controlled when implementing industrial efficiency measures. But variation in emergency departments foils the input side. Industry can decide how many widgets roll in the front door. EDs cannot control how many patients show up. This is why scale is important.

The most successful hospitals that have solved their efficiency issues are ones that finally embraced the idea that an overwhelmed ED is not simply an ED problem. It’s a hospital-wide problem.

The scale of ED efficiency must be widened to include systemwide efficiency. Efficiency is like a biological organism where one system affects another in a symbiotic fashion. Think about chaos theory and the butterfly effect.

If patients aren’t being efficiently discharged in minutes on the inpatient side, they aren’t going to be admitted to the floor in minutes from the ED side. An inpatient nurse may have received three patients back to back. But, so did the ED nurse. Failure to have equal urgency is myopic.

Ancillary service delays spill over into the ED. Psychiatric services can slow mental health dispositions. Clinic services can force higher ED volumes if patients can’t get med refills or secure an appointment. It’s a symbiotic problem with a symbiotic solution.

Then there is the question of how much variation and scale is within the control of human intervention. We don’t know the precise answer. I statistically correlated ED volume to throughput years ago. The math revealed about one-third of ED variation in terms of length of stay could be directly attributed to simply how many people were waiting in the ED lobby.

It sounds trivial. But, EDs have little control over how many patients show up, and one-third of the variation that determines a patient’s length of stay is due to how many people are waiting to be seen at that moment in time. Therefore, 33 percent of ED variation is random from the start. By the way, the weather accounts for 1 to 5 percent of ED variation. I was studying how weather fronts affect ED volume. But no journal is going to publish a study when the variation is that low.

It has little impact. So even weather accounts for a small amount that can’t be controlled and each variable adds up. Scale at least mitigates controllable variation.

To that end, we need to stop chasing yesterday’s issue today. We need to understand variation as there is no universal problem. There are only problems. Some problems can be controlled, and some cannot. Problems also vary greatly and often.

We mostly need to establish broader scale solutions. ED overload is a systemic symptom that needs a bigger ditch with more people willing to dig.

Phillip Stephens is chief physician assistant, department of emergency medicine, Southeastern Regional Medical Center, Lumberton, North Carolina. He is the author of Winning Fights: 12 Proven Principles for Winning on the Street, in the Ring, at Life, and can be reached at his self-titled site, Dr. Phillip M. Stephens.

Image credit: Shutterstock.com

Prev

When gender identity confuses the electronic health record

June 5, 2019 Kevin 4
…
Next

How anti-vaxxers are just like the rest of us

June 5, 2019 Kevin 0
…

Tagged as: Emergency Medicine

Post navigation

< Previous Post
When gender identity confuses the electronic health record
Next Post >
How anti-vaxxers are just like the rest of us

More by Phillip Stephens, DHSc, PA-C

  • Why doctors crash planes

    Phillip Stephens, DHSc, PA-C

Related Posts

  • Solving the problem of non-emergent care in the emergency department

    Michael Kirsch, MD
  • Solving the low-acuity emergency department problem

    Dillon Mercado
  • 3 ways to decrease emergency department wait times

    Robert Pearl, MD
  • Violence in the emergency department puts patients and physicians at risk

    Vidor E. Friedman, MD
  • A place for music in the emergency department

    Thomas Scary
  • Don’t blame doctors for outrageous emergency department prices

    Peter Ubel, MD

More in Policy

  • Pediatricians grapple with guns in America, from Band-Aids to bullets

    Tasia Isbell, MD, MPH
  • Health care wins, losses, and lessons

    Robert Pearl, MD
  • Maximizing care amidst provider shortages: the power of measurement-based care

    Tom Zaubler, MD
  • Unveiling excessive medical billing and greed

    Amol Saxena, DPM, MPH
  • Chronic health issues and homelessness

    Michele Luckenbaugh
  • The impact of certificate of need laws on rural health care

    Jaimie Cavanaugh, JD and Daryl James
  • Most Popular

  • Past Week

    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Motorcycle helmet laws: Balancing freedom and financial impact

      Stephen Cohn, MD | Conditions
    • Contemporary weight loss: Unveiling the quest for elusive elixir

      Osmund Agbo, MD | Conditions
    • How compassionate leadership saved this physician [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Navigating the broken medical system: challenges faced by foreign medical graduates

      Anonymous | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • The essence of medicine: genuine connections in practice

      Jennifer Tillman, MD | Physician
  • Recent Posts

    • Contemporary weight loss: Unveiling the quest for elusive elixir

      Osmund Agbo, MD | Conditions
    • Balancing efficiency and compassion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Why patients write: stress relief, self-care, and sharing experiences

      R. Lynn Barnett | Conditions
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Did Gabapentin Improve Post-COVID Olfaction?
  • Fentanyl Death Trends; Food Additives and Heart Disease
  • What If the Doctor Is Out?
  • Reduced Mortality Seen in Cancer Survivors Who Meet Exercise Guidelines
  • CDC Advisors Endorse Maternal RSV Vax to Protect Newborns

Meeting Coverage

  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • ERS Roundup: Cell Transplant Boosts Lung Function in COPD Patients
  • Most Popular

  • Past Week

    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Motorcycle helmet laws: Balancing freedom and financial impact

      Stephen Cohn, MD | Conditions
    • Contemporary weight loss: Unveiling the quest for elusive elixir

      Osmund Agbo, MD | Conditions
    • How compassionate leadership saved this physician [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Navigating the broken medical system: challenges faced by foreign medical graduates

      Anonymous | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • The essence of medicine: genuine connections in practice

      Jennifer Tillman, MD | Physician
  • Recent Posts

    • Contemporary weight loss: Unveiling the quest for elusive elixir

      Osmund Agbo, MD | Conditions
    • Balancing efficiency and compassion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Why patients write: stress relief, self-care, and sharing experiences

      R. Lynn Barnett | Conditions
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Here’s the secret to emergency department efficiency
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...