How to destroy a great ER: A step by step guide


I took a fantastic emergency medicine (EM) job when I finished residency.  There was no question in my mind that it was the best job within a hundred mile radius, maybe more.  When I first started, my expectations were met.  My group held a contract to staff a busy but well-staffed suburban emergency department, and had held that contract for almost 20 years when I signed.  The hospital was independent, locally administrated, and not part of a mega healthcare system.  Its atmosphere was collegial and clinician-friendly.

The ER was well-staffed with all-star nurses and techs with experience.  Everyone who worked in the hospital wanted to get a job in the ER.  There were three nurses per nine-bed zone with a float nurse (gasp!) in each zone.  Sure there were snags and busy days, but it ran about as efficiently as an ER could.  The patients were well-cared for and generally pleased.

About a year after I took this job, a large regional health care system bought our hospital.  It was called a merger, but we all knew otherwise.  We took their name, adopted their colors and logos, and began answering to administrators who worked 40 miles away and didn’t know us.

In the nine years that followed, my perfect job turned into a nightmare.  Similar to beach erosion, each wave of change slowly washed away an aspect of the job which had previously made it great.  The job I took ten years ago would be unrecognizable to me today, just like the way a coastline can become unrecognizable after the ocean pummels it over time.  Dozens of experienced staff members left, wait times exponentially increased, satisfaction scores nose-dived, morale dramatically dipped, and most importantly, clinical care greatly suffered.   I left the job a few months ago; shortly thereafter my former group lost the contract with the hospital after over 25 years of service.

There were numerous forces and issues which caused my former emergency department to implode.  I recognize that some of these forces were well beyond the control of hospital administration.  However, this piece focuses on factors which were under their influence and were, in my opinion, grossly mismanaged.

If you are a hospital administrator and want to know the best strategies to quickly destroy your emergency department, this list is for you.

1. Ignore and undervalue clinical experience. A warm body is a warm body.  Decades of experience with acutely ill and injured patients are overrated.  A few days of training and a preceptor who knows the ropes will ensure every new nurse or tech has adequate clinical competence.  This strategy also saves money, since less tenured employees cost less on the payroll.

2. Don’t ask clinical staff what they need, tell them what they get. Is the staff clamoring for more space, more help, more security, and more resources as their volume and acuity rise?  Ignore those requests.  You attend enough meetings to know what it takes to provide sound, timely emergency services; staff will always ask for more, even when they have everything they need.

3. When the ER is showing signs of distress, address it by creating more administrative positions. The wait times are long, the patients are angry, and the staff is overwhelmed.  Conventional wisdom would argue that increasing clinical FTEs is a reasonable first step.  Ignore conventional wisdom.  True geniuses “think outside the box.”  What that struggling ER really needs is another layer of administrators to right the ship.  It would be best to promote a few of the exceptional clinical nurses who haven’t yet left to these new administrative positions, where they can truly shine.

4. Automatically turn down any request from clinical staff in the name of saving money.  It’s great that all employees see your multi-million dollar administrator salary which increases on a yearly basis.  What better way to create a culture of honesty, generosity, and respect?  Your organization is a non-profit, so your employees know already that you’re a great humanitarian.

5. No one knows the unique struggles, challenges, and problems that your emergency department faces like an outside consultant. These consultants are professionals, and are well worth the price tag.  They can show up, flip through a few spreadsheets, and instantly tell you what to correct.  Nothing improves staff morale like a mandatory meeting with a stranger telling them all the ways they are doing their job wrong.

6. Make sure your EM physicians are constantly reminded that they have no negotiating power. You have the say on whether their contract is renewed. There are two ways they can choose to do it: your way or the highway.  A collegial relationship with your physicians is terribly overrated.

7. All of the many EDs in your system are doing exactly the same thing, so it is fair to directly compare them to each other. Sure, there may be vast differences in patient volume, staffing levels, acuity, EMS arrivals, admission percentage, available hospital beds, payer mix, patient age and education level, etc. across your emergency departments.  All of these factors even out.  It is perfectly reasonable to compare the satisfaction scores and wait times of a low-volume free-standing ER in an affluent area with the ED of a tertiary referral hospital which is crushed by volume and acuity on a daily basis.  Make it easy on yourself by keeping the spreadsheet simple.

8. Create an environment where it is impossible for your clinical staff to succeed, then blame them for the failure. The clinical staff is blowing smoke when they come up with a litany of excuses (increasing volume, acuity, staffing holes, absurd amounts of required charting, meaningless tasks, and increasing pressure to perform better) for why the scores are low and wait times are high.  The fact is they are lazy and don’t want to do a better job.  Let them leave: Why should you even try to retain employees like that?

I hope this list helps.  If your goal is instead to provide an environment where your emergency clinicians feel valued, respected, and supported, then just take the suggestions listed above and do the opposite.  They will dazzle you with what they already know how to do all by themselves.  Happy administrating!

Thomas Paine is an emergency physician.

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