Healthy Habits for the New Year Start With the Emergency Department Chairman

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The new year offers a unique opportunity for directors to implement important department improvements.

While January typically brings high volumes and high acuity, it’s important not to take our eyes off the administrative ball. The new year brings an opportunity to refocus our administrative agenda for the upcoming year and maybe gives us an excuse to forget about the flu and the waiting room for a day to do some strategic planning.

State of the Department

Just like the president goes before Congress, medical directors should consider going before their departments. This is a wonderful opportunity to highlight accomplishments from the past year, review metrics, and outline the goals of the current year. Be sure to comment on whether you achieved goals from the previous year and what steps were used to accomplish these. This isn’t about you being the sole presenter, however. Be sure to include your nursing leadership in a joint presentation and get extra mileage out of it by presenting it at the first nurse staff meeting of the year as well. Having a unified front with nursing is critical to getting everyone in the department on the same page and puts further emphasis on how each department’s successes (and failures) are shared by all who work there.

Goal Setting

Goals should set the agenda for the year and give staff the administrative focus and priority setting that drives its agenda and energy. If your hospital works on a calendar year, you should have spent some time in the fall setting your goals. If you haven’t set your goals, it’s not too late, but it’s time to get them down on paper. Even if your goals are unclear, it’s likely that the nurse manager has very clear objectives. If you work for a contract management group, your group may have established goals that are part of a company directive or related to the terms of the contract. Either way, some important things to keep in mind: your CEO (and the rest of the C-suite) may want to set your directives. There’s no point in focusing on increasing critical care documentation or reducing CT utilization if your CEO wants you to reduce door to doc times (though reducing CT utilization may reduce LOS, which may reduce door to doc). Your goals should also align (maybe even be similar to) the nurse manager’s goals for the ED. It’s much easier to get to the finish line when we’re all rowing in the same direction. As we set goals, it’s important to develop solutions to help each person achieve the goal.

Often there is incentive compensation attached to achieving certain goals. It’s important to consider if there are levels of achievement for partial success and a stretch goal or is it all or none? If it’s all or none and you get none, how much of your total income is involved? I had a job where I had about 25% of my income based on goal achievement. The goals were designed to be reasonably attainable since that piece of my compensation basically brought me to market value. Then we got a new CEO who believed that no manager should hit 100% of their bonus and goals needed to be much loftier. While I think having a tiered goal plan with stretch goals is great, a bonus program needs to take into account your compensation target to keep you focused on your job and not focused on beefing up your Linked In profile.

While academic research has shown that by setting goals people work harder and are more focused, newer research shows that goal setting can lead workers to “cheat, act selfishly, or feel demotivated.” We’ve probably all had discussions with our nurse leaders about docs who “click” on a patient to stop the door-to-doc clock and then not see the patient for an hour. That’s an example of cheating to achieve a goal that ultimately hurts the team (distrust and dissatisfaction among nurses, increasing LOS).

Get Social

One of the best ways to dive into the weeds and determine goals and their solutions is by having a department retreat. Obviously, the whole department can’t attend, but you can work with nursing leadership and get representation from each role in the department. We’ve had pretty good success over the last couple of years from doing 4-6 hour retreats on our campus in a conference room. We’ve used them to bring nurse and physician leaders into the same room to review metrics and create goals and action items for the new year. We’ve also brought our more clinical people in to find solutions to improve a myriad of bedside issues. Staff is definitely more apt to invest in improvements when they’re involved in the goal setting and help to devise ways to achieve the goal.
Last year, my CEO said the most important goal was reducing the number of patients who left without being seen. For a variety of reasons, it had climbed to unacceptable rate (in my opinion, too, not just the CEO’s), and he told our leadership team we needed to improve it. We used our retreat to identify our top 10 priorities list (including reduction in LWBS) and then had a follow-up retreat to develop our strategies for success. It took a couple months to get our strategies implemented, but in the end, we cut the LWBS to the lowest it’s been since I joined the hospital.

There are a lot of other social events we can do around team building. The most game-changing thing I ever did to improve the relationship with my hospitalist group was spend about $250 on a happy hour after work one night. Having had the chance to sit around and realize they’re all good people and that we have similar interests (working hard, playing hard, our families) has paid dividends. We’ve had others since and brought in the ICU docs as well.

If you didn’t have a holiday party for your ED already, there’s still time to celebrate the winter and add some joy to a dull Thursday night. I’ve always found the nursing staff to be incredibly appreciative of these events, and it’s a great way to build relationships within the department. It’s amazing to me what I learned about some of our staff members for last year’s party (We had a nurse emcee parts of it, and turns out he does Stand-up comedy.). It’s also a great chance for you to thank everyone as part of a toast. Some EDs have a social coordinator. Other EDs have a variety of intramural teams. I don’t think the medical or nursing director has to coordinate all of these, but I love hearing that I have a couple docs on the department kick ball team.

Since the medical and nursing directors need to be so aligned, you may want to consider jointly attending a conference that impacts the issues you’re working on. There are plenty of patient engagement, operations, or even risk management conferences where you can have discussions, brain storm ideas based on the lectures, and get to know each other a little better over some meals. Better yet, bring others from the leadership team.

Go Outside Your Comfort Zone

You likely became a leader based on your strengths. In fact, in one of my favorite books about leadership, The Extraordinary Leader, authors Drs. Zenger and Folkman describe the 16 competencies that leaders often have. They also describe the importance of building on our strengths and how that is more likely to make us better leaders than focusing on our weaknesses.
However, each of us probably has a project or two that we’ve been putting off because it’s too overwhelming or painful. You shouldn’t expect to knock off a huge project in a month, but the new year is the perfect time to identify a major endeavor that needs doing and split it into chunks that you can accomplish over the course of the year. Since most hospital dashboards are based on a calendar year, it’s a great opportunity to show progress throughout the course of the year. My project for this year is to see if I can make a dent in our psychiatric patient length of stay.

Another issue that is probably outside all our comfort zones but nonetheless is important to address is burnout. Our hospital did an internal burnout survey. No surprise that the ED responders led the pack in burnout, which is consistent with burnout studies. While there are no easy answers, there are some things we can do. Within our meetings, consider presenting “great saves” or other interesting cases at the department meeting instead of only M&M’s.

Remind others how good it can feel to make follow-up phone calls, hearing gratitude for jobs well done! Consider inviting a patient or two who had a good ED experience or had their life saved to speak at a department meeting. We often take for granted the impact we have on people, so putting positive outcomes front and center can help us to appreciate why we went into medicine. You may also consider a humanities-focused “journal club” at a home or restaurant. Burnout is a very tough issue to fix obviously, but it’s an elephant in the room not to be ignored.

Give Positive Feedback

Some weeks (and months) it feels like I do nothing but put out fires, and conversations with my docs revolve around complaints, a stroke, “miss,” or some other issue. While critical feedback is important for growth, remember to “praise” twice as much as you “polish.” This should be done publicly as much as possible, but a comment while crossing paths in the ER or a quick note (personal, handwritten is best), goes a long way towards reinforcing great behavior, building the team, and retention. This is equally, and perhaps more effective, if done with your nursing staff as well. Catch people in the act of doing a great job!

Coach

As medical directors and chairs, sometimes we forget that we’re responsible for continuing to develop our team. Giving negative feedback can be difficult but we’re in the position of needing everyone on our team to maximize their skill set. You should have enough data analytics to figure out who needs help with what aspect of their performance. Ranging from productivity to efficiency to length of stay, half of your docs are performing below the median, and some of those at the bottom may be able to make some significant improvement with proper coaching. When they’re doing better, your ED will do better.

Conclusions

Truthfully, I’m not big into personal resolutions since my diet or exercise programs typically do not survive the month. However, I do believe it’s critical to be looking forward and making them as a Director. By resolving to make a few changes in the coming year, you’ll have a sense of purpose that will help to keep you energized and focused. And that spells a happy new year!

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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