Dear Director,
I’ve been in my position for a while and while I’ve been able to make some improvements with projects, I don’t feel like our ED has hit its potential yet. Are there any secrets to getting my agenda moved forward throughout the hospital?
Signed,
Stymied
Leadership is about having a vision and implementing a plan. As a medical director, some plans are easier to implement than others. Making change inside the ED is typically easier than making improvements in combination with a department outside the ED, but the core of any plan comes with a few key components. These include providing education as to the reason and the benefits of the change. Remember that adult learners always need to know why, requiring you to build consensus and negotiate. Taking the temperature of a project from trusted, close colleagues is a good way to decide how to proceed with a plan and helps to build a consensus from the inside out.
Inside the ED – Improvements within the Department
While it’s possible to run the ED like a dictatorship, this generally won’t generate the type of respect or response that most leaders strive for. Although I don’t recommend it, within the ED, a medical director could unilaterally make a decision, such as changing the physician schedule. And while there may be some mumbling and complaints, docs will continue to show up for shifts. However, it’s not so easy if you’re looking to make meaningful behavioral changes such as closing the triage room and doing bedside triage. This can require a huge shift in work flow for both the doctors and the nurses. If the medical and nursing directors took a Machiavellian approach, they could mandate that bedside triage begins tomorrow and the staffs would adjust. Of course, you would likely fail because you don’t have the appropriate buy in and commitment from the staff.
Instead, start having meetings with the nursing and physician staff weeks prior to your desired start date. Working as a team with your nurse manager, present the problems to the group. In this case, let’s use that the patient’s arrival to provider is above the hospital’s desired metrics. Breaking this process down, educate the staff about the opportunity to save time by utilizing open beds for triage rather than having patients wait to be triaged and then moved to an ED bed. Remind the staff that we need to view the process from the patient’s eyes and that we need to always keep the patient’s needs first when developing new plans. Allow the staff to poke holes in the ideas you present and then be prepared to find solutions to their problems. It’s likely that the staff will make improvements to your plan since they’re on the front lines of patient care. Be sure to point out the benefits of the new plan as well, such as improved patient satisfaction, which typically translates into improved staff satisfaction. Ultimately, assuming your plan is solid, you need to pick a start date and roll it out, as there still needs to be some decision making. However, allowing the staff to give feedback into the process to improve it once it’s started will make for a better process and a more committed staff.
Outside the ED – Improvements involving other departments
Obviously you give up a lot of control when you work with departments outside of the ED. How many of us have really fixed our back-end processes (admission cycle times) without significant involvement with at least one other department? It’s just not doable. However, many EDs have made dramatic improvements by working with other departments to accomplish common goals.
Let’s start with an easy one such as arrival-to-balloon time for STEMI patients. While there are a lot of pieces to this project, it only involves two departments, its success is essentially mandated by the government and it’s a high profile measure within the hospital. The common goals are established and there should be little negotiation between departments. By working with the cardiologists and effectively communicating when reviewing individual cases, particularly fall-outs, each piece of this puzzle can be reviewed and improved upon.
Now let’s go back to our admission process. It’s not as easy as the ED’s goal of freeing up beds and it is not necessarily in line with the goal of the inpatient floors. Certainly a discussion with all parties articulating the benefits to the patient (comfort, progression of in-patient work up) is a good starting point. It may be hard to establish other common goals, though patient comfort often leads to improved patient satisfaction for the important HCAPS inpatient survey, and that might get their attention. Negotiation may likely be necessary, and you may need to compromise on writing holding orders or on how nurses give reports.
When you’re really looking to make interdepartmental improvements, you may need to get executive sponsorship. This is when someone from the executive team, typically CNO, COO or CMO, realizes that the potential improvement is so significant to the hospital that they take the time to supervise and influence the process. Having an executive sponsor will keep the program on track and keep the process more formal. Remember, however, that executives are business people and invest their time in areas that have direct payback to their goals. And having an executive sponsor does not necessarily mean that you’ll get the outcome you’re hoping – after all, all the parties might report to the same executive. In our example, having the CNO influence the admission cycle process when the inpatient floors and the ED report to them would be like having to decide which of your twins gets their ivy league education paid for while the other takes loans for a state college. The CNO wants both departments to be successful but will have conflicting interests. Before considering a project that might benefit from executive sponsorship, ask yourself how important the desired outcome is to the hospital, how can it make the hospital more successful, and do you have enough rapport with an executive team member to ask for and get help.
Summary
As medical directors, we work in a competitive environment where we need to continue to adapt in order to improve. Often, implementing a new program involves behavioral and work flow changes that ultimately lead to a cultural shift in the environment. The key is to understand and explain the “why,” communicate with those involved, and be ready for compromise through negotiation. Making change outside the ED is more challenging, but the likelihood of success can be improved by obtaining an executive sponsor.
Michael Silverman, MD, is a member of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.
