Death by Interruption: Lessons in ED Efficiency

Dear Director,
Although I’ve been a chairman for a while, I feel like I don’t have enough time to get all my administrative work done and I’m getting behind. How can I improve my efficiency in the office when I‘m wearing my chairman‘s hat?
-Not enough hours in the day

I’ve been in ED administration for almost 15 years and I am amazed by how complex and time intensive the roles have become. There seem to be more committees, more audits, and more attention to metrics than ever before. This translates into a more cluttered desk and greater challenges when it comes to balancing your clinical responsibilities with administrative deadlines.

Appropriate Time Allotment
A good friend of mine was chairman of his ED. He didn’t have any real interest in the job but his group rotated the chair position every two years and it was his turn. What they didn’t do was change his clinical hour requirement. Their stance had always been that everyone did the same number of weekly clinical hours, regardless of administrative responsibility. My friend had the skill set to be an outstanding chairman, but he went into the job lacking the time. Although designated administrative time will vary depending on your group culture, the size of your ED, and the complexity (number of meetings and committees) of your institution, it’s important to make sure you have an appropriate allocation split between clinical and administrative time in your work week. For a smaller ED, it may mean having one administrative day a week versus a larger ED which may require 3-4 admin days and thus only 1-2 clinical days a week. If your administrative responsibilities have increased, it might be time to renegotiate your contract.

Death By Meetings
There’s at least one meeting a day on my calendar that I could attend. This would mean doing every clinical shift before or after administrative meetings or leaving in the middle of a shift to attend a meeting, and that makes for some really long days. When you’re an administrator, being available and visible around the hospital is a part of your life. For scheduling purposes, I find it helpful to separate meetings into those that I can control, and those that I can’t. My administrative schedule is built around the meetings that aren’t in my control. I need to be there and will either set aside the entire day as an administrative day and thus try to schedule meetings that I can control (monthly meetings with hospitalists, ICU, etc…) around the ones that are set in stone. Meetings can be a giant time suck (see Patrick Lencioni’s book called Death By Meeting) so make sure they are worth your time to attend.

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When feasible, try delegating a lower level meeting to another physician – you’ll free up some much-needed time, show the broad involvement of the emergency physician group and earn that physician positive exposure around the hospital. It should go without saying that the meetings you personally schedule should have an agenda and clear objectives.

Since hospitals love having meetings at 7:30 a.m. or noon, consider following those meetings with a 9 a.m. shift or an afternoon shift. I do not, however, recommend leaving a meeting early to do your shift or risk getting to a meeting late because you were finishing your shift.

I am an advocate for being a clinician during clinical time and an administrator during admin time. Unless I’m called by the hospital president to a meeting during a clinical shift – which has happened – I do everything in my power to not leave the ED for a meeting during a shift. Although I always end up spending a small portion of the clinical shift doing email or phone calls, I try to leave that for the occasional break or when I’m eating lunch. I’m on my smart phone all day long (more on that later) but I’m always amazed that when I work clinically and fall 50 emails behind, the world doesn’t come crashing to a halt. Although we may only have 2 administrative days a week, the rest of the hospital works 5 days a week so it’s hard to lose an entire administrative day. Therefore, I highly recommend spending 30-60 minutes in your office before and/or after your shift to catch up. I really find the time between my shift being over and waiting for that last radiology report to dispo a patient a great time to retreat to the office and knock out a few emails while tracking the patients on the computer. This extra time should be enough to catch up on the critical issues of the day.

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Death by Interruption
When my wife became an executive, her coach taught her how to organize her desk, how to deal with mail (only touch it once—trash it, file it, or act on it) and email (have dedicated time throughout the day; don’t answer as they arrive), and how to be generally more efficient in the office, and in life. Not only have I not had that kind of training, but as an ER doc I’ve been lulled into the belief that I’m automatically a master of multi-tasking. I admit addiction to my smart phone – it’s not called a Crackberry for nothing. For me, it takes an enormous amount of restraint not to look at every single email as they trickle in throughout the day, interrupting me from pressing tasks such as writing policy, analyzing staffing, or writing this column. However, every time we fall for that “beep beep,” we actually put ourselves behind. We’ve experienced this in our clinical practice – when we are interrupted to review an EKG we lose our train of thought and it takes some time to get back on track. Although Timothy Ferriss’ book, The 4-Hour Workweek, is probably best geared towards those who want to run their own business and no longer be emergency physicians, it gives a variety of time management techniques that we can utilize.

Since we have many projects and not enough time, we need to prioritize how we spend our administrative time. I find that some chairman do a crummy job of prioritizing tasks, choosing rather to work on things that are interesting, fun, or easy for them over the tasks that will have the biggest payoff. In order to prioritize, Ferris suggests that you follow Pareto’s Law, which is essentially the 80/20 principle you learned about in medical school. Most likely, there is a big impact from a small portion of people or problems. Eliminating core measure misses is one priority and when I realized that 80% of our ED’s core measure misses came from one category, I knew where I needed to focus my energy. Spend some time thinking about your job in this 80/20 world to help find your priorities. As an interesting hypothetical, Ferris suggests considering your work week if you were medically disabled and only had two hours per administrative day. What gets prioritized to the top and what would you eliminate?

Ferris also gives suggestions for ways to literally eliminate elements of your workday in order to stop wasting time. Although you need to use your judgment on this section since you can’t stop going to all meetings, I am amazed at how many decisions can be handled with a conversation or via email and don’t require an entire hour blocked on my calendar. He suggests checking email as infrequently as possible – this might start as once a day but Ferris has backed off to once a week. That might be a quick way to lose your job or the contract, but there is some truth to the fact that every time you interrupt what you’re doing to respond t
o the phone or email, you’re losing productivity. My compromise when I’m working clinically is that I usually scan my inbox from time to time and look for anything critical (my bosses, patient relations, risk manager, ED nursing director) and let the others wait until the end of my shift. A better solution would be to eliminate the automatic push of email to my phone and have email delivered every two hours.

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Ferris’s book also makes a pretty convincing argument for outsourcing much of life to low-cost workers. Though I don’t support this in the hospital, I’ve been amazed over the years at how many clerical tasks I’ve been able to trust (eliminate from my work pile and outsource) to hospital support staff. Everything from data entry, OPPE work, typing my own minutes, etc…I’ve gained back hours each month that can be more appropriately used on topics that require an MD. Finally, throughout Ferris’s entire book are links to a tremendous amount of technology that can be found on the web and incorporated into your administrative life. Everything from programs that turn voicemail into text messages to apps that track how much time a day you lose on Facebook.

Administrative jobs will continue to increase in complexity and time demands. We need to dedicate the appropriate amount of time to the job, think strategically, work more productively, and take advantage of time saving techniques, or we will most certainly fall behind.

Michael Silverman, MD, is a partner of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.