Friday, December 14, 2001

After the Disaster: Denial, Cognitive Dissonance and Preparing for the Next Time.

I had planned to write last month about the experience of "going live" with our electronic medical record system. We switched it on at 7:00 a.m. eastern time on September 11 and switched it off shortly after 10:00 a.m. and reverted to paper. Lisa Hoffman, Editor of EMN kindly allowed me to skip writing the column last month. Our small loss of time pales into insignificance next to the human tragedy and now wartime circumstances we find ourselves experiencing.

How well did we do at Maimonides, 7.5 ground miles and a 12-minute drive from what we now call "Ground Zero"? Given the small number of injured, mostly themselves rescuers, for whom we cared, it would have been difficult to have performed poorly. Yet, as I write this piece, newspapers and airwaves are full of alerts about Anthrax and the count of those exposed or sickened by the disease, while still in single digits, has grown daily. So too has the stress upon our ED staff -two nights ago I was paged at 3:45 a.m. to advise me that the ED had been "contaminated."

Perhaps the most important lesson I can offer from our experience of September 11 is that activating the disaster plan doesn't truly activate your plan-rather, the experience of caring for your first patient is the true activator. "Cognitive dissonance" is the term used by psychologists for describing the confusion and "denial" we experience in the abrupt wrenching from "business as usual" to attack and disaster management. Having experienced cognitive dissonance on September 11 and subsequently reflecting upon that experience has caused me some personal discomfort and simultaneously appreciation for our team.

It took me 60-90 minutes to recognize that the disaster meant shutting down the "go-live." Fortunately, it didn't take others as long. This wasn't merely because of my psychic investment in the project; rather it was cognitive dissonance and the consequent inability to actually incorporate what I was seeing in front of me. Because the attack occurred at prime work hours, our Vice-Chairman and Medical Director, Dan Murphy, who chairs the disaster committee and had been lead author of our hospital disaster plan was on-site and led our efforts. He knew that all non-essential activities--the very definition of a "go-live"--must stop. His experience at running drills and critiquing them gave him the assurance for necessary action. Practice made it easier--though still not easy--to change gears and move to disaster mode.

Our staff was and still is fearful. Less so as we train with personal protective equipment and review plans for responding to chemical-biological-radiological events. Sharing copies, in the "pit," of the actual faxes received from the New York City Department of Health containing authoritative recommendations for surveillance, patient evaluation and treatment may be helpful for some. Confidential conversations among staff members are reassuring for others. Strong support from senior management through regularly scheduled "Town Hall Meetings" and visits to patient units, including the ED also help. Yes, the passage of time helps, but I'm convinced that establishing a common frame of reference through focused training supported by authoritative sources gives a better result both for the individual and the organization than simply allowing people "time to heal."

In the aftermath of the collapse of the World Trade Center towers many individuals spoke about their desire "to help--to do something." Capitalizing on this helping impulse by improving your preparedness gives proof to your staff of their value to the organization as both individuals and caregivers, while simultaneously reassuring them about their personal safety and their capabilities as responders.

I also learned patience on September 11. In the early hours, even when I was ready for action--delayed though that may have been--not everyone around me was as prepared as I was. Other parts of the hospital were less willing to respond at first, many comparing the events of the day to the experience of responding for the 1993 World Trade Center bombing where very few patients arrived, yet all routine was disrupted. Our COO asked me to join the senior management meeting she convened (our CEO was on vacation in Europe) and I spoke directly to the needs of the hospital's disaster plan. Initial reticence to "changing gears" was overcome through discussion as all came to a group realization of the extraordinary, human tragedy unfolding. To their credit, administrators listened, changed their minds and acted appropriately and necessarily on behalf of the hospital and the community-doing so not precipitously, yet still timely. My leaders and colleagues did the right thing.

All of us now have been bloodied; our brains will shift gear more quickly the next time--"denial/cognitive dissonance" will be less likely. A delay in incorporating the consequences of terrorism won't be a feature of a response this week. However, as the days pass it is likely that the alertness you and we have developed subsequent to September 11 will diminish. Next time we may not have the luxury of more than an hour before the first patient arrives yet activating our disaster plan must help us "activate our brain and behavior" more rapidly than occurred on September 11.

I think that what helped the staff in the ED gain the proper mindset was seeing Dan Murphy standing at the corner of the nurses' station with the sight-line into the ambulance overhang and triage station with the only red binder in our ED--our disaster plan--open in front of him on the counter. All came to him; he did not roam. Locking down the ED also sent a message. We transferred ambulance patients onto our stretchers in the ambulance bay and did not permit EMS providers into the ED. Only our staff and police officers with badge and weapon were permitted into the ED. Hospital staff that did not have an ID badge coded for ED disaster status (a red border around their picture) were stopped by hospital security and turned away.

Responding to disasters is what we do in emergency medicine, one patient or many it's the career we've chosen, yet most of us are not trained for the battlefield itself. Acting effectively when cognitive dissonance and fear for our loved ones and for ourselves slows our response and requires new and additional preparation we are just undertaking, and we must.

This column is dedicated to the memory of my first cousin, Barbara Ellen Pollard Silverman, 40, a life-long advocate for social justice who was manager since 1992 of the Ronald McDonald House of Washington and at her death was grants coordinator for Ronald McDonald House Charities of Greater Washington. She died of liver failure September 15 awaiting a liver for transplant.

Sunday, October 14, 2001

Are You a Professional or Merely an Economic Wo/Man?

Making a profit from emergency medicine whether for individual or corporate benefit is neither unethical nor illegal. Yet, if as emergency physicians we don’t invest in the communities we serve and their institutions, have we behaved ethically? Can we live our professional lives extracting profits and maximizing only our own well-being? Aspiring to ownership of our practice and maintaining open financial books with physician control of our fee revenue is the behavior of an economic wo/man, but are these sufficient aspirations for emergency physicians? Where is the investment in community and hospital, both entities which will outlive any individual physician and which enable our practice in the first place?

The current debate speaks regularly to physician entitlement through its emphasis on the benefits or detriments to the emergency physician of the particular business model through which we organize to earn our living. With varying degrees of explicitness, proponents of these various business arrangements presume that revenue in excess of expense will accrue to either the corporation or the individual. Rarely do proponents of any particular business arrangement address our concomitant responsibility for service to our community and its institutions—our hospital—with which we are inextricably bound in partnership. Mostly in our work and through our professional societies we’ve become caught up in the business of medicine and have become neglectful of the ideals that first brought us to the profession.

More than a decade ago, George Lundberg then Editor of JAMA wrote of the problem in "Countdown to millennium—balancing the professionalism and business of medicine. Medicine’s Rocking Horse." (JAMA 263(1):86-719; Jan 5, 1990). Later follow-ups including those after the AMA’s debacle in contracting with Sunbeam in 1997-98 have seemingly served only as markers of medicine’s fall as a respected profession. While our professional societies proclaim their social concern through their political lobbying and attendant efforts on behalf of the profession, few of our individual practices look beyond mere business arrangements to wider professional responsibilities.

I come from an academic tradition and practice in a community-based tertiary teaching hospital, so I’ll acknowledge my idealism. Yet in these times we all must be practical. James C. Robinson in "The End of Managed Care," (JAMA 285(20):2622-2628; May 23/30, 2001) convincingly documented a shift to the consumer as the locus of health care priority setting, driven by widespread skepticism of governmental, corporate and professional (emphasis added) dominance. Despite what you may believe, patients don’t come to your ED to see you, most come to your ED because that is where their private physician tells them to go. In communities where primary care is otherwise unavailable, patients come because your ED is where your community-based hospital makes primary care available. A few patients come because your hospital operates a trauma, pediatric or cardiac specialty center. But the patients come to the hospital, not to you.

A year ago in describing a new paradigm for physician leadership "Leading Beyond the Bottom Line" I wrote about physician leaders striving for an optimum balance among the competing goods of financial health, patient care, employee well-being, and community commitment. In our excessive focus on our own financial health through delivery of patient care services we’ve neglected our communities and the institutions that do and will serve them. We’re training a generation of residents and novice practitioners of emergency medicine to set aside the idealism that brought them to medicine. We’ve tipped the balance to the business of medicine as Lundberg feared and we are harvesting the bitter practice environment that Robinson predicts. As leaders we have a responsibility to leaven the practicalities of emergency medicine practice today with the larger professional goal of service.

Yet, most emergency physician practice business models compensate clinical staff at a higher hourly rate than front line physician managers, those physicians with locally based direct operational administrative and process improvement responsibility in the ED. Even though an effective physician-manager enables the clinical staffs’ delivery of improved care and service. Some practices deliberately restrict the funding available for such non-clinical work; subjecting such funding to a vote within the practice is sure to limit support for such investment as long-term strategic planning takes a backseat to more immediate financial self-interest. Such a preoccupation further estranges emergency physicians from their hospital-based colleagues in nursing and administration and neglects the community-at-large.

Some practices and practitioners do reinvest in their hospitals and communities. Whether taking a public health perspective of emergency medicine and addressing under-served communities or engaging systematically in community-based education programs these practices commit time and money in addressing concerns raised by the community they serve. These same and other practices participate in hospital based process redesign so that patient flow improves thereby reducing ED overcrowding. The benefits for the practice are manifold as patients and staff are less harried and hospital administrators can apply scarce capital funds to other institutional priorities. This demonstration of good hospital citizenship can only redound to the benefit of the practice. Learning and professional development opportunities for physicians abound in these groups because this work requires the efforts of more than a single physician leader.

W. Edwards Deming remarked that great leaders almost always get great results, but that was not enough. He asserted that it was the responsibility of great leaders to build systems so that average leaders could attain great results. Without reinvestment by our practices in our hospitals and the emergency physicians who would be our future leaders how will we attain great results (improvements in quality of service and care) for our patients, hospitals and communities in the future?

A comfortable, secure livelihood in a professionally rewarding practice is an accomplishment for all emergency physicians to earn—we’re not entitled to it. Earning that livelihood entails more than delivering good patient care; it requires investment—whether personally or through our practice—in our hospital organization and the community it and we serve.

Doctor William Kissick, one of my professors at Wharton, taught in his health care policy class, "Where you stand (on an issue) depends upon where you sit." So let me disclose that I’m a salaried employee of Maimonides Medical Center, a large tertiary care teaching hospital, where I lead both the clinical and operational aspects of a ~78,000 visit/year ED and its associated ambulance service. I belong to both ACEP and AAEM among other organizations. Given the array of my responsibilities, in the past two years I have worked very few clinical hours—just enough to allow me to examine for ABEM. I’m quite ambivalent about this withdrawal from the "pit," yet I enjoy my managerial role immensely, even as I mourn the clinician I used to be. Hospital employed by contract, our emergency physicians are accountable to me and receive guaranteed base pay and benefits. Additional earnings based on a variety of measures of economic, academic, team-building and less objective measures of productivity and effectiveness have been paid out semi-annually for six years as of this writing. Physician contracts have no restrictive covenants or non-compete clauses but do require that physicians relinquish most of the usual medical staff due process rights; although, they have due process rights built into the contract--the same due process rights I have with the hospital, our mutual employer. All department and practice finances are open to all emergency physicians. I focus my daily work on team building and system building so that our hospital and community may rely on continuously improving service and care.

Friday, September 14, 2001

Team, What Team? We’re fighting like cats and dogs. Can we recover?

This past May 2001 in my column entitled, "Teamwork or Why Did You Come to Work Today?" I wrote of the virtues of true, interdisciplinary teamwork and offered some suggestions as to how you might proceed to achieve that goal. Perhaps some (all?) of you who read that column thought that I had my head in the clouds and that real life never worked as I described. Well, even those of us who aspire to outstanding teamwork are forced to confront ugly realities from time to time and indeed, we’ve had some episodes in our ED these past months, which have been discouraging. Yet, we are not resigned to failure and to the "bunker mentality" where physicians and nurses go to their separate corners and communities to shore up their egos and disparage one another, rather we are re-energized to address our failings anew.

In this column for the past 18 months I’ve tried to encourage leaders to aspire to finer service and clinical performance in their emergency departments. Aspirations and plans are fine and important, but execution and implementation are everything. Realistically, every new effort will fail in some way, small or large. It is how one addresses those failures that can give hope for ultimate success of the effort or lead to disillusionment among colleagues and ultimate failure of the leader’s vision.

I’ve been extraordinarily fortunate to work with a wonderful team and this month I’m asking Barbara Sommer, RN, CEN, CNA, MA, Director of Clinical and Administrative Operations at Maimonides Medical Center Department of Emergency Medicine to share her thoughts on our communication and teamwork failings and our plans for renewed efforts at team-building.

Excellent customer service for our patients, their families and the community comes out of quality care and excellent communication with our workplace colleagues. Using our customer service skills in communication with our colleagues in the workplace, especially active listening skills helps develop partnerships between physicians and nurses. Through active listening we demonstrate concern for and understanding of the other professional’s point of view and thereby bring both our minds and efforts to bear in providing quality care to our patient. Unfortunately, we’ve recently experienced two episodes where active listening was pushed aside as if only one professional’s view mattered, in so doing; the nurses’ concerns for the patient were demeaned. Was it not for each nurse’s strong personal commitment, serious consequences would have befallen these patients.

The first instance involved the dosage of a medication and the second involved a treatment. In both instances the nurses’ question was taken as a challenge, rather than an effort at clarification or initiation of a professional dialogue. Each nurse was discouraged by the physician’s response and feeling uncertain and insecure, sought support through discussion of the problem with their colleagues. Fortunately, because of our management structure, colleagues in our department include the senior physician leaders as well as our nursing colleagues and nursing management staff. Thus, despite the initial blow to professionalism and professional self-assurance experienced by these nurses, we’ve been able to help them understand that their questions were asked on the patients’ behalf and thus were not only appropriate, but also necessary. This support from senior physician and nurse leaders was our key to reducing resentment among nursing staff who otherwise may have built greater barriers over the issue. But what of the physicians involved?

Unfortunately, neither physician acknowledged either their behavior or their potential error to the involved nurse. The physician involved in the potential medication dosing error kept his own counsel and the physician involved in the other episode later acknowledged in an email to our medical director that the nurse’s suggestions may have had merit and greater patient benefit than his own approach.

These failings of communication and perhaps professional maturity force us to acknowledge that we must do more to improve communication among our staff and customer service behaviors. We will make improving communication and these behaviors a departmental priority in 2002.

We approach this challenge recognizing that changing what is in each professional’s own mind is not our task; it is their behavior we wish to change. Behaviorism may or may not fit with your approach to management, but training staff members to behave in a particular fashion in a particular situation, coupled with regular reinforcement has been shown to change behaviors and hold the change as staff members themselves recognize improved results, usually gaining job satisfaction as a consequence. There are different approaches for improving communication among professionals who work together and establishing the team-building, nurturing and listening environment in the workplace.

MedTeams™ has gained great recognition of late for its data-driven development and focus on reduction of errors specifically in the emergency department. If you are looking for an "evidence-based" approach you probably can’t do better than this rigorous but expensive program.

Yet, fundamental customer service skill courses whether offered by Disney, Ritz-Carleton or a more locally/regionally based training organization may be as effective in inducing the behavior changes you seek. While the course content differs, the training goals and the process of training all disciplines together are similar. Focusing on the specific forms of communication most effective in facilitating patient care, reducing error and supporting professionalism, team-building and mutual regard; customer service skills training backed up by continuing reinforcement inside the ED, establishes the team environment and identifies appropriate behaviors. Consequent to the change in behavior, professionals develop both a sense of accomplishment about their patient outcomes—including quality of service and patient satisfaction—and mutual respect among the professional clinicians and technicians at the bedside. This improved staff satisfaction improves external customer—our patient’s—satisfaction.

Leaders acknowledge failures of implementation quickly—"Fail fast." I was taught. Yet if accomplishing your vision is important to you, choosing another approach, including going beyond your own efforts and seeking the help of outside experts is not evidence of failure as a leader, rather it a sign of personal and professional maturity, subordinating one’s ego to the needs of the organization. Just as the physician who is open to learning—indeed, "correction"—from a nurse colleague, enhances patient outcomes and safety.

Tuesday, August 14, 2001

Charting for Patient Care—Is There Only One Way?

A recent issue of The Journal of Cost and Quality included a letter from the editor; Bruce Gipe, MD; about charting (sorry, the link is no longer active) in which he questioned the use of template charting and asserted that "templates are robotic; narrative charts try to tell a story." Doctor Gipe followed with, "I can’t prove this, but the process of actually writing things down seems to result in thought, questioning, introspection, review (‘If I write this Assessment down, can I actually defend it, based on the data noted in the rest of the chart?’). Doctors are supposed to think, question, review, muse—that’s what we were trained to do, that’s what patients want us to do for them. To be, or not to be—a robot—that’s the question."

Why do we have to define things as "either-or?" Why do we have to prescribe only a single approach? Why do we insist that "Doctors are supposed to think, question, review, muse . . ."? Consequently, concluding that templates are bad and dictation or legible handwriting is good. Why can't we use both, each in its proper role? Why do we as leaders create this and other false dichotomies?

In these pages commenting on quality of care (QoC) as a subset of quality of service (QoS), this past April, I asserted, "The debate is long over because reliable measurement of quality-of-care remains elusive, while quality-of-service measurement has become codified for the ED through the institutionalization of patient satisfaction surveys and measurement of patient throughput intervals."

Perhaps as professionals we've convinced ourselves that our patients want us to think, but is that always the best way to deliver and document the care as our patients seek it? I'm not so sure. From my perspective as Chairman of a busy, urban ED what I hear from patients and their families and what I’m persuaded our patients really want—at least in the ED—is expeditious, compassionate, clinically appropriate and correct care delivered without error.

Some fraction of care delivered to patients in any setting is "routine." In many emergency departments it may run as high as 80-85% of patient presentations. Feel free to argue with my estimate—that’s fine, but don't argue the number to dismiss the point that clinically routine care is best delivered in a clinically routine fashion and documented accordingly. Now, that doesn't mean unthinkingly. To the contrary, it means that best practices have been identified, codified and taught to the care providers: physicians, mid-level providers, nurses, techs, etc. Furthermore, care is monitored to assure that the best practices are adhered to and best practices are monitored to assure that complacency doesn't overtake excellence, since we know that best practices evolve based on science, patient preference and practice.

Note that I've focused first on clinical aspects of delivering care. I did that despite the fact that patients are mostly not judging that aspect of care—in the ED. Most ED patients have come to assume that the care available to them is clinically appropriate and that emergency physicians are pretty much all capable of delivering clinically appropriate, correct care. You and I may disagree, but most patients won't, until they have a life-threatening illness and then they’ll research where to go for care on the Internet. For most ED visits, they won’t, not yet, anyway.

Organizing to deliver and document clinically routine care "routinely" allows for the building of system efficiencies that enable both excellent QoC and excellent QoS. This is where reduction in variation directly benefits patients by allowing physicians the opportunity to think about their patient, not about their chart. Yes, I believe physicians should think, I just don't believe that every patient encounter—especially not the "routine" visits—requires a Pulitzer Prize winning chart. This opportunity to think about the patient, rather than remembering what and how to chart, may allow for recognition of a disease pattern—a thinking function at which the human mind excels—which otherwise would be overlooked, suppressed by the necessity of remembering—a thinking function at which the human mind frequently fails.

If physicians would more generally adopt systems that allowed for routine accomplishment of routine work—including documentation; I believe physicians would find themselves liberated to expend their greatest energy, intellect and knowledge on behalf of those patients whose problems are not routine—and better recognize when that is the case. Some patients do require the most profound, thoughtful and creative professional effort of the physician to garner the best possible outcome for the patient. I believe that most emergency physicians would find practice in this manner challenging, fulfilling and less prone to the pitfall of narrow diagnostic focus.

I believe it is the responsibility of physician leaders to bring this message to the profession and to help individual practitioners, groups and other practice organizations adopt the tools that facilitate continuing improvement of QoS and QoC for "routine" patients while enabling physicians to expend enormous best efforts on behalf of those—fewer in number—whose clinical circumstances and complexity require remarkable efforts for best possible outcome.

No service organization uses only one process to address all users all of the time. For example, when occasionally the magnetic ink on your check isn’t readable your bank processes that check with extra steps, requiring a clerk to attach a strip with the same characters that are magnetically readable. This "exception process" may only apply a tiny fraction of the time, but it’s necessary to deliver full-service. The bank makes no false dichotomy and no false economy by omitting this step when necessary.

So too, we, in emergency medicine, must not omit necessary steps nor create a false dichotomy by insisting that documenting our care must always be done in the same way. Yes, our patients require our consistent best efforts, but mostly those efforts are best documented through a structured process that supports systematically organized, highly consistent evidence-based care readily available, delivered by affable and able emergency physicians who do their work quickly. Nonetheless, in exceptional circumstances, as we deliver the most profound, thoughtful and creative professional effort on our patient's behalf, we will find structured tools—template charting—limiting. We will need more—typewriting, dictation and transcription or handwriting. Why can’t we fit the tool to the circumstances? Why can’t we have both?

Saturday, July 14, 2001

Patients are waiting. There are delays in my ED. And I’m doing something about it. - Part 2 (of 2)

Last month I wrote about some of the ways you might measure how long patients were waiting in your ED. This month I’d like to suggest some approaches to reducing the waits and delays your patients experience and your community fears.

While many different approaches to evaluating and reducing waits and delays have been used, probably one of the best breaks the patient care episode into three periods. Everyone at Maimonides Medical Center knows that we track "T1, T2 and T3." These three intervals mark the period from patient arrival until first physician contact, initial physician contact until a disposition decision is made and lastly the period from disposition decision until the patient physically leaves the ED. Various consultants use a variety of terms, the Advisory Board Company for example names the same three intervals in terms of their recommendations for improvement: "Expediting Time to Physician," "Expediting Diagnosis" and "Expediting Inpatient Admission." Of course this leaves those patients who are discharged—usually the majority of those patients seen. Perhaps this is not an issue in your ED, but in ours, where our physicians teach the patients, handing the printed discharge instructions to the patient, this is an issue.

Your efforts at reducing waits and delays should be focused where you’ll gain the greatest benefit, but it’s important to be practical and for most of us it’s more realistic to start with processes that take place entirely within the ED rather than processes that involve outside departments. Clearly, if everything in your ED is running perfectly, except for the interval to get a chest x-ray or CBC, well then you have to go where to the problem. But for most of us, working to reduce "T1"-the period from patient arrival until first physician contact is a good place to start, because while it involves workers who may have different managers or supervisors, the workers are all based in the ED and are accustomed to working together. Both of the other intervals require working with personnel based in the lab or radiology departments (if addressing "T2") or on the floors (if addressing "T3"). Starting in the ED says to others that you are serious about first cleaning up your own mess.

Among the most commonly adopted approaches to reducing "T1" is bedside registration while the patient would otherwise be waiting. Not sending the patient back to the waiting room after triage also gives the patient the sense that they are moving forward in the process of care. Instead, with the patient on a stretcher, register the patient. If your ED is low-tech, a clerk can do this with a form, interviewing the patient and entering the information into the computer at a later time. If your ED is high-tech, the clerk can use a wireless-networked workstation wheeled up to the patient’s bedside. If space and funds are available, a PC can be placed at each patient care location, but based on experience I think this is the least useful approach as crowding often makes it difficult to reach these. But perhaps that’s just Brooklyn and your ED isn’t that crowded (tongue firmly in cheek). Electronic medical records impose their own banal logic on registration, as many systems won’t allow entry of orders or observations prior to patient registration. The electronic handcuffs thereby applied may force registration earlier in the process of care. An abbreviated triage with a short registration entered by the triage nurse solves the problem.

The key factor here is using the waiting time productively. Many opportunities for using waiting time exist early during the patient’s ED visit. A brief triage followed by a more complete assessment by the first available practitioner, whether physician or nurse can facilitate the ordering of laboratory tests or imaging studies through either physician order or nursing initiation of standing medical orders by protocol. In either case, the results will be available sooner than waiting for complete physician assessment. The downside of over-utilization is a risk of this early testing strategy, but monitoring with feedback to the entire group can mitigate the problem through the "Hawthorne Effect" and the tendency for any group of people to modify their behavior to be in-line with that of their colleagues.

Brief triage reduces waits by freeing the triage nurse for the next patient, thereby reducing the waiting time for triage itself. You may not be aware of this wait, I’ve not described it above and we’ve only started to track it, but this "T0" the period from patient presentation until triage can be a cause for significant patient displeasure and morbidity. Both reticent patients, and those seriously ill, may not make enough of a fuss to receive an urgent response and while waiting quietly, deteriorate.

Another intervention, though not reducing the "T1" interval will reduce the "T2" interval. Many times patients wait for the physician to make a decision even though laboratory results have become available, but the physician is not aware of them. Bringing the lab results directly to the physician along with the chart can reduce "T2" as absent an electronic tracking system, the physician must periodically check to see if results are back from the laboratory thus interrupting other patient care work. By knowing that the results and the chart will come to her when results become available, the emergency physician will interrupt other work less often and through the prompting provided by the chart and results together will disposition the patient that much sooner.

Reducing waits and delays not only improves your patients’ experiences in your ED, your Emergency Department’s standing in your community and your administration’s perception of you, but it also provides you with the capacity to see more patients. Since as patient move through more quickly you open up space to see the next patient, surely an effective response to the continuing growth of volume in most of our EDs.

Thursday, June 14, 2001

Patients are waiting? There are delays? In my ED? I’m shocked, shocked! - Part 1

But are you? As patient volume climbs and primary care providers and consultants become ever less available, waiting in the ED stretches on forever, or seems to if we listen to our patients’ complaints or review the results of recent satisfaction surveys. You have heard this, haven’t you? Hasn’t your administrator brought you recent results of the hospital’s patient satisfaction survey from the winter just past and wasn’t ED waiting time one of the hospital’s lowest rated measures?

For over one year now I’ve been encouraging you, gentle reader, to measure various facets of what goes on in your ED. Patient time in the ED is only one measure, but one very much on the minds of your patients and your administration. As I described two months ago in the April 2001 column, patients are "demanding excellent, speedy, available convenient health care." Your administration, which is actively competing with nearby hospitals, is looking for the same.

Measuring the patient’s "registered time in the ED," "waiting time" or "throughput interval" is the first step towards addressing it? How are you measuring and reporting this parameter at your hospital? Unfortunately, many of you, with the poor quality tools available can only measure pretty broadly—for example from patient arrival until patient discharge. You may not be able to group patients by disposition in our measurements and most assuredly you don’t measure and report patient time in the ED in percentiles, but more likely only as an average. Reported as an average, this measure is not merely insufficient, but misleading, but is often all that’s available from your systems.

Why should you measure and report your "throughput interval" in percentiles rather than as an average registered patient time in the ED? Because averages assume a uniform "bell-shaped" distribution and we all know that some ED patients spend unusually long periods in the ED, in fact we call them "outliers." Percentile reporting permits the acknowledgement of outliers yet allows for tracking and management of service performance.

For example, most of you can recall when going to the bank meant choosing a teller’s line, getting into it and immediately regretting that you had not chosen a different line. About 15-20 years ago many banks began implementing a single queue for all waiting customers and as a result, we all got to the front of the line faster than if we had chosen a "slow teller" but perhaps not as fast as if we had luckily chosen a "fast teller." What does this observation have to do with measuring ED patients’ "throughput interval?" Well, your bank has a standard for customer waiting time in line and the people who work in that branch know at what point in the queue the standard will be breached. The bank has set a customer service standard for example (this may not be true for your bank) that 85% customers will get to a teller in 10 minutes or less and the branch manager knows at what point on the queue that standard will be breached. Typically, the branch manager or teller supervisor will open another teller window as the waiting line of customers approaches that point.

Ah you say, now I understand, if only the airlines operated that way. Well, they do, they just set their standard much lower, perhaps as low as 70% of customers waiting 20 minutes or less.

Getting and analyzing data in this way is easy with an ED information system, but difficult if the only automation you have is the hospital registration system. Of course, measuring patients’ registered time in the ED does nothing to get at the causes for it.

Another way of getting at the same idea is to look at preset intervals. Some hospitals have learned to report this interval in multi-hour "chunks." Intervals of less than two hours, two-to-four hours, four-to-six hours and over six hours are often used. One can then describe the fraction of the total patient volume (percentage of patients) whose registered time in the ED falls into each of these tracking periods. This is the approach to reporting at the QI Project® for registered patient time in the ED.

If you’ve been reading my column over the past year, you’ll recall that I’ve extolled "base-lining" and discouraged benchmarking. So why do I point you to the QI Project®, a benchmarking site? Mostly so that you can consider adopting the definition they use and also so that you can determine if your hospital is one of the 1500 or so hospitals that report data to this consortium. If so, it will make your measurements, the first step to improvement, easier.

In the examples of the bank and the airline counter I describe different standards. Setting standards is a rather foolish way to operate. It is what your administration does when without consultation with you and consideration of the ED’s capacity to adhere to the standard, your administration advertises, for example, that all patients will be seen by a physician within 30 minutes of arriving at the ED. Here, the standard is that 100% of patients will have a waiting time of 30 minutes or less to see the physician. Is that achievable? Yes, but not unless your ED has the capacity to perform at this level and few do, though many can be improved—over the course of years—to meet or even exceed this level of performance. Knowing where you stand today is the first step and one well worth undertaking for it tells your administration that you intend to actively manage this measure of quality-of-service.

Next month I’ll address what some hospitals have accomplished in reducing the patient "throughput interval." In the meantime, you might determine if your hospital shares data with the QI Project® or belongs to the Advisory Board Company, a research and consulting organization to which about half of the hospitals in the country belong.

Monday, May 14, 2001

Teamwork or Why Did You Come to Work Today?

Times are tough in our Emergency Departments and not likely to improve for a while. We’re all doing too much with too little, too many patients waiting too long for some portion of their care in too crowded spaces while too few professionals try to keep the patients "safe" and family and friends informed. Every winter, this past one included, the local and national press seems to discover just how crowded our EDs have become and just how stressed we who work in them feel.

Recent predictions of a worsening shortage of nurses trumpeted by the general press seem laughable to those of us who have been working in EDs that have had vacant nursing positions for more than two years. Overtime hours for our nursing staff, short-staffing and "coverage" by agency nurses in an effort to fill that gap just add to the stress. Emergency physician practices are seeing shrinking income for many reasons including insurers denying claims, even when submitted with a copy of the chart, because despite state level "prudent patient" laws and regulations if the insurer holds onto the money longer, they benefit from the "float" and perhaps you won’t appeal because of the cost in your time and billing expense. Reduced practice income translates into physicians working longer hours in order to maintain income or holding off adding an additional physician to the group, even though growth in patient volume may warrant it.

Most EDs in the country are staffed with hospital-employed nurses, clerical and technical personnel. Outside of the Northeast and academic health science center hospitals, most emergency physicians work for themselves or for a contract group that may staff one or hundreds of hospital EDs. It’s been said by some that, "Nurses run the ED, physicians just work there." Still others have pointed out, "Emergency Physicians enjoy a truly collaborative practice and this is what drew many of us into our field." What are you as the leader doing to support your entire team?

In 1994 I began working with the Institute for Healthcare Improvement Inter-disciplinary Professional Education Collaborative, and despite 19 years of emergency medicine experience as a resident and attending physician, I came to learn for the first time the true nature of an inter-disciplinary team and inter-disciplinary collaboration. Few readers will have the same opportunity, yet all of you reading this, practice collaboratively to some degree in your ED. How can you improve upon the collaboration—the interdisciplinary team—that currently exists for the benefit of both your patients and yourselves?

In my October 2000 column I urged cooperation with your ED nurse manager in refining the details of documentation, both physician and nursing, that would support appropriate billing of ambulatory payment classifications (APC) for hospital payment for ED services. More recently, we’ve all enhanced our assessment and management of pain for all patients, an effort that required collaboration among all ED staffers.

These opportunities for collaboration are a continuing reality in our professional lives and they provide the opportunity to go beyond bedside collaboration to a true inter-disciplinary team building effort in which mutual respect and support are the goals. These opportunities allow us to "walk a mile in the other’s moccasins" not so that we can learn what it takes to perform nursing duties, but rather so we learn how truly different and difficult those nursing duties are and therefore why we must partner with nurses.

Nursing is not practicing medicine and as a physician, you and I intelligent, well educated and medically trained as we may be simply do not know what goes on in both the training and acculturation of a nurse anymore than a nurse understands these same experiences and perspectives in a physician’s life. Oh, there are always exceptions: nurse-physician couples with exceptionally good communication skills and receptivity to one another’s viewpoint or the rare colleague who practiced as an emergency nurse before going to medical school and who now practices as an emergency physician. And while I won’t discuss it further, the same issues pertain among all specialized employment groups that work in your ED including clerical staff, tech staff, pharmacy staff, environmental services staff and others.

Step one to building an inter-disciplinary team is truly acknowledging nurse to physician and physician to nurse, out loud and in public, that neither truly understands the other’s training, practice culture, legal and regulatory concerns among many other issues. Why out loud and in public? Because once stated in this way, there’s no going back to the old way of doing business. Once stated this way, you’ve essentially agreed that you each must engage the other in addressing your issues because you’ve agreed that you need the other’s "take," i.e., viewpoint on whatever it is you’re addressing. From this foundation a new relationship can develop if you will work at it. Would alternative management structures help? Certainly, but ultimately success here rests on person-to-person relationship building. In the ED where care of patients is our agenda, building that effective relationship—the interdisciplinary team—must be on our agenda.

Ideally, the respective physician and nursing leaders should make the statement together and to a joint gathering, reinforcing the position by on subsequent occasions and individually, slowing the rush to complete a project until the other is engaged. For example, discussion at a physician staff meeting to start shifts 30 minutes earlier to facilitate morning commuting could bring up the comment from the meeting leader, "I’ve no problem with that, but perhaps we should engage the nurses before we commit to the change." Then engage in a meeting—not merely "on the fly"—the nurse manager, the evening or night shift charge nurse or both and staff nurses so as to get the widest range of opinion. Meeting with the physicians and nurses together is better, yet, but usually entails involving representatives of the groups rather than the whole staff.

Inter-disciplinary teamwork begins by acknowledging the expertise and necessity of the "other" and builds through engagement in progressively more complex problem solving. While in the main, physicians give treatment orders and nurses implement them, smooth operations in the ED come not only from each knowing their role, but also from successful, trust-building work that acknowledges one another’s unique expertise and culture. Achieving those successes in a structured, non-clinical setting will carry-over to the patient’s bedside.

Saturday, April 14, 2001

Public Accountability and the McDonaldization of Your Emergency Department

Controversy is useful when it leads to learning and useful changes, less so when engendered merely for its own sake. My title this month coupled with my opening sentence probably has alerted you that what follows in the body of this column may be provocative. I seek neither your concurrence nor your disdain publicly expressed; rather, I encourage you to discuss what I raise here with your colleagues if you are so inclined, for it is most likely through that discussion that learning and change, hopefully useful, may follow. Remember too, the aphorism attributed to Walter Lippmann, a great newspaper writer, "When all think alike, no one thinks very much. "

Last month, in writing about the "Emergency Medicine Continuous Certification (EMCC)" program of the American Board of Emergency Medicine, I went on to discuss lifelong learning but only after acknowledging the development of the EMCC program as at least in part a consequence of the public’s demand for physician accountability. This month I thought to extend the idea of public accountability to the "McDonaldization" of the ED, a topic recently raised on the emed-l mailing list (subscribe by sending "SUB EMED-L your name" without the quotes to or go to the subscription page at NCEMI.

A physician, whose contributions to the list have been frequent and valuable, broached the topic by reporting a radio news story about an ED that offered movie tickets to any patient who was not seen within 30 minutes of arrival. This list correspondent then went on to discuss his concern that quality was now being assessed by hospital administrators through "speed-of-service" first and "quality-of-medical-care" second. Over the ensuing five days more than two-dozen additional postings by generally indignant emergency physicians mostly agreeing with, adding anecdotes of their own and extending the arguments of the initial poster were added to the list.

I was astonished. This outpouring of emotion over a legitimate effort at improving the competitive position of a hospital surprised me. Aside from failing to recognize that competition for patients among hospitals is very much the norm in any community with more than one hospital, it seemed to me that these emergency physicians had forgotten that our specialty developed consequent to public demand for just the service that had precipitated the passion: readily available quality medical care. In the late 1970’s, many of our leaders who were seeking the sanction of organized medicine for our specialty were proud to assert public demand as measured by increasing numbers of ED visits as evidence of need for our specialty.

The debate is long over and both quality-of-medical-care and speed-of-service have won, but relying solely on the former and ignoring the later will assure that you as a provider or your group practice as a contractor will not long succeed in the current and likely future environment of practice for emergency medicine. Setting this false dichotomy in place is a diversion that will in the long run reduce your credibility in your hospital.

For nearly a decade now I’ve been troubled by what I was told by one of the former (now discredited) leaders of my former employer, the Allegheny Health, Education and Research Foundation. He said, "Steve, the chefs don’t run McDonalds." in response to my question as to the opportunities for physician-leadership of operations inside our healthcare system. He pointed to an example, nearly identical to the one I recount above, demonstrating that physicians insist upon setting quality-of-care and quality-of-service at odds with one another rather than embracing both as legitimate measures, each insufficient without the other.

The debate is long over because reliable measurement of quality-of-care remains elusive, while quality-of-service measurement has become codified for the ED through the institutionalization of patient satisfaction surveys and measurement of patient throughput intervals. The assumption on the part of hospital administrators has become that quality-of-care is a given, it is what it is and it is sufficient. Yet, quality-of-service matters because among the public, quality-of-service distinguishes one ED from another. Lamenting this state of affairs won’t change it. The pronouncements by study groups based on limited findings of clinical superiority of trained and/or board certified emergency physicians won’t change the view of hospital administrators, even though you and I may believe the conclusion.

No, I don’t propose giving up, taking my ball and going home to lament our fate. Rather, I urge you to undertake the effort described exactly one year ago in my first column: measure operations performance in your own ED as a first step to improving it.

My professional activities for most of the last decade have been a living rejoinder (at least in my mind) to the administrator who rebuffed my interest in operations leadership nearly a decade ago. So too, your active participation in solving the problems that plague your hospital today will gain you the power to influence your hospital administrator’s agendas. Dismissing your administrator’s concerns about competitiveness, market share and revenue growth as ludicrous, insulting or trivializing of emergency physician’s professional services will only add to the barriers between your hospital and you while empowering the corporate staffing companies which understand these concerns and often partner effectively with hospital administrators in addressing them.

Few emergency physicians add to their professional agendas both the management and improvement of quality-of-service in the ED. Whether the time is volunteered (unlikely) or compensated (usually at less than the clinical service rate) working alongside the hospital administration in improving quality-of-service without setting this effort against quality-of-care is essential to gaining an opportunity for participation in setting your hospital’s marketing and advertising agenda.

Hospital administrators today have just begun to acknowledge the same public demand our specialty’s founders heard more than three decades ago. The public began demanding excellent, speedy, available convenient health care decades ago as I learned on entering emergency medicine residency in 1975. I was told that success in emergency medicine would be conditioned on achieving "four-A’s" and that both my chosen field of emergency medicine and I would succeed through "availability, affability, alacrity and ability" in that order. My experience over the past quarter century has born out the wisdom of my teacher.

Wednesday, March 14, 2001

Lifelong Learning, the Key to "Preserving the Passion"

I’ve been hearing from colleagues who have asked me about the "Emergency Medicine Continuous Certification" program of the American Board of Emergency Medicine, which was announced in the Fall/Winter 2000-2001 issue of the ABEM Memo a publication mailed to all ABEM diplomates and others associated with the ABEM. The Board’s early sharing of information and the detailed description of the proposed process, along with candid acknowledgements of methods yet to be developed and work yet to be done gives me confidence that standards are being upheld, yet the impact of this new process on diplomates has been and will continue to be considered.[1] Questions about specifics of the program and your comments are best addressed to the ABEM, either by letter or by email. (The details of the EMCC program have been updated since original publication of this piece.)

The EMCC will entail annual self-assessment testing following review of "Board-selected literature on specific topics in the specialty." I suppose all of us certified by ABEM will find ourselves engaging in review of the same content more-or-less at the same time, whereas presently we pick and choose among many formal and informal CME content providers. Unquestionably, the real and growing public concern about physician knowledge and skills is appropriately enhancing attention to physician accountability both as directly transmitted to the ABEM and as manifested by other components of medicine’s private self-regulating specialty structure. Yet, most of us have managed to stay current without the encouragement of EMCC. While I support this pending and timely implementation of EMCC, I can’t help but admire my many colleagues who continuously strive for excellence by engaging in their own "lifelong learning" plan.

In conversations with colleagues prompted by the ABEM newsletter, we have frequently moved into discussions about "keeping up." For those of us in academic centers or regularly engaged in teaching residents and students, keeping up is part of our daily work and daily challenge and motivation is regularly provided by the bright, aggressive resident who wants to demonstrate that s/he can "out knowledge" us. But as I speak to those of you practicing in the majority of EDs across the country, I’m constantly humbled by the efforts you undertake in "keeping up."

Marcus Reidenberg, an internist and clinical-pharmacologist who taught clinical correlation sessions during my pharmacology course in medical school, recommended a three-part approach to keeping up with new pharmaceutical developments: a medicine text, a pharmacology text and a subscription to The Medical Letter. With ever more therapeutic agents available, it has been challenging even in hospitals with a strong formulary system where one only has to learn a single H2-blocker or third-generation cephalosporin and while I’ve stopped buying the two textbooks, for more than 25 years now I’ve subscribed to The Medical Letter. Arriving in it’s usual 4-8 page (rarely more) format every two weeks, I can honestly say it is about the only publication that doesn’t get "stacked" before it gets read, and mostly I read it cover-to-cover. With The Medical Letter and a drug database in my Palm™ I seldom am taken by surprise by a new drug.

As I’ve become more of a physician-executive and less of a clinician-educator, I’ve found my time for reading the medical literature more and more limited; or maybe it’s the recent requirement for reading glasses that has driven me to replace music on the audio tape/CD player with audiotape based CME. I won’t tout any particular provider of audiotape programs, but I’ve found these tapes to be a wonderful way to spend time during my regular train commutes between Philadelphia and New York.

On summer vacations and other longer trips, when the occasional opportunity to read presents itself far from the stack of journals in the corner, what do you read? Over the past 20 years I’ve become accustomed to carrying The Yearbook of Emergency Medicine in my bag.[2] Whatever works for you, it is certainly useful to have a single volume to carry on a longer trip that can be read in "small bites."

Does everyone in your group keep current or do you as the group leader cast about for ways to help your colleagues keep learning? Medical Staff CME requirements are a potent inducement for gaining minimal compliance, but are your colleagues really learning what will be most useful to them in their own practice? Probably not if their CME is devoted to only one or two trips to courses or symposia; probably yes if they add to this general learning reading and study about the difficult clinical problems they have faced in giving care in the ED. Research, which examined the daily practices of exceptional physicians, has identified the combination of general topic CME with patient-oriented study as leading to the best results in "keeping up."[3]

The addition of this "practice-based CME" whether formally recognized for credit or not; though practiced as a student and resident by most of us is only variably carried on by practitioners. Too rare is the practice, common in sports, of inviting observation of even simple commonplace activities such as performing a physical examination or eliciting a patient’s history. Yet every great sports figure is supported by coaches who commonly drill those they train in the fundamentals. As Manning and DeBakey point out, "The things that human beings do best they do every day. You will therefore practice better medicine if you engage in daily study and daily evaluation of your performance."[4]

Just as many of you have adopted computer technology creatively to enhance your learning and patient care, so too must all of us who practice medicine adopt learning and evaluation strategies that give the public confidence that our intent to do good for our patients is supported by expert knowledge and skill.

[1] Disclosure: I'm a senior director of ABEM. Which means in English that I was a director (1986-95). I currently do oral exams for the board. I was trained in EM finishing in 1978, first certified by ABEM in 1980 and recertified in 1990 and 1999.

[2] Disclosure: I was an Associate Editor of the Yearbook of Emergency Medicine from 1980 through 1999 and received royalties based on sales during that period. Former colleagues of mine presently edit the publication.

[3] Manning PR & DeBakey L: Medicine-Preserving the Passion. Springer-Verlag, New York, 1987.

[4] ibid, page 276

Wednesday, February 14, 2001

Emergency Medicine and Internet Technology: Here Today, More Coming Tomorrow

Technology has always fascinated me. I built Heathkits in my early teens and received my amateur radio license before I was 14. But I’m not you and many of you tell me that you’ve only just come into using a family computer to browse the web and only rarely do you check your e-mail. At a recent gathering one long-time colleague confided that he had only recently decided that computers were not just a fad and that he was going to have to learn to live with them.

In this space in the June 2000 issue, I presented an overview of some issues relevant to selecting an ED information system. I don’t intend to reprise that here; rather, I thought I’d share some of the sites that I’ve learned from in recent months or used as a clinical reference both in delivering care and in case review. If I’ve not included your favorite site please don’t "flame[1]" me.

The National Center for Emergency Medicine Informatics is the one site I suggest everyone in emergency medicine explore first. This site is a wonderful "home page"[2] for your favorite workstation in your ED if you don’t already have a standardized home page. Among the many fine tools on the page, "MedBot" a search tool focused on a dozen or so medicine sites pops up a friendly window for your search terms while keeping the main page visible. Another area of page offers "Medical E-tools and Calculators" including algorithms to compute GI bleed complication risk, hypernatremia treatment, and hyponatremia treatment along with a bradycardia treatment algorithm and a rash diagnosis algorithm.

When away from the ED and direct clinical care the NCEMI site still holds my interest for both its daily and weekly educational and amusing nuggets including aphorisms, eponyms, cartoons, phobias and questions. The overview of the current literature relevant to emergency medicine through the "Daily Sample" column frequently prompts me to start reading an article that I then finish in the journal that had been sitting on the pile by my desk. Many other features may appeal to individual users including the ability to customize the NCEMI homepage with your most used links.

Jeff Mann in his "Site Philosophy" describes his EM guidemaps as "quick-to-read" references that can help neophyte emergency physicians optimize their clinical practice of emergency medicine. Doctor Mann explains that, "My EM guidemaps should be seen as a supplementary informational tool - specifically designed to help you manage acute clinical problems in the ED setting. They are based on a combination of my evidence-based medical knowledge and my personal experience, and they reflect my problem-solving approach to acute medical emergencies. These ready references provide a pared down how to get through the night quick hit of practical wisdom. Don’t confuse these few dozen screens that cover selected ACLS, medical, toxicological, neuro-opthalmological and trauma topics with a comprehensive text, but when you find yourself with a hole in your brain for the evaluation of a patient with for example, diplopia, Jeff Mann ’s guidemap will help you care for the patient with just a quick read of his site.

One of the external sites that we in the Maimonides Medical Center ED use extensively is the emergency medicine on-line text, Emedicine. This commercially supported site (multi-million dollar investments by pharmaceutical and health-care advertising firms) is the home of multiple texts in many areas in medicine, but the emergency medicine text was the first one. The text chapters are well organized with a front-page folder screen allowing easy selection of top-level topic (Allergy and Immunology, Cardiovascular, Dermatology, etc.) and a frame down the left had side of the screen for sub-topic: Aneurysm, Angina, Aortic Regurgitation, etc. The chapters include prominent notice of date and time last updated. Many of the chapters I recently browsed had been updated within 8 weeks of the time I am writing this column.

Another site, EMedHome offers regularly updated content, free CME and has recently implemented a relatively inexpensive CME program in support of the ABEM Life-Long Learning and Self-Assessment program of the Emergency Medicine Continuous Certification program now required of all diplomates. The longstanding, regularly updated "database" of Adobe Acrobat documents described as Protocols, Algorithms, Sample Orders, and Guidelines remains available for download, printing, and distribution. This site has some advertiser support but explicitly asserts its editorial independence.

What if you don’t have Internet access in your ED? While wireless alternatives are available, your hospital should be importuned to support Internet connectivity from your ED as a matter of patient care. Looking up references in the hospital library, no matter how nearby is not the same thing as pondering the advice from any of these sites with the chart in your hand and the patient visible across the ED. Almost certainly you have one or more computers in the ED that could have a web browser installed and a network connection upgraded to include Internet access for negligible expense. Build a coalition of your colleagues, including nursing staff, before you approach hospital administration with your request. Point to this article as describing current practice and request basic Internet connectivity as a tool for patient care.

Today, access to clinical references over the web as described above is the routine in many emergency departments. As hospitals, even small hospitals, implement electronic medical records through the web the Internet and the web browser will likely become important tools for organizing, tracking and documenting care delivered.[3] Applications supporting scheduling and tracking of residents’ hours and demographic, education, evaluation and procedure databases have already come to the web at for example GME Toolkit from Dataharbor.

The Internet and computers are not a fad. Those of us in leadership positions who’ve yet to embrace the web, should begin exploring it at once. I’m proud of my colleagues at Maimonides who have bought home computers and typing tutor programs and have begun learning their way around the web. Just as they learned to read head CT scans long after residency, so too are they learning to navigate the web. When will you?

1 To send an offensive email message or newsgroup posting, especially one containing strong language and personal insults. Compact American Dictionary of Computer Words. Copyright © 1995, 1998 by Houghton Mifflin Company.

2 For a Web user, the home page is the first Web page that is displayed after starting a Web browser like Netscape's Navigator or Microsoft's Internet Explorer. The browser is usually preset so that the home page is the first page of the browser manufacturer. However, you can set it to open to any Web site. For example, you can specify that "" or "" is your home page. You can also specify that there be no home page (a blank space will be displayed) in which case you choose the first page from your bookmark list or enter a Web address. Compact American Dictionary of Computer Words. Copyright © 1995, 1998 by Houghton Mifflin Company.

3 An application service provider (ASP) is a company that offers individuals or enterprises access over the Internet to application programs and related services that would otherwise have to be located in their own personal or enterprise computers. Sometimes referred to as "apps-on-tap," ASP services are expected to become an important alternative, especially for smaller companies with low budgets for information technology. Definition copyright © 1996-99 by Inc.

Sunday, January 14, 2001

Community Engagement

I've asserted that "all emergency departments are local" and that among other attributes, leadership entails involvement with your community. Several months ago in discussing the concept of the pareto optimum, I briefly discussed, but didn’t detail, engagement with the community you serve. Engaging your community goes beyond the minimum of delivering excellent clinical care in your ED, it is a value-added service that helps you demonstrate to hospital administrators that you think in terms of the big picture and not narrowly, only in your own financial interest. Of course, contributing to the quality of the relationship between your hospital and your community is very much in your self-interest.

Regardless of whether your ED is in competition with nearby hospitals or yours is the only ED in town we know that while the expression might be a cliché, the ED is truly the bridge between the community and the hospital. How can you as an emergency physician support that bridge? The key is becoming known for your support of your community’s agenda both within and outside of your hospital.

Most folks are preoccupied by the details of their life. They don’t spend a lot of time thinking about your hospital, your ED or your staff. Only in time of need do they think of the hospital, the ED and you. Engagement is essentially a political function. You are seeking to place your ED in a favorable light in the minds of your community members. You do this by meeting them on their "turf" and addressing their interests.

Every community hosts school and religious institutions. Many include volunteer ambulance corps as well. All of these locations and organizations provide opportunities for your engagement. Seek them out whether or not they seek you out. Use the hospital’s public relations staff if they are available, but even if they are not, make the calls yourself.

Prepare yourself before you call by finding out about the organization from hospital resources such as your public relations or development office. Learn about the number of members or participants and how broadly the organization or school affects the community. Clearly the only high school in the region has a different influence within the community than one high school out of a dozen in the town. Prepare by seeking the help of your public relations, development or printing department in the creation of both publicity materials such as posters and "leave behinds" a handout that will serve to remind both those who attend and those who don’t that you’ve visited and you represent the hospital, the ED and emergency medicine physicians. A standard drape for a podium and a table showing your hospital ED’s logo along with your practice’s if you have one is useful. Don’t rely on the standard hospital table drape; insist upon one that clearly touts the ED, even if you have to pay for it yourself. Remember you are representing the ED to the community and you want to emphasize that association.

Prepare a presentation that will be relevant to the audience. Speaking from your heart about alcohol related motor vehicle crashes that have killed or injured teen-agers in your community, whether high school students or those off at college will have still greater impact if done as a brief presentation and discussion. Engaging another point of view can be helpful as well. I recall that some years ago several of my colleagues participated in "Doctor-Lawyer" presentations at high schools on the topic of drinking and driving. Even absent physical injury, the legal impact of underage alcohol use can catch an audience’s attention.

Tragedy is not the only "hook" for an audience and might better be reserved for a time when you’ve already become known as a supporter of community groups. Speaking to the gardening society about how to handle pesticides, fertilizers and herbicides—in other words hazardous materials disposal which you can prepare for by getting the information from your community’s trash disposal department or service will have much more impact coming from you and the hospital ED then any bill-stuffer or reminder slipped through a mail slot. While this or other topics of interest to a community group may at first blush seem "out of your field" in speaking to a lay audience, it’s more important for the topic to be of interest to the group than that it is of interest to you. Then too remember that your community organizations are pleased to have your interest and participation, so while you may not practice environmental toxicology, you already know more, including how to prepare to speak on the topic, than does any member of your audience. Selecting topics of interest and organizations to approach is easily done by attending to the news in your community. Weekly community newspaper(s), school, church or association newsletters are good sources of topics of interest.

Along with speaking to outside organizations where you facilitate the introduction and the contact with the organization, you want to make yourself available to hospital personnel who have need for hospital spokespersons. Set up an appointment with whoever handles hospital public relations. Offer to speak to them on background when issues come up elsewhere in the hospital. Tout your expertise as a generalist who will take the time, even if the cardiologist won’t to explain what angioplasty means and why having it available at your hospital—or not—matters in your community. Then take the telephone calls that are sure to come and do your best to answer the questions. Pretty soon you’ll find that your name will get out to local reporters who need background information on a medical story or who are looking for a local twist on a national or regional story. Since all of this contact with the press is intended to bring your hospital and ED to the favorable attention of your community, more than it’s intended to advance personal recognition, be sure to talk about the hospital and ED and refer the press back to hospital contacts.

Building community relationships begins with serving the community through excellent medical care, but includes communicating more broadly with the many "micro-communities" in every town.