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.

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