Saturday, December 14, 2002

Living in the Fishbowl When “Experts” Throw Stones.

I’ve just returned from the ACEP annual meeting, the largest ever with a turnout of nearly 4000 emergency physicians and others. I learned lots there and also had a bit of a pre-JCAHO mental break. I heard a lot of discussion about “fairness for emergency physicians” and even participated in a lunchtime panel that considered the topic. However, while pulling my thoughts together for this month’s column, my focus was overtaken by events both in my own ED and in an exchange on emed-l, the emergency physician mailing list (subscribe using the ED Subscriber at the National Center for Emergency Medicine Informatics). So my thoughts on “fairness” will wait for next month.



Without belaboring the subject, at our hospital the discussion revolved around the management of a difficult airway. On emed-l the discussion recounted the challenge confronted by an emergency physician in managing a patient in active DTs ultimately with the use of propofol, a therapeutic decision that was castigated by the intensivist who admitted the patient. In both instances the emergency physician—in the fishbowl—was criticized for decision-making on the spot, which was associated with if not directly correlated to the patient’s salutary outcome. The public discussion on emed-l was particularly revealing because the widespread participation of emergency physicians confirmed for me that the phenomenon we were experiencing locally—was in truth universal.



The long thread of the discussion included recounting of experience and interpretation of scientific literature. I was reminded of how far we’ve come from treating patients in delirium tremens with paraldehyde (ask a long-toothed, gray-beard in your own institution). The comment that most resonated for me as a leader whose task these days is increasingly focused on developing other leaders, came from James Li, an assistant professor in emergency medicine at Harvard. What follows are his words.



“To echo the support many others have already given you, choosing propofol was warranted, given the course you outlined. More than that, the choice to use it indicates a thoughtful process of adaptability to failing therapy, where others might remain sighted only to traditional ways. Understand that a sign of superb training is a program's ability to evolve with state-of-the-art techniques. We didn't have the benefit of propofol (or RSI [rapid sequence intubation]) when I trained, and I recall first learning of its use in withdrawal therapy for heroin through an article I read several years after residency the same week I saw it used on ‘e.r.’



Aside from the benefit that practice gives over simple book awareness of updated techniques, know that if you practice in any environment conducive to continued growth, you will never outrun expert critics. Many things you choose to do will be severely questioned, not the least the choices you make that are novel ones, whether based on good evidence or not. Thus the greater lesson here is not that the intensivist was wrong (or simply overly rigid in his views), but that you must deal with him on a level showing some kind of professional maturity. This takes guts (to remain calm while undergoing criticism from someone possessing expert credentials), great communication skills (to be able to succinctly summarize, often while on your feet and in the middle of active management issues, the reasons why you choose to do what you do), intelligence (so you are actually making the right choices and have thought through the criticisms beforehand), and a solid psyche (so you are able to see even the harshest criticism in a professional light, and don't get sucked into personal affronts).



As a resident, it is often difficult to communicate on a collegiate level with attending-level experts when questioned about one's actions. There is a power play innate in these interactions that is never easy to ignore. So I'll just say this. We look for a quality in the residents we train that combines humility, competence, and fearlessness. These are the residents we send into the surgical M&Ms to defend the thoracotomy or facial trauma airway scenarios they faced in the ER. Where emotions run high, they are able to calmly defend their actions on a professional level (and one open to constructive criticism) that tempers the power plays and educates us all. In the great programs, the emergency attendings do the same for their own cases, to show you how it's done.”



Doctor Li reminds those of us who would be leaders that whether it is our residents, our colleagues or ourselves, equanimity in the face of our critics and our patients’ neediest moments best serves all: patients, profession, specialty and our leadership.



Also mentioned in the course of the discussion on emed-l was Teddy Roosevelt’s famous quote, “It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”



While stirring, the focus of this quote is on the accomplishments of the “doer.” As physicians, our focus must be upon our patients. Thus, while I strongly endorse Dr. Li’s statement, I also teach that our role as a leader is to serve our patients, hospital, communities and staff—striving for the Pareto optimum among these competing goods. Our normal role is that of servant leaders. On a daily basis and as professionals, we can be quietly confident in our competencies. However, when challenged for acting in a crisis, where others might not, we must also be able to rise to the occasion, combining our humility and competence with fearlessness, in our service to our patients.



Thursday, November 14, 2002

Computer-based Patient Records in the ED and me . . . or how I learned to stop worrying and love the machine.

Regular readers know of my appreciation for information technology’s power as a facilitator of useful change; but, the recent successful implementation of physician charting and order entry into our ED information system made me smile and enjoy a sense of accomplishment—if just for a moment. Then too, last week brought news of Maimonides’ recognition with the Nicholas E. Davies CPR Award of Excellence from the Healthcare Information and Management Systems Society.[1]



Over the years I’ve extolled the virtues of both measurement and interdisciplinary teams in these columns. These recent information system accomplishments at Maimonides Medical Center came to mind when I was thinking about “leadership” in the context of a column for this month because the accomplishments underscore the importance and effectiveness of both measurement and interdisciplinary teams, albeit on different scales.



When I was hired into my current position in 1995 I set only two conditions: unified management of the entire ED and support for an ED computer-based patient record. Readers know that our ED operates with a unified management model. Now we have a fully implemented computer-based patient record.



Ann Sullivan, our CIO joined Maimonides Medical Center shortly after I did and I talked to her during the hiring process. She questioned my resolve for the work required for implementation of an ED Information System as I described it then. She questioned how the work would be divided between information system professionals and clinicians. She asked if we in the Department of Emergency Medicine would support information system personnel in our department. She challenged me to participate fully in the effort. We did and went beyond her expectations by also supporting the capital acquisition expense through practice earnings. We justified the support because we believed that the practice was sure to benefit from a successful implementation of a computer-based patient record.



In submitting our application to the Nicholas E. Davies award committee, we wrote:



“Many elements have contributed significantly to the success of the project and, if omitted or poorly executed, could have derailed it. Foremost among these was establishing programs and methodologies aimed at physician participation, buy-in, and ownership. Other key factors included building a clinically-focused MIS staff, selecting appropriate vendor partners, conducting training to meet the needs of all user constituencies, and winning the support of key leaders and advocates. The result is an information system environment that has brought dramatic improvements in the delivery of patient care while positioning Maimonides to continue to fulfill its mission as a world-class medical institution in the years ahead.”



Note how in this document excerpt—directed to a committee of a healthcare MIS organization: “physician participation, buy-in and ownership” is emphasized. The paramount clinical focus is evident and the technology is subservient to that focus. The outcome of “improvements in the delivery of patient care” is noted and supported elsewhere in the document with an array of numbers obtained both before and after CPR implementation. Ann Sullivan led the writing team though she included 11 others as authors of the document, seven of them full-time clinicians in the hospital and only four others based in MIS. Of those four, three are nurses.



Is this interdisciplinary teamwork, or what?



The work accomplished by these nurses and pharmacists has been invaluable in our departmental system implementation because they understand the process of delivering patient care and they understand the work process encompassed by the computer system so that they have helped us anticipate challenges and plan alternate approaches for using the system, particularly because of the important interfaces and combinations of our ED system with the hospital registration, laboratory and radiology systems and the inpatient order-entry and results reporting system. As to measurement—just one example—our compliance with pain assessment improved from 65% to over 95% because of the prompting of the CPR.



The Davies Award surveyors’ visit had been scheduled for a day that happened to coincide with the third day of our ED CPR go-live. They first visited two different MIS sites; the ED was the first clinical site where they stopped. They later told us that they noticed specifically the dedication and drive of everyone they met throughout the walk through, but especially the ease of physician use in the ED on the third day of our “go-live.” The surveyors asked me to stop a physician at random. They asked that physician to perform several functions at the computer. The physician was so proficient on the third day of use that in the surveyors’ minds, that physician’s capability attested to the hospital’s training and implementation approach. Yet another example of interdisciplinary teamwork observed as a result.



I’ll end this short column with another smile. It’s not truly a measurement, but even Deming acknowledged, “Not all improvements can be measured.” Just a few hours ago, our pediatric emergency medicine chief, Giora Winnik, MD, called me to say that instead of needing a day to prepare for the child safety and protection taskforce, he had needed only an hour because everything he needed he was able to get from the system. You don’t know our history together, but suffice it to say that Giora is the senior physician in the department and has been at Maimonides Medical Center for more than 20 years. He had been skeptical of implementing the CPR, but he called me to make me feel good. He succeeded.




[1]The Nicholas E. Davies C[omputer-based] P[atient] R[ecord] Recognition Program was established to encourage and recognize excellence in CPR development by recognizing health care provider organizations that successfully use CPR systems to improve health care delivery.



Monday, October 14, 2002

You can’t take care of others if you’re hurting. Personal Protective Equipment in the era of terrorism.

I learned this lesson between my sophomore and junior year of medical school. My physician father had permitted me to practice histories and physical examination by seeing patients of his at the hospital where he was chief of medicine. One of his patients presented to the ER there short of breath and he called me and told me to examine the patient. When I arrived, the intern—it was 1973 after all—was trying to get an IV started in a wrist vein, after he gave up the effort I volunteered. The patient, a below-the-knee amputee from his diabetes seemed to be in pulmonary edema so an IV was important. I attempted a stick of what appeared to me as a large wrist vein—later I realized it was probably thrombosed. My patient kicked me with his stump. Since I was straddling his amputation you can envision the effect. I spent the next 10 minutes trying to pull myself off the floor and catch my breath.



I’ll never forget that man—I’ve omitted his name from this retelling out of an abundance of caution and concern for confidentiality though I’m certain he’s long since deceased. He taught me a critical lesson: You can’t take care of others if you’re hurting yourself.



As a leader, I owe the same consequences of that lesson to my staff. It’s my responsibility to assure them of safe working conditions. In these times, among the many components of this responsibility is the requirement for personal protective equipment (PPE) sufficient to protect our ED staffs from exposure to various hazardous materials. I don’t have sufficient space to discuss the regulatory basis and the challenges of interpreting OSHA, NIOSH and EPA regulations as applied to circumstances where weapons of mass destruction could be a possibility—there is no simple intersection of these considerations. Healthcare facilities were never a consideration for the regulatory agencies mentioned above when they promulgated their regulations. Nonetheless, bad news doesn’t go away and the need for PPE at each hospital is also a JCAHO standard so if you’ve not yet addressed it, you soon will be doing so. Where might you start?



Fundamentally, you’ll have to decide whether or not to develop a PPE Level “B” capability. Level “B” provides respiratory protection through either self-contained breathing apparatus (SCBA) or supply air by hose from either compressed air tanks or a central source of compressed air. Level “A” capability is infeasible for effective patient care, is expensive and requires extensive training for its use.



Level “A” PPE presumes a fully encapsulating suit that totally protects the body from vapors; level “B” and level “C” do not. Level “B” and level “C” presume the use of a chemical suit that does protect against splash, but may introduce vapors. Level “C” PPE provides respiratory protection through the use of air purification respirators or masks that are specific to the type of exposure.



The problem we confront in the ED is that we are often the first responders “in-place.” Patients come to us whether under their own power or brought by field first responders and we don’t know about their exposure. Level “B” PPE is the lowest level recommended for use in the event of exposure to an unknown agent.



It is for that reason we at Maimonides Medical Center decided in 1999 to train a cadre of staff to operate in Level “B” PPE. Today we have well over 100 staff members from a variety of departments and with a variety of clinical and non-clinical backgrounds trained to work in PPE Level “B.” As a hospital we work hard to schedule staff so that we are able to mount four two-person teams for patient decontamination around the clock. This allows us to operate two decontamination stations and spell the teams at 20-30 minute intervals—an important consideration when wearing an impervious chemical suit, breathing compressed air through a full-face mask and tethered to an air line—especially when as in our drill last week (early August) ambient temperatures are in the high 90’s. Our goal is to maintain an ability to rapidly decontaminate ten patients and up to twenty-five patients total before progressive intoxication would become a pressing patient management concern.



Training staff entails a minimum of a four-hour course in donning and doffing PPE and basic patient decontamination practices and you will need refresher programs and a mechanism to train new employees. As the ECRI Advisory points out there are risks to users of PPE Level “B” such as tripping over an improperly configured airline, so making the decision to go with Level “B” PPE should not be automatic.



The Greater New York Hospital Association has recently circulated a draft consensus statement on hospital decontamination needs and PPE in an effort to help hospitals in our area with their decision. The Department of Veterans Affairs and it’s associated healthcare system—our country’s largest health delivery system—has publisheddetails of an approach recommended by the VA’s Emergency Management Strategic Healthcare Group and its Technical Advisory Committee.



Regardless of your local situation some thoughtful decision-making about PPE and decontamination efforts is necessitated by service and regulatory requirements. The 1995 Tokyo subway Sarin vapor attack senitized us all to the possibilities. Hospital personnel were secondary casualties then in several instances. Personal protective equipment is not a panacea, but it is part of the answer. You can’t take care of others if you’re hurting yourself.




Further resources can be found at the following websites:



Recommendations for Hospitals: Patient Decontamination Algorithm, Staff Protection and Equipment Required During Patient Decontamination” from the California Emergency Medical Services Authority.



A three-volume set of materials entitled “Managing Hazardous Materials Incidents” includes ED management of patients exposed to hazardous materials incidents.



A JAMA piece that addresses PPE, triage and patient decontamination.



Saturday, September 14, 2002

Have the ambulances stopped coming? Is it real or only accounting?

As I sit down to write this column in early July, I’ve been pondering our first six-month results. You’ll recall that a few months ago I wrote about our electronic medical record startup in April and with a few months of experience and the statistics from the first half of this year—well suffice it to say this column nearly wrote itself.



Yes, the ambulances are still bringing patients to the Maimonides Medical Center ED, but for a week or so, it appeared as though we had many fewer ambulance patients in the first half of this year than in the same period last year; although, total patient volume was up 1.6% and admissions were nearly constant. So while I still don’t have all the answers as I write, I think our experience—particularly because it derives from our electronic medical record (EMR) implementation is instructive.



When Charlie Howe, our billing manager, brought the first six months of statistics to me—an unusual hand delivery, he called my attention to the drop off in ambulance patients, particularly for April-June. When we drilled down on the data that day it appeared as though something had happened to patient deliveries (“ambulance drops”) from the voluntary hospital ambulances and to a lesser degree from our volunteer community based ambulances.



EMS in New York City, led by the Fire Department of New York (FDNY), is an amalgam of the publicly operated fire department ambulances, voluntary hospital based ambulance services also dispatched through 9-1-1 and a web of community based volunteer ambulances and proprietary ambulances dispatched through seven digit telephone numbers. One of the larger and better organized of the volunteer ambulances in NY is the orthodox Jewish group, Hatzolah. Our hospital sees Hatzolah volunteers mostly from two nearby communities, though other Hatzolah volunteer organizations also bring us patients less regularly. Other community based volunteers, Bravo and Bensonhurst Community Ambulance service bring us patients, as do several nearby voluntary hospitals and our own hospital based ambulance service. The ambulances dispatched through 9-1-1, whether FDNY or voluntary hospital based, use the same ambulance call report (ACR) while most of the volunteer ambulances and the proprietary ambulances use their own form for meeting state requirements.



In trying to find out what was happening to our “ambulance drops”—we asked, “Were there really many fewer ambulance drops, was it merely accounting or some of both?”



Well I didn’t ask myself this question before I reported the apparent reduction in ambulance drops to our CEO. I reported it as a fact—uh oh.



Stanley Brezenoff, Maimonides’ CEO is a long-time public servant. His past seven years at Maimonides has been one of his very few private sector employment experiences. A skilled administrator and troubleshooter, he has taught me about the emergency department’s role in reaching out to the community. His leadership has transformed Maimonides even as he has personally visited more than 150 community organizations to listen to them and learn from them what they needed from the hospital. Sometimes he has brought me along. He has brought the message of the hospital’s openness to the communities’ needs everywhere in Brooklyn (and beyond) where he’s gone, the volunteer ambulance corps among them. He truly believes and teaches that our hospital belongs to the community—we who work there are merely stewards. He was concerned by the reported diminution in ambulance drops.



Until April 9, when we went live with our electronic medical record (see EMN, June 2002) our ambulance triage nurse completed a triage form that went to the registration clerk along with the ACR. The triage form captured through check boxes and write-ins the name of the ambulance company that had brought the patient. The triage nurse enters the same information in the EMR, but the information hadn’t been made available to the registration clerk. We missed it. In all the work we did with the registration clerks around changes in workflow we overlooked the registration clerks’ usual process for getting the transporting ambulance information—they did not read the ACR; they did read the ambulance nurse triage note.



Well, between the time we discovered the deficit in ambulance transports and had drilled down to its apparent genesis we took advantage of the fact that our Maimonides’ ambulances bring patients to our own ED. So we undertook a one-day comparison of the registration system’s data with our own ambulance department’s ACRs. Whew! Of 11 ACRs showing Maimonides as the destination, only five were noted in the hospital registration system as Maimonides’ ambulance transports. Four others were attributed to other ambulance operators and two weren’t even recorded as ambulance drops—thus explaining our missing numbers.



Looking further I realized that in April, we might have experienced a true decrease in ambulance drops. To some extent this is explicable through our early days of learning the ropes with our new EMR, yet, here it was July and I was only just examining the quantitative data—I’d neglected to do so for too many months. I had spent time in April and May on the telephone with some of our volunteer ambulance providers. I’d listened to their concerns about the “computer system” and their frustration over waiting times at ambulance triage—potentially bad for patients and always bad for the volunteers who wanted to get back to work or family.



We’re responding now, by reconfiguring our clerk staffing to bring a registration clerk over to the ambulance triage location so that a clerk can enter the initial patient information while the nurse focuses on the patient and ambulance personnel. We’ve also changed the information available on the registration icon so that the registration clerk can see the nurse’s selection of the ambulance provider. Using the feature in HealthmaticsED™ which when “mousing over” the icon—a “tooltip” box opens on the screen displaying text, which now includes means of arrival and the ambulance company’s name.



Just like at your hospital, our lab calls us with “panic” values—which sometimes don’t make sense in the given situation. What do you do? You build a safety net for the patient and then repeat the test. Next time, I’ll call the ambulance companies while rechecking the accounting—before I call my CEO. Even though he always says that bad news can’t wait; first I’ll make sure it’s news at all.



Wednesday, August 14, 2002

Emergency Preparedness, Weapons of Mass Destruction or “How I Learned to Stop Worrying and Love the Bomb.” (With apologies to Peter Sellers and Dr. Strangelove)

Well actually I never did stop worrying, but that was then, this is now. Our current circumstances of poorly characterized enemies threatening poorly characterized mischief have heightened everyone’s anxiety. While, in January 2001 the JCAHO published updated requirements for emergency preparedness, since September 11 our hospitals have been asked to further improve their preparedness for emergency response to the use of weapons of mass destruction: chemical, biological, radiological, nuclear and explosive (CBRNE); a pretty horrible litany of potential death and destruction to our friends, families and communities.



Last autumn’s anthrax bio-terror and the 1995 experience of the Tokyo subway Sarin vapor attacks both remind us that preparation and effective medical response is possible for some of these events and that both community and hospital preparation can reduce casualties and mitigate the harm. Perhaps the signal example, of emergency physicians at Inova Fairfax successfully diagnosing anthrax and saving a postal employee, showed the effectiveness of the prepared mind in recognizing anthrax in an unexpected patient category and thereby saving at least one life. Those who would argue that no preparation is possible for any of these horrors would have to explain such a result.



So, how should one proceed? Yes, we in New York are especially pre-occupied, but every hospital, particularly those JCAHO accredited should be updating emergency preparedness plans and training staff to the hospital emergency incident command system. Bioterrorism will pose a particularly grave challenge to the hospitals as it is far more likely to manifest insidiously, than through public announcement as with the anthrax attack. The JCAHO consulting organization, Joint Commission Resources published a useful guide in December 2001 which can still be read on-line at http://www.jcrinc.com/subscribers/perspectives.asp?durki=1122.



Yet in this era of strained resources how to address these recommendations? Where are the people, the money and time to come from? Well, I’ve no easy answer, but if as is likely you’ve been charged with any of these responsibilities, make it clear to your leaders that you will not be able to meet the mandate without additional resources. Completing the paperwork and creating a manual can be accomplished by anyone given enough time, but a manual on the shelf will not truly establish the preparedness that may make a difference for your loved ones, organization and community. Training and alliances with community-based organizations are critical steps in this preparedness.



Training your staff in the following areas is the step that moves your program into reality. The JCAHO identifies six necessary areas for training: emergency identification, triage, decontamination, treatment, media and crowd control and stress management.



Regardless of resources and likelihood of seeing ED patient’s needing decontamination, addressing emergency identification is a process of identifying potential threats, planning for and training for the response to those threats. The “on the job training” provided through mailings, emails, websites and more to clinical staff during the anthrax bio-terror episode of last fall is an example of such training. Public health departments trained clinical staff in recognition of both the clinical syndrome and populations most at risk as anthrax was spreading. Early recognition and diagnosis clearly saved some lives.



Should a more widespread bio-terror episode occur, even non-urban emergency departments would see patients with illness or at least patients fearful of having contracted the disease spread by the attack. Our emergency departments are open to the community. It is in the nature of our work as a door to our community. Yet, planning for and training in media and crowd control should be an early effort since it helps assure the security of the facility and the safety of the staff. (As an aside, it has been said that in the event of a widespread bio-terror attack, it is not even clear that sufficient staff would come to work. Facility security would clearly play a role in reassuring staff of their safety at the hospital.) The JCAHO suggest that, “selected staff should be educated on how to handle a large influx of other people into a facility in the wake of an emergency. Large numbers of people present security problems and impediments to smooth operation if not handled properly. Included in this group are members of the media, families and friends of possible victims, and volunteers wanting to help.” This is fine advice, but if the alert is broadcast in the evening, marshalling the staff to direct the large influx of people away from the ED won’t be easy unless you have a call list prepared. The police and other public safety agencies are likely already over-committed; so anticipate that your initial response will in fact be your initial response, with little if any support from the larger community until hours have passed.



At the May 2002 Society for Academic Emergency Medicine Annual Meeting in St. Louis, more than three hours of program focusing on “the age of terrorism” and the EM response (The schedule and handouts are available) presented a sobering picture, particularly with regards to response from the outside. All speakers agreed that local communities must be self-reliant for at least the first 24 hours following any terror event. Many of us feel we have excellent working relationships with local police, fire and ambulance services, but all of these professional organizations will themselves be stressed in the event of terror attack. Do you know all of your local organizations? Is there a volunteer group you’ve not visited or invited to your ED that could be of service? Even in New York City such organizations exist and Hatzolah in our part of Brooklyn and the Bedford-Stuyvesant Volunteer Ambulance Service more to the north render service to their community and delight in a strong ongoing relationship with my hospital and others in their service area.



These community-based organizations would be a welcome ally in managing the many of challenges inherent to responding to a terror attack with a weapon of mass destruction. Actively engaging your local volunteer agencies and properly training your staff are critical steps for your hospital’s emergency preparedness.



Sunday, July 14, 2002

Great Leaders have great flaws . . . and you do too.

So do I. But, that’s not the point is it? All of us could be better somehow, yet we manage to serve and succeed to some degree most of the time. Yes, our flaws may bring us low or even bring us down, but they are part of the package.



Much of the advice historically offered to developing leaders was along the lines of, “Learn to go to your left.” In other words you should work to improve your weaknesses. Today, most psychologists and teachers and researchers of management principles instead point to the importance of playing to your strengths and working with others in collaboration to support your personal weaknesses. Such collaboration, if robust and focused upon the mission at hand is not brought down by personal differences when all participants have agreed to and are aligned around the same agenda.



In clinical practice that agenda or “Mission Statement” may be as simple as, “Practice high quality medicine for which we receive fair compensation while supporting the mission of our practice site—our community’s hospital.” An academic practice may incorporate its academic missions of research and teaching in its one sentence statement. Regardless, adhering to the mission is sure to require the collective efforts of the entire practice if for nothing else covering the schedule. Yet, even at this level swapping shifts after the schedule is published requires a degree of collaboration . . . and trust, that your colleague will do likewise for you when you need it.



How does one build such collaboration, particularly in a small single hospital group practice, and keep it on track as the individual personalities all pursue individual priorities?



The many small courtesies such as swapping shifts on short notice and working together to the same standard of practice build this bond over time, but what about the situation where someone who’s been part of the collaboration seemingly leaves the fold? Rarely manifested through a single startling deviation but more likely through a (too) protracted series of small infractions, how do you address the trouble? Unfortunately, some physician leaders, myself among them, may prefer to minimize or otherwise cover for the colleague whose behaviors create difficulties in the larger collaboration. Wanting to wish the bad behaviors away is all too human—and flawed.



Confronting our colleague’s deviations with them is the only solution. Challenge the behaviors, not the individual is easy advice, but hard in practice. Postponing the confrontation—waiting for the pressure to build—and tackling the conflict after upset has turned to exasperation and anger is a sure route to the feared commotion that rather than lasting a day may lead to substantial, prolonged or even complete disruption of your practice. Whatever the inciting event or events: whether you fear your colleague’s behavior originates through a substance abuse problem, personal or family upset or even the manifestation of a character flaw long suppressed, confronting the behavior is the essential first step.



Do not roll this confrontation into the fact-finding phase should the precipitating event be of sufficient magnitude that an investigative process is required. Complete the investigation and have all the facts in hand before confronting your colleague. If possible, gain your colleague’s agreement to the facts separately and prior to scheduling the confrontation.



Tackle the confrontation in a private circumstance. While your impulse may be to address the problem over food in a restaurant, you are probably better off meeting your colleague in a more structured and formal environment. An office is not necessary and may be counter-productive, but a conference room in the hospital that can be scheduled could be a good choice. Make sure you have sufficient time, don’t schedule yourself for a half-an-hour between other already scheduled meetings. If possible, schedule two hours even if you only plan for 20 minutes.



Begin by acknowledging how difficult it is for you to have “forced this meeting.” Recount as best as you can recall the specific event or events that troubled you so much that you scheduled the meeting. Focus on the behaviors that distressed you and explain your distress. Speak in the active voice and put yourself on the line. Don’t accuse or attempt to explain the behavior. State your shock and distress and why the behavior is not acceptable.



Two years ago I suggested that a practice leader could adopt the pyramid of medical staff development, even at the department level. I pointed to “the interlocking components of setting expectations, measuring and giving feedback as [are] the key components of the change process.” I went on to assert that, “Like you, I believe that most physicians want to ‘do the right thing.’ Unfortunately, most of us are increasingly uncertain as to what the ‘right thing’ is these days, which is why clearly setting expectations is so important [to beginning measurement.]”



The exact same statement of expectations is the key to either remedying the commotion in your practice or identifying the magnitude of the problem so that you can confidently take definitive action. You’re giving feedback now, perhaps without having previously, explicitly stated expectations, so reaching the occasion where you can take definitive action will take additional time, which must be expended. For when addressing behavior, acting on the past events—unless heinous and of imminent risk to patients or staff—is not sustainable. For a colleague and collaborator, the chance to right themselves must be offered. Whatever the “bad behavior” you must describe, demand that it stop, describe the behavior that is desired and observe for the correct behavior. If found, praise it; if behavior reverts to that for which your colleague has already been rebuked, then you must discipline your colleague. Or otherwise intervene, perhaps in accordance with JCAHO Standard MS.2.6 if appropriate.[1]



Delayed response to disrupting behavior within a close-knit group of collaborators is a far too common flaw in leaders. It risks the entire collaboration. Confrontation though difficult to initiate is the only route to resolution.




[1]The medical staff implements a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function.



Friday, June 14, 2002

Implementing your ED Information System: The Reality

Some of you may recall that back in December I briefly mentioned turning on our ED information system on September 11 and then for obvious reasons, turning it off again. Well, on Tuesday, April 9, 2002 we tried it again and right now I’m sitting here with a large smile. Our ED information system (HealthmaticsED™ from A4HealthSystems) is up and running and working pretty well. The staff is tired but mostly upbeat, proud of themselves and their new skills. Justly so. And I’m sitting here, basking in the sense of accomplishment and achievement that I’ve spent nearly seven years at Maimonides reaching for. All is not perfect, there’s still lots to do, problems yet to solve, but we strike more issues off the top of our list every day than we add at the bottom.



One of our greatest challenges, particularly during the first two days we were up was with the creation of two entries on the tracking board. Our triage nurse would create an entry with the first encounter with the patient. This entry would put up an icon of a computer that would alert our registration clerk to the patient then needing registration. The registrar would start registration, but insert the patient’s medical record number into the triage record and then the interface would combine the formal registration in the hospital’s admission-discharge-transfer (ADT) system with the entry in HMED.



Well, we’ve discovered at least five different ways that this plan can fail. I’m not going to describe them for you, but I do think it is worth characterizing the way systems “fail” or at least have troublesome problems in the early days of “go-live.”



First and most commonly system failures occur during implementation because your staff is climbing the learning curve. People make mistakes and even though our staff has been trained (originally for our September 2001 scheduled go-live) and then retrained for this effort in April, people forget or never learned the proper procedures. Some will not truly learn the new process until they are in the midst of it and only then will they grasp the lessons taught in the classroom.



Next, and somewhat overlapping with our first cause, system failures occur because staff fails to adhere to new procedures or because the new procedures themselves are flawed. Distinguishing between these two causes is important, because staff errors are most likely evidence of need for more training and are remediable thereby. Yet, most people will prefer to displace blame onto process, blaming the procedure and possibly obscuring the best means to remediation.



Lastly, technical failures or software shortcomings produce sometimes subtle and sometimes obvious and potentially catastrophic failures depending upon the extent of the problem and whether its impact is restricted to a single workstation or process or more broadly affecting the use of the system.



The late W. Edwards Deming in point six of his fourteen points stated, “Institute Training and Retraining.” During our first few days of running the new system we have learned and relearned this lesson.



All of us who trained in emergency medicine (or any specialty or profession) trained for a fixed period of time. Deming always asserted that training for a fixed period when learning a skill or process was the wrong way to train: That skills should be taught until mastery is demonstrated. He advised “train and test, train and test.” By this he meant that staff should be trained until they demonstrate no further improvement in testing and that the purpose of testing was to evaluate for mastery, not for a grade. Yet in most cases we train for a fixed period, whether in residency or when learning the use of a new ED information system.



This past week we had MIS staff, vendor support staff and our own super users: emergency physicians and nurses, continuously on duty in the ED. As I’ve already mentioned, errors abounded, but we had staff to help train—on the spot—those who erred or were confused. Some detective work and learning about the system in each instance helped persuade the staff that the problems were related to the user, not the system. Corrections to the database and interface errors were the responsibility of other MIS and vendor staff, some on scene and others connected from A4HealthSystem’s headquarters in Cary, NC. We had the personnel on scene around the clock to support the staff that was delivering patient care. We trained and re-trained on the spot. We supported and encouraged staff, helped them learn how to accomplish the tasks for which they were responsible and praised them for what they did well.



Now after one week our MIS staff tells me that we are exceeding their expectations for our low error rate and success in gaining staff confidence. Many of our nurses are already asking to move on to nurse charting rather than waiting for the three months originally scheduled before we implement the next phase. All staff realizes the benefit for patients and for other staff in the hospital. Their enthusiasm, support for one another and persistence in working through their mistakes and identifying problems for our support team has been outstanding. They have performed magnificently and I am incredibly proud of all of them.



Yes, I am delighted. Thirteen years ago I saw an ED information system in a booth at a professional meeting. I knew the moment I saw it that this was a tool that I had to have in my ED. It has taken me since then to successfully bring my vision to reality. But my real lesson of the past week has once again been the realization that it’s the people who make it happen.



People are valuable. Technology is cheap.




Disclosure: I serve as a member of the medical advisory board to A4HealthSystems HealthMatics ED product. I receive no compensation for this service.



Tuesday, May 14, 2002

Intangible Assets: Ethics, Colleagues and Staff

As I write, it has been a very thought provoking recent past for me. The Enron fiasco is back on the front page and Andersen Accounting has been indicted. The ED Benchmarks 2002 Conference concluded and a discussion of the ethics of direct to consumer marketing of prescription pharmaceuticals is raging on the emed-l emergency medicine mailing list (subscribe using the ED Subscriber at The National Center for Emergency Medicine Informatics). In our ED this past week, we implemented the computerized telephone system directory with answering and calling that the hospital telephone operators use, while we continue to struggle with too many patients in too little room with not enough nurses. At peer review on Wednesday one of my colleagues concerned about a problem angrily demanded, “Who do I see about that?” I don’t have an easy answer, so there’s lots to think about and lots to write about.



The thread that pulled all these diverse occurrences together for me was Bob Lewis’ March 2002 column in Infoworld, a weekly trade publication for the information technology business. Over the past two years, Bob’s column has become the prime reason I still read Infoworld, since while I have the interest in technology, I don’t really have the time. Through story telling, Bob’s column often identifies human foibles that impair information technology effectiveness in a particular business scenario.



In this week’s column, “The Moral Compass” Bob Lewis concludes:



“You are a moral entity, and confine your actions to what your moral code allows. But you're employed by a corporation, which isn't a moral entity, and you're supposed to act in that corporation's best interests. I've even been told that this is a moral obligation.



Nonsense. ‘Maximizing shareholder value’ is a financial proposition, not a moral one.



Which is why, if you want your company to behave morally, you'll have to bring the morality there yourself.”



The connection to morality and ethics is I suspect pretty apparent to most of you in regards to the situations of Enron and Andersen. Many of you, regardless of your feelings about “big pharma” do at least acknowledge that there can be different views regarding direct to consumer marketing, including those informed by the physician’s ethical imperative, “Primum non nocere.” But, what’s the connection to my other activities of recent weeks and why should it matter to you?



Since I’ll presume that you seek to “lead beyond the bottom line” as do I (see my EMN columns of October and November 2000 on “Leading Beyond the Bottom Line” in emergency medicine at my website and go to the American College of Physician Executive’s website for the original columns at http://www.acpe.org/lbblarticles.pdf) then you know the value of your employees, staff and co-workers. At the ED Benchmarks 2002 conference (The syllabus will be posted at the Florida Emergency Medicine Foundation site about the time you read this.) Thom Mayer spoke about compensation models and briefly raised the issue of what constitutes “open financial books.” While not much explored directly in his presentation, Thom clearly was thinking about and talking about ethical and supportive models of working with colleagues and employees in group practice. He readily acknowledged the struggle implicit in fair compensation and reinvestment in the group and the hospital—the many competing “goods” that could be weighed. He identified compensation or “pay” as more than mere dollars but included the recognition and supportive working conditions that we strive to create. He didn’t prescribe a specific answer, but through the complexity of the individual issues and the potential overwhelming number of considerations in front a single group practice provoked the thought that no one approach necessarily suits everyone.



Just last week I again learned the same message from our ED communication clerks. Practically all of our clerk-registrars rotate among the various clerk roles in our ED. While some prefer registration and others the telephones or flex-clerk duties, all do everything at one time or another. This past week we implemented the Xtend MediCall√§ system in our ED, the same product used by our hospital telephone operators and I’m told at over 500 hospitals around the country. (Disclosure: I have no relationship to Xtend beyond that of a satisfied customer.) We worked with Xtend personnel to customize screen prompts for our use in the ED, a novel application for the vendor. We committed to hours of training and two weeks of continuous on-site support. We told our docs and nurses that they would have to be patient with the clerks while telephone message handling went slower and that lots of mistakes would be made during the early days and weeks since this was a new way of working for the communication clerks. Still, some of the clerks were fearful. Why?



These men and women feared that they could not live up to their own expectations for their performance as communication clerks. They did not fear reproof from the physician or nursing staff. No. They feared that their ineptitude with the new computer based telephone system would slow down the works for all of their co-workers and delay patient care. That was their concern. Just as the physician staff expressed their distress at one of our patient outcomes during peer-review this past week, our clerks feared failing our patients and their own high expectations for themselves. Wow! I’m proud of all of them.



The world of healthcare, indeed all of the “knowledge economy” of which we are a part has never been more dependent on the intangible assets of employees, patients (customers) and community acting in ethical interdependence as moral human beings. Andersen Accounting, its competitors and today’s giants of our economy don’t and won’t measure those intangible assets in their own businesses, let alone ours. Yet, I truly believe our leadership in our EDs, hospitals and communities is conditioned on bringing our morality as people—which as Bob Lewis points out preceded both government and corporations—with us everyday to our work while manifesting it through our work as physicians and leaders.



Sunday, April 14, 2002

The Joint is Coming. The Joint is Coming.

Every three years or so most of our hospitals are visited by the Joint Commission on Accreditation of Healthcare Organizations. The mission of “The Joint” or “JCAHO” is “to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits nearly 18,000 health care organizations and programs in the United States. An independent, not-for-profit organization, JCAHO is the nation's predominant standards-setting and accrediting body in health care.”



For the emergency physician “Joint Commission year” at our hospitals includes reviewing the ED policies and procedures with our nursing colleagues and addressing issues in hospital-wide policies and procedures that include aspects relevant to the ED. We’re asked to review and update these so the policies and procedures reflect current reality. This is important work, but routine.



What’s not routine and critically important is reviewing any of the issues cited by the Joint Commission on their last review of your hospital and any new or revised standards with particular relevance to the ED. This year we are looking towards our Joint Commission survey in October or November and we’re particularly focused around the areas of moderate sedation (formerly “conscious sedation”), pain management and restraint management. Peer review is always an area for JCAHO scrutiny and recent standards updates are prescriptive in their requirements. We’ve substantially increased the detail in our peer-review policy and have been part of an effort that revamped peer-review across all departments and resulted in a new hospital medical staff peer review committee.



Moderate sedation in the ED is an increasingly common practice for the avoidance of pain associated with procedures ranging from fracture and dislocation reduction to incision and drainage of abscesses. As a colleague put it on the emed-l mailing list, “Expectations have changed. It isn't OK to use Brutane (2 nurses and an aide holding down a patient) for a painful procedure in this day and age.”



Credentialing for moderate sedation is a hospital medical staff function that is delegated to department chairpersons. A single hospital-wide standard is required, but that does not mean that the standard must be that of the Department of Anesthesia alone. In fact, once the Chairman of Anesthesia realizes how much moderate sedation is administered in your ED s/he will be delighted to support your credentialing process which should assure that emergency physicians are experienced with airway management (usually not an issue) and familiar with the pharmacology of sedating agents. The latter is usually tested with a single multiple-choice test used across the hospital for credentialing any physician who wishes to include moderate sedation as part of their practice. Working with the department of anesthesia to create the test will help win friends and influence people, especially as it will bring the clinicians’ perspective to an exercise that might otherwise be excessively focused on pharmacology. Your colleagues in gastroenterology, orthopedics and radiology will all thank you.



How might you address the pain management and restraint management standards? Your hospital and nursing staff have almost certainly already addressed this issue and created the policy and procedures necessary for implementing these standards. They’ve discussed what is expected from physicians as part of pain management and restraint management and have probably cajoled you to exhort your physician colleagues to do a better job in documenting pain evaluation and ordering restraints.



You and your colleagues can contribute effectively by working with your nursing staff through “open record audits.” Using the audit form your QA reviewers used on closed, completed records a staff emergency physician arriving 30 minutes early for a shift can review the records of several patients present in the ED at that time who have complained of pain or have been restrained. The engagement of the department’s own physician staff in the open record review helps convince nursing leadership and hospital administration of your interest and engagement.



The review with on-the-spot criticism from a physician colleague will speed learning and necessary behavior change so that the one-year of compliance necessary in advance of your JCAHO survey will be easier achieved. The effort of coming to work early for a few shifts each is not much, but will impress those with whom you work.



Peer-review is a specifically physician focused aspect of the JCAHO survey process. Standards promulgated more than 18 months ago now require a great deal of attention to and documentation of process that may have been handled less formally in previous years. Particularly with smaller, single hospital groups, the process now required including advance specification of who may participate in peer review, a process for gaining input from the physician whose care is under review and explicit criteria for seeking an external review must now all be incorporated into your departmental process. Consistent reporting of determinations so that data can be aggregated across departments and so that the medical staff can be assured that a sufficient number of cases are reviewed are all part of the new standard.



Getting started on JCAHO at least one year ahead of your anticipated survey will give you sufficient evidence of compliance with JCAHO standards, but living day-by-day in accordance with the standards while a worthy goal is a challenge made all the greater by the constant changes in standards. “Who moved my cheese?”



Thursday, March 14, 2002

Leadership Can Come out of Systems Thinking and Profound Knowledge.

Writing these words seems a rather empty act on a day in which our ED has been “up for grabs.” As I write in early January our average daily census is running at over 250 patients—our usual is about 215. We’re holding more than a dozen admitted patients almost every morning and some mornings more than two-dozen. So what’s new you ask? Isn’t everyone? Well, yes it seems that the season of ED congestion has rolled around once again as we all knew it would and yet here we are, not much different than we were one or two years ago. Isn’t that so for you too?



So, you might ask how could he write about leaders transforming their EDs into “learning organizations” as I did last month when obviously I haven’t learned much about managing overcrowding these past several years? Well, yes and no—isn’t life just like that?



Yes, like you, we at Maimonides have learned how to handle an ever-increasing census, indeed our adult acute area functions pretty well even with 45-50 patients receiving care though we have only 20 designated stretcher locations and six “asthma chairs.” By functioning pretty well I mean that patient throughput intervals don’t suffer and it seems as though our clinical events don’t spike. So, we’ve probably learned something about managing this kind of volume. However, when the in ED census goes beyond those 50, it’s then that we hit gridlock and become vulnerable to giving patients less attention: both compassion and clinical care may suffer. You face the same challenges.



Resource constrained as we all are, though you may get support from your hospital administration, it’s pretty hard for them to manufacture additional critical care beds when the census is already at 100+% so we all soldier on. Yet, both the direction and the level of the effort are growing. The efforts are taking place and come out of sound systems thinking.



Last month, in writing about Peter Senge’s The Fifth Discipline and the opportunity for transforming our ED into a learning organization, I briefly mentioned the five component technologies necessary to the creation of a learning organization: “systems thinking,” personal mastery (proficiency), mental models, building shared vision, and team learning. Of all of these skills, systems thinking probably comes easiest to an emergency physician, after all we think about EMS systems, trauma systems and multi-hospital systems.



In helping you grasp Senge’s technology of “systems thinking” I put forward what I learned from W. Edwards Deming as his system of “profound knowledge” which Deming described as consisting of four parts, all related to each other: appreciation for a system, knowledge about variation, theory of knowledge and psychology. Building through these tools, you as leader of your ED can address specific issues in ways that broaden everyone’s knowledge of the system within which they labor.



One large teaching hospital group had been laboring under the “gift package admission concept” (this leader obviously both appreciated the system for admissions and the psychology behind it) that required the emergency physicians to spend impossible energies and efforts at completing work ups on each patient before the patient would go off to a floor bed. This hospital and its ED have implemented rules that abort the workup at the point that the bed is ready; though they still labor under the delays caused by bed and consultant availability. The leader identified what in the system were the greatest contributors to admission delays and specifically tackled those problems, first. Other problems persist and must be worked through, but the group thought about the whole system, not just the ED—the “gift package admission concept” probably originating with a teaching service.



Perhaps you’ve implemented an intervention when you do hold many patients overnight. We have the laboratory come and draw the morning blood work and the heart station come and do the morning ECGs if we have more than ten admitted patients in the ED. The department of radiology, which usually only staffs with a single technician until 11:00 am, assigns additional technicians at 8:00 am. We saw that organizing the morning care for the admitted patients in the ED facilitated the patient’s early movement to beds as they became available. It reduced the load on an ED staff that tends to be a bit thin first thing in the morning and it reassures the patients that they were receiving the same care in the ED that they would have received up stairs. Then on other days, just yesterday for instance, we see 268 patients and yet this morning we only have four patients awaiting bed assignment. Why? Perhaps because there were many discharges yesterday, Sunday, so that all of our admissions could be accommodated.



Building a mental model that incorporates the effects of the magnitude of the same day’s discharges on ED throughput and admitted patient holding time is another technique readily accessible to the emergency physician, but often we lack sufficient knowledge to create an accurate mental representation of reality. How many of you know all the details of the bed assignment in your hospital or the time of day when the patients actually leave their beds to go home? Yet, if you want to address the movement of patients from the ED to the inpatient nursing units through systems thinking based on a realistic mental model, you must learn what presently exists. I’ve previously discussed interdisciplinary teamwork and collaboration (May 2001 and September 2001). Creating a mental model to underlie your systems thinking provides yet another opportunity for pro-active collaboration with hospital administration.



My 83 year-old father, an internist-gastroenterologist thinks all of this just might be hooey, so he lectures me, “Just take care of the patient, that’s what you’re there for.” But, then I point out to him that he always has liked to end our discussions by talking about how everything is connected to everything else, “The head bone’s connected to the foot bone.” I’ve heard from him since I was in grade school. The systems in our hospitals and emergency departments are connected, too. Effectively improving seasonal overcrowding requires broadening your view to include the rest of the hospital, the EMS system and perhaps the community’s facilities for primary care. Be a systems thinker—think of them all together.



Thursday, February 14, 2002

Counter Complacency and Gain Career Stability by Transforming your ED into a “Learning Organization.”

Everyday, emergency physicians care for the patients of community-based physicians, physicians who started or joined a practice and remain in the same practice and community throughout their career—or plan to do so. Likewise, many emergency physicians envision the same trajectory for their career; although, concerns about restrictive covenants and contractual arrangements make this more of a wish than a possibility for some. Is career stability a realistic aspiration for the ED Director, the leader of your emergency department?



Historically, leaders in the not-for-profit world have enjoyed a level of career stability that their peers in the for-profit and governmental sectors have not. Perhaps this has been a reflection of different mechanisms for accountability or perhaps it is a manifestation of complacency, on the part of the managers and the boards of these not-for-profit organizations.



As we all recognize, hospitals are no longer part of that genteel not-for-profit tradition. Hospital CEO’s turnover is now at a nationwide average of 17% (2/3’s of it “voluntary”) according to the American Hospital Association. This is not much different from the 19% CEO turnover in major corporations reported by BusinessWeek Online. While it is likely that the proximate cause of any particular CEO’s departure is an error committed by the individual, to some extent they are setup for failure through expectations of CEO performance, which have been inflated, to the point where mere mortals no longer qualify. When the rare leader performs well for a sustained period, this raises the bar impossibly high for everyone else.



Over the past five years as the level of complexity of the hospital CEO’s job has grown, so too has the complexity and challenge of the ED Director’s job. While some directors’ positions may require little more than physician scheduling and quality assurance review with a modicum of “fire-fighting” the majority of ED Directors’ positions have evolved significantly as regulatory complexity, budget strictures, healthcare consumerism, technology and other factors have grown in importance. The job of ED Director is probably more difficult today than it once was: competition for patients and referring physicians has grown, new technology is pervasive, everything happens faster. There is much the ED leader must master and there is little agreement about the fundamental task the ED Director must accomplish. By comparison, defining the corporate CEO’s fundamental task is simplicity itself: Get the stock price up. Period. The hospital CEO’s fundamental task is no more obscure, though usually articulated as, “No margin, no mission.”



So, I’ve started wondering if longevity in the leadership role of a busy hospital ED is possible or is turnover inevitable. I’ve been contemplating my future as I’ve now completed six years as chairman at Maimonides Medical Center and I’m in the midst of finally settling myself and my family into a permanent living arrangement where my long-distance commuting is eliminated thereby attempting another 20 year or longer run in a single organization.



Some recent issues—including the speed of processing arriving ambulance patients through triage—have caused me to realize that the pareto optimum I described seeking in the October 2000 Emergency Medicine News isn’t a static point. (See the American College of Physician Executive’s series “Leading Beyond the Bottom Line.” target="_blank") Remembering that biological systems both decay at the level of the organism and evolve at the level of the species, so too, the ED as a unit must constantly evolve. If I as ED Director fail to support that constant evolution, inevitably my career stability will be compromised.



For the first 20 years of my career, my role models were all academic leaders, some among them the founders of our specialty. Some of them continue today in the leadership roles they held when I first met them 25-years ago. Others have changed positions but remained within the same institution or community. Their success and stability has come from doing a few things very well: running excellent training programs and delivering good patient care. I doubt if that formula is sufficient today.



I suggest that the ED Director’s fundamental task is or should be to recreate the ED as a learning organization. Peter Senge in 1990 wrote in The Fifth Discipline: The Art and Practice of the Learning Organization of the need for authoritarian organizations to transform into learning organizations if they are to overcome the risk of failure. While failure in the marketplace has not been the primary motivator for most ED Directors—that once unthinkable possibility challenges some of us today at the organizational level and consequent to our own human failings is always a possibility in our own career. Senge teaches that through the integration of the five component technologies of “systems thinking,” personal mastery (proficiency), mental models, building shared vision and team learning an organization could overcome the risk of failure but at the expense of the leader’s unquestioned authority.



How can such a model of management enhance career stability for the ED Director? Won’t transforming your ED into a learning organization enable the hospital to get along without you? Well, yes, it certainly could. But, then you would have built the reputation of accomplishing such a transformation and it’s likely that other opportunities—even in the same organization would develop for you, for remember that security truly comes from the inside and is not given to you by anyone else.



Those of us with children know that the joy of the daily work of child rearing leads to the important accomplishment of sending forth an independent person into the world. A strong, Emergency Department and learning organization would be a marvelous legacy for any director to leave behind.



When you get right down to it, for career security and countering complacency as in all of life, “Even if you’re on the right track, you get run over if you stand still.” (Will Rogers)



Monday, January 14, 2002

Lessons in Leadership from the Chestnut Hill Fathers Club Coed Soccer League.

My son’s team the Earthquakes just won their league championship, undefeated and scored upon only twice. Many games were played with no or only one substitute player, rarely there were as many as three or four, yet the kids played 30-minute halves and they played full-out. Mike and Dennis shared goalie duties for most of the season since more than half of the season my son, Zoey, couldn’t play the position his customary second-half after fracturing two metacarpals while playing the weekend I was in Chicago administering oral examinations for ABEM (or was it attending ACEP)? This was his third year with the team and because of our pending family move from Philadelphia to Brooklyn, it will be his last. He’s already asked me if he can come back to Philadelphia on weekends to play next year. Surely he loves the game and is excited to play with his teammates. How did this come about?



I credit Steve Fillebrown, one of the fathers, the Earthquake’s coach and the League Commissioner. Most games this season I watched my son—wearing his sock-covered splint play offense, but I kept being drawn to watch Steve, who in his march up and down the sideline and his squat in the dust at the edge of the field drew my attention with his concentration, his many comments to his players and his rare words to a parent.



At a post-season barbecue at one of the assistant coaches’ home, I spoke to most of the parents present. While during the season we had cheered together and spoken some on the sidelines as our children played, at the barbecue I had the chance to learn a bit about each of them: career, avocations, travel experiences and other children. Through the thread of all of this conversation on an exceptionally warm November Sunday afternoon into evening our conversations all returned to Steve and what he had given our children: confidence in themselves, ambition to do better, courage to challenge opponents on the field, trust in one’s teammates and most of all love for the experience of playing soccer together.



I wish I could better help my emergency physician colleagues find similar joy in our work. I wish I could help colleagues find the strength to play full-out even when there’s no substitutes to relieve them on the field.



For nearly two years I’ve been writing about "leadership" with a special focus on our role as service providers to both communities and patients. Yet, recent postings on emed-l (subscribe using "ED Subscriber" at the www.ncemi.org website) leave me feeling dejected. These postings in a thread titled, "ED abuse," discuss interactions with patients referred to the ED by community based primary care physicians and specialists. Most writers seem to believe that this behavior is both abusive of the ED and disrespectful of the emergency physician. One writer comments, "Locally there is a lot of ‘abuse’ by doctors. Many routinely refer patients to the ED who clearly have non-emergent problems that could be better dealt with in the office with the availability of old records, previous knowledge of the patient, and sub-specialty expertise of the ‘referring’ physician."



In another time I would have launched into a polemic. After citing data about marginal costs of care of non-urgent patients and the value of offering a generalist’s "second opinion" to a practitioner and patient in need I would have figuratively waved my finger in your face suggesting all the while that you were neglecting your responsibility to your medical community and patients. But I’ve learned something from Steve Fillebrown.



It’s a good ball—your idea about holding your colleague accountable for referring the patient off to you and the ED. But your sentiment about abuse is neither a good pass nor a goal scored, because it is just your sentiment, not your team’s action.



If this behavior on the part of your hospital’s medical staff is "ED abuse," what is your team doing about it? Who is your team? Is your team just a few grumblers in the ED or have you built a coalition with the rest of the medical staff? Are you attacking the challenge by developing an alternative for delivering the service or through planning an educational program you will present to the malefactors whose behavior you wish to change? Or is your role as another emed-l correspondent wrote, ". . . to figure out what they [the patient] need[s] and how to get it for them, if that is possible."



Based on my soccer field experience I suggest that our role is to work as a team—a committed medical staff—in the ways that have already been defined—playing the game by the rules—and that as a consequence sooner or later our ball will go into the net, i.e., the patient’s care will be optimized and the load on the ED mitigated. Complaining about it won’t change things, practicing with our team—ED colleagues and members of the medical staff may just bring a score—in the future.



It seemed like at least once a game Steve Fillebrown would specifically praise one or another opponent’s play. Maybe the referring physician when sending the patient to you is similarly "praising your play." The question is not whether you or I have neurosurgical (or some other sub-specialty) expertise—we obviously don’t. No, it is the "new eyes and ears" the different approach to problem solving that’s wanted. If you can’t handle the ball, try passing it directly or even across the field—talk to each other.



Coed soccer on the weekends is a child’s game for 12-15 year old boys and girls. The lessons of trust, communication, teamwork, respect for opponents (challenges faced) are all worthy of our attention. For myself, Steve’s example on the field encourages me to moderate my polemics and focus more on the positives of each medical staff member while remembering that through teamwork we buttress each other’s weaknesses and call forth each other’s strengths.