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.

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