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Dear Director,
We’ve tried LEAN techniques and “thin slicing” but our average productivity still lags behind other EDs in our hospital’s network. What are some ways we can get docs to work more efficiently?

As you have pointed out, provider productivity and department efficiency are inextricably linked. Often the search for productivity focuses entirely on the former. Many surgeons have told me how many more cases they need to do each week to keep their income stable; the same could happen to emergency medicine. Ironically, the difference between good and bad productivity numbers comes down to about two patients more per shift and the ability to pick up patients during surge times.

Although maximizing physician productivity is important – it will be necessary to handle future volume growth and it just might help you avoid a pay cut – it also makes sense to have a better, more efficient system in place. We need to cultivate departments where people are working at reasonably high (not insanely busy and dangerous) levels of productivity. Most docs I work with enjoy shifts more when they’re busy and productive. When you look around your own group, there are clearly different levels of productivity that each provider brings to the table. The director’s job then becomes maximizing individual potentials by having the right systems in place. Here are the top ways that you can impact productivity on a system level.

Staffing: Get flexible
If you’re still using the same schedule template from five years ago, you’re probably not staffing efficiently. I’ve seen many EDs who staff the same arrival patterns and total daily hours of physician coverage for all seven days of the week even though their volumes fluctuate from day to day. It’s also not unusual to see shift start and end times at the traditional 7am, 3pm, and 7pm, even though these times may not correlate well with patient arrivals. I used to work in a department that consistently got a rush of patients around 7am, yet the morning doc came on at 8am. That meant that those patients who were arriving waited for the incoming doc because the night shift doc was too busy tidying up loose ends and too tired to see new patients. The 8am doc walked into a mess of cranky patients and became equally cranky.

When designing a scheduling template, start by determining the number of hours of coverage you need to hit your productivity goals. For example, in a 36,000 annual visit ED (about 100 patients a day), with a provider goal of 2 pts/hr, you need approximately 50 hours of coverage. Odds are your Mondays average 110 patients and your Thursdays are closer to 95, so it requires 7.5 less clinical hours a day than your Monday. Staffing needs to be flexible when there is day-to-day variability. You can take it to the next level by factoring in your fast track population and the hours that it’s open. Your fast track productivity goal may be 3 pts/hr, which would then further decrease the daily amount of coverage needed.

I build my schedule template annually by evaluating patient arrivals to our main ED and to Fast Track by the hour of the day and by day of week. We bring in additional docs throughout the day to keep up with patient arrivals and have shift change based on desired shift length and when we need a fresh body to handle a surge. We have three different models depending on the day of the week so that there are enough patients to go around. We found that we needed extra coverage on some days but could eliminate a shift three days a week as well. In order to work fewer weekend shifts, we do longer shifts on the weekend and use one less physician per day. At the end of the day, you want there to be enough patients so that your providers are able to hit their targets, yet enough coverage that it’s safe for patients and providers.

EMR: Recruit ‘super users’
Just about every doc I know is in some stage of the process of switching ED documentation systems. The voice of the emergency physician needs to be heard in the debate between best of breed systems (those more tailored towards the emergency department) and enterprise systems (hospital-wide EMRs that are retrofitted to work in the ED). While there are pros and cons to each, most important is to understand how your particular system will impact ED flow.

Regardless of what system you get, it’s essential that you have docs who will commit to being “super users” and all of you then take the time to completely understand how to maximize its use and teach the rest of your staff these lessons. The super users will learn the ins and outs from the EMR’s trainers and then can work together to customize the EMR to fit your ED and maximize your operations. This means doing the homework before installation to build your order sets and maximize the efficiency within the CPOE. Spend the time to get it right so your doctors are spending less time clicking and more time with the patients.  Super users will also hit the ground running when it comes to implementation, knowing the short cuts to improve efficiency, and helping teach your slow adopters techniques to improve their efficiency. Transitioning to a new EMR is tough, but with preparation and team support, you can have positive outcomes such as legible charts, better CPOE, improved documentation with templated medical decision making and algorithm support, all of which ultimately leads to improvements in patient safety and better quality of care.

All about the support staff
The next step is to make sure you have a plan for increased clinical assistance. In the broadest sense, this means having the right nursing, tech and secretarial staff on hand. This might also mean having scribes.  A scribe program pays for itself if docs increase their productivity by about 0.1 to 0.2 pts/hr. Depending on where your baseline productivity is, and the negative toll an EMR might be taking on you, well-trained scribes can likely increase your productivity by 0.5 pts/hr. Your scribe becomes your personal assistant and is able to perform the vast majority of documentation and patient tracking. Their tasks can be as simple as tracking results of tests or reminding you to make a disposition on a patient.

I’ve heard it said – and I couldn’t agree more – that scribes decrease your cognitive load. In other words, as our day progresses, there are numerous high level patient details to remember as well as many low level details. Scribes can keep track of the important yet lower level details and free your brain up to focus on the clinically relevant parts of the puzzle.

Your scribe takes on the burden of keeping you on track. Consistently you hear docs say that working with scribes increases their productivity and allows them to focus on doctoring rather than typing on a computer. That’s been my personal experience as well and getting a program up and running in your ED could be a game changer in efficiency. In tough budget times, it can be hard to get the money to add on a scribe program without a good ROI, but a groundswell of support is growing. The Advisory Board Company gives scribe programs the grade of A and calls them, “Strongly recommended for most members; highly effective practice for reducing ED LOS and improving patient satisfaction.”

Cultural shift
The most challenging task for any medical director is likely that of changing the culture of the department. This also happens to be the one thing that, if done well, can have the highest impact on the department. Getting buy in from docs that there is a need to increase productivity isn’t easy. Medical directors can use monetary incentives, but money alone isn’t enough to change culture. A better first step is to understand your group’s dynamics and how each doc will respond to publicly or privately reported data comparisons. Then, use that data to inspire, coach, and educate. Being clear and fair on expectations starts in the hiring process and continues throughout regular meetings with your team. An individual doc’s understanding of your expectations may ultimately lead them to decide to practice in another location.

Productivity is in many ways inversely proportional to length of stay. By decreasing length of stay, you actually have more time to see patients, and more beds to put them in. Therefore, culture change is not just limited to the physicians.

You must engage nursing and work with them so they have similar goals.  Cultural changes occur over time and in waves, but I regularly work to get buy-in on the following core concepts. One, we’re in this together. Two, increased productivity is good and it brings tangible rewards. Three, charts in the waiting-to-be-seen rack are bad. Four, the medical director will be there to provide the necessary support so they can be successful in their job and attain the department goals.

Conclusion
Increasing productivity is a necessity if we want to be successful in our practices. Medical directors have direct input into many areas that will impact the individual physician’s speed and productivity. While the baseline speed of an individual physician will vary and needs to also be evaluated and coached, medical directors have the responsibility of making sure that the system is as efficient as possible. While there is no magic bullet that can bump your pts/hr upwards by 1, there are numerous ways to make small, yet meaningful increases to your department’s productivity.


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

 

 

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