The Hawthorne Medical Center emergency department (ED) sees 50,000 patients each year. The fast track, open 16 hours a day, often sends patients to the main ED when it shuts down at 1 AM. The staff is convinced that adding another mid-level is the solution, although the numbers indicate the current staffing should be adequate. Will adding a mid-level solve their issue?

The Matterhorn Medical Center ED averages 45 patients per day with single physician coverage, just under 2 patients per hour. But the 7 p.m. doc often walks in to a full rack and can’t catch up until late in the night. On average, most of the volume is seen between 4 and 11 p.m., a pace closer to four patients per hour. LWBS and LOS are creeping up, but the financial picture is not. One doc just got back from a conference where the expert advised that a mid-level would solve their issues. But will it?

By applying “lean” principles – a management methodology focused on ‘’doing the valuable work that better solves a patient’s problems, and doing it well, but with less burden and the fewest resources required– we can answer these questions in an effective and systematic way.

Any Lean approach begins with three questions; we’ll apply each in turn to the use of mid-levels.

Q1) What are the results we need to achieve? Is success only about seeing more patients per hour?

Q2) What is keeping us from achieving these results right now? Merely adding a midlevel provider may not improve throughput unless the corresponding support staff and institutional capacity are available to handle the increased work pushed on them

Q3) What do we need to learn to be better at to achieve these results? What skills and knowledge will people need to overcome the difficulties that currently prevent the ED from keeping up.    

Moving Forward
The first step in building the concensus required to successfully implement any plan is to establish a starting point, the shared perspective everyone involved can work from. From there, you’ve got to agree on the measure of success. Learning measures show if the process is performing as expected; performance measures connect your work to what patient’s need. Ease of implementation depends on each stakeholder realizing at least some benefit from the solution. Searching out these varying and often disparate needs first, before devising any plan, is crucial. A clear and agreed upon standard for measurement reflects the needs of individuals and the institution and forms the second necessary step.

The third goal is to agree on the best countermeasure to try. Now you should have a good theory about what might work. The final step, testing against the measure of success, surfaces the unintended consequences that are inevitable even with the best designed plans.

So how did these institutions fare?

Q1) What are the results we need to achieve? The fast track needed to achieve an average 2.8 pph, faster than the current 2.3 pph the data indicated, but the range was 0-7 arrivals. They chose to aim for the 75th percentile at 3.5 to be sure they had adequate capacity most of the time.

Q2) What is keeping us from achieving these results right now? The midlevels felt they were sitting around waiting a lot. The nurses complained they did too many non-nursing tasks, and the midlevel couldn’t keep up. Both felt the CNA wasn’t willing to do much. Observation revealed that often, the nurse would fill the rooms, the midlevel would hustle to see patients, and then wait around for tests and discharges to be completed, before the nurse filled up the rooms again. The CNA wasn’t sure what to do and roamed around trying to be helpful.

Q3) What do we need to learn to be better at to achieve these results? This uneven pace led to wasted effort and time and hindered everyone’s ability to see the real problems.

Agree on the Problem.
They tried an additional midlevel for a few days, but still had some backlogs s. They decided to look closer at each individual’s work flow, the tasks required to move a patient through, and how to better level the work load.

Agree on the Parameters of Success
The nurse wanted more time to explain discharge instructions. The CNA’s wanted some guidance and training. The midlevel wanted to be more productive, but not without doing the work safely and well. An empty waiting area became the learning measure, a real time metric as to whether they were keeping up, and the performance goal to comfortably handle 3.5 discharges per hour.

Agree on the Best Countermeasure to Try
Training to skill and knowledge gaps was done. A better coordinated work flow made the pace more even. A plan to address backlog in the waiting room was implemented to get caught up quickly before getting too far behind.

Discharges per hour are nearly 3.0, and waiting room is empty 80% of the time. This surfaced supply issues and other obstacles to an even flow. Although they still need to get to 3.5, there are more things with the current staffing pattern to work on, and they are not yet convinced that the answer is an additional midlevel.

Q1) What are the results we need to achieve? Although they comfortably handled their load most of the day, there was an abrupt influx on some days, up to 9 patients sometimes during 4-11 PM period. Current data showed the doctor could ramp up to 3.5 pph comfortably for short periods, as long as the acuity was not too high, but not up to 4.0 pph needed to keep up.

Q2) What is keeping us from achieving these results right now? The capacity of the doctor was being exceeded.

Q3) What do we need to learn to be better at to achieve these results? Was it realistic to expect a midlevel new to their ED to achieve 1.5 discharged pph? Combined with the doctors’ comfortable pace seeing 2.5 pph, this should result in the 4 discharged pph they needed. One doctor noted that at another facility, his productivity actually went down from 2.5 to 2.2 pph due to the supervision required to assure appropriate care, because midlevels came with varying skills, experience and comfort levels.

Agree on the Problem.
They were quite confident adding a midlevel was the proper step but could the midlevel comfortably see 1.8 pph, while maintaining quality care? How would the doctors and midlevel coordinate their efforts? How would this be judged and rewarded?

Agree on the Parameters of Success
The doctors needed to know about the patients, but if they went to see them all, they might as well just see all of them. They needed help keeping the triage 4 and 5 patients moving. The midlevels wanted to do their work safely and comfortably, but also wanted to advance their skills and knowledge. They established a goal of getting each midlevel to a consistent comfort level, allowing the more experienced and able to take on higher acuity patients as they demonstrated their ability to do so safely and comfortably. There was no fast track area, but they agreed that success would entail keeping the level 4 and 5 patients moving through their process no matter what else was going on. They expected by investing in the development of each individual midlevel, they would eventually reach their goal of 4 discharged pph in the next 6 months.

Agree on the Best Countermeasure to Try
An initial orientation assessing the new midlevel’s comfortable level of practice and on the job training to skill and knowledge gaps was established. Criteria were established to indicate when the midlevel had demonstrated the ability to take on more complicated patients. Criteria were established for when the midlevel should do a brief review with the doctor and what information should be shared to make the best use of everyone’s time.

They are still early on in this endeavor, but note the increased capacity to handle 3.5 discharges per hour with the midlevel on board. The doctors already feel less burdened, especially at the 7PM shift change; LWOT’s are down, overall throughput is better; this has spurred efforts to address other areas of uneven flow in their ED.

The experience of lean organizations is that by addressing problems in a prescribed, shared manner, the timeline from problem identification to effective implementation is markedly compressed. Lean practices and tools provide the detailed structure to deeply understand how work is currently done, to identify exactly what prevents the work from being done well, and to put in place a system to achieve those elusive results. Best practices and expert advice provide suggestions that can be a valuable starting point, but can only be your answer once they are evaluated in light of your own unique circumstances. There are few, if any, easy plug and play fixes out there.

Can a mid-level practitioner improve the capacity of your ED to provide effective care to more patients? Can they ease the work burden? Can you afford it? You could sit around a table and guess at the answers, or you could try a Lean approach, which provides the structure for your organization to learn collaboratively, by safely experimenting, to find what actually works for your ED and your patients.




# Hueydoc 2011-10-26 04:05
What I find scarey is that with all of the numbers followed in the ER, NONE have to do with whether the patient was correctly diagnosed and treated or if they even lived.
# PR 2011-10-26 15:40
What I find scary is the silly hyperbole purported by those docs who claim that patients are in danger when midlevels are caring for them... of course, there is no data to support their position or statements. Just scare tactics.

Of course, these are the same docs who work in the backcountry and inner cities because they were "called" to medicine to serve some higher purpose. Oh, wait, that's right. They don't. There are enough "other" BC/BE EM MDs who are willing to do it... that's right. There isn't. But instead of providing solutions all they do is continue to propagate the problems...
# Mark Jaben 2011-10-26 17:47
Yes, you are quite right, and I wholeheartedly agree. What attracted me to the Lean approach is the emphasis that without quality, we can not achieve delivery and cost requirements. And without real dialogue between all the parties involved, one where all sides are committed to learning mutually workable countermeasures to a problem, we will find it difficult, if not impossible, to consistently achieve quality care for our patients.
A crucial issue is what constitutes quality. Certainly, an accurate diagnosis and appropriate treatment is necessary, but is it sufficient?- that is a topic for another day.
Thanks for your comment.

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