Whether you’re talking about the people, spaces or equipment in an emergency department, one can always find ways to increase efficiencies. But as you work toward that goal, it’s helpful to recognize that achieving 100% utilization or efficiency is simply not possible, nor even desirable.
Rather, it’s wise to build in a little slack or downtime into any plan for process improvement. People and things just work better — and more sustainably — when they’re not operating at full capacity.
Recognizing the need for slack
It’s worth noting that more than 100 years ago, Henry Ford introduced the world to a brilliant, and far more efficient, manufacturing model. In Ford’s assembly lines, the products being built were conveyed past a line of workers who each performed a specific step. One of the keys to the success of Ford’s approach was that the employees never had to move far from their work area, thus allowing them to spend more of their time actually building vehicles. In practice, they collectively functioned like parts of a machine.
But of course, that’s not what healthcare is all about. Based on my experience working with EDs on process improvement, I believe that when people are working at 70 to 80% of their capacity, they reach a “sweet spot” of efficiency. That might seem to some like a low target to aim for, but experience shows that it’s fast enough where people are getting things done, but not so fast that errors are occurring or staff are getting burnt out.
Consider the treatment rooms, for example. These can never truly be 100% utilized — if for no other reason than the act of moving one patient out and bringing another patient in requires a certain amount of down time between patient treatments. Just as importantly, there’s the time needed in between uses of the room or equipment to clean the room and/or equipment and to restock supplies. These incidental steps may seem like “wasted time.” However, they are not only important; we couldn’t treat patients without them.
Looking at processes to find the inefficiencies
When Catalyst works with a client to improve process efficiencies, we conduct a variety of inquiries. One of our key steps is to conduct a process documentation, where are our medical and statistical staff meet with the client and talk through each of the steps involved in providing care to a patient (whether or not the step has a direct bearing on patient care). We create a process flow chart that includes each particular step, with minimum, average and maximum times needed for an individual to perform that particular step. Often, once all the steps are documented, it’s very obvious that the process is linear, cumbersome and inefficient. Mapping helps the team visualize the linear nature of existing processes and the potential parallel nature of improvements. Whenever possible, we try to remove steps entirely.
In some engagements, we also do time travel studies to quantify how many steps are required to walk from one area to another to find ways to increase efficiencies. For example, in one case, we examined an inpatient department and evaluated the impact of the location of medications areas on nurses’ efficiency. The existing department had two meds areas, one on each end of its space. But it was expanding to almost three times its existing size, and one of our tasks was to determine the optimal placement of meds areas in the new space.
Ultimately, we ended up persuading the client to keep the two existing meds areas, but also add a third area in the middle of the unit. We demonstrated that nurses working with patients near the center of the unit would not only have significantly shorter distances to travel but would also have a convenient alternative if there was a queue backing up at the location nearest to them. There was an additional cost for our solution, but the efficiency gain more than offset the one-time expense.
Other problems, other solutions
There are additional examples of creating “wasted space” that improve patient care. For example, more and more of our clients are creating “quiet rooms” or “decompression areas.” Some of these were previously little more than a small closet or storage room. However, with the addition of a comfortable chair, now a member of the healthcare staff can retreat for a few minutes from the pace and stress of the ED environment to decompress, clear their mind and recharge.
Ironically, not everything benefits from building extra capacity. Increasing your number of treatment rooms, for example, can actually have the impact of slowing down care, as an empty waiting room can signal to staff that it’s time to slow down. What’s more, although adding a fifth treatment to four existing rooms might seem like it would create the type of “slack” that can be helpful in other parts of the ED. But in practice, the room is likely to end up being far more difficult to staff.
Emergency departments have a difficult balancing act of keeping their staff and facilities busy — but not so busy that staff exhaust themselves, or that patient care suffers. As a first step, I recommend adopting the perspective that even “wasted” effort or spaces can still improve the ability of an ED and its staff to care for patients.