Reflections on Efficiency

In Commentary, Opinion by Nadim LalaniLeave a Comment

I was at a great conference on Emergency Medicine in San Francisco. My wife and I went to a diner for breakfast. While there I was struck by how efficient the whole experience was.

From Mels Drive In Click on Pic for Link

I think that things that made this experience really efficient were:

  1. Enough space so we didn’t wait in line
  2. Menu’s already on table
  3. Menu itself was stuff that they were really good at  and relatively simple to create – American Food
  4. Waitress enters order on Ipad that alerts others/kitchen
  5. Dedicated staff for orange juice/coffee
  6. Dedicated staff for turning over tables [this guy was lightning-fast]
  7. Bill left on table pre-discharge

I got thinking about things that we could borrow from this diner. My reflections have raised more questions than answers.

  1. Can we triage minor vs everything else?
  2. Can we have parallel registration and only one set of vitals – i.e can the bedside nurse do only one assessment/whilst the clerk gets the personal details?
  3. Can we enter in our own chart/orders on an Ipad  and alert the phlebotomist/Xray tech immediately?
  4. Can we make the ER process quicker by specialising in “EM stuff” and having the consultants come down more immediately? Could we even consider “parallel assessment” – that way the consultant can set the plan early and we can execute it? Do obs/work-up units allow us to “fast-track” other things?
  5. Turnover is the main obstacle. Everyone needs to drink the cool-aid – so is there a way that “hospital flow” can be taught at an undergraduate level?

I put these questions to my local QI guru and got the following:

nl … I think you’re definitely on the right track.  The amazing change I found was when I started asking questions instead of trying to come up with answers.  As physicians we are trained problem solvers.  Give us the problem, we give you the answer.  I think this is why we struggle with system redesign.  When it comes to system redesign I don’t think anyone knows the answer.  You have to approach it with questions…’
  1. Can we triage minor vs everything else?

I’ve often thought, could we divide people at triage into:  “going home”, “staying” and “maybes.”  Then divide the dept into these 3 zones.  Man each zone with one physician.  

  1. Can we have parallel registration and only one set of vitals – i.e can the bedside nurse do only one assessment/whilst the clerk gets the personal details?

You’d think this would be possible.  Why not have registration go to the patient instead of the patient go to registration?

  1. Can we enter in our own chart/orders on an Ipad  and alert the phlebotomist/Xray tech immediately?

Do you remember doing this in Calgary?  We entered all of our own labs and medication orders on that archaic computer system.  It was a great idea, just not an exceptionally friendly interface.  A better interface would make it great.

  1. Can we make the ER process quicker by specialising in “EM stuff” and having the consultants come down more immediately? Could we even consider “parallel assessment” – that way the consultant can set the plan early and we can execute it? Do obs/work-up units allow us to “fast-track” other things?

Thats a really interesting question.  I wonder if it could be combined with question number 1.  Have a consultant/resident present in the “staying” zone.  They get involved earlier for the ones we know for sure are staying.

  1. Turnover is the main obstacle. Everyone needs to drink the cool-aid – so is there a way that “hospital flow” can be taught at an undergraduate level?

Most definitely.  And I think this is where the U of S can differentiate itself from other schools.  We have the SK Health Quality Council which may be the best HQC in the country.  Very advanced.  Good relationships with gov’t and health regions.  We should make our research focus on hospital and system flow.

I have had time to reflect on my initial questions.
  • I think it’s worth moving on with the parallel registration.
  • At a recent planning event one of my nurse colleagues was open to having only me do the assessment [while she documents]. One history and one Physical period.
  • The specialising in “EM stuff” meant leaving the syncopals, chest pains and the CHF’ers to the Cardiologists to streamline as they’re going to get consulted anyway – why not have them involved right at the begining and cut out 2-4 hours of Lead Time? This would leave us to do what we do best … fix lacs and broken bones, cardiovert people, manage trauma etc … Marks comments about a “staying zone” seem like a great idea. I know of ER’s that have an Internist in the ER during the day time.
  • I think that there is a desperate need to re-educate people about efficiency. Starting at Med School and Nursing School.
  • We need to mandate LEAN processes for everyone – or at least taking a look at your processes regularly. If the powers-that-be have to accredit hospitals – why don’t they mandate that departments look at their operations from a value stream perspective and not just focus on hand-washing? We ALL owe it to the taxpayer to be more efficient with our hard-earned dollars. here’s an example of how successful LEAN can be in one department … imagine an entire system!

again … more questions …

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Nadim Lalani
Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.
Nadim Lalani
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