QIPS TIPS #34: The Efficient ED Doc

Shari Welch, MD, FACHE, FACEP

Almost every emergency department and physician group contains a physician that is wildly efficient when compared to his partners. Whether this is because he is naturally an operational thinker or multi-tasker, he is more confident in his clinical decisions or whether he takes more risks in clinical practice…it is often hard to pin point. But in emergency medicine there are vast differences in the ability to efficiently process patients in the ED.

In a piece published in the New Yorker titled “Personal Best” Atul Gawande observed that many highly paid professionals employ the services of a personal coach to improve their skills and performance. From the concert violinist to the professional tennis player, the drive and quest for professional improvement becomes a way of life. By comparison, the typical emergency physician, who participates in one of the lengthiest and most expensive education and training regimens, typically gets a two hour orientation to his emergency department and thence begins his professional career. We do very little to enhance practice performance over time.

Though most physicians in a group (and nurses for that matter) can tell you the most efficient physician in the practice, we do little to explore that efficiency. The strategies utilized by these efficient providers are not disseminated by the group or incorporated into individual practices. This is an opportunity lost.

The efficient physician cultivates habits that move him to higher levels of practice efficiency. Two of the most important mantras for the efficient physician are:

  1. Touch it Once
  2. Limit Interruptions

“Touch it Once” is a concept borrowed from LEAN manufacturing that employs the notion that a task is most efficiently completed when it is done in one encounter. Examples of this applied to the work of the ED Physician include:

  • Check all labs and imaging that are available at the time of a logon
  • As you begin sense making and then diagnosing, order all tests at once; avoid constant add-ons

“Limiting Interruptions” can be difficult in the unscheduled environment of the ED but a few ideas that help limit workflow interruptions of the physician:

  • Inform the team as to your plan for each patient
  • Train staff to avoid interruptions when you are on the phone or performing computer tasks
  • Develop non-verbal communication methods to facilitate workflow including computerized cues and visual cues (flags, whiteboard communications, lights etc.)

An emergency physician has to be continually assessing and re-assessing his patients to be certain that patient flow and workflow are optimized. Running the board periodically to see what needs to be done is an efficiency strategy for the individual physician. Since the short term memory can only hold 7 items at a time, lists, prompts and reminders are also a good idea for the efficient physician.

A study in the American Journal of Emergency Medicine noted that it takes approximately 1500 hours to maximize work efficiency (measured by RVUs and patients per hour) in a new clinical environment. Then efficiency levels off with little additional improvement over time. Most physician groups do not assess whether a physician has optimized his workflow, and efficiency. And a physician performance coach is unheard of in the ED. But is it an idea whose time has come?

Consider these ideas to improve personal practice performance:

  1. Catalog the habits of the most efficient physicians in the group and make them available to the practice at large
  2. Have the most efficient physicians observe other physicians and offer strategic ideas for improving efficiency
  3. Meet with IT experts to review computer support for workflow and identify at the individual physician level areas where efficiency could be improve
  4. Retrain on the EMR periodically to make sure that each physician is using the most efficient strategies on the computer to do his/her work
  5. In particular, explore the possibility of optimizing IT support for workflow in the form of order sets (including discharge prescription sets for the most commonly treated conditions)
  6. A second monitor makes the user 40% more productive so consider multiple monitors at each computer terminal open to the commonly used applications for the physician with one time logon for each shift

A final idea for emergency physicians is to “Tee Up Discharges”. One of the most reliable assessments in medicine is physician’s blink response to the patient. Emergency physicians are highly reliable at predicting admit/go home, sick/not sick. We are even good at predicting whether a patient will survive an ICU admission or not. Take advantage of this by getting the paperwork ready for a patient you anticipate will go home. This strategy has been noted among efficient emergency physicians.

So each of us can improve our practice in emergency medicine.  It requires that we be open to the idea of continuous improvement, coaching, and retraining in the various elements of our practices.

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