Just Seeing

I stood in the ER to the side of the desk where all patients had to pass. I was standing with an ER doctor who had over 20 years experience at this very hospital and had designed or inherited all the processes we were observing. From where we stood we could see patients coming in by ambulance, the staff station, the admin desk and about 60% of the treatment rooms.

We stood quietly with clipboards and just watched. We had chosen a day and time when it was likely to get busy because the problem we wanted to understand was how the ER got so behind when a serious case arrived. A serious case might be an auto accident where two or three people needed immediate life-saving attention. When that event occurred all work on the less serious cases seemed to come to a halt and the waiting room would back up for hours. Instead of working on the regular flow everyone was soon either working on or milling around the serious case.

It might seem obvious that there would be a problem in these situations, but in asking questions about staffing it was clear there was enough staff on duty during the predicted heavy times to handle serious trauma as well as the regular flow of the ER.

We stood and watched. One process in this ER decided which staff member got which patient. After a patient checked in, a printout was generated that gave their symptoms and history that went into a rack on the wall. That rack would then be viewed by the doctor who was in charge for that shift. He or she would assign patients based on a match of the doctor’s knowledge, the length of time treatment or diagnosis would likely take (you don’t want to assign a 2-hour case to someone who is about to go off shift if you have an alternative) and, since this was a teaching hospital, who needed more experience.

It all worked until the serious case arrived. Then the problem was obvious. The senior doctor would routinely go to work on the serious case. That meant nobody was assigning work. Doctors and nurses were doing nothing while the senior doctor worked the serious case and patients backed up in the waiting room.

A quick discussion afterward began the process of testing a new way to assign work in the ER.