Health care is under pressure to move in two directions: The public wants medicine of higher and higher standards. But no one wants to pay more: No one wants to pay higher taxes or more for insurance. Most governments plan big spending cuts now the economic crisis is ending. Hospitals are being sold by many governments to private companies. Companies want hospitals to make a profit.
Medicine is a social service. We want everyone to have the best care possible regardless of their wealth. To provide the best care the health sector must do more with the same money - or more with less money.
We must be more professional. We need new ideas: not only about how we treat patients, but about how we organise our work.
The medical expertise and resources needed in an ED are simple to define:
Stabilisation, diagnosis, treatment, handover, evaluation of illness or injury level and assessment of risk are among expertise needed. And - an efficient method of working, interface management, interdisciplinary capability, short waiting times and general workflow expertise generated by lean management. All of these can create more potential for success in the overall ED enterprise.
The ED can be a market-orientated service organisation, the ED can provide a model for creation of a customer and patient based hospital organisation. This in turn creates makes hospitals more competitive by improving care quality and efficiency. An ED can be transformed from simply the first point where patients arrive in a hospital, to the point which defines and starts a correct treat-ment course. By saving resources and saving costs. The ED can be the corporate center of excel-lence for clinical treatment processes.
The Triage takes place at the entrance to the ED. All patients arrive at the entrance whether they come by foot or ambulance. All are first seen by a nurse trained in triage. The nurse then makes an assessment of the category of the patient and the level of emergency care needed. We have a fast track unit, acute area and clinical decision unit.
The initial triage by a nurse is followed by a First View examination by a senior doctor. First View permits diagnostics and treatment to be started leading to hospital admission or discharge. Using First View has achieved a big time gain – of up to 36 minutes - and so achieved a total wait-ing time of ALL patients in our emergency department of about 12 minutes.
The optimisation of the processes to add value can be achieved partly by cutting waiting times and with expertise in organising work-flows. First View means the support of Lean Management in the entire hospital. It means the first contact with a specialty doctor for ALL patients inside 15 minutes with a corresponding large cut in waiting times. The First View Concept means: fast, re-source-orientated diagnostics and treatment following SOPs. The First View doctor must ensure all the cogs in the ED work together perfectly. First View – as on a production line – means flow instead of a standstill and a significant improvement in the working climate in the ED. The senior doctor (the First View doctor) has to have an overview of the entire patient flow and he monitors the patient flow, supported by intelligent management technology - like E.care.
The ED can be the model for a customer and patient orientated hospital and the First View Con-cept is a key method to provide process and service-orientated medicine. The First View concept is also an example of the expertise work flow organisation needed in an emergency department. 2
The ED is changed from a place where a patient arrives – purely an admission unit - to the creator of treatment chains reaching across disciplines. The potential work responsibilities for the ED were defined by the German Association for Emergency Medicine DGINA as the pre-hospital phase, diagnosis and treatment, handover into hospital or discharge. On the management level this means the potential level, requiring Hardware, Software and Peopleware, the process level, requir-ing workflows, routines and interfaces and the result level which includes the outcome quality and customer satisfaction.
ED leaders must deal with very different challenges. Inside-out challenges are inside the depart-ment itself. Outside-in is the challenge to move the patient further inside the hospital. Potential problems can be quickly identified for ED infrastructure, medical equipment, budget responsibili-ties, assessing the length of time the patient may stay in hospital, the lack of emergency medicine professionals in Germany and the lack of reputation among EDs. Possible problems in working processes include interface management, patient control, no First View concept or Fast Track pro-cedures and lack of case management. Other problems are perception of medical care quality, per-ception of nursing quality, the different quality assessment standards in fact used and rising de-mands for high standard emergency care. We also face problems with anti-social behaviour and the PR and marketing an ED requires.
Even when the workflow in an ED is highly organised and functions well as it does in Hamburg, the ED can still have problems with the outside-in question: The exit problem for the ED is big.
Why? Because hospitals have too many bunkers with their own specialist knowledge. They think about their own work only. Their management creates isolated thinking. They work on an island alone, away from the rest of the hospital.
I believe the ED can be a centre which helps hospitals work better. But we have to move away from providing medicine in isolated bunkers. We must provide harmonised workflow medicine with the patient at the centre, supported by intelligent management technology - like E.care.
We have already positioned the ED as a market-orientated service organisation and we have achieved the fulfilment of a paradox: Raising the quality of medical care, raising the satisfaction of patients, doctors and nurses but at the same time reducing the resources used. This makes us a corporate center of excellence for clinical treatment processes, which can make a significant con-tribution to the success of the hospital as a whole.
Now there must be a focused application of the principles of lean management in hospitals. This means finding better ways of working, using flow principles, principles of excellence in operation, principles of transparent process implementation, the principle of peopleware before hardware. Then we can achieve Lean Management and Total Quality Management in hospitals.
But - the future holds more. I believe the excellence the ED can achieve will change organisation throughout hospitals. The ED will be a center of excellence with a central coordination role, which uses such concepts as First View and organised workflow to enable the hospital to provide first-class medical care.
DR. BARBARA HOGAN
PRESIDENT EUSEM (EUROPEAN SOCIETY FOR EMERGENCY MEDICINE