4 Common Emergency Department Culture Issues and How to Fix Them

Emergency Department culture impacts everything from provider retention and patient experience to efficiency metrics and care quality. No matter the performance issue an emergency department faces, the solution to that issue is invariably culture change. When an emergency department leader focuses on culture first and aligns the team around a culture of service, performance improves.  

So, what exactly is “culture of service” and how can you influence it?  

A culture of service prioritizes the needs of team members and customers over individual needs. It depends upon a servant leader leadership style, which is also defined by making sure that other people’s highest-priority needs are being met.

The Robert K. Greenleaf Center for Servant Leadership defines a servant leader as a leader who “focuses primarily on the growth and well-being of people and the communities to which they belong. While traditional leadership generally involves the accumulation and exercise of power by one at the “top of the pyramid,” servant leadership is different. The servant-leader shares power, puts the needs of others first and helps people develop and perform as highly as possible.”

The culture of your emergency department is shaped by your medical director’s leadership and communication style, daily interactions between team members, team attitudes, and your leader’s and team members’ level of engagement in their practice. A healthy culture is evidenced by reduced provider burnout, improved communication, improved patient satisfaction and care quality, and boosted efficiency metrics.

Here is an overview of the five most common emergency department culture issues I have run across and their antidotes:

1.    Hierarchal Leadership

When leaders let their ego get in the way of putting their team member’s needs first, the team has a tendency to feel unempowered and disengaged. Top-down leadership fuels a lack of engagement and trust amongst the team. When leaders consider it their responsibility to serve their team rather than the team serving them, engagement and trust builds. Engendering a culture of servant leadership at your facility requires that you develop an engaged medical director who encourages staff involvement, leads by example, puts team-member needs first, and truly listens to team needs.

 A few tactical ways to replace hierarchal leadership with servant leadership include:

·      Encouraging leaders and team members to ask themselves, “How can I serve this person?” at every interaction.

·      Asking all staff, “What is one thing I can do to make your life easier?” and then truly listening to their feedback and taking action to put processes in place that consider their feedback.

·      Performing anonymous surveys to seek feedback on what you can do to improve the way you serve the team.

2.    Siloed Thinking/Misaligned Goals

If team members are not clear on departmental goals or how their actions impact those they interface with, tension and inefficiency is inevitable. A team that is not aligned around shared values and goals lacks accountability and motivation. An aligned team has defined core values and metric goals, is locally invested, and prioritizes communication with all they interface with.

A few ways to replace siloed thinking with aligned thinking include:

·      Instating regular interdisciplinary meetings

·      Clearly documenting and communicating shared goals

·      Establishing shared incentives  

3.    Incivility

Studies have shown that when people experience incivility at work their performance declines, they are less committed to the organization they work for, and in some cases, they take their frustrations out on customers. In the healthcare sector, incivility is common in the form of bureaucratic culture, extremely siloed processes, and uncivil communication. This results in a decrease in quality of care, higher provider turnover, loss of productivity, lack of provider engagement, and poor patient experience.

We have found that when we encourage respect at every interaction, positive communication, and simple gestures like a smile or a hello when you pass team members in the hall, productivity, patient experience, and engagement all improve.  

A few simple ways to promote civility include:

·      Setting a new standard by defining civility as important as metric success

·      Modeling the standard through your own behavior

·      Asking team members to hold you and each other accountable

4.    Burnout and Turnover

It is no secret that burnout and turnover is a concern in healthcare, especially in emergency medicine. It has a toxic ripple effect, resulting in unstable teams (mostly staffed with temporary providers who are not invested in community), high recruiting costs, lost revenue during recruitment, inefficiencies due to lack of engagement, and poor patient experience. We have found that engagement is the antidote to burnout and turnover.

A few key ways to improve provider engagement include:

·      Providing leadership development programs and other education and peer review opportunities

·      Recruiting a local provider team who is invested in the community they serve

·      Increasing doctor-nurse engagement and interdisciplinary process improvement efforts

·      Offering providers the opportunity to share in ownership of their practice  

In summary, replacing hierarchal leadership with servant leadership, misalignment with alignment, incivility with civility, and disengagement with is bound to not only remedy your department’s culture issues, but also make a substantial positive impact on your provider team’s quality of life, your ED’s quality and efficiency metrics, and your bottom line.

9 Important Issues Hospitalists Should Discuss with ED Counterparts

Hospitalists and emergency medicine physicians interface at a crucial point in the patient care continuum: where patients in need of further treatment are discharged for outpatient treatment or admitted to the hospital. Both groups share the same prerogative: provide high quality patient care and achieve positive outcomes. However, there are times when the two groups are at odds, especially when there is a gray area regarding the best care setting for a given patient.

Hospitalists and ED physicians have different, and sometimes conflicting, priorities. ED physicians are driven by throughput: moving patients through the ED quickly and efficiently. Hospitalists are driven by efficiently managing inpatient length of stay. The key to reducing tension between the two groups is to bring them together to discuss how they can better serve one another.  

In my experience as a hospitalist, I have found that there are a few key issues that are crucial to discuss with my ED counterparts. The list below is a good reference for common issues to address at an interdisciplinary meeting.

Inpatient Patient Sources

The ED is not a hospitalist’s only source of patients. We also manage consults from other services, direct admissions from primary care physicians, ICU transfers, and admissions from free standing emergency departments. Simply discussing the patient load and being open about the fact that the ED is not the only source of patients can help reframe your conversation. A hospitalist and ED physician should always take time understand the volume of patients the other practice is handling to better understand one another’s perspective and make informed requests and decisions together.

Labs and Imaging before Admission Calls   

When possible, it is extremely helpful for hospitalists when the ED completes labs and imaging before admission rather than admitting a patient with pending results. Sometimes, the results change whether the patient can be admitted to the floor vs. the ICU. A good starting point is to determine a protocol for labs and imaging and establish common exceptions so that everyone shares the same expectation of how labs and imaging will be handled.

Protocol for Borderline-for-Admission Patients

When it is not clear whether a patient needs to be admitted, it is helpful for an ED physician to ask their hospitalist counterpart their opinion before making a decision. Guidelines evolve and patients that we would have been admitted just five years ago can often be treated safely as an outpatient (e.g. in the case of a stable pulmonary embolism). It is helpful to discuss these types of cases and establish an interdisciplinary algorithm on how to handle each case.

Documentation of Conversations with Consultants

To avoid confusion over whether an ED physician spoke with a consultant, it is important that ED physicians always document whether they talked to a consultant directly or whether they are awaiting a call back from a consultant. If this is not mutually understood, confusion and delay of patient care is common, especially if the patient is admitted overnight and there is a handoff to a daytime hospitalist. A good remedy for this is to establish a protocol on how to handle overnight admissions handoffs and documentation of conversations with consultants. Thorough communication and documentation are critical. 

Batching Admissions

Sometimes, calling in multiple admissions at once is impossible to avoid. However, it can be very difficult for a hospitalist practice to handle 3, 4, 5, or even more admissions at once. In my experience, there are certain ED physicians who have a reputation for calling with a bundle of admissions at the end of their shift. Often, this is simply because that physician does not fully grasp the effect it has on their hospitalist counterpart. The best solution is to openly communicate and establish mutually beneficial strategies to avoid bundling admissions.  

Treatment Updates

There are often changes in things like recommended antibiotics for certain infections or new drugs like novel oral anticoagulants (NOACs).  When these changes occur it often changes the recommendations related to treatment and which labs to order or not order. I recommend establishing regular interdisciplinary meetings where updates like these can be shared. And, when in doubt, I recommend that providers speak to one another about their choice to ensure there is no confusion and that the patient receives the best treatment possible.

Stating Patient Name and Room Number

As hospitalists, we understand that the ED is always working to make patients better in the fastest way possible. However, it is crucial to slow down to communicate details to avoid errors. I recommend establishing a simple checklist for the order of information shared on a phone call between a hospitalist and ED physician. In my experience, it is very helpful for the ED doctor to slowly and clearly spell the patient’s name and state their room number before sharing any diagnosis or medical information.

Being Upfront about Challenges

Hospitalists understand that we will not always know precisely what is going on with the patient at the time they present. As hospitalists, we have the luxury of figuring it out over days instead of hours. I recommend establishing a safe, trusting culture of communication between the two practices, where ED physicians feel comfortable stating that they are not sure what is wrong with the patient, that it is a social admission and there is no safe place for the patient to go outside of the hospital, or that they forgot to order something important. When a hospitalist is not informed, it puts us in a difficult position, especially if we cannot see the patient immediately. 

Protocol for Primary Psychiatric Diagnosis.

Most hospitalists and acute care hospitals are not equipped to take care of primary psychiatric patients safely. If this is the case at your facility, it is important to make your ED colleagues aware that often once a primary psychiatric patient is admitted, transfer is much harder from the inpatient side vs. from the ED. Establishing a set protocol for handling psychiatric patients will alleviate difficult situations for both practices.  

Overall, the best place to start is to ask your ED colleagues how you can make their life easier, and brainstorm collaborative, mutually beneficial solutions. Simply being aware of our counterpart’s perspective and establishing interdisciplinary protocols to reference goes a long way to improve transitions of care from the ED.

Teamwork Culture in Emergency Departments Improves Care Quality and Team Morale

Leaders building a brand-new rural community hospital in Texas asked me (along with some of my colleagues who now make up CareCulture’s leadership) to help them optimize their emergency department. The new facility was a fresh start, despite the fact that most of the doctors and nurses were familiar with each other and had been working in the same community for a long time. Most of their existing team members were entrenched in traditional, hierarchal methods of delivering emergency care. The hospital administration tasked us with establishing a culture based on teamwork, mutual respect, and a focus on patient needs. Because the team was deeply immersed in their long-established practices, shifting their approach was a formidable challenge.

I have served as medical director at a wide spectrum of emergency departments over the years—rural critical access hospitals and trauma centers alike—and every time the root cause behind the performance issues they face is their culture and the leadership style that perpetuates that culture. This department had a culture issue that was woven tightly into the traditional culture of healthcare delivery. It is one I felt strongly about unraveling: hierarchal, top-down leadership. As an alternative, I always encourage emergency departments to replace top-down management with team-based leadership that cultivates a safe environment for all team members to be empowered to speak up in the interest of better care for our patients.

When we arrived at this rural facility, we were seen as the “city folk”, outsiders from Dallas. The nursing staff and techs were anxious about our presence, assuming that we would follow the stratified approach to emergency department leadership to which they were accustomed. The leadership style depicted in the famous book, The House of God, in which attending physicians dictate orders while all other team members are expected to bow and nod their heads in agreement, carrying out their orders without question.

Inevitably, top-down leadership and the attitude that the entire ED staff exists to serve the medical director and attending physicians leads to conflict, unspoken frustration, and poorer care quality for our patients. When we started managing the new, small community hospital in Texas we took a different approach. Instead of dictating, we invited the nurses, techs, and administrative staff to the table and asked them how we could make their lives easier. We encouraged them to share their opinions and to question us (the physicians) if they saw a better way or had a question or suggestion.

It is a new way of viewing emergency department hierarchy. The team-based approach eliminates the feeling that nurses and techs exist to serve physicians and replaces it with the attitude that the entire team exists to serve each other to best serve the patient. This is not to say that the doctor will not have the final say on a course of action, but it does mean that the nurse or tech’s ideas are thoughtfully considered before making the final decision.

To shift the mindset of the team, we first speak with everyone on the team to discuss what is working well and what is not working. Any power dynamic between nurses and physicians needs to be broken down. We do this by creating regular opportunities for discussion and feedback, such as regularly scheduled all-hands meetings and an open dialogue during daily interactions. In the meetings, we make it clear that a nurse or tech questioning a physician is not just allowed, but expected. We expect to be held accountable. We impart the philosophy that we are servant leaders who do not just expect to be served, but are beholden to serving and respecting our colleagues as equally significant and influential members of the team—regardless of title.  

Nurses and techs are not the only ones who need to shift their mindset in order for this culture to take hold. Physicians must also feel comfortable and secure giving and receiving feedback and being questioned regularly and openly. Traditionally, some physicians may view being questioned by a nurse or tech as demeaning or a mark of failure. They may feel that because of their extensive training they know what is best. In turn, nurses may feel that it is disrespectful to question doctors. This new team-based, service-oriented culture enables physicians to set any pretense or power dynamic aside and prioritize what is best for the patient—no matter whose idea it is.

This culture change goes beyond the nurse-physician power dynamic, extending to EMS personnel, social workers and other professionals the emergency department regularly interfaces with. As part of our team-based approach, we encourage emergency department care providers to reach out—beyond the walls for the ED—to seek feedback and improve communication across the continuum of care. For example, at this particular hospital, EMS personnel who frequently brought patients to the ED were accustomed to being immediately interrupted by the doctor. This recurring behavior led them to immediately stop talking when a physician entered the room. As part of our management change, we encouraged EMS personnel to give a full report and encouraged our physician team to listen for the full report without questioning or interrupting. This approach worked, and more vital information was passed from the EMS personnel to the ED, allowing us to take better care of the patient.  

When this open, team-based approach takes hold, the entire team is more empowered and invested in the collective success of the department and hospital. Physician-nurse interactions are more open and positive. Communication between providers and patients improves. Team members are more excited about coming to work each day.

When we implemented this change at this newly rebuilt facility in rural Texas, we saw a notable improvement in the interactions between all emergency department providers and staff. Shortly after the opening of the hospital, several experienced nurses volunteered to take on more significant roles in the emergency department because their input was taken seriously, which empowered and inspired them to be more involved. The newer nurses were also more comfortable asking the doctors questions, which helped their understanding and improved the quality of care for the patients.

Taking a more open, lateral rather than hierarchal approach fosters a more nurturing, safe environment for physicians, nurses, techs, administrative staff, EMS providers, and other people who interface with the emergency department to openly share their ideas, which improves department efficiency, care quality, and patient experience as a whole.

3 Reasons to Combine your Low Volume Hospital’s Emergency and Inpatient Service

The idea that a hospitalist program is cost prohibitive for smaller community hospitals (less than 12,000 annual emergency department visits) is a dated myth. Reaping the benefits of a robust hospitalist program and emergency department without the cost of two full programs is possible. It simply requires innovation. Hybrid emergency department and inpatient care management is that innovative solution.

Emergency medicine and hospital medicine can be integrated by combining the two services into a single patient care service. In this model, inpatient care is provided as an extension of traditional emergency department services by providers who are skilled in both emergency and inpatient care. A single physician (or physician and advanced practice provider team) cares for the same patient throughout their hospital visit.

This model is a good fit for smaller hospitals because it allows for the most efficient use of provider coverage. The staffing model will vary based on your volume trends. When designing your staffing model for a hybrid program you must consider:

·      Arrival and average daily census patterns

·      Physician shift length (12 or 24)

·      How to cover volume surges

·      After midnight admission processes

In our experience, the program works best when there is a backup call schedule arranged for volume surges and physicians work 24 hour shifts, handling rounding in the morning before ED volumes peak for the day and writing H&Ps during rounding time for patients admitted after midnight. 

The hybrid model is a cost-effective and efficient alternative to running separate programs or managing rotating call with community physicians. Below are the top 3 reasons to adopt a hybrid model at your small community hospital, rural hospital, or critical access hospital.

1.     Cost effectiveness.

The price tag associated with running emergency and inpatient programs is typically cost prohibitive for smaller community hospitals. The patient volume in most smaller community hospitals doesn’t financially support two separate programs. The hybrid approach offers a lower cost solution than two programs while also improving admit/ transfer ratios.

2.     Improved care continuity.

In the hybrid ED and hospitalist management model, one physician cares for a single patient as they transition from emergency care to inpatient care. This eliminates the risks often associated with transitions of care, including: communication breakdowns, unnecessary readmissions, poor patient experience, and more. The hybrid model allows you to implement standardized clinical pathways and order sets that transition seamlessly from the ED to inpatient care so the patient has a positive, consistent experience.

3.     Added inpatient care delivery stability and consistency.  

Traditional ED and hospitalist programs can have difficultly aligning performance and patient experience. Additionally, the two common alternatives to two separate programs—rounding by community physicians and reliance on locum tenens providers—make it difficult to ensure consistent, reliable care. A community physician’s primary commitment is to his/her outpatient clinic patients, so rounding often happens outside of clinic office hours. This results in delays to inpatient codes, patient status changes, order clarification and/or changes, and consultations, which increases length of stay. By implementing a dedicated provider or provider team that is committed to both ED and inpatient care, unassigned admissions are reduced because all patients are admitted by the same service line.

A hybrid emergency and hospitalist program is a great alternative to two, high-cost separate programs, relying on community physicians to accommodate rounding in their already-busy schedules, or calling in locum tenens physicians who are not invested in the community to provide inpatient care. The hybrid program adds more continuity to your patient’s experience, shortens length of stay, increases efficiency of the admissions process, and improves admit/transfer ratios, ultimately improving hospital performance overall.