July brings new interns. They certainly have a lot on their plate, but seeing them work through their first shifts always reminds me that while they are learning how to practice medicine we depend on them to keep the patient flow moving – something most of them have never considered. Efficiency and flow management are skills that are learned. I’ll share my thoughts, even though I do not feel I am gifted in this area.

I have some colleagues that are incredible at this skill, and they do not all get there by the same means. I’ve learned a lot from working with them, and I have heard some really smart people talk on the subject as well. This post is not evidence based, and my own opinions continue to change over time. I consider this a guideline because I break it frequently as circumstances dictate, but this is how I encourage the interns and residents to think about efficiency in order to make the best use of their (and everyone else’s) time.

The lowest hanging fruits in managing the department are “prioritization of tasks” and the use of “efficiency multipliers.” Prioritization is self-explanatory, but not intuitive. I’ll give some general thoughts below. Efficiency multipliers are small investments of time that save large chunks of time down the road – four people spending five minutes now that save the patient an hour in overall throughput, for example. Let’s put these thoughts to work.

First of all, your main job as the provider in the ED is to take care of critically ill or injured patients. If there is one of them around, you give them your full attention until you full attention is no longer required or a more critically ill or injured patient trumps them.

After that, you always have a task list. Whether you are the type that writes that list down or keeps it internally, you should always be aware of the things that you have to do. As the physician, many of my tasks set others into motion to do their tasks: writing nursing orders to give medicines, ordering labs or radiography studies, discharges, admissions, etc. These are “department tasks.” Other tasks only affect me and/or a single patient: writing my chart, doing a procedure, speaking to a consultant. These are “me tasks.”

With that in mind, you should prioritize those tasks that let others start to work. If after seeing a patient you sit at your workstation and have to decide whether to write the note or write the orders – you should write the orders. Let the lab, radiology department, and nurses start working; then write your note while those wheels are turning. This sounds simple, but pay attention to the people around you and notice how often this type of thing happens out of order.

Even within the category of “tasks that let others start to work,” their is a hierarchy. If you ever have the chance to write discharge orders, do that first!! Of anything you can do to manage the department, only one task literally frees up bed: discharging. If your tasks at a given moment include admitting a patient, writing orders, sewing up a laceration, discharging a patient, and writing progress notes – do the discharge first. Admissions and transfers are high yield as well, but those take time; a discharge opens a bed right now.

In general, once you have all of those “department tasks” done and the rest of the staff is now accomplishing their tasks, that is when you catch up on your “me” tasks: write notes, sew up the laceration, go to the bathroom, etc. There is nothing worse (in terms of department flow) than coming back from a 30 minute procedure (or the cafeteria or bathroom) and realizing that you didn’t do all of your “department” tasks first. The patient you hoped would be gone is still there, and you are half-an-hour behind on tests and treatments for another patient because you failed to knock out those department tasks before doing your me tasks.

This scheme is the backbone on which I manage my time, but admittedly at a given moment I have to break it. Sometimes a patient has no venous access and placing a CVL moves from being a “me task” to a “department task” as it has created a bottle neck for meds, labs, and CT. Sometimes I’m so far behind on notes that the department is just going have to give me 15 minutes to catch up, because my mental clutter is preventing me from giving good care. These things happen. When it does, I put out that fire then get back on track. These are guidelines, not rules.

I feel that simple task prioritizing is an often overlooked, but essential aspect of flow management. It’s a great place to start thinking about these issues. Other small habits that will help include the following efficiency multipliers:

1. Run your list. Every time you sit down at your workstation, quickly start at the top and make a list of your tasks. It should literally take 30 seconds and can be in your head or an actual list on paper. Then prioritize them and knock them out in the order described above. Remember to do ‘department tasks’ before ‘me tasks.’
2. Run the board with the whole team. Running the board with the residents, nurses, techs, and social workers can pay vast dividends, because it puts everyone on the same page as to what the plan is and what the barriers are to executing that plan on every patient. When you do this, you will be shocked how often ‘one hand doesn’t know what the other is doing’ or how often a barrier to flow could have been addressed if the appropriate person had known about it. Ideally this is done at regular intervals, but I admit that it often only happens when the department feels chaotic.
3. Swarm. This means do things in groups when possible. A perfect example is when an ambulance arrives. If the resident, attending, nurse and registration all see the patient on arrival and get the story once, it saves everyone from having to get it individually. Everyone knows the plan from the beginning. This is a huge time saver.
4. Use the “Comments” section of the EMR. A little note like, “labs back, ready for CT” that can be seen by everyone (including the CT tech) is a nice way to keep people abreast of developments without them having to break their workflow to take a phone call. Be careful though, as the tone of these can be interpreted in negative ways – just like a text message. I would never use this call someone out, simply to make the the plan/barrier clear to the team.
5. Use the unit secretary as a resource. If I personally page the medicine resident, I’m stuck by the phone until they call back, because no one else knows that I called them. If I ask the unit secretary to do it, they now are in the loop and will know whom the call was for when the resident calls back. Now I can go into a patient room while waiting for the call (being sure to tell the secretary, “I’m in room 12 if medicine calls back”) and am no longer anchored to that phone. I feel that interns often feel that they haven’t yet “earned this privilege,” but they have.
6. Use closed loop communication: In our department we can communicate with the nurses station by two way radio. However, when a doctor says into the radio, “can we get urine on room seven?” without addressing an individual – or even knowing whether or not anyone is at the nurses station – they are not likely to get a good response. On the other hand, if you call or go to that patient’s nurse or tech directly and ask that person individually to collect that urine – in other words assign a task to a specific person – the loop is much more likely to get closed in a timely manner.

Most of us can get better at the skill of departmental efficiency. People who are great at it almost certainly prioritize department tasks over me tasks and make use efficiency multipliers although they may be doing these things consciously or not. You may already be doing some or all of these things, or you may feel I’ve missed the mark or only scratched the surface. However, whether or not you agree with this framework, I think the important thing is that you put thought into some framework, as any effort in this area will likely yield positive results.