COLLABORATE UNIFY HEAL
It’ s Rarely a Person
In seven-plus years of emergency medicine, I have never seen a resuscitation fail because the people in the room didn’ t know their jobs. When collaboration breaks down, it’ s almost never a competence problem or a character problem; it’ s often a design problem. While problems of character or competence may be an isolated event, when the same issues tend to rear their head repeatedly, the design is the issue. It is the wrong process asking the right people to do something it was never built to support.
Let’ s take, for example, the consolidation of our three health systems. All of us have likely experienced ambulances transferring to the wrong UofL or the wrong Norton. After eight occurrences, the problem is likely not the ambulance service or the emergency medical technicians’ fault, nor the fault of our system-wide transfer centers; it lies within the process. How can we ensure the ambulance services are getting to the right hospital, right address and right floor? Is it an educational issue, or can we produce a system or set of instructions to eliminate the chance for this mistake? This is where a root cause analysis can absolve the EMT and identify the issue within the process.
Manufacturing figured this out decades before medicine did. Six Sigma, for all its corporate jargon, rests on one idea worth borrowing in the clinical world. When a defect keeps happening, you stop asking who made the mistake and start asking what in the process makes the mistake easy to make. A missed detail in sign-out, a stalled consultation, a patient waiting 12 hours for a bed slip, a disposition disagreement that drags on for three hours; if you treat these as an isolated human error, the system never repairs. What we can incorporate from the house of business is to treat these issues or misses as data points. If we begin to treat these as data points, a pattern typically appears: the same phone tree, the same unattended pager or phone line, the same ambiguous ownership, the same gap in the workflow, showing up under a different name each time.
The Hidden Bottleneck
Most of what strains collaboration in medicine, particularly in an emergency department, traces back to constraints nobody in the room chose, nor can they fix alone. Often, it’ s the issues that are out of the physician’ s control: capacity, staffing, the sheer volume moving through a finite number of beds and hands. When a system is under this kind of pressure, the emergency department doesn’ t just treat its own patients; it absorbs the overflow of every unit that is also full. That strain on the system doesn’ t stay contained. These strains surface downstream sometimes as a shorter, less detailed call with a consultant, a disposition debate that is really a capacity problem wearing a clinical disguise or sign-out that happens two minutes faster than it should, missing a key diagnostic detail.
It’ s tempting, in the moment, to read this as a breakdown between departments or between people. It almost never is. It’ s a systems problem rearing at the point of human contact, which is exactly where it’ s hardest to see as anything other than personal. It also leads to animosity between people, departments and hospitals. This animosity grows, which creates an animus culture and dissolves continued collaboration.
What We Can Learn From the“ Happiest Place on Earth”
I’ m not a big Disney fan. In fact, the thought of going to the Orlando airport fills me with existential dread even for a conference. However, the Disney Corporation is a well-oiled, profitable organization that manages to bring unique, unrelated sectors together to succeed and expand its business. Is this no different from a hospital or health system?
One of the greatest pieces of advice I received in medical school was,“ The most important person in the hospital was the environmental services staff.” Those positions are not really healthcare related on the surface, but how do you turn over an OR when the trash hasn’ t been taken out? How do you prepare another bed for a patient in the emergency department when the bed isn’ t made or sanitized? If you have never been part of a janitorial staff union strike, I promise you it will humble you. As a third-year medical student, I spent some days of my rotation mopping spills off the floor of a rural hospital just to make sure patients could walk safely to the emergency department. The hospital is no different than a multi-national mass media and entertainment conglomerate. It has different departments that may be related or not, trying to provide a great experience, to care for our patients.
Fred Lee, a hospital executive who later worked as a Disney cast member, spent a career arguing that hospitals and theme parks have more in common than they would like to admit. In his book, If Disney Ran Your Hospital, he argues that hospitals, just like theme parks, are both in the business of experience and that both live or die on what happens at the seams: the handoffs, the transitions, the moments where one person’ s role ends and another’ s begin, the emergency physician to the hospitalist or surgeon. The core of Lee’ s argument wasn’ t that hospitals need to be more entertaining and kowtow to patient demands. It was that satisfaction is the wrong metric to chase, because this satisfaction
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