PROGRAM FOR INNOVATION IN CLINICAL EDUCATION
"working on efficiency:" the worst shift goal ever?
When you ask residents to self-identify their goals at the start of the shift, how often do you hear that they “want to work on efficiency?” It seems like every day, right? No matter their level of training, “efficiency” seems to be what they think we want to hear. But what does that even mean? The next time you hear this, push back on efficiency as a training goal.
As a reminder, shift goals should be specific and measurable. Since efficiency is neither of these things, ask learners what they really mean. From the intern who is trying to improve his or her ability to chart in real time to the PGY4 who is trying to master resource management in the ED, efficiency means different things to different residents. Once you have an understanding of the real goal, you can work with the resident to develop goals that fit their individual needs. Usually, when a resident says he or she wants to work on efficiency, they mean one or more of the following:
Identify critical data during initial evaluation and limit unnecessary return trips to the bedside. Backtracking for information is time-consuming and potentially leads you down the wrong initial diagnostic path. Each time inefficiencies in data collection become apparent, work to identify solutions. Consider direct observation if trainees are struggling to gather information efficiently. Are they getting too much, too little, or the wrong kind of information? Do you have ways of asking questions that could streamline their histories?
As residents progress, efficiency of data collection for critically ill patients becomes an important skill. Do they prioritize the right questions to the dyspneic patient about to go on bilevel ventilation? Are they appropriately de-prioritizing questions that can be answered by others or are reasonable to delay in favor of critical interventions?
Document efficiently. One symptom of inefficiency can be after-shift charting burden. Set specific goals with residents for chart completion. Ask what percent of charts they’re usually able to complete by the end of the shift – then ask them to increase that number. Talk with residents about how you get it done and offer tips that help you get out on time.
Yes, see lots of patients, but do it well. Encourage residents to see as many patients as they are able to manage well, but ask them to self-identify when they are becoming task saturated and let them know if you start to see things slipping between the cracks before they do. They should not pick up new patients if they are failing to manage their current workload. We want them to be challenged – not set up to fail.
Triage tasks. It can sometimes be difficult for residents to determine the next best task to complete, especially when they are beginning to stack up – something like a task MCI. This can lead to a sense of overwhelm, decision paralysis, and flow dysfunction. Generally, a good rule of thumb is to address critical patients and procedures first, followed by pending discharges and other rate-limiting issues, then new evaluations. Your coaching and feedback can residents learn to triage tasks in a more efficient manner.
Anticipate road blocks. It was obvious to you that it might take a long time to get labs back for the dialysis patient with a history of breast cancer, right? Residents should be identifying patient and team-specific factors that slow down care and work with their teams to limit non-value added waiting. Similarly, if their time and attention is likely to be diverted by a procedure or incoming resuscitation, they should consider getting new orders started or dispositioning patients first.
Run the zone. As residents progress, they are starting to manage not just their own patients, but an entire zone or ED. At this point, efficiency is all about zone management and resource utilization. Senior residents should know the workloads for each member of their team and attempt to limit the task-saturation that leads to delays and errors. They should deploy trainees in a manner that promotes efficient patient care, which in some cases may require that they see patients first. Give them feedback if you notice patients getting stuck due to avoidable delays, indecision, or poor task switching.
Lastly, residents sometimes might have an efficiency goal when what they mean to say is, “I would like to see as many patients as possible.” This one requires a bit more unpacking. As a group, EM residents are a hard-working motivated bunch who usually come to each shift hoping to see as many patients as they can. Our medical students are often of a similar mindset. It’s absolutely true that residents and students learn a lot from seeing a high volume of diverse patients, but picking up too many has important consequences for patient care and education.
When residents and students are attempting to manage too many patients, the quality of the care that they are able to provide suffers. They are no longer able to follow up on results in a timely manner, re-evaluate their patients, investigate their knowledge gaps, or keep up with documentation. As more things start to slip through the cracks, supervising becomes more burdensome. They are learning to see a lot of patients but not how to manage them. Encourage trainees to “own” the patients they sign up for and hold them accountable for the entirety of the ED course. Obviously, you can help out by implementing plans agreed to in advance – i.e CT if the d-dimer is positive, discharge if ED workup negative, etc.
When variation in inter-arrival rate results in a large influx of patients to the zone over a short period of time, encourage residents to continue to see patients at a comfortable pace, even if it results in them not seeing every patient (1-2 extra patients that hour, NOT 4-5). Peaks in patients per hour significantly above the resident’s baseline are actually associated with an overall detrimental effect on the number of patients seen per shift. Remind residents that they will actually accomplish their goal of seeing more patients if their peak number of patients per hour is closer to their baseline.
Work with your learners to create efficiency goals that have defined endpoints and are appropriate for their level of training. Provide reassurance that efficiency is a driven by a collection of skills and that putting all of their attention on patients per hour may make them less efficient rather than more so.
Joseph JW, Novack V, Wong ML, Nathanson LA, Sanchez LD. Do Slow and Steady Residents Win the Race? Modeling the Effects of Peak and Overall Resident Productivity in the Emergency Department. Journal of Emergency Medicine 2017;53(2):252–9.