How to Destroy a Great ER: A Step by Step Guide

Article from KevinMD by Thomas Paine, MD & Physician

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I took a fantastic emergency medicine (EM) job when I finished residency. There was no question in my mind that it was the best job within a hundred mile radius, maybe more. When I first started, my expectations were met. My group held a contract to staff a busy but well-staffed suburban emergency department, and had held that contract for almost 20 years when I signed. The hospital was independent, locally administrated, and not part of a mega healthcare system. Its atmosphere was collegial and clinician-friendly.

The ER was well-staffed with all-star nurses and techs with experience. Everyone who worked in the hospital wanted to get a job in the ER. There were three nurses per nine-bed zone with a float nurse (gasp!) in each zone. Sure there were snags and busy days, but it ran about as efficiently as an ER could. The patients were well-cared for and generally pleased.
About a year after I took this job, a large regional health care system bought our hospital. It was called a merger, but we all knew otherwise. We took their name, adopted their colors and logos, and began answering to administrators who worked 40 miles away and didn’t know us.
In the nine years that followed, my perfect job turned into a nightmare. Similar to beach erosion, each wave of change slowly washed away an aspect of the job which had previously made it great. The job I took ten years ago would be unrecognizable to me today, just like the way a coastline can become unrecognizable after the ocean pummels it over time. Dozens of experienced staff members left, wait times exponentially increased, satisfaction scores nose-dived, morale dramatically dipped, and most importantly, clinical care greatly suffered. I left the job a few months ago; shortly thereafter my former group lost the contract with the hospital after over 25 years of service.

There were numerous forces and issues which caused my former emergency department to implode. I recognize that some of these forces were well beyond the control of hospital administration. However, this piece focuses on factors which were under their influence and were, in my opinion, grossly mismanaged.

If you are a hospital administrator and want to know the best strategies to quickly destroy your emergency department, this list is for you.

1. Ignore and undervalue clinical experience. A warm body is a warm body. Decades of experience with acutely ill and injured patients are overrated. A few days of training and a preceptor who knows the ropes will ensure every new nurse or tech has adequate clinical competence. This strategy also saves money, since less tenured employees cost less on the payroll.

2. Don’t ask clinical staff what they need, tell them what they get. Is the staff clamoring for more space, more help, more security, and more resources as their volume and acuity rise? Ignore those requests. You attend enough meetings to know what it takes to provide sound, timely emergency services; staff will always ask for more, even when they have everything they need.