How Does it Happen?

Let me explain the problems that have been happening in my ED. I am going to put my administrator hat on for a moment and explain how a hospital emergency room can become as poorly managed as this. Our previous manager was fired about a year and a half ago. The reason she was fired, we were told, is that she was running the ED over budget, and rumor has it, she was a million dollars over budget. Now my ED sees about 100,000 patients a year. Since the average emergency room bill is more than $4,000, that means the department is seeing $400 million a year in billables. A million dollars is about a quarter of a percent of annual billables- in other words, it’s a rounding error.

Still, medicine is a business, and many business leaders can’t see past this quarter’s cash flow statement, so they make the mistake of focusing more on metrics than on patient (customer) outcomes. Instead of being used as a yard stick to guide in decision making, metrics become the purpose of the manager’s decisions. The powers that be decided that they wanted to look good to their bosses, so they found a scapegoat to make it appear as though they were doing something, and fired the old manager.

One of the first things that the new manager did was to begin focusing on metrics. In this case, she is focusing on throughput. You really can’t blame her, and understand why she is making the decisions she is. I wouldn’t do the same, but I understand it. What she is doing is reasonable, even if it is wrong: The last manager was fired for being over budget and having poor metrics, so she is going to ensure that the numbers look good. When the government rates hospital emergency rooms, the following metrics are the largest factors in the ratings:

• Median time from ED arrival to ED departure for discharged patients
• Median time from ED arrival to ED departure for admitted patients
• Median time to being seen by a health care professional in the ED

So the chase for good numbers begins. Patients who leave before getting out of the waiting room are called “Left without being seen” (LWBS). They damage throughput because they count against it. To lower that, we have to get patients into a room as quickly as possible- but the rooms are full. So we make the decision to empty rooms by putting patients awaiting inpatient beds into the hallway- sometimes for as long as 36 hours. When they are placed in the hallway, they get assigned to a holding unit that appears not to be part of the ED, even though it’s a back hallway in the ED that is staffed by ED nurses. They have only left the ED on paper. Who cares if it is a violation of Joint Commission standards? We can fool those guys by hiding the beds whenever they come to inspect. Aren’t we clever?

You know what else we can do? The nurses that come in at 11:00 am take over a combined total of 12 patients. Let’s put patients from the waiting room into those rooms before those nurses get here. That empties the waiting room, making it appear like they are being seen faster, and the nurses can hit the ground running when they come in. Who cares that it’s only 8:00 am and the patient will be in the room for 3 hours without being seen? The chart says that the patient in room 24 has been assigned to a nurse AND a doctor, so that looks good. On paper.

Also, let’s reduce nursing staff. Since the old manager took over, we reduced nursing staff from 234 nurses to only 162 nurses, some through attrition, some from layoffs or firings. We also reduced nurse assistants from 54 down to only 36. Cutting a third of your staff makes your expenses less. Now we are under budget. The nurses who are left are expected to take on the increased workload, but that’s OK, they can do it.

With the staff that stays, we will maximize productivity by forcing them to do all required training off duty, but we will do all we can to not pay them for it, up to and including modifying their time cards and not approving the pay for them to do it. We will assign training that can theoretically be done in 2 hours, but usually takes 4. We will only pay for 2, and anyone who can’t do it in 2 hours is simply lollygagging.

The nurses who complain are just disgruntled and lazy. If they complain that things are unsafe, they are just being troublemakers. In fact, when I complained, I was told that “I understand. People just don’t like changes, and this is just you resisting the changes I have made. In time, you will see that things are better now. Look at our numbers, they look great.”

The senior nurses who care left in droves (again- we lost a third of the staff). Training has been focusing on the basics, because all of the nurses who remain are young and don’t know any better. They are just happy to have a job.

These are the classic indicators of a deteriorating unit culture caused by cost driven management. It’s a style of management where costs and metrics become more important than the final outcome. It isn’t unique to healthcare, its a problem in nearly every business sector. When left to fester long enough, you begin seeing red flags:

• Selective accountability
• Secret documentation of faults that are used against staff when needed and by surprise to get rid of “problem” employees
• Normalization of risk caused by chronic understaffing
• high turnover that management explains away
• dismissal of safety complaints as “problematic staff” who are just resistant to change
• more documented discipline and terminations- this silences outspoken staff who are labeled as “troublemakers”
• so employees stop speaking up

The result of these red flags is called cost-driven collapse. This shows a pattern of theoretical labor accounting- they have a theory on what it SHOULD take to run this unit, and are forcing the facts to fit their idea of what things should be like.

Management is not paying for what is actually worked, but for what they believe is “reasonable.” That is a hallmark of a system that values financial predictability over factual accuracy. Reality is inconvenient. Optics are cheaper.

They are optimizing for:

• Throughput
• Labor cost
• Optics
• Short-term financials

This isn’t incompetency- it’s a deliberate decision to value metrics over patient safety, ethical considerations, legal considerations, sustainability, as well as professional and organizational integrity.

The best thing anyone can do in these situations is: get out. In the meantime, keep quiet, be the grey man, and stay out of the limelight. You have to understand that this sort of manager is doing what they do to keep their jobs by looking good on paper. They will crush anyone who interferes with that- they are willing to lie to accreditation bodies: they won’t hesitate to fire you and have you blackballed. They, in their own minds, think they are working for the greater good, and therefore anyone who stands in the way of that is evil. You aren’t a team player, you resist positive change, etc.

Even after you leave- keep your mouth shut. As tempting as it is to try and get even, you won’t. In the end, nothing changes and all you did was create an enemy and burn a bridge. Just leave and let the coming collapse of the unit and the manager’s eventual firing be your justice.

I’ve had bad bosses who have done this before. I once, when I was a paramedic, worked for a guy who famously told us at a staff meeting: “The customer is always right, but the patient isn’t our customer. The customers are the insurance companies and hospitals that select our service. The patients are just cargo, and no one cares what cargo thinks.” It was much the same as this time- we were prohibited from taking lunches, pressured into doing unethical and unsafe things, then left out to dry when something bad happened. See, there was a written policy against it, and the employee violated that policy. (Because all businesses have exhaustive policy manuals that are designed to protect the company. They aren’t enforced, with the way it’s really done being nothing close to following policy. This allows management to blame the employee when something goes wrong.)

This type of organization is performing transactional leadership. This is where leaders care about metrics more than sound, ethical business. Patients become flow. Nurses become cost. Ethics become obstacles.
Reality becomes inconvenient.

It’s a poor way to manage, but sadly it’s a tactic that far too many managers follow because in the short term, the numbers look good. This sort of system always fails in the end, and the manager never does figure out why so many people left.

As a manager, I ascribe to the theory of Just Culture. Just Culture is an organizational approach to safety and accountability that seeks to balance learning and improvement with fair responsibility. Instead of asking “Who is to blame?” it asks: “What happened, why did it make sense to the person at the time, and how do we prevent it from happening again?” The goal is to design a safe system that seeks to improve systems, not just punish individuals, preventing recurrence of sentinel events in high-risk fields like healthcare and aviation. 

I practice a Just Culture approach. When something goes wrong, I start by asking what made sense to the nurse at the time: what the workload was, what barriers existed, what competing priorities were present. Human error is consoled and learned from, at-risk behavior is coached, and only reckless behavior warrants discipline. My goal is to fix the system so the same error is less likely to happen again, while still holding people fairly accountable. Part of my role as a manager would be advocating for staffing models and workflows that make the safe choice the easy choice. The goal is learning, prevention and the elimination of errors, not punishment and blame seeking.

If you build a quality organization that seeks to minimize risk and error without placing blame downstream but instead seeks organizational change, it allows professionals to maximize their skills and the team works for a common goal- excellence usually follows from that sort of system. That’s the philosophy I want to bring as a manager to my next, hopefully leadership, role.

That’s what I am selling in my job interviews.