A gray-haired emergency medicine physician once provided the most succinct view of ED efficiency ever uttered. He said, “Sometimes they ask us to dig a ditch. Then they give us spoons with which to do the job.” Though cynical, it is the view of many. There really is only one problem and a single solution to ED efficiency. The problem is variation. The answer is scale.

Biologists understand variability best. Biologic variation is partly heritable and partly acquired. Variation is then passed through the system. Some days, the challenge in emergency departments is patient volume. The next day volume is low with fewer people, but acuity is high with sicker people. On another day, boarding is an issue. Hospital beds are full due to high volume or acuity on previous days. Another day staffing is a problem.

EDs aren’t killed by a single bullet. EDs die by a thousand cuts. Hospitals then make two mistakes: They either chase yesterday’s problem today or search for a universal solution where none exists.

Author Malcolm Gladwell often tells the story about Harvard trained psychophysicist Dr. Howard Moskowitz. In a TED talk, Gladwell explains how a cola company asked Howard to determine the perfect cola sweetness. Moskowitz tested different formulas on thousands of people to determine the perfect level of sweetness. Instead of a bell curve, the data was all over the place. Why wasn’t there a perfect cola everyone liked?

Instead of dismissing the fact that figuring out what people think about cola may not be easy, Howard thought a lot about the problem. Suddenly, he realized rather than looking for the perfect cola; he should have been looking for the perfect colas. But just like understanding ED variation, few understood Howard’s epiphany.

Sometime later, rather than finding the perfect pickle, he helped a company develop more pickle varieties because in his view there wasn’t a perfect pickle. There were only perfect pickles. People preferred different types of pickles and really didn’t even know what they liked until given an option. Spaghetti sauce varieties are also credited to Howard.

Understanding variation was revolutionary to the food industry that had always looked for universal truths. Ultimately, there wasn’t a single best cola. There were only perfect colas. It’s an important distinction for ED’s to understand.

A different causation for ED inefficiency arises each day. Hospitals search for a sole cause. But in actuality, there isn’t a cause. There are only causes. Hospitals have little control over variables such as geographic location or socioeconomic factors that impact efficiency. Hospitals do control factors such as staffing or resources to varying degrees.

The only constant is that efficiency barriers vary widely then permeate the system. Many are controllable, and some are not. Managing efficiency becomes more a matter of understanding the range of variation a specific ED faces rather than chasing yesterday’s problem. To do otherwise is simply treating the symptom and not the disease. Understanding variation prevents ED’s from being reactive. The solution is non-reactive as well because the solution is scale.

The term “capacity over demand” was coined by researchers who have studied this problem. It is defined as staffing and resources able to handle over 100% of expected variation whether it’s volume, acuity or other input issues.

It’s a great term and gets closer to an efficiency solution than others that have been attempted. The challenge is capacity over demand solutions require a larger budget than most hospitals can expend. Efficiency experts have applied manufacturing solutions to EDs with varying success. The problem, though, has always been variation. Inputs can be controlled when implementing industrial efficiency measures. But variation in emergency departments foils the input side. Industry can decide how many widgets roll in the front door. EDs cannot control how many patients show up. This is why scale is important.

The most successful hospitals that have solved their efficiency issues are ones that finally embraced the idea that an overwhelmed ED is not simply an ED problem. It’s a hospital-wide problem.

The scale of ED efficiency must be widened to include systemwide efficiency. Efficiency is like a biological organism where one system affects another in a symbiotic fashion. Think about chaos theory and the butterfly effect.

If patients aren’t being efficiently discharged in minutes on the inpatient side, they aren’t going to be admitted to the floor in minutes from the ED side. An inpatient nurse may have received three patients back to back. But, so did the ED nurse. Failure to have equal urgency is myopic.

Ancillary service delays spill over into the ED. Psychiatric services can slow mental health dispositions. Clinic services can force higher ED volumes if patients can’t get med refills or secure an appointment. It’s a symbiotic problem with a symbiotic solution.

Then there is the question of how much variation and scale is within the control of human intervention. We don’t know the precise answer. I statistically correlated ED volume to throughput years ago. The math revealed about one-third of ED variation in terms of length of stay could be directly attributed to simply how many people were waiting in the ED lobby.

It sounds trivial. But, EDs have little control over how many patients show up, and one-third of the variation that determines a patient’s length of stay is due to how many people are waiting to be seen at that moment in time. Therefore, 33 percent of ED variation is random from the start. By the way, the weather accounts for 1 to 5 percent of ED variation. I was studying how weather fronts affect ED volume. But no journal is going to publish a study when the variation is that low.

It has little impact. So even weather accounts for a small amount that can’t be controlled and each variable adds up. Scale at least mitigates controllable variation.

To that end, we need to stop chasing yesterday’s issue today. We need to understand variation as there is no universal problem. There are only problems. Some problems can be controlled, and some cannot. Problems also vary greatly and often.

We mostly need to establish broader scale solutions. ED overload is a systemic symptom that needs a bigger ditch with more people willing to dig.

Phillip Stephens is chief physician assistant, department of emergency medicine, Southeastern Regional Medical Center, Lumberton, North Carolina. He is the author of Winning Fights: 12 Proven Principles for Winning on the Street, in the Ring, at Life, and can be reached at his self-titled site, Dr. Phillip M. Stephens.

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