Remember the first time you ordered a soft drink at a fast food restaurant, and the fellow behind the counter handed you an empty paper cup? Baffled you said, “What's this?” and he directed you to a machine where you could fill your own cup with ice and a soft drink, and there were lids and straws, too. Now this process is routine in fast food restaurants, and is an example of something we should understand and be trying in our emergency departments. Utilizing customers in this way is termed “customer participation,” and is part of a broader area of study within service industries termed demand capacity management (Fitzsimmons J, Fitzsimmons M. 2006. Service Management: Operations, Strategy, Information Technology, 5th Edition. Boston: McGraw-Hill.)
Service capacity is a perishable commodity. Unlike products which may be stored in warehouses for consumption at a later date, services are intangible personal experiences. They are created and consumed at the same time, and cannot be transferred to others. The variability in service demand in health care can be quite pronounced. Some EDs may vary in volume by almost 50 percent from one day to the next. How do you staff for such variability? How does any service industry match such variable demand with fixed capacity (resources)?
As it turns out, there are a number of techniques to help mitigate against this predictable mismatch between demand and service capacity, even when it occurs in the service industry called “emergency medicine.” (Jensen K, Mayer TA, Welch S. 2006. Leadership for Smooth Patient Flow. pp. 94–104. Chicago: Health Administration Press.) The problem can be approached from two different directions: Smoothing consumer demand or matching service capacity to meet the demand. Scheduling can help smooth demand, while customer participation, cross training, shared capacity, and other strategies can help expand capacity.
Hotels offer discounts for off-season travel. Cell phone companies offer reduced rates for off-peak service. Could we offer incentives to patients to come back to the ED for nonurgent complaints during low-census periods? Though few EDs can control the price structure for an ED visit, patients could be encouraged to return with promises of faster throughput. The number of patients returning to the ED for follow-up care continues to swell, and as the number of uninsured grows and access problems accrue, this will likely be the state of affairs for years to come.
In addition, the types of patients presenting for follow-up and their needs have changed. At one time, follow-up patients were simple wound checks, dressing changes, and suture removals. As more care has become outpatient, many EDs are doing follow-ups for abdominal pain requiring ultrasound or HIDA scanning. Chest pain patients at low risk may return for stress testing using adenosine through the ED. Outpatient treatment of pneumonia, cellulites, and pyelonephritis may commence in the ED with the only place to refer patients for follow-up being the ED again! At LDS Hospital in Salt Lake City where follow-up visits make up as much as 12 percent of ED volume, we have tried to instruct follow-up patients to return during low census. In addition, some stable patients are off-loaded from the busiest part of the ED cycle (evening hours) to the day shift by asking them to return for certain ancillary studies. Agreements were struck with ultrasound, nuclear medicine, MRI, and cardiology to give the first appointments of the day (for ultrasound, HIDA scan, MRI, and stress testing) to unnamed ED patients. This effectively matches capacity to demand.
Increasing Customer Participation
Service industries are recognizing opportunities for involving customers in their operations. The notion of self-service is so widespread that we forget that less than a generation ago all gasoline pumped into cars was done by a service station attendant, restaurant meals were almost uniformly served by waitresses, and banking was done in banks by tellers. In this new age, customers are involved in their services. This is one way to increase service capacity.
This concept has applications for health care, particularly emergency medicine, but hold on to your hat! Some of these ideas may seem very far afield and wild compared with the way emergency departments are currently functioning. But patients can be educated about how to set up their own follow-up appointments and to orchestrate the next phases of a complicated work-up as an outpatient. The Utah Heart Clinic in Salt Lake City, a large cardiology group with a wide variety of cardiovascular services created brochures for ED patients who are low risk telling them how to schedule stress tests, arrhythmia work-ups, and echocardiograms.
Realizing that the ED is a good customer, they are now venturing into the realm of TIA work-ups. They have set aside the first appointments of the day for emergency department patients. Instead of ED staff dedicating time and energy to arranging these follow-up diagnostics, the patients or their families are taking the lead with instructional pamphlets. This may be the wave of the future. Many EDs also are using family members for comfort care. Family members are instructed where to find warm blankets, how to adjust the head of the stretcher, and where to get ice chips and ice packs. In these days of profound nursing shortages, freeing up nurses from non-nursing tasks by utilizing family members or the patients themselves makes good sense.
The ultimate example of customer participation in the emergency department was reported to me by a physician who had practiced in Taiwan. He said patients who are not critically ill are actually sent to the “diagnostic waiting room.” This room was specifically designed with small cubicles to house patients and their family members. In full view is a large tracking system so patients can monitor their own progress. When the tracking system indicates that all tests and treatments are completed, the patient is asked to alert the staff so that the doctor may reconcile the results and make a disposition.
The diagnostic waiting room manages waits with televisions, cell phones, laptop stations, games, and other tricks borrowed from service industries such as Disney and the Ritz-Carlton that have become masters at managing waits. (Maister DH. 1985. “The Psychology of Waiting Lines,” in The Service Encounter: Managing Employee/Customer Interaction in Service Business, JA Czepial, pp. 113–123, Lexington, MA: Lexington Books, and Lee F. 2004. If Disney Ran Your Hospital. Bozeman, MT: Second River Healthcare Press.)
Has anyone noted some of the fast food partnerships that have been springing up? For instance, combinations of Taco Bell, Kentucky Fried Chicken, Wendy's, and A&W Root Beer are now often seen as double franchises. While sharing registers, personnel, and kitchen space, they offer both products through the same venue. This is efficient and makes sense. The costs of service are held down, more service is provided in the shared space, and an opportunity to capture market share is realized. (If you don't want a taco, how about a chicken sandwich?)
Are there applications for the emergency department? How about an adjacent walk-in clinic that closes at 5 p.m. being utilized as an overflow for the ED on the evening shift? Maybe an observation unit or clinical decision unit could open in the unused space. Or perhaps ED boarders could be housed there by overflowing into the unused space at night. Or what about an ED-based lab that also services the nearby outpatient clinics? Sharing capacity within an institution or even a system is an idea whose time has clearly come.
Aren't you impressed when standing in a line that is rescued by a worker who is unexpectedly trained in the needed task? The manager who jumps in to help seat customers in a restaurant, the supervisor who opens up another register at a retail establishment, the theme park worker who leaves his attraction to help your toddler ride Dumbo. These examples of cross training to accommodate demand are unexpected, appreciated, and frankly brilliant!
Why haven't we embraced such a scheme in health care? In particular with diagnostic imaging, it is helpful to have personnel cross trained. Many smaller EDs are training radiology technicians also to do CT scans, particularly on the night shift. This is efficient and helps build elasticity into radiology operations. Likewise ED techs may be trained to start IVs, nurses can be trained to do respiratory treatments and EKGs, and there are unlimited numbers of permutations possible that allow for idiosyncratic staffing solutions. The model is efficient and functional. Many EDs are playing with cross training to find the right skill mix for maximum efficiency in their departments.
Slack Times for Tasks
Have you ever noticed that you never see floors being mopped in a restaurant during the dinner hours? You don't see a bartender restocking his liquor and mixes during happy hour. Hair salons don't stock products when clients are in the salon. It is important that the maintenance activities of a service industry not coincide with peak service hours. This takes personnel out of service activity with customers, and has the potential for creating bottlenecks. Though stocking for demand makes sense — do you know how many IV's you will start today? why not have pre-made IV fluid bags? — the key is to do this without disrupting service and flow.
To interfere the least with service capacity may mean staffing ED techs on the graveyard shift, not a common practice now. Implicit in this scheme is knowing your peak and low service hours. You need to be able to forecast from an operations standpoint. (I will explore forecasting models in an upcoming column.)
Any innovation which helps match demand to capacity in the ED is useful and should be embraced. Service industries are continually looking for ways to smooth variation and off load customers to less busy times. We must watch them closely for ideas applicable to our domain. In the meantime, pass that patient a paper cup, and show him the ice machine!
STRATEGIES FOR DEMAND CAPACITY MANAGEMENT
▪ Customer participation
▪ Shared capacity
▪ Cross training
▪ Slack times for supportive tasks