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Every System is Perfectly Designed to Get the Results It Gets

Walker, Graham MD

doi: 10.1097/01.EEM.0000731700.49297.b2
    admissions, crowding

    You may have heard the title of this article previously quoted and applied to health care with several misattributions. As best I can tell, it was originally stated by Paul Batalden, MD, a health policy expert at Dartmouth Medical School. (PSQH. July 1, 2008;

    I actually prefer the longer form in context, which feels more like a motivator for change than a cynical eyeroll about inefficiency: “Getting started begins with the simple, self-evident premise that every system is perfectly designed to deliver the results it produces.”

    I wrote last month about three patients waiting in the ED for the next step of care. It was the OR for the patient with appendicitis, sedation and reduction for the patient with a shoulder dislocation, and a stepdown bed for a patient with a CHF exacerbation. But I'd really like to look at why there was all that waiting.∗

    If we look at this from a giant health care system perspective using a five whys approach, we'd get something like this:

    • Why did the uncomplicated appendicitis patient wait seven hours for the OR? Because there was no OR availability.
    • Why was there no OR availability? Because the ORs were filled with elective cases.
    • Why were the ORs filled with elective cases? Because elective cases make more money than ED admissions. (Acad Emerg Med. 2008;15[10]:900.)
    • Why do elective cases make more money than ED admissions? Because the reimbursement schedules tend to favor procedure-based specialties.
    • Why do reimbursement schedules tend to favor procedure-based specialties? Because the RVS Update Committee is represented by members from most U.S. physician societies, and there are more procedural than cognitive specialty societies. (AMA.

    This is an oversimplification, but it's important to follow the money because it helps explain why hospitals don't keep a slot open for the inevitable appendicitis, incarcerated hernia, cholecystectomy, or another emergency procedure that needs OR time. It's the bottom line, stupid.

    Elective Cases

    Your ED patients are competing with elective OR cases for coveted hospital beds, and elective cases win most of the time. Your patient is less valuable than the meniscus clean-up. He who pays the piper calls the tune. (I'm not pointing fingers at specific surgeons here or saying their procedures lack value or don't help their patients; I'm pointing fingers at a system that assigns a lower dollar value to our patients.)

    If insanity is doing the same thing over and over again and expecting a different result, what would you call our hospitals that don't anticipate ED demand for the OR?

    A psych hospital is refusing to take a patient because of insurance status, violating EMTALA? Have him wait in the ED. (CMS. July 2, 2019; Never mind that definitive care is delayed; never mind all the other patients who might need the ED bed.

    A consultant tells you it's more convenient for him and the workflow to send a patient to the ED rather than direct-admitting even though the patient has no emergent diagnostic or treatment needs? Cool; collect a juicy co-pay (and a four- or five-figure bill) from the patient and have him seen unnecessarily by a board-certified emergency physician and emergency nurse, and then have him wait in a bed for six hours for the hospitalist to see him (because he is stable and low priority). And during a global pandemic, mind you, when the ED has nothing better to do.

    As I've said before, we are the path of least resistance. This doesn't mean concluding, “Wow, the ED sure is good at getting my patients admitted when it sends them over!” Instead it means, “Wow, the direct-admit process sure is inefficient, laborious, and complicated, and we have no incentive to improve it.”

    Everyone Suffers

    Our patients suffer. Our patients are lying in hallway beds being stitched up in front of the nursing station. Our colleagues are assaulted by the escalating psych patient who is tired of waiting 36 hours for a bed.

    We have systems in place to get a patient through the process of a colonoscopy, an operating room, or a cardiac catheterization or even to pay for parking, fill a prescription, or sign up for the patient portal online. These systems focus on safety, quality, and efficiency. Despite an unpredictable number and severity of patients constantly walking through our doors, the typical and expected response before the patient gets to the next step in our process is stop. Pause. Hold.

    Have you ever had a shift where even a quarter of your patients had a straightforward process? Where there wasn't a delay because the lab was down, the pharmacy didn't see your order, the surgeon was busy in the OR, or the floor wouldn't take report? It's so normal to us that we don't even realize how chaotic it all is.

    We know on a daily basis that the hospital is going to have 15 to 20 colonoscopies, eight to 10 EGDs, and 12 to 15 caths. Why is it a surprise when we predictably admit 10 to 20 patients a day requiring one or two OR add-ons, one cath, and one to four ICU beds?

    The results of our perfectly designed system? Wait.

    ∗I am pointing a lot of fingers in this article, and I acknowledge that EDs certainly have waste and inefficiency that could be improved. In this case, however, I focus on the fact that the ED work in most cases is completed within a few hours, and the time waiting for the next step is often double or triple that.

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    Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (, a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (, and The NNT (, a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter@grahamwalker, and read his past columns at

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