In this column, we will look at making the department efficient at the micro level by optimizing workflow at the provider level.

In a piece published in The New Yorker titled “Personal Best,” Atul Gawande, physician, writer, and visionary, observed that many highly paid professionals employ the services of a personal coach to improve their skills and performance. From the concert violinist to the professional tennis player, the drive and quest for professional improvement becomes a way of life. By comparison, emergency physicians, who participate in one of the longest and most expensive education and training regimens, typically get a two-hour orientation to their emergency department and begin their professional careers. We do very little to enhance practice performance over time.

One of the most reliable assessments in medicine is a physician’s blink response to patients. Emergency physicians are highly reliable at predicting admit/go home, sick/not sick.

Consider this: Though most physicians (and nurses, for that matter) in a group can tell you the most efficient physician in the practice, we do little to explore and cross-pollinate that efficiency. The strategies utilized by these efficient providers are not analyzed and disseminated. This is a lost opportunity.

Efficient physicians cultivate habits that move them to higher levels of practice efficiency. Two of the most important practices for the efficient physician are:

1. Touch It Once: This concept, borrowed from lean manufacturing, employs the notion that a task is most efficiently completed when it is done in one encounter. Examples of this applied to the work of the emergency physician include:
   • Check all labs and imaging that are available at the time of log on.
   • As you begin making sense of a situation and then diagnosing, order all tests at once. Avoid constant add-ons.
2. Limit Interruptions: This is a challenging area for emergency physicians as it can be difficult in our unscheduled environment, but here are a few ideas that help limit workflow interruptions:
   • Inform team members of your plan for each patient so they need not interrupt you for information.
   • Train staff to avoid interruptions when you are on the phone or performing computer tasks.
   • Develop nonverbal communication methods to facilitate workflow, including computerized and visual cues (flags, whiteboard communications, lights, etc.).

Emergency physicians have to be continually assessing and reassessing the department and their patients to be certain that patient flow and workflow are optimized. Running the board periodically to see what needs to be done is an efficiency strategy for the individual physician. Since the short-term memory can only hold seven items at a time, lists, prompts, and reminders are also a good idea.

Another practical idea for emergency physicians is to “tee up the discharges.” One of the most reliable assessments in medicine is a physician’s blink response to patients. Emergency physicians are highly reliable at predicting admit/go home, sick/not sick. We are even good at predicting whether a patient will survive an intensive care unit admission or not. Take advantage of this by getting the paperwork ready for a patient you anticipate will go home. This strategy has been noted among efficient emergency physicians.

In most work settings, there is a period when efficiency and productivity improve, then efficiency levels off with little additional improvement over time. Most physician groups do not assess whether physicians have optimized their workflow and efficiency, and a physician performance coach is unheard of in the ED. But is it an idea whose time has come?

Consider these ideas to improve personal practice performance:

1. Catalog the habits of the most efficient physicians in the group and make them available to the practice at large.
2. Have the most efficient physicians observe other physicians and offer strategic ideas for improving efficiency.
3. Ask the health unit clerk (HUC) for ideas to improve physician efficiency and share these ideas.
4. Survey the nursing staff for ideas that would improve the efficiency of physicians.
5. Meet with information technology experts to review computer support for workflow and identify, at the individual physician level, areas where efficiency could be improved.
6. In particular, explore the possibility of optimizing information technology support for workflow in the form of order sets (including discharge prescription sets for the most commonly treated conditions).

Each of us can improve our practice in emergency medicine. It requires that we be open to the idea of continuous improvement, coaching, and retraining in the elements of our practices. Don’t your patients deserve your personal best?