Over at Slate, Zachary Meisel and Jesse Pines have a sensationalist article entitled Waiting Doom that describes how hospitals are killing emergency room patients. They claim Esmin Green’s death was caused by the length of time that she waited in the E.R. which they blame on the hospital practice of boarding inpatients. In their words,
Despite increasing evidence that crowded E.R.s can be hazardous to your health, hospitals have incentives to keep their E.R. patients waiting. As a result, there has been an explosion in E.R. wait times over the past few years, even for those who are the sickest. […] If there are no inpatient beds in the hospital (or no extra inpatient nurses on duty that day) then the patient stays in the E.R. long past the completion of the initial emergency work. This is what happened to Green, and it has become widespread and common.
To be clear, this death is tragic and, from what I’ve seen and read, there does appear to be some hospital negligence. However, I’m worried that Meisel and Pines’ suggested cure is worse than the disease. Like many that mistakenly believe in activity measures, they recommend that we force hospitals to measure and report waiting time. As evidence that this is the right solution, they cite:
In England, the National Health System now has a rule that 98 percent of patients have to spend less than four hours in the E.R..
However, as I blogged in Unhealthy Measures more than a year ago, when the National Heath System mandated a waiting time limit, ambulences waited outside hospitals with patients in the back. Since the activity measure started when patients came in the door, it seemingly solved the waiting problem but didn’t address the real problem – getting patients healthy. Outcome measures such as ‘% cases diagnosed correctly’ and ‘mortality rate’ would assess the effectiveness of the care being provided, not just the speed at which it was provided.
It’s hard to know whether using performance management would have helped Esmin Green. But I’m certain that spending a lot of money to measure waiting time isn’t the answer.
Esmin Green didn’t quietly expire in a chair while waiting for treatment. She lay, face down, on the emergency room floor for an hour before being checked upon. In that hour, apparently other emergency staff observed her on the floor but ignored her. It’s hard to believe that measuring waiting time in ER would have changed the behavior of those that walked by her.
But this also supports motivating people toward improvement instead of measuring into compliance. The staff could still ignore a patient lying on the floor until the target waiting limit approached if that is what they were measured on – much like keeping people out in the ambulance. A motivated staff person, who believed in and understood the vision of that hospital”… to provide comprehensive quality health services to all, regardless of ability to pay. Customer service is a priority …” would more likely have immediately checked on the condition of the patient.
I don’t have any answers on how to motivate an ER staff, I just know that changing punishment standards (masquerading as performance standards) won’t improve service or care.