This document summarizes strategies for emergency department clinicians to improve efficiency and patient flow. It discusses organizing the ED to maximize situational awareness and relationships with staff. Clinicians are advised to start shifts strong by seeing patients quickly early on. Improving documentation, such as using templates and dictation, and playing well with others by understanding nursing roles are also covered. The document recommends focusing on value-added activities, avoiding distractions, and improving end-of-shift handoffs to finish shifts efficiently. Self-care strategies like recognizing personal stress levels and boundaries are also presented.

1. WHITE PAPER
Fast and Efficient Practice:
The Emergency Department Clinician on the Emergency Department Autobahn
BY:
Kirk B. Jensen, MD, MBA, FACEP
Content
What Matters Most in Your ED?
The ED Physician Roles
Flow in the ED
Taking a Higher Look at the ED Clinician
and Clinical Work
Readings to Change Your Practice
To-Do’s

2. CONTENTS

3. FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN
Introduction................................................................................................................................................. 2
What Matters Most in Your Emergency Department?.................................................................................. 3
Flow and the Emergency Department.......................................................................................................... 4
Start Strong.................................................................................................................................................. 4
Organize the ED to Work Effectively With You and For You....................................................................... 4
Improve Documentation.............................................................................................................................. 5
Play Well with Others ................................................................................................................................. 6
Finish Strong................................................................................................................................................ 6
Taking a Higher Look at the ED Clinician and Clinical Work..................................................................... 6
Recommended Reading................................................................................................................................ 8
To Dos......................................................................................................................................................... 9
About the Author...................................................................................................................................... 10
References................................................................................................................................................. 11
Contact..................................................................................................................................................... 14

4. INTRODUCTION
Patient safety and satisfaction are the focus
within any emergency department. To streamline
navigation on the ED autobahn, i.e., flow, and
thus accomplish these goals most efficiently
can be accomplished by the consideration of
several factors and the application of several
key techniques.
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5. FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN
What Matters Most in Your
Emergency Department?
Most people would say it is taking care of your
patients; and this is true. But let us look a bit deeper.
While a fast, efficient, and effective emergency
department means greater patient safety and greater
patient satisfaction, you have to take care of your team
and you have to take care of yourself. Finding the
place where all three come together is the sweet spot
that we strive for. That is why it is critical to optimize
flow – important for your patients, your team and
yourself.
85 percent of their time waiting. We do not want to
cut down on the 15 percent of our time spent with
patients; we want to improve and streamline our
processes. We want to be fast at fast things and slow
at slow things. Fast and efficient is not about racing
through everything. We can only go as fast as the
slowest processes in the ED.
TRIAGE
PLACEMENT
TRIAGE AND REGISTRATION
MD
IN THE ED
CALL FOR BED OR DISCHARGE
TEST AND TREAT
EXIT ED
DISPOSITION DECISION
TO EXIT THE ED
ROOM UTILIZATION
There are opportunities to improve flow and
throughput throughout the life cycle of an emergency
department visit:
The three most important drivers of human behavior
are love, money and fear. There are days you show up
for work because you love it and wouldn’t want to be
anywhere else. There are days you show up because
you don’t want to let your team down. And there are
days you just want to earn your paycheck. Being a
good emergency physician means you need to think
through why you’re doing this and what it’s all about
for you.
There are three major dimensions to what an
Emergency Department physician does: Doctoring,
Deciding and Documenting. Patients spend 15
percent of their time receiving direct patient care and
• Leverage your clinical talent. Clinical talent
should be roving intellects engaged in value-added
activities at all times.
• Hire right (or repent at leisure)
• Optimize the physician, mid-level and nursing mix
and consider the use of scribes.
• Find the right clinical support mix for the team.
• Tailor the clinical hours and staff to the facility
and to patient flow.
• Have your A-team on the floor at all times.
The role of the clinical staff is to make diagnostic
and treatment decisions and to manage the team
and patient flow. Anything else is a non value-added
activity. To truly understand this, try this exercise in
your ED: take a 3 by 5 note card and write down in
five-minute intervals what you are actually doing for a
whole day or clinical shift (or only for one hour!) See
how much of your time is actually spent on valueadded activities, how much of what you did could and
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6. “We are what we repeatedly do.
Excellence is not an act, but a habit.”
~ Aristotle
should be done by a physician and only a physician
(substitute “mid-level practitioner” or “nurse” as the
situation requires), and how much of what you do or
did should or could have been offloaded to someone
else in your system or on your team, or perhaps,
should not have been done at all.
Flow and the
Emergency Department
• Start strong
• Organize the ED to work effectively
with you and for you
• Improve documentation
• Play well with others
• Finish strong
Start Strong
The first part of starting strong is getting prepared
before you start. Take a few moments to get organized
and mentally prepared. Bring your meals with you.
Get there early. Work hard early in your shift; it sets
the tone for the rest of your day. Let’s say your goal is
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to see 20 patients in a 10 hour shift at an average of
two-plus patients an hour. Many times you can get
five to ten patients started within the first hour. The
less “batch and queue” you have, the better off service
delivery is for everybody.
Organize the ED to Work
Effectively With You and For You
You are the captain of your ship.
Position yourself near a place where the patients
and their charts enter the emergency department.
This is called situational awareness. Good situational
awareness means you will know when patients are
coming in to the ED, when family members are
arriving, and who needs what kind of treatment.
Putting yourself where you can keep your eyes on
the entire emergency department is powerful and
effective.
Evaluate patients as the charts are
“put into the rack.”
Find the flow that works for you. Put your hands and
eyes on the charts or carry a patient log. It allows you

7. FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN
to organize your day and have the information you
need when you need it.
Develop good relationships with your attending
physicians and call them early.
Make the unit clerk your best friend.
Get the family members involved early.
A good unit clerk (unit coordinator) knows exactly
what is going on in the ED at all times. They can keep
you and your ED humming. They can remind you of
the chest X ray you wanted, the surgical consultant
that you need, the hours when Dr. Smith is in the
hospital or outside the hospital. The unit clerk and the
charge nurse are far and away your most important
allies when it comes to keeping the ER running
smoothly and effectively.
They play a critical role in the relationship. They
can be a valuable source of information. They will
certainly play a role in your disposition plans.
Sign out safely and effectively.
Personally sign out to your patients when you go offshift. Let them know that you are leaving and you are
handing over the patient’s care to your partner. It’s the
right thing to do – it’s good for you, your patients,
Recognize what you can do by and for yourself.
Don’t batch charts. Seeing patients one at a time is
seldom the most effective approach. On the other
hand, batching five or six charts isn’t either. It’s like
the “pig going through the proverbial python.”
Batching loads up and temporarily overloads your
system and your processes. Figure out what the
optimal blend is for you and your department.
Usually it’s two or three charts or patients at a time.
Avoid serial workups.
Sit down.
and your team.
Patients think that you spend twice as much time with
them when you sit down. It’s easy on your knees, it’s
easy on your back, it puts you at eye level with your
patients, and it doubles the amount of time they think
you have been spending with them.
No counting down.
Ask the key questions right up front – don’t wait until
the end of your patient encounter. Engage family
members as well.
Improve Documentation
There will be days you show up in the ER and are
counting down from the first hour. It happens. But
we are professionals, and professionals perform even
when they don’t feel like it.
“I just don’t understand why an emergency department
physician would go to all that trouble to do the work and
not take the few extra minutes to get paid for it.”
~ Mel Gotlieb
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8. Documentation is important. It may not be the
most mentally rewarding thing you do but it can be
the most financially rewarding thing that you do.
Write succinctly and legibly. Bad writing can lead to
inadequate records and even medical errors. Hire a
scribe. Once you’ve used a scribe, you will probably
never want to go back to your previous ways of
delivering patient care. Other ways of improving
your documentation include utilizing templates for
routine charting work, using dictation for important
to make their lives easier and/or better. Then actually
listen and adjust your behavior accordingly.
To knock it completely out of the park, spend 2-4
hours working in triage. You only have to do this once
at the hospital you are working in and it will last you
the rest of your career. You are “the doc who worked
triage,” the doc who “understands what it’s really like.”
Spend 4-8 hours actually working as a nurse. It will
significantly change your point of view as to how your
ER actually works – and it really sets you up with the
nursing staff.
Finish Strong
parts of the history and physical exam, and organizing
discharge instructions.
Play Well with Others
It is critically important to your work and
performance to work effectively with your nursing
staff. Learn their names. Know their individual and
team practice patterns. Invite them in as part of your
team, learn how they work, understand their hopes
and fears – these are all vital to your success and
effectiveness.
If you really want to be the emergency department
physician of the year, ask your nurses what you can do
6 |
Know your best practices for end of shift
management. This means you probably shouldn’t
batch charts. Be careful with handoffs. You do not
want to stop seeing patients four hours before the end
of your shift, and at the same time, you want to hand
off as few patients as possible. Treat your colleagues
the way you would like to be treated.
Negotiate pain medicine needs yourself. Do not
expect the nurse to do it.
Check for allergies.
When you are seeing patients who have a medical
background, ask them, “What do you think is wrong?
What do you want me to check for? What treatments
do you need or want or expect?”
Address service complaints immediately and on the
spot. It’s easier, quicker and better for everyone in the
long run.

9. The “Swiss Cheese” Model
Hazzards
Other holes due to latent conditions
Successive layers of defenses
Taking a Higher Look at the ED
Clinician and Clinical Work
Ask yourself: are you really superman or superwoman?
Or can you aim for just being somebody with the
“right stuff.” Somebody who can take on the mission
and carry it through with equanimity, decisiveness,
grace and humor?
Take care of yourself.
Taking care of yourself is vitally important. If you
don’t, who else is going to do it? Know your stress
tolerance levels. Know your behaviors. When you
know how you behave under stress and stressful
situations you understand how to better mitigate
the effects of stress – on yourself and on your
relationships.
Remember the importance of the other things in
your life.
Eat, sleep, exercise, and nurture your relationships.
Learn to juggle well. Know what drives you, whether
it’s love, money, fear or something else. Learn
the importance of the little things that make you
operationally effective and the importance of the big
things like taking care of yourself and taking care of
your team, as well as taking care of your patients.
Learn not to think too much.
As Henry Ford once said, “Thinking is the hardest
work there is, which is the probable reason why so
few people engage in it.” Your goal as an emergency
physician or an emergency clinician in training was
to actually get to the point where you did not have to
think too much. Lucian Leape, in his article “Error
in Medicine,” points out that the more expert you
are, the less you really have to think. It’s more about
pattern recognition. When you really have to think,
it’s intense and time-consuming. What we consider
thinking is often just selecting the appropriate
diagnostic and treatment pattern from our memory,
then making sure that the selected pattern is
successfully executed and that it works as planned.
Multitasking makes you stupid.
A study at Carnegie Mellon University found that
doing several things at once reduces the brain power
a person can devote to each task. Sometimes we don’t
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10. have a choice. Sometimes we have to multitask. But
understand the consequences. Teenagers can drive a
car, dial a cell phone and IM simultaneously faster
than adults can, but they can’t recognize the danger up
ahead as well as your mature and savvy brain can (the
one focused primarily on driving, situation awareness,
and threat recognition, not the teenage brain totally
absorbed with a cell phone, talking with passengers,
and instant messaging). Learn where, when, and how
you can control or limit your need to multitask.
Be familiar with James Reason’s operational model
for institutional error, or the “Swiss cheese” model for
error. (See above)
It is seldom one “mistake” or one “slip” that gets you
in trouble. It is the summation of a number of small
errors that will most often get you into trouble.
Avoid interruptions.
A study from the University of Illinois found that
it takes on average 16 minutes and 33 seconds for
a worker interrupted by email to get back to what
he or she was doing. Think through the number
of interruptions that you experience. Emergency
department doctors are interrupted 9.7 times per
hour while office physicians are interrupted 4 times
per hour. It is amazing that we do as well as we do. In
fact, the only reason clinical and operational outcomes
aren’t worse is that you are so good at what you do. It
helps make up for all of this – the interruptions, the
multi-tasking, and the continuous partial attention
paid to multiple patients.
8 |
Recommended Reading
Patrick Croskerry, MD, PhD. has written eloquently
on error management, thinking and what we can do
in the ER to optimize what we do. I would urge you
take the time to review some of these references.
Read the book “The Goal” by Eli Goldratt. It’s a
novel that delineates the Theory of Constraints. After
you read this, you will not walk into an ER without
thinking about the theory of constraints. You won’t
stand in line, walk into a lecture hall, or wait for a
cup of coffee at Starbucks without thinking about the
theory of constraints, dependent events, statistical
fluctuations and how someone could make this
process (and your life) a bit better.
Spend an hour reading the article “Error in Medicine”
by Lucien Leape. It can positively change your life and
your outlook.
“The Psychology of Waiting” by David Maister
(davidmaister.com) will take you through the eight
principles of waiting, what people experience and
think while they are waiting and what you can do. A
cardiology friend who read it ten years ago went back
home to his work and changed his office cardiology
practice. He did not add staff, he did not redo the
building, he did not rank and yank, hire and fire.
He simply changed his processes based on this one
article – and his patient satisfaction survey results
went from worst to first. This is powerful material.
It can be wonderfully effective for you and your
Emergency Department.

11. TO DOS

Discuss your practice profile with a couple of trusted colleagues.
ASK:
– How do you practice?
– What works?
– What could work better?
– What doesn’t work so well?
– What’s it like for you or for the team when I am in the ER?

Have your work patterns observed by a trusted colleague or nurse.

Become a student of others.
– Observe the people who are good or the people whose practices
you admire.
– Spend part of a shift tagging along with them.
– Always look for ways to get better at what you do
(CQI for the individual clinician).

Take a course or two.

Emulate Benjamin Franklin. Ben Franklin worked on one trait a
week. Know your weaknesses and work on one every week.
Remember, we are emergency clinicians.
We can do this.
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12. About the Author
Kirk B. Jensen, MD, MBA, FACEP, is Chief Medical Officer for
BestPractices, Inc., a leading emergency physician staffing and practice
management group. He has spent over 20 years in Emergency Medicine
management and clinical care and is directly responsible for the coaching,
mentoring, and career development of BestPractices’ Medical Directors.
Kirk B. Jensen,
MD, MBA, FACEP,
Dr. Jensen is a faculty member for the Institute for Healthcare
Improvement (IHI) and has held numerous leadership positions with IHI
focusing on quality improvement, patient satisfaction, and patient flow
both within the ED and throughout the hospital. Dr. Jensen also serves as
a Medical Director for Studer Group. He was honored by the American
College of Emergency Physicians as the 2010-2011 Outstanding Speaker
of the Year.
Copyright © 2011 BestPractices Inc.
All rights reserved. This publication may not be reproduced, stored in a retrieval system,
or transmitted in any form or by any means – electronic, mechanical, photocopying,
recording, or otherwise – without prior permission of the copyright owner.
This White Paper is an informational document. Readers should note that this
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custom graphics are service marks, trademarks, and/or trade dress of BestPractices, Inc.
All other trademarks, product names, and company names or logos cited herein are the
property of their respective owners.
Any comments relating to the material contained in this document may be sent to the
BestPractices Marketing Department:
Email: info@best-practices.com
Mail: BestPractices, Inc.
Marketing Director
10306 Eaton Place, Suite 180
Fairfax, VA 22030
10 |

13. REFERENCES
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15. FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN
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• Croskerry P. Critical thinking and decisionmaking: avoiding the perils of thin-slicing. Ann
Emerg Med. 2006;48:720-722. Abstract
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16. Contact
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