The Broken Bus: a Public Service Allegory

Once upon a time a bus station in a big city had only one broken bus on an essential route into town where all the services were. It spouted toxic fumes into the cabin and had three loose wheels and a broken back door. Now and again, passengers would die in it because it would crash, they were overcome in the toxic atmosphere, or the back door jammed and they couldn’t get out and asphyxiated. The bus drivers had been saying for 10 years the vehicle would wear out if it continued to be thrashed every day. 

They repeatedly contacted their managers about the safety of continuing to drive in it with passengers at high speed. Their managers said they were just poor drivers who just needed to do fewer journeys (like they did in a town far away who liked to speak to the government). Staff often went off sick rather than drive it, and some left for jobs with Uber.

The drivers were fed up and decided to take the bus to an allegedly independent garage who said they would review it. Unfortunately, the garage didn't look at the vehicle - they just asked the managers who said it was fine. The drivers then asked the garage owner to look again properly, and he apologised and said he would do a proper mechanical inspection. Meanwhile, the managers bugged the drivers rest room and threatened disciplinary review of anyone suggesting the vehicle wasn't roadworthy. 

The managers finally offered to visit the drivers to understand their issues, despite them being very busy and important people. They explained that they have superior knowledge of driving buses and were very passenger-focused, but that they would make time to visit the bus station to show staff how much they care. The garage report on the vehicle could wait, they said: "We are all one big team that needs to respect each other, and actually fixing a bus is difficult". 

The drivers told the managers they would prefer not to meet until they had the garage report. “We believe it needs a new exhaust, a working back door and three new wheels. There is no point in meeting until it is safe to drive again. Then we can meet with you and discuss how we maintain the vehicle and expand the fleet to prevent this problem in the future.”

So the meeting was cancelled, the vehicle was fixed, and passengers arrived safely. The managers were given MBEs for services to transportation and lived happily ever after. The End.

The Good, the Cheap and the Fast: the Iron Triangles of ED

The Iron Triangle is a model that describes the relationship between good, fast, or cheap in any given enterprise. Two sides of the Iron Triangle dictate the nature of the third.

 

Increasing speed may compromise quality unless further resource is deployed. Increasing the quality (or range of services provided) may require additional resource to be spent unless more time is allowed. Decreasing the cost requires a compromise in either speed or quality. Emergency Medicine is subject to the same trigonometry, but only one format prevents the shape from corroding and fracturing.

For an Emergency Department, each attribute might be defined and measured as follows:

1. Quality: How “Good’ is the ED? 

Look at the key performance indicators for clinically important conditions such as hip fracture, major trauma, cardiac arrest, sepsis. Next review the ability of the department to fulfil its role in the provision of emergency health care by looking at its breadth of service. A “Good” department will protect primary care and the in-patient specialties from work best addressed in an Emergency Department by Emergency Physicians, such as the rule out of serious conditions, reduction of fractures/dislocations, wound management, and front door critical care interventions such as emergency anaesthesia. It will reliably deliver “well-packaged” patients to the in-patient units and avoid hidden cost and delays downstream. Finally, a “Good” department will have low rates of bad outcomes as measured by x-rays misses, left without being seen, reattendance rates, death after discharge, drug errors, procedural complications, and other serious or adverse events.

2. Speed: How “Fast” is the ED? 

This is more straightforward. The most significant overarching metric is the 4-hr target. This can be broken into component parts such as time to triage, ambulance offload, first assessment, decision to admit and discharge from the department. 

Fast is not only popular with patients, but also reputationally good for the hospital (and managers and government) and prevents the harm resulting from crowding and delays to admission. Speed will be determined by the input demand, staff processing capacity and the speed of discharge to the community or an in-patient bed. These factors are then inextricably linked to “Cost” in terms of staffing and bed availability.

3. Price: How “Cheap” is the ED? 

The most easily measured cost is the direct staffing cost in the Emergency Department, together with the related cost of supporting services such as radiology access, lab tests, and administration. Higher staffing levels are likely to be associated with better quality and higher speed if effectively deployed.

The direct ED costs are however only part of the story. Flow out of the department is critically dependent on bed availability in the in-patient wards, and this is directly related to hospital occupancy. Keeping occupancy at the ideal level for ED flow of around 85% requires a commitment to covering the cost of some flexible bed capacity. Running at higher occupancy is superficially more cost-effective but leads to severe impacts on ED speed (and subsequently quality).

Departments that offer limited scope may divert work to other places concealing the true cost. Extensive pre-hospital screening such as phone advice lines designed to reduce ED demand may be expensive, and savings are only possible if this additional tier diverts very significant numbers with minimal or no costly errors. Redirection to primary care may displace cost to the community sector which may not be recouped as these patients are likely to be the “cheapest” (especially if primary care is less well equipped to process the nature of the conditions diverted e.g. injuries requiring x-ray). Similarly, handing off specific conditions or tasks to in-patient specialties such as chest pain assessment or resuscitation may mean costly duplication of “front doors”, when these tasks were previously all efficiently covered by the Emergency Department.

So, what departments can we have (assuming any two of three Iron Triangle conditions can be met):

Department A: Cheap, Fast. Not Good. Low staffing, limited scope – work is displaced to community or in-patient specialties and may be of low quality. ED staff either hate it or love it depending on their philosophy. Costs hidden elsewhere due to work displacement. Popular with managers (good 4 hr target) and patients who are not displaced or damaged (quick turnaround). Unpopular with specialties and GPs unless resourced (see hidden costs). FAIL

Department B: Good, Cheap. Slow. Low ED staffing, high hospital bed occupancy leading to processing and discharge delays. Scope often attempted to be maintained, but quality eventually suffers due to harm from crowding and delays. Unpopular with managers (poor performance on target), staff, and patients due to delays and adverse events. Ends up costing more anyway due to complications and issues with staff retention. FAIL

Department C: Fast, Good. Expensive. Well-staffed, low bed occupancy so excellent flow. Costs high and visible upfront. Comprehensive scope, good outcomes, low adverse events. Popular with staff, patients, and managers. Perceived as not cost-effective by accountants. Significant downstream savings in absence of hidden diversion costs, staff retention and avoidance of adverse outcomes for patients. PASS.

Most EDs are currently a failing Model B with long waits due to high bed occupancy and understaffing. Quality and safety inevitably suffer, and staff leave. There is often a short-sighted executive / political push to move to Model A which better hides its failings, though ultimately it becomes just a shell triage service incapable of providing Universal Healthcare to those in urgent need and incurring heavy downstream and upstream costs. Model C is the only corrosion resistant Emergency Department Iron Triangle that maintains its shape.