Answering ED design by asking how might we?

'In regard to "Aging population will impact capacity, admissions" in the November 2013 issue of Health Facilities Management [Page 5], many trends are elucidated that will tax our health care delivery system. The article states that Dr. Pallin's referenced study estimates that emergency department (ED) visit length will increase by 10 percent in the coming years, hospitalizations arising from ED visits will increase 23 percent while ED visits per capita will remain level through 2050.

There is a phrase that I learned at IDEO, a wonderful design company based in Palo Alto, Calif., that works in the toy industry as well as many others, including medicine. This phrase is only three words long but it wields great power: "How might we?" In researching this phrase, I learned that in 2012, the Harvard Business Review Blog Network published "How Might We, The Secret Phrase Top Innovators Use." I would pose that rather than solving any given problem directly and by oneself, as most try to do, we should use the phrase "How might we?" as a far more potent tool.

The first question I'd ask is "How might we shorten length of stay in the ED?" and I'd ask it of everyone who works in a given ED. While I have ideas as a physician, I'm sure that others from nurses to environmental services personnel have ideas. And, I'd ask them to offer practical to completely "crazy" ideas. Without looking at and analyzing all of these ideas, even the ideas that seem crazy, we'd be trying to solve a problem without all of the wisdom of all of the players. That is just a waste of human observational power, if one stops to think. And, many times the so-called crazy ideas lead to revolutionary innovation.

The second question that I'd ask is, "How might we offer appropriate care without using the hospital the way that we do now [to decrease unnecessary hospital admissions]?" Similarly, I'd ask this of a heterogeneous group of people who have anything to do with the decision to admit a patient from the ED through anyone who touches an admitted patient through discharge. The variety of ideas offered would boggle the mind and using one of many techniques to pare down possibilities, we might come up with ideas that use telemedicine, skilled nursing facilities and even home care to offer care that we currently only utilize hospitals to deliver.

These problems, in their simplest forms, are design challenges. These processes were designed in a transactional environment that is changing to an outcomes-based environment. We know that hospitals are not the best places for the elderly ill to be, unless absolutely necessary, yet we use this modality because it is what we know. "How might we" allows us to design for improved outcomes and escape the barriers of traditional, transactional thinking. It is a paradigm shift that beckons us to use. Let us embrace it and see the success that it has brought to other industries.

Gregory Busch, D.O., CPE, CMD
Chief medical officer of a state Medicaid Plan Licensed physician in Delaware and New Jersey