11
Chapter 2
It’s Not about the Tools:
The Management Engineer’s
Role in Achieving Signicant,
Sustainable Change
Steven R. Escamilla
Management engineering and performance improvement professionals, both inside and outside
of the healthcare industry, are trained with a multitude of skills to improve organizational perfor-
mance. Armed with expertise that includes team facilitation, data analysis, project management,
decision analysis, and organizational behavior—and many other skills—management engineers
(MEs) typically have a portfolio of tools at their disposal to address most barriers to designing
and implementing improvement. Recently these tools have been summarized and taught under
Contents
e RME
®
Story: An Example of Large-Scale, Signicant, Sustained Success ............................. 12
Where Were the Tools? ...............................................................................................................13
Leadership .............................................................................................................................14
Communication ....................................................................................................................14
Site Visits ...............................................................................................................................14
RME Manual (the Tools) .......................................................................................................14
Coaching ...............................................................................................................................15
e Make-or-Break Role of the Management Engineer as Coach ......................................15
Predicting Successful Change ................................................................................................. 15
Active Ingredient of Improvement .........................................................................................16
Successful Coach and Tools ...............................................................................................16
Endnotes ....................................................................................................................................17
12 ◾ Steven R. Escamilla
catch-all terms such as Lean and Six Sigma, and previously as Total Quality Management (TQM)
and Continuous Quality Improvement (CQI).
Tools of this sort can be perceived to be the backbone of the management engineering profes-
sion. is focus on tools asks the question, “Tools: How important are they, really?”
I hope to provide some answers, or at least some perspective, on that question. More speci-
cally, we will explore how important tools are in the context of large-scale, signicant, and sustain-
able change.
The RME
®
Story: An Example of Large-Scale,
Signicant, Sustained Success
To begin to illustrate the role of management engineering tools, let’s examine a story of large-scale,
signicant, and sustainable change. e story comes from CEP America, a large emergency physi-
cian group based in Emeryville, California, which operates 79 emergency departments across the
US. is physician group was originally established in the early 1970s as California Emergency
Physicians; then in 2005 changed its name to CEP America to reect its national growth stem-
ming from its operational success.
While CEP America was always a successful group of physicians, most of its aliated emer-
gency departments (EDs) struggled with patient ow—like most every ED in the country. Across
its 46 aliated EDs in 2002, its overall average door-to-provider time (the time from a patient’s
arrival at the ED until the time they see a physician, physician assistant, or nurse practitioner)
was 49 minutes. While this was better than many EDs, it was still far from the generally accepted
industry goal of 30 minutes or less.
Unsatised with typical patient waiting times, a renegade CEP America medical director at
an emergency department in Brawley, California, took it upon himself to experiment with a new
model of seeing patients in the ED. In the typical ED patient ow model, a patient will arrive, see
a triage nurse, wait (sometimes hours) for a bed to become available, wait in the bed for a nursing
evaluation, and only then will see a physician. In the renegade medical director’s experimental
model, an arriving patient would see a physician very early in the process, immediately upon
arrival, where the physician would be physically located together with the triage nurse. With this
process, some low-acuity patients could be discharged literally within minutes of arriving, while
higher-acuity patients would have their diagnostics and treatment initiated much sooner than in
the traditional model.
e change seemed subtle, yet dramatically improved door-to-provider times at the renegade
medical director’s emergency department, and in turn greatly improved overall service times. As a
result, patients at the ED in Brawley were cared for more expeditiously, both patient and sta sat-
isfaction increased, and as turnaround time decreased, ED capacity increased, and patient volume
and revenue climbed. e change was far from simple though, both operationally and culturally.
e change not only required signicant operational changes to stang and all other aspects
of ED patient ow; more importantly, the change went against a long-standing culture of how
patients should ow in an emergency.
Observing the success of this nontraditional patient ow model, an innovative regional medi-
cal director mandated that each of the 9 emergency departments in his region try to replicate
the success. Working very diligently to address challenges to implementation, the regional medi-
cal director, in partnership with an assigned practice management consultant (a management
It’s Not about the Tools ◾ 13
engineer by background, but with a dierent title), facilitated change at each of the 9 emergency
departments, one by one. Most of these EDs recognized dramatic success (though some did not)
and the Rapid Medical Evaluation (RME) process was born.
e practice management consultant (PMC) team went to work to examine the keys to suc-
cessful RME implementation, and the reasons why some implementations did not work. e
PMC team at the time consisted of a management engineer, two MBAs with process improve-
ment consulting backgrounds, and an administrative assistant. Together, this team “packaged” a
process for successful RME implementation, including tools for project planning, stang analy-
sis, current- and future-state process planning, change motivation, and return on investment
(ROI) calculation.
As a result, the renegade medical director’s countercultural patient ow process spread across
virtually every emergency department within CEP America. New practice management consul-
tant sta were able to work with newly aliated CEP America EDs, and successfully achieve
dramatic improvements in patient ow similar to the renegade medical director’s ED and the
innovative regional medical director’s 9 EDs. e results were phenomenal. As of 2011, CEP
America had grown from 46 EDs in 2002 to 79 EDs in 2011, and overall average door-to-provider
time dropped from 49 minutes in 2002 to 32 minutes in 2011—including newly aliated EDs who
were still in the process of implementing RME (see Figure2.1). is was truly one of emergency
medicine’s epic stories of long-term, signicant, sustainable change.
Where Were the Tools?
How was it that such widespread success was achievable by a medical group? ey found some-
thing that worked, and structured a large organization for successful dissemination of the innova-
tion, among multiple dierent emergency departments, each with their own unique operations,
Minutes
50
45
40
35
30
25
20
15
10
5
0
# of Sites
90
80
70
60
50
40
30
20
10
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
49
49
41
43
43
41
39
35
32
32
# of Sites. 46
# of Sites. 49
# of Sites. 53
# of Sites. 54
# of Sites. 57
# of Sites. 62
# of Sites. 63
# of Sites. 67
# of Sites. 67
# of Sites. 79
Figure 2.1 CEP America time to provider.
14 ◾ Steven R. Escamilla
management styles, and cultures. What made the successful RME process reproducible, and
where were the tools?
Several elements of successful dissemination of innovation contributed to this story of success.
Leadership
Without proper leadership, successful, sustainable change is dicult (though not impossible) to
achieve. e innovative regional medical director, who declared that each of the 9 EDs under
his responsibility would implement a new model for patient ow, was an important key to suc-
cess. His mandate served to create a necessary burning platform. Further, the medical group
leadership, including the chief medical ocer (CMO), chief operations ocer (COO), and chief
executive ocer (CEO), declared a goal of a door-to-provider time of 30 minutes or less for
every emergency department. As individual EDs achieved signicant improvement, the COO
would publicly grant awards to successful emergency departments at organizationwide events.
is not only recognized successes, but also spurred competition among those EDs that were yet
to achieve the 30-minute goal.
Communication
e advantages of successful RME implementation were diligently communicated, frequently,
to all levels of the aliated organizations. With successful reduction in door-to-provider times,
physicians achieved improved productivity, satisfaction, and revenue. Nurses saw improved sta-
ing and greater satisfaction. ED directors achieved the accolades of being recognized innovators.
Hospital CEOs saw increased market share, revenue, and patient satisfaction.
Each of these advantages was identied for each audience, and turned into standardized
yet customizable presentations. Understanding the advantages of the change helped most indi-
viduals (“targets of change”) break through reluctance to change based on previously existing
cultural barriers.
Site Visits
For many, merely hearing about the advantages of a change is not enough to motivate action. For
them, it is necessary to see the advantages. Frequently, before attempting a local implementation of
RME, ED teams would engage in onsite visits to see successful EDs. (For the emergency depart-
ment in Roseburg, Oregon, the site visits required chartering a small jet for the ED team to visit
EDs in neighboring, yet distant, Northern California. Ultimately well worth the expense!)
Site visits enabled peer-to-peer interactions that more eectively fostered understanding of the
advantages of change. Skeptical physicians could speak with other physicians; skeptical nurses
could speak with other nurses. Experienced, successful individuals served as advocates of change,
based on their personal successes.
RME Manual (the Tools)
e tools that were required for successful RME implementation were captured and summa-
rized in the RME Manual—essentially, a handbook used to jump-start implementation and begin
addressing barriers to change. e manual contained tools such as standard (customizable) project
plans, presentations, stang calculators, examples of patient communication brochures, and ROI
It’s Not about the Tools ◾ 15
examples. Other available tools included sample treatment protocols, sample owcharts (though
no two EDs’ ows were ever identical), and sample patient satisfaction scripting.
Coaching
An important part of successful RME implementation was the role of the change coach, in this
case the practice management consultant. PMCs were involved to skillfully apply the multiple
tools and resources available to support the change. While the general concepts behind patient
ow changes were similar at all EDs, the path toward success was never the same twice. e coach-
ing role of the PMC greatly impacted an individual ED’s probability of success by customizing
implementation to the site’s needs.
Tools were certainly critical to the successful implementation of RME across more than 70
emergency departments. However, glaringly absent in this story is the presence of traditional
tools of Lean or Six Sigma—they were virtually nonexistent! How can it be that such dramatic
improvements in patient ow and overall ED performance can be achieved broadly across such a
large number of organizations, in this day and age, without Lean or Six Sigma?
The Make-or-Break Role of the Management Engineer as Coach
As with the emergency departments implementing RME, each organization, each facility, and
each department ultimately has a unique blend of leadership, vision, culture, and personalities. As
it turns out, as important as a management engineer’s tools are, the most critical variable aecting
sustainable change is the role of the coach.
Predicting Successful Change
David H. Gustafson, industrial engineer and health systems engineering professor and researcher
from the University of Wisconsin in Madison, has conducted multiple studies on change. In
the article, “Developing and Testing a Model to Predict Outcomes of Organizational Change,”
1
Gustafson et al. determined 18 factors that predicted the likelihood of successful change:
◾ Mandate
◾ Leader support
◾ Supporters and opponents
◾ Middle manager support
◾ Tension for change
◾ Sta needs assessment
◾ Exploration of problems and customer needs
◾ Change agent prestige and commitment
◾ Source of ideas
◾ Funding
◾ Relative advantage
◾ Radicalness of design
◾ Flexibility of design
◾ Evidence of eectiveness
◾ Complexity of implementation plan
◾ Work environment
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