The High Reliability Emergency Department – Deference to Expertise
Posted on February 9, 2013
“Surround yourself with people smarter than you, they will come in handy”
As many of you might know the northeastern portion of the United States was hit with a large amount of snow. When I went to start the snow blower this morning I discovered it leaking gasoline. I called my brother-in-law Joe. Amongst Joe’s many talents is his thorough and complete understanding of small engines. A short while later the problem was fixed and I was on my way.
The same was true this afternoon when I brought my car to our mechanic with a flat tire. Frank rapidly identified the problem (a nail), plugged the hole and again I was on my way. For both these were simple nonchallenging problems. For me not so much because I lacked the critical expertise that they had.
It is important to distinguish between an Expert and Expertise. When I write about a Deference to Expertise it is easy in our hierarchical world of medicine to think about nurses deferring to physicians and physicians deferring to specialists.
It is not. Expertise (proficiency; skill; specialist knowledge) is not a permanent state of being but rather situational (based upon current needs, previous experiences, etc). Often this deference must be downward rather than upward in the established hierarchy (Weick, Sutcliffe Managing the Unexpected).
HRO PRINCIPLE #5
DEFERENCE TO EXPERTISE
- Pushes decision making down and around.
- Decisions are made on the front line.
- Authority migrates to the people with the most expertise.
- Makes an effort to see what those at the sharp end know.
- Does not mistake experts with expertise.
COLUMBIA SPACE SHUTTLE LOSS
NASA’s space shuttle Columbia broke apart on February 1, 2003 as it returned to Earth from a 16-day science mission. All seven astronauts were killed. The physical cause was …superheated air (5,000 F) entering the wing during reentry through a hole in a Reinforced Carbon-Carbon panel. Regarding organizational causes….organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion; [and a] lack of integrated management across program elements [also contributed].
EMERGENCY DEPARTMENT LESSONS
Who has expertise in our departments? The list is extensive. We start with the highly educated physicians and nurses. Each bringing vital expertise to the care team. But what about others? Clearly the patient and their family possess intimate information about their health and past medical history. Is that expertise?
What about the paramedics and EMTs? Their instincts on who is sick tend to be unmatched and they possess valuable information about the originating environment (home, vehicle entrapment). How about our colleagues without medical training like transporters and clerks? Surely we should consider them trained observers based on thousands of patient interactions. All have a role in the care of the patient and bring perspectives not completely duplicated by others.
The emergency department is unique because so much of the daily control is pushed far down and placed into the hands of those most local to the care. I often introduce myself as one of the doctors in charge of the ED. But the charge nurse is really the one who controls the flow and operations of the department. The nurse in a given section carries out my orders but the manner, timing, and other decisions surrounding implementation are their’s to make. Control and responsibility of any given patient flows from one person to another often seamlessly over the course of an encounter.
Communication is a recurring theme in much of what I write about. How deference to expertise fits in with our care is no different. The expertise of the team will always be greater than the individual. The need for all team members to focus on the “big picture” (safe, quality care) is predicated on the respect shown for their contributions to the expertise pool. I am frequently humbled by what I do not know, but more often I am humbled by what the others I work this do know and share.
Next week I will be finishing up this series with HRO #4 (Commitment to resilience). On deck is a deeper dive into “EDQA and Lessons from the Sharp End” The original lecture continues to be available at: HRED.