Over the last two years, I’ve had the great pleasure and privilege of visiting A LOT of Emergency Departments. I’ve also spent A LOT of time with ED Directors, trainees, FACEMs and other staff. While I still have a quite a few EDs on my President’s bucket-list, I reckon I’ve had a pretty good exposure to a range of departments, from rural to metro, from well-resourced to under-resourced, public and private.
So, I feel I’m in a reasonable position to make comment on some of the most important components that make-up a great ED.
Undoubtedly, the most important aspect – the stand out number one – is… you guessed it… ”the culture”. So, what have I seen which sets this undefined, unmeasurable entity at the top of the list? What makes “the vibe” of an ED so important that it ticks the boxes and puts everything else a distant second.
“The culture” is what drives an ED strive to be the best it can be. It supports staff to do the best they can do in their role; allowing individuals to feel part of a great team, to feel and be valued, to thrive by allowing the pursuit of individual goals, which, in turn, provides a positive feedback loop to “the culture”.
There are several components that contribute to culture.
A key component is leadership: a leadership culture where everyone has the capacity to ask questions, to challenge the status quo, where the “titled leaders” (ED Director, DEMT, NUM) allow their staff to develop and use their own leadership skills within a flat hierarchy.
An inclusive culture will allow staff to speak up AND BE HEARD when they have concerns about patient safety or concern for a fellow colleague. An inclusive culture respects the individual and addresses issues of discrimination, of conscious and unconscious biases and works openly and honestly to address these issues with the knowledge that embracing inclusion and diversity will see improved staff engagement and better patient outcomes. The best ED has a culture where all staff are respected and equal and have the same opportunities to advance their careers, regardless of gender, race, culture.
A culture of support enables individuals to maintain a balance between work demands and their individual needs, whether they be with family, doing a PhD or spending a lot of time working with ACEM (for example, as the President…). In the best ED, staff can ask for support for their stress and burn-out, without eyebrows being raised. Where pregnancy, family, maternity leave are celebrated and returning to work is supportive and adaptable to an individual’s needs.
A culture of learning which supports education for all staff and a “patient safety culture” will ensure that patients are put in the centre of everything the ED does: minimising risk, using EBM, and embracing cultural safety and support.
A culture of integrity means you don’t walk past behaviour you don’t accept, and bullying is recognised and addressed, both internally and from external sources.
But, here’s the pinch.
The ED is part of a bigger system. We can be the best we can be only if we work in a system which is responsive, which understands that it’s not okay to leave patients in hallways, or in waiting rooms, on ED trolleys.
We need to advocate for a system where it’s not acceptable to have patients with mental health issues languishing in an overcrowded and stressed ED for days. We need a system which understands that, in order for an ED to be the best it can be, clinicians need access to Clinical Support Time (CST) to run the education programs, to develop a Quality and Audit program, robust Morbidity and Mortality meetings, professional development, to provide the support for the Doctors in Training through peer support programs and mentoring.
So, the good ED’s have a sense of team, a culture of support and a leadership team which will step up and advocate for their patients and their staff. But, to be great, to really nail it, the best ED will be part of a health service where there is collaboration, understanding of roles, and clinicians across units who treat each other with genuine respect, who operate with integrity, with trust and in partnership.
Only then will we see ED’s, ICU’s, medical teams, surgical units all with a common purpose. We will be better for it. More importantly, our patients will be treated in a system which is truly focussed on their best outcomes.
As the President of ACEM, I have seen these qualities in many of the hospitals I have visited. But I have also seen and heard where there are significant challenges. It is up to each one of us to realise that we all have a common task, an obligation. We all need to step up and challenge a system which impacts on our capacity to be the best we can be for the sake of our patients and our communities.
There is much to be done. Fortunately, I think we are on the path.