s a new director of ambulatory care at HCMC, Dr. Davis, started to review issues in the hospital and it was clear that something was wrong. Everyday patients and families waited for hours to see a doctor in the emergency department. Although the department seems to be running smoothly the hospital was typically diverting ambulances to other hospitals stating that they did not have any beds and staff to accept more patients just because the emergency room could not handle anymore patients. This was unacceptable for the new director because the hospital was loosing potential revenue every time an ambulance was diverted to another hospital. The nurse manager of the emergency department has been with the hospital for 25 years and Dr. Davis brought the issue to her. The nurse manager stated that the situation was no worse than usual and actually did better than most hospitals in the area. This was an unacceptable reply for Dr. Davis and she wanted the situation "fixed" setting a goal of having 90 percent of the emergency department outpatients in and out within four hours and for ambulances not to be diverted anymore than once a month. Dr. Davis was unaware what the current percentage was, but given her previous experience at other hospitals she aimed to accomplish this objective in six months. With the problem identified and clear objectives set, Dr. Davis set out to implement a new strategy, which involved (1) teaching the staff about root cause analysis, (2) reengineering the triage work flow to speed access to o the clinician, and (3) making what she viewed as a minor fix to the current electronic registration system to improve team communication. This approach had worked well in her former hospital, reducing wait times by more than 30 percent within six months. After much planning Dr. Davis held a staff meeting of the nurse manager and the three emergency department supervisors who reported to her to discuss the new strategy. Dr. Davis described the new processes, which were suppose to smooth out redundancies and save time. The staff seemed to like the reengineering process ideas best, so Dr. Davis decided to start with those. Dr. Davis suggested that they could begin the new work flow in two weeks after staff education and training. The staff meeting was friendly, and no one said much. The nurse manger had to leave early but the supervisors said the training should be no problem and that two weeks gave them plenty of time. They agreed as a group to start new process in two weeks. Come "go live" day Dr. Davis had morning meetings and was not present at the hospital but she knew that the nurse manager was there to implement the process. In the meantime there were several staff members out for the go live day and the charge nurse for the day was late coming in also. When Dr. Davis got to the hospital the nurse manager was waiting in her office and upset. The nurse manager stated that the new work flow process had fallen apart and that the emergency department wait time was even longer now. She was mad and raised her voice stating that Dr. Davis had not fixed anything but made it worse and we need to go back to the way we use to do it. Dr. Davis also noted that emergency department was full and that the medical director was already suggesting to divert ambulances to other hospitals and it was only noon. Dr. Davis went back to her office and wondered what she should do now and what went wrong.

(1) What problems does Dr. Davis face? (2) Consider individual-level, team-level, and system-level problems. For each, set an objective that is SMART. (3) Could Dr. Davis have avoided the current situation? How? (4) What concepts of leadership and management should Dr. Davis use to go forward?