Section 2. Forming a Patient Flow Team
Numerous research studies have shown the importance of creating multidisciplinary teams to plan quality
improvement interventions.17,18 One of the benefits of a multidisciplinary team is that members will bring
different perspectives and knowledge about problems, their underlying causes, and potential solutions.
Members may also be able to offer different resources and encourage buy-in for the solutions among their
peers. For all these reasons, identifying the right individuals to participate in implementing the patient
flow improvement strategies will be central to the success of your effort. Once formed, the team should
meet on a regular basis (e.g., weekly) throughout the planning and implementation stages.
Based on the experience of the Urgent Matters Learning Network (UMLN) hospitals, we recommend
that, at a minimum, your team include a team leader (day-to-day leader), senior hospital leader (e.g., the
chief quality officer), individuals with technical expertise related to the strategy, emergency department (ED) physicians and
nurses, ED support staff (e.g., clerks, registrars), a research/data analyst, and representatives from
The experience of the UMLN participants highlighted the important—yet often unrecognized—roles
played by registrars, clerks, and technicians, as well as other ED support personnel in the successful
adoption of strategies and the need to include these individuals in planning and implementation. In
addition, many of the UMLN participants stressed the importance of obtaining the explicit support of the
chief executive officer (CEO). The CEO does not necessarily need to serve as your system leader, but a
verbal expression of support or approval of resources from the CEO signals to staff that the strategy is
important to the organization.
As you assemble your team, we recommend that you consider these questions:
1. Who will lead your team?
The Institute for Healthcare Improvement recommends that quality improvement teams include three
types of leaders: a day-to-day leader, a senior hospital leader, and a technical leader.19 The day-to-day
leader is responsible for seeing that tasks are completed on time and motivating the team when challenges
are encountered. He or she is also responsible for communicating information about the strategy to the
team and to relevant parties outside of the team. This individual will need sufficient time to devote to the
improvement strategy. The day-to-day leader should be someone who is able to work effectively with
others and someone with sufficient authority to have his or her requests heeded.
Senior hospital leaders are those with sufficient authority within the organization who will be able to
assist when barriers arise (e.g., chief nursing officer, chief quality officer). They are able to recognize the
implications of the quality improvement effort for the organization and all affected departments.
Importantly, the system leader should be someone who can assist with the acquisition of resources to
support the strategy, as needed.
A technical leader is someone who will be able to offer technical support or guidance to the team. For
example, if your strategy involves changing a form on your electronic medical record, your team will
likely need a technical expert from the information technology (IT) department. A technical leader also
might be someone who understands processes of care within your organization. For example, a strategy
to improve flow within the fast track might require a fast track nurse who understands the steps that each
patient goes through from admission to discharge in the fast track. Teams are likely to require multiple
technical leaders, for example, a technical leader for processes of care and a technical expert for data
abstraction and analysis.
Example 1. Team Leadership at Hahnemann University Hospital
The patient flow improvement team at Hahnemann University Hospital in Philadelphia, PA, chose to
implement the five-level Emergency Severity Index (ESI) triage system as part of their participation in the
UMLN II. The ED assistant director assumed the role of team leader (day-to-day leader) and assembled an
implementation team that included the hospital's chief nursing officer (senior leader), an ED physician who
had experience teaching ESI and implementing it in other organizations (technical leader), a nurse
educator, and seven additional ED nurses. Importantly, the nurses selected to participate on the planning
team were strategically recruited because of their general openness to change and their leadership among
the department's nursing staff. The assistant director felt strongly that it would be easier to communicate and
implement ESI to the ED nursing staff if nurses were included in the planning process.
Note: Emergency Severity Index: Version 4. Rockville, MD: Agency for Healthcare Research and Quality;
May 2005. Available at http://www.ahrq.gov/research/esi/.
2. Which departments will be affected by your strategy? Which departments need to participate in order for your strategy to be successful?
ED crowding is a complex, hospital-wide issue. Although some simple ED throughput strategies may
affect only ED processes (e.g., implementation of ESI), more complex patient flow strategies are likely
to impact, or be impacted by, other departments. In these cases, success will require cooperation from
individuals outside the ED. Many of the ED teams that participated in the UMLNs recognized that they
could not do it alone; inviting representatives from other departments was critical to the success of the
strategies. It is important to include these individuals as early as possible during the planning process.
Expanding the number and types of departments represented on the team may provide new ideas and
creative suggestions that ED staff alone may not have considered.
Example 2. A Hospital-Wide Strategy at Stony Brook University Medical Center
The patient flow improvement team at Stony Brook University Medical Center in Stony Brook, NY,
implemented a strategy to speed specialty consultant requests. The team, which consisted primarily of ED
staff, established a specific timeframe within which consulting physicians were expected to respond to the
request (within 30 minutes) and complete the consult (within 120 minutes). ED clerks were responsible for
tracking response and completion times.
Consulting physicians were not included in the planning process, and many were resistant to the change.
However, once the processes began and initial data on response times were available, the patient flow
team presented the information to the service department chairs. The chairs recognized that there was room
for improvement and communicated to their staffs the importance of meeting the 30- and 120-minute goals.
The patient flow team found the support of the service department chairs to be invaluable. The chairs
constantly reinforced to their medical staff that compliance was not optional. One member of the patient
flow team noted that it takes a tremendous amount of vigilance on the part of the service department
leadership to be sure that people are following the new processes.
3. Who will be a champion for your strategy? Who will oppose it?
Quality improvement efforts require staff commitment and buy-in. Previous quality improvement studies
have shown that staff are much more likely to support change if they are involved in developing the
solution and have the opportunity to voice their concerns.17 One of the benefits of taking a team
approach to improving patient flow is that the individuals involved in the planning processes can
champion the effort to their colleagues. However, it is also important to involve those who might not be
supportive of change. These unsupportive individuals may be able to offer ideas to strengthen the
improvement strategy so that it may have broader appeal to staff.
Example 3. An Inclusive Approach to Improvement at Westmoreland Hospital
There was general agreement that ED crowding and boarding at Westmoreland Hospital in Greensburg,
PA, stemmed from inadequate communication between the inpatient units and the ED, with departments
acting in isolation instead of collaboration. However, previous efforts to improve communication between
the ED and inpatient units had failed for a number of reasons, including insufficient input from inpatient
floors and objections to proposed communication tools.
To overcome these barriers, the team engaged inpatient managers and staff in the early stages of the
design of their new communications tool. Managers and staff from all inpatient units were invited to review
a new Inpatient Report Tool, a one-page standardized summary and communication fax designed to be
sent from the ED to the inpatient floors in advance of the patient's chart arrival. Although inviting the
participation of inpatient staff and incorporating their feedback added several weeks to the planning
process, it allowed the team to identify potential problems and address them early. For example, nurses in
the progressive care, cardiac step-down unit expressed concerns that the tool was not detailed enough for
their patients. As a result, the patient flow team worked with the IT department to create an electronic
version of the report tool for patients requiring more complex care.
According to the patient flow team, diligent and ongoing communication with nurses from the inpatient
units has been instrumental in acceptance and use of the form. Simple solutions and shared responsibility
have been crucial to success. Key lessons include:
- The value of engaging inpatient staff at the outset to make them part of the process.
- The importance of inpatient nurse managers taking a leadership role in championing the tool and
addressing staff concerns.
- The value of soliciting broad input in promoting buy-in and ownership.
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