Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
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 inpatient units.
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: