Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Section 5. Preparing to Launch
Once the strategy is selected, you will need a road map for the implementation process. An implementation plan (IP) should be completed by the team to document the goals, resources, budget, and performance measures. An IP template can be found in Appendix B. The IP comprises four steps, each of which is described more fully below:
- Identify goals and strategies.
- Plan the approach.
- Estimate the time and expenses associated with implementation.
- Identify performance measures.
Once completed, we recommend sharing the IP with hospital and department leaders to ensure that they are aware of the effort underway and understand the timeline, budget, and resources that will be needed for the effort. You may need to update the IP periodically as new team members are added or new resources are identified. Still, the original IP should be maintained so that your team can periodically check progress against the initial budget and timeline.
This section provides instructions on completing the IP. Appendix C presents an example of a completed IP.
Step 1. Identify Goals and Strategies
In this first section of the IP, your team will develop the problem statement. The problem statement should briefly describe the current practice that needs to be changed and how it adversely impacts patient flow. To the extent possible, the problem statement should contain measures of the problem. For example, "The department currently does not use a valid and reliable triage system, and 10 percent of patients triaged to fast track are later determined to require a higher level of care" or "Due to a lack of inpatient capacity, the emergency department (ED) holds admitted patients for an average of 10 hours."
Next, your team should develop a brief goal statement. The goal statement should clearly identify the process that will be improved and include a measure that can be used to assess whether the strategy is successful. For example, "Specialty physician service consultations will be initiated within 30 minutes of request. The modified consult request process will reduce length of stay by 25 percent for patients requiring consultations." The goal should be relevant to patient flow, attainable, and measurable. For example, "reducing lab turnaround times by 50 percent" should only be selected as a goal if your team has access to data on lab turnaround times.
Finally, the strategy description should provide an overview of the process to be changed. Your strategy description should contain sufficient detail and be written in plain language so that it is easily understood by individuals in various departments and those with nonclinical backgrounds.
Step 2. Plan the Approach
The next section of the implementation plan focuses on outlining how the changes will be made and who is responsible.
- First, compile a list of all project team members, along with their titles and departments.
- Second, the team should identify potential barriers to successful implementation. Consider issues related to current processes, organizational culture, or other issues that might delay or derail implementation. We recommend reviewing the information in the next section of this guide (Facilitating Change, Anticipating Challenges) for more information on common barriers that patient flow teams have encountered during implementation. Identifying potential barriers to the implementation of your improvement strategy up front is important because efforts to mitigate those barriers can then be included in your work plan and timeline. It will also help to consider whether other individuals should be included in the team or other resources might be needed.
Third, choose a formal method for improvement. We recommend that you use the Plan-Do-Study-Act (PDSA) process, which has been used extensively in the health care field. PDSA is an iterative cycle in which organizations conduct planning for the change (Plan); carry out a small-scale test of the planned change (Do); collect and analyze data on the impact of the change, identify issues or problems, and learn from the consequences (Study); and determine what modifications should be made to the change and whether to proceed to full-scale implementation (Act). The repetition of the PDSA cycle will help your team determine what works and what does not, as well as what should be kept and what should be modified. The change is repeatedly refined until it is ready for broader implementation.
Testing changes on a small scale (e.g., during a single shift) has several advantages. First, it can be accomplished quickly with a minimal expenditure of resources and provide an indication of what to expect from full-scale implementation. Second, staff may be more willing to test a change if they understand that the change will be modified as needed.
Still, there are several other quality improvement approaches to use, such as Lean or Six Sigma, and many of these popular quality improvement approaches employ similar techniques. Appendix D contains information on where to find more information on these approaches.
Fourth, identify the implementation steps. This section of the IP should be a comprehensive work plan that includes the milestones or "gates" that must be accomplished in order for the strategy to be implemented. Each step should identify the PDSA tests of change that will inform progress to the next gate. The multiple iterations of PDSA may reveal additional milestones that are needed, and the timeline should change accordingly. The implementation steps are the heart of the IP and will reflect the dynamic nature of quality improvement in the complex hospital setting.
Along with each step, your team should identify who is responsible for the task and when the task should be completed. To draft this section of the IP, consider the following questions:
- What data need to be collected?
- Do staff members need to be trained?
- Do forms (electronic/paper) need to be developed?
- Do purchases need to be made?
- Finally, your team should consider a communications strategy. The patient flow team should meet periodically, information about the PDSA cycles and full-scale implementation should be communicated to staff, and progress should be communicated periodically to hospital and department leaders. This component of the IP requires your team to think about each of these issues, identify who is responsible for communication, and create the timeline for communication.
Example 7. Lean as a Method of Improvement
In 2008, Thomas Jefferson University Hospital in Philadelphia, PA, hired a new chief operating officer who saw a need to provide Jefferson staff with resources to improve performance. He arranged for General Electric (GE) to teach 45 employees the methods of Lean and Six Sigma. These 45 facilitators were made available to departments to lead Lean-driven improvements. The patient flow improvement team at Jefferson then used Lean methods to improve flow in the ED's fast track.
The Lean-trained facilitators, who were part of the patient flow improvement team, began by conducting interviews with fast track and ED staff. They observed work processes in the ED and documented how long it took to complete various tasks. Through this process, the facilitators discovered that the fast track nurse practitioner (NP) spent less than 40 percent of her time on NP tasks, and the nurse spent less than 6 percent of his or her time on nursing tasks. They also discovered sources of waste. For example, nurses spent a lot of time searching for equipment and supplies.
Next, the patient flow team participated in a 3-1/2-day kaizen (i.e., continuous quality improvement) event. The team spent the first 2 days observing and creating a value stream map of all tasks that occur between patients' arrival and discharge from the fast track. After identifying value- and non-value-added tasks, the team determined that the fast track could meet a goal of a 90-minute turnaround time for patients by making the following changes:
During the last day-and-a-half of the kaizen, the team implemented the changes listed above (with the exception of changing the fast track location) as a test run. There was a lot of enthusiasm among the kaizen team members, fast track staff, and ED leadership about the changes identified; however, more work was needed to sustain the changes. The team had several followup tasks, including ordering a permanent welcome sign for the waiting room; planning ESI education and competency assessment for triage nurses; developing written guidance about the roles of the NP, nurse, and technician in fast track; and cleaning and organizing the fast track supply cart. The team met weekly for 1 month after the kaizen event to discuss progress on these followup tasks, as well as any other issues associated with the implementation and maintenance of the changes. After the month, followup tasks were completed, and responsibility for the maintenance of improvements and analysis of data was turned over to the director of strategic initiatives.
Step 3. Estimate the Time and Expenses Associated with Implementation
This section of the IP is focused on planning for the resources needed to get your patient flow improvement strategies implemented.
Your team should estimate the total number of hours that will be spent planning and implementing your strategy. We recommend developing estimates for each staff member so that expectations are established up front about the commitment of time needed to support the effort.
The amount of time that team members will spend on the effort will vary considerably, based on the strategy and individual staff member roles. During the Urgent Matters Learning Network (UMLN) II, the total time spent planning and implementing the strategies ranged from 40 to 1,017 staff hours per strategy. The most time-consuming strategies were those that involved extensive staff training, large implementation teams, or complex process changes. ED nurse managers, charge nurses, and staff nurses spent more time planning and implementing strategies than others, primarily because several of the strategies involved extensive nurse training.
Though it may be tempting to form small teams or minimize staff training in an effort to reduce total planning hours, dedicating ample time to these tasks up front may reduce miscommunication and/or the need for more retraining later on. Several members of the hospital patient flow improvement teams noted, in retrospect, that they wished they had devoted more hours to planning in order to smooth the implementation process. Others said that they would have included other individuals on the implementation team earlier in the process in order to reduce staff resistance later.
Example 8. Hours Spent Planning and Implementing Strategies
Large training effort. To implement the five-level ESI triage system at Hahnemann University Hospital, a committee of nine nurses spent 92 hours each (828 total hours) planning the transition and developing the first training seminar. An additional 160 hours (4 hours each for 40 nurses) were spent on the initial training of staff nurses. After ESI was fully implemented, nurse leaders devoted additional time auditing cases and conducting a second training seminar.
Large vs. small teams. Hahnemann University Hospital and Thomas Jefferson University Hospital both implemented strategies to improve patient flow in their fast tracks and established dedicated fast-track teams. Hahnemann used a top-down approach, with planning conducted by the ED director and assistant director, so the number of individuals involved in planning and implementing the strategy was limited. Since the strategy at Hahnemann largely involved the acquisition of new resources (e.g., hiring new staff, overseeing a construction project), it was amenable to a top-down approach. Conversely, Thomas Jefferson used a Lean approach, which involved participation from multiple team members. The team was charged with identifying the reforms to the fast track that would improve patient flow, and multidisciplinary viewpoints were needed. The team consisted of three physicians, two nurses, two nurse practitioners, a technician, a registration manager, and three quality improvement facilitators. As a result, total planning and implementation time was considerably higher at Thomas Jefferson than at Hahnemann (371 hours vs. 160 hours, respectively).
High vs. low complexity. The strategy that was least time-consuming to plan and implement was bedside registration, which was implemented at Hahnemann. The strategy was planned by the ED director, assistant director, and nurse educator, who simply announced the policy change during staff meetings. It was a relatively straightforward change in protocol that did not require staff training or a large number of planning meetings. In all, 40 hours were spent planning and implementing the strategy. Conversely, development of a new protocol for requesting physician specialist consultations at Stony Brook was a relatively complex strategy that involved gathering data to study the problem, developing a new system for tracking consults, and educating clerks and physicians on the process. That strategy required 256 total hours.
Next, your team should estimate expenditures. What purchases need to be made? Should additional staff be hired? Like time estimates, expenditures will vary based on the strategy selected. Of the eight strategies adopted during UMLN II, five required little or no new expenditures. Many of these interventions involved a simple process change, a change in policy, or a shift in staff responsibilities, rather than the addition of new staff or equipment. Only three strategies involved sizable expenditures, ranging from $32,850 to $490,000. Construction and the addition of new personnel represented the most costly expenditures.
We recommend that you list all resources needed for implementation, including those that do not require expenditures. For example, if a new chair is needed for fast track, and you plan to use a chair from another area or department, list the chair as a needed resource in the IP so that your team and others are aware of the need to pull the chair from another location.
Example 9. Expenditures on Patient Flow Improvement Strategies
Small expenditures. Westmoreland Hospital, in Greensburg, PA, focused its efforts on improving communication between the ED and inpatient units in an effort to expedite admissions. The team developed a communication tool to enhance the way that information is shared between the units. Their strategy requires the ED nurse to fax a one-page form to the inpatient unit within 20 minutes of the ED admission order. The fax provides a concise description of the patient's current condition and recommended care path. The only purchase was a $200 fax machine.
Moderate expenditures. The patient flow improvement team from St. Francis Hospital in Indiana developed a strategy to standardize the registration and triage process. The hospital adopted a zoning strategy for registration (i.e., assignment of one registrar to a set of geographically close rooms), which required the addition of two computers on wheels ($8,000 each). Also, two nurses attended a train-the-trainer triage course ($16,850).
Large expenditures. For mid-track at Good Samaritan Hospital Medical Center, one ED physician was hired ($267,293) to provide triage and initial treatment to a subset of mid-acuity patients in a renovated triage room ($8,000). This enabled this category of patients, who traditionally wait the longest and have the highest rate of leaving before being seen, to be evaluated by a physician much faster. A tech was also hired ($33,390) to escort these patients to a separate area where a nurse practitioner could continue treatment under the guidance of the ED physician. An obstetrics chair was purchased ($12,000) for this separate area.
Next, list all approvals that will be needed prior to implementation. Who needs to approve the strategy and relevant components of the implementation plan? Think about approvals needed from various levels including hospital leadership, ED leaders, and staff supervisors.
Step 4. Identify Performance Measures
The final section of the IP is designed to help measure progress. First, consider the performance measures that will be affected by your strategy. Several suggested performance measures are included in the IP template (e.g., ED arrival to ED departure), but organizations with sophisticated data collection systems may have access to others. We recommend that you select multiple performance measures, as they measure different aspects of patient flow. Be sure to check whether you have access to the measures from your information system.
Additional resources may be needed for data collection (e.g., computers, software, staff time). Remember to list these resources in Section 3 of the IP. Similarly, consider whether you need permission to gain access to the data, and list those approvals in Section 3.