Section 6. Facilitating Change and Anticipating Challenges

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

This section describes common facilitators for the implementation of emergency department (ED) improvement strategies, as identified from the experiences of the hospitals participating in Urgent Matters Learning Network (UMLN) II. In some instances, facilitating change involved anticipating challenges and taking steps to forestall them.

Securing a Champion

As was noted earlier, the importance of securing leadership support in facilitating the implementation of improvement strategies cannot be overstated. This is especially the case for many strategies requiring additional resources or potentially impacting units outside the ED. Several of the UMLN II strategies required hiring additional personnel, and some of the hospitals struggled with recruitment and hiring freezes. Due to the economic recession and overall financial pressures, hiring additional staff was not an option for some hospitals that did not have an executive champion.

Example 10. St. Francis Hospital: Securing a Champion

St. Francis Hospital in Indianapolis, IN, focused on front-end improvement strategies. One of the strategies employed by St. Francis was registration zoning, which assigns a staff member to fully register patients in a specific "zone" of rooms using workstations on wheels (WOWs). Initially, hospital leadership refused to approve the purchase of WOWs because funds were limited, and the entire health system was moving toward standardized mobile units. With the support of the director of business transformation, the chief operating officer became a champion for the project. These two leaders eventually succeeded in lobbying for the purchase of two WOWs. Since the WOWs were not in place until February 2010, progress was held back during the early phases of the collaborative.

Creating Structure and Accountability

The UMLN II provided the hospitals with structure, a firm timeline for implementation, and the external accountability needed to ensure that the proposed improvement strategies received appropriate attention among many competing priorities. As a condition of participation, hospitals were required to provide UM staff with detailed implementation plans, which meant that the teams had to consider all of the intermediate steps needed to implement their strategy, the resources required, and the individuals who should be involved. In addition, the external accountability created by UM helped to ensure that the proposed improvement strategies received appropriate attention despite other large projects underway during the same time period (e.g., large hospital construction projects, the implementation of electronic medical records).

While most hospitals will not be able to participate in a formal collaborative, developing informal partnerships and collaboration may provide similar opportunities for shared learning, as well as some degree of accountability associated with promises to report progress or share data. In addition, the experience of the UM participants points to the value of formally using the IP template—even in the absence of collaborative participation—in providing a structure for planning and implementing change.

Aligning the Reporting Structure

Having a supportive supervisor and/or senior leader who oversees multiple units or staff likely to be impacted by the changes can significantly improve the chances for much-needed coordination, cooperation, collaboration, and compliance. An aligned reporting structure was critical to the success of strategies at several of our UMLN II hospitals where multiple hospital units and/or staff with different roles were involved.

At one UMLN II hospital, the chief operating officer established a new position—vice president for emergency medicine for clinical operations—responsible for overseeing all ED operations. This change was significant because for the first time, all ED physicians and nurses reported to the same individual. The new vice president was a proponent of patient flow improvement, and staff understood that improving the fast track was a priority for the department.

Adopting Staff-Driven Strategies

Engaging diverse staff throughout the planning, design, and implementation of patient flow improvement strategies is critical to facilitating successful and lasting change. Engaging staff likely to be impacted by the changes can provide valuable perspectives, knowledge, understanding, and expertise while reducing the likelihood of encountering staff resistance later.

Lean process improvement methods may be especially useful in engaging staff, as was demonstrated at two UMLN II hospitals. Both hospitals formed multidisciplinary teams to map current processes, identify changes that would improve efficiency, test the changes over a short time period, and make adjustments until the goal was met. At one participating hospital, respondents reported that Lean tools resulted in a better understanding among nurses as to why the changes were being made.

Careful selection of capable, adaptable, and willing staff to pilot the changes is also important. The planners at two participating hospitals knew that the strategies would not initially be embraced by all staff members, and they selected individuals who would put significant effort toward testing the process change. These employees became staff-level champions for the strategies and helped convince others of the strategies' merits.

Engaging in Robust Data Collection

Robust data collection can help performance improvement teams obtain needed resources and address staff resistance. For example, capturing data to illustrate the problem of crowding was crucial in recruiting an administrative champion needed to secure essential resources at one UMLN II hospital. Data also can be used to prove to leaders that ED overcrowding is a hospital-wide issue rather than just an ED issue, potentially increasing the likelihood they will support the strategies. Finally, data can be used to feed information back to staff, so that they can see the impact of their work.

Realistically Appraising the Need for Resources

Being realistic is a key to success. Hospital teams should ensure that they have the resources they need and that their strategies are compliant with national, State, and local regulations. Success should not be predicated on pulling resources from elsewhere. At one hospital, it was clear to the team that a dedicated nurse and technician were needed to assist the NP in fast track. One respondent said, "We asked the administration for an additional tech, but I can tell you they said "no.'" An ED nurse and tech were pulled from the ED to staff fast track, though as one respondent put it, "We robbed Peter to pay Paul." A respondent from another hospital indicated that one of the lessons learned was that there "needs to be dedicated personnel, and the strategy cannot be predicated on pulling people from the main ED."

Anticipating and Addressing Staff Resistance and Culture Change Through Education

More often than not, some level of staff resistance will be encountered, typically because of increased workloads or disruption of familiar staff workflow patterns. In UMLN II, some proposed strategies ran counter to the culture of the department, and many of the patient flow improvement teams found it difficult to change attitudes and habits. Previous failures to implement or maintain quality improvement efforts led to cynicism among some staff members. Culture trumps strategy, and as one respondent put it, "You have to change how people think."

There were a couple of approaches that the patient flow improvement teams in UMLN II hospitals used to successfully overcome staff resistance and facilitate culture change (Figure 3). The first is staff education and reeducation. As one staff educator put it, "there can never be enough education." Improvement team members from several hospitals said that more time should have been allocated to staff training. For example, reflecting on the implementation of the strategy at Good Samaritan, one staff member said, "Whenever you start a new process, you always find that the time you've allocated for education is never enough, and that the education component takes more effort and more time than anticipated." Team members from Stony Brook University Medical Center, who implemented a new process for requesting specialty consultations, speculated that additional training might have reduced some of the miscommunication about the new process and saved time in the long run.

Another important factor in addressing staff resistance is leadership that is completely transparent with data, sending clear and positive messages to staff and providing constant reinforcement to staff about the importance of following new processes.

Example 11. Overcoming Staff Resistance and Culture Change at Hahnemann University Hospital

As part of its participation in UMLN II, Hahnemann implemented an open-bed policy, where patients are directed to an open bed as soon as it becomes available for triage and registration. The traditional protocol at Hahnemann had been to triage and register patients when they arrived in the ED and have them sit in the waiting room until a nurse was ready to see them. Patients waited hours, even if a bed was empty, because nurses thought that they had too many patients to care for and were overwhelmed at taking on more patients. The open-bed policy was designed to reduce the bottleneck of patients in the waiting room, getting them into a bed sooner. Additionally, it reduced the likelihood of patients leaving the ED if they were already in a bed.

The implementation of the open-bed policy occurred gradually. The ED director stressed the importance of the open-bed policy at all staff meetings, but there was resistance by staff. Nurses focused on the number of patients that they were responsible for, regardless of the intensity of time that patients required. The nurses were overwhelmed when they had responsibility for more than four or five patients, even if some of the patients were simply waiting for laboratory results.

In addition, many staff members were skeptical about the implementation of the open-bed policy because of failures by previous department leaders to sustain change. This situation resulted in staff being skeptical that the ED leaders were serious about making it a permanent part of operations. It was initially treated as a "flavor of the month," where operations would be modified for a while but would slowly revert back to the old method.

One factor that helped foster acceptance of the open-bed policy among staff nurses was that the triage or charge nurses would often begin patient work-ups when they brought a new patient to an open bed, relieving the staff nurse from the responsibility. Further, in 2008 the department experienced considerable turnover, resulting in a need to hire 30 new nurses. Department leaders and nurses reported that it was easier for the new nurses to adapt to the process changes because they were not as familiar with previous processes. The open-bed policy gradually gained acceptance during the day shift. It is the hope of ED leadership that the night shift will soon follow in acceptance.

In addition, to sustain the changes, there were constant reminders by the department leaders about the importance of the changes. The presence of outside technical advisors and evaluators under the UM collaborative also conveyed a message to staff that these changes were different and would be sustained.

Post-Implementation Adjustments

Several UMLN II strategies required constant tweaking and readjustment. For an inpatient report tool strategy, one implementation team made changes to address the concerns of staff from a cardiac unit. They worked with the IT department to create an electronic version of the tool with more detailed information for complex patients. It is important for leaders to be transparent with performance improvement data and encourage continuing, two-way communication. At one hospital, staff support for the improvement strategy lagged because management did not share up-to-date data with staff.


Figure 3. Recommended approaches to addressing implementation challenges

Challenges AddressedApproachRationale
Culture changeConstant reinforcement of the strategy by leadersSignals to staff that the improvement strategy will become standard procedure
Staff resistanceStaff educationProvides staff with the capabilities and knowledge to carry out the strategy
Staff resistancePost-implementation adjustmentsSignals responsiveness to staff concern
Staff resistance
Culture change
Lack of staffing resources
Use of Lean quality improvement methodsFosters a team environment
Lack of staffing resources
Staff resistance
Robust data collectionProvides concrete evidence of need for action; demonstrates success to hospital leaders and front-line staff; is crucial in securing executive champion

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Page last reviewed October 2014
Internet Citation: Section 6. Facilitating Change and Anticipating Challenges: Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.