NK6EO Nurses are involved in the design and implementation of workflow improvements and space design to enhance nursing practice.
Provide one example, with supporting evidence, of nurse involvement in the design and implementation of work flow that resulted in operational improvement, waste reduction, or clinical efficiency. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
OR
Provide one example, with supporting evidence, of nurse involvement in the design and implementation of work space that resulted in operational improvement, waste reduction, or clinical efficiency. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data
NAME OF INITIATIVE
Workflow Improvement: Capacity Management
BACKGROUND/PROBLEM
Crowding in the Emergency Department (ED) has gained national attention over the last several years due to the growing concern for patient safety. Over-crowding refers to the inability of the ED to function at its best due to limited resources available to manage a large influx of patients, leading to an increase in “wait times” to be seen by a provider and an increase in number of patients leaving without being seen (LWBS). As a result, the Center for Medicare & Medicaid Services (CMS) together with National Quality Forum (NQF) chose to address this issue by adding several performance measures related to throughput beginning with the patient’s entrance into the ED. These measures are designed to improve health care quality by publicly reporting through Hospital Compare; pay-for-performance; and internal quality improvement measures.
Homestead Hospital has not been immune to these same problems. Over the course of several years, multiple initiatives such as “door-to-doc” were implemented to improve ED processes. As a result, the “wait times” and LWBS had markedly improved. However, the total time a patient spent in the ED was still exceeding the benchmark.
In April of 2012, the hospital’s process for capacity management was revised to include the National Emergency Department Overcrowding Study (NEDOCS) score, which predicted gridlock based on the acuity of patients in the ED and the availability of beds in-house. When NEDOCS score reached the threshold, MS3, an area previously used as a Medical-Surgical Unit, was opened as part of the surge plan. By May 2012, Chief Nursing Officer and Vice President Gail Gordon, RN put together a task force to streamline the process due to concerns from clinical nurses regarding the time-consuming and cumbersome method of opening the unit. During several meetings, which included clinical nurses, patient care house supervisors, environmental staff, pharmacy and infection control, the team developed a flow chart of the steps involved. They identified opportunities for improvement related to equipment, supplies, notification of ancillary staff and staffing. By July 2012, the group developed a checklist that provided a systematic method for the activation of MS3. Consequently, the time it took to open MS3 as part of the surge plan was reduced in half.
Despite this and other measures implemented such as use of bed tracking system to identify available and pending beds; philosophy of “one-call-does-it-all;” and monthly compliance reports that had been taken to improve throughput times, there was a continued challenge with ED capacity and volume. Consequently, the ED Task Force was revitalized. It was comprised of physicians, case managers, clinical nurses, ancillary department staff members, and nurse leaders.
GOAL STATEMENT(S)
Decrease the median time for “Request to Occupy” below 75 minutes. This was defined as the median time when a bed was requested by the ED to the time the ED patient occupied an inpatient bed.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
Changes in Workflow
Minor improvements had been seen but not significant enough to impact ED throughput. In February of 2013, a Discharge Task Force was established aiming to facilitate discharge and identify delays in the process. The group, led by Patient Care House Supervisor Laurie Cogar, RN, was composed of representative from each nursing unit as well as Room Control Clerk, Patient Care Supervisors, Performance Improvement Nurse, Case Manager, and the Environmental Supervisor.
The first set of initiatives the team implemented throughout 2013 included:
- “Discharge Ticket”- A process in which the person discharging the patient would drop off a “Discharge Ticket” in Room Control Office to ensure timely cleaning and placement of a new patient.
- Assigning of beds when “In progress” in the bed tracking system - Designed to use the time spent cleaning to call report and move the patient to the assigned room.
- Automatic printing of admission/discharge orders to staffing office - Intended to decrease delays in reporting patients being admitted/ discharged.
- Escalation calls based on admission/ discharge orders - Aimed to increase awareness of pending orders and need to place incoming patients.
- Elimination of the “Golden Hour”- Removed time constraint before and after shift change to allow patient movement at any time a bed is available, thereby reducing time to discharge from ED.
Continued workflow changes
As a result of the changes made to the admission and discharge workflow, small but incremental improvements had been seen. In light of this, the Discharge Task Force reevaluated the process. They found that delays in discharges related to variety of issues coupled with late discharge orders contributed to the problems. MS3 was opened intermittently when there was overflow as part of the surge plan. The task force proposed keeping MS3 open regardless of ED volume and use it as an Admission/ Discharge Unit. Patients pending discharge with minimal needs (i.e. waiting for ride home, waiting to tolerate next meal) would be moved from the inpatient unit to MS3 where the staff would focus on discharge education and planning. Likewise, patients waiting for inpatient beds were moved up to MS3 to have their admission process started and then moved into an inpatient bed, when available. Each process would free up beds in the ED and on the inpatient units to improve throughout.
In February of 2014, the senior leaders approved the pilot of MS3 as an Admission/ Discharge unit. They also granted some nursing full-time equivalents (FTE). Additional resources had to be allocated (e.g. environmental staff, pharmacy support, and case manager) and collaboration with other departments was sought by the Discharge Task Force in order to implement the new workflow into daily practice. Initially, the new workflow was limited based on staff availability. Due to consistent improvements seen in throughput times, senior leaders supported additional FTES that enabled full time opening of MS3.
PARTICIPANTS
OUTCOME(S)
Operational Improvement
Exhibit NK6EOa: Homestead Hospital “Request to Occupy” Median Time
Analysis: Above graph demonstrates that the Discharge Task Force has met its goal of reducing the “request to occupy” median time to below 75 minutes and sustained it for 6 consecutive months.
Summary Attachments/Hyperlinks/Evidences
Exhibit NK6EOa: Homestead Hospital “Request to Occupy” Median Time