Ambulatory Care Quarterly: Low-cost strategies help improve flow
Low-cost strategies help improve flow
Diversions virtually eliminated — LWBT cut by 2/3
The ED at the University of Kansas Hospital in Kansas City, KS, has virtually eliminated ambulance diversion; there were two diversions in June. It also has reduced its rate of patients leaving without being treated from 12% to 4%. Both achievements are thanks to a targeted program developed by a team representing the entire department.
Among the strategies they developed were several that appeared fairly simple, were quite inexpensive, and yet made a visible difference in patient flow. For example, the centralized rack for patient charts was replaced with smaller racks hung on the wall near the nurses' workstations, to give them easier access. This solution came as the result of a staff suggestion during off-site meetings.
"We picked the process of a visit apart and examined all of the steps," recalls Brian Selig, RN, BSN, MHA, CEN, ED nurse manager. "One nurse said, 'I was stuck in Room 20, and had to come all the way to Room 3 for a chart.' It's ridiculous to keep them all in one place." Because physicians now go to the racks to write orders, additional time is saved. He says the racks cost "maybe $100, and the nursing time saved back and forth was tremendous."
Another strategy involved the development of a new flag system for physician orders. Small flags are located outside each exam room. When an order is written, the doctor positions the flag so the nurse can see the patient is ready to be moved. This step, too, was the result of a nurse's suggestion at the staff meeting. "One of the wasteful practices they noted was the physicians writing orders, putting the chart back in the rack, and not telling anyone," says Selig. "So, we bought two flags for every set of chart racks [there are 10 of them], and the nurse can see them from down the hall."
Other solutions (not so low cost) included the addition of a second around-the-clock triage nurse and the creation of standing orders for the 10 most common patient complaints. However, the one Selig might be most proud of is one creating the new position of team leader.
"It is not the most cost-effective strategy, because they're not out there taking care of patients, but we had some throughput champions on the task force that noted we had charge nurses trying to manage 30 different people," he says. One of the task force members pointed out that in the military you never have a reporting structure of more than six people. "We were prepared to increase staffing anyway, and this was common sense. The charge nurses were struggling," Selig says.
This position was designed to address an additional challenge, recalls Carol Cleek, RN, MSN, CCNS, CNAA, ARNP, director of emergency and critical care services. "We knew that [for any other nursing positions], we were going to have to hire predominantly new graduates because the pool of experienced nurses was not there, but the doctors had verbalized in the off-site meeting that they needed expertise to help them drive throughput," she says. "Knowing that 'newbie' nurses needed guidance and mentoring, how could we structure that to achieve both goals at the same time?"
Cleek and Selig met with the hospital educator to come up with a mini job description. Selig says, "We wanted customer satisfaction stewards so that patient needs were met. For employee satisfaction, we wanted the new nurses to feel supported by this [team leader] resource, not like they were thrown to the wolves." In terms of throughput, he notes, they had to be able to help the doctors in terms of knowing where X-rays were or calling the admit team for them. "They really needed to push the staff on both sides," he says.
The staff chose the team leaders. "We sent out a survey, told them the qualities we thought a great team leader should have, and asked them to rank current staff on how well they met those qualities," says Selig.
The team leaders are assigned to three nurses a day. "The nurses know there's someone there for them. If they are due for a lunch break, they have someone who can watch their patients," he says.
In addition, he says, "These people have developed leadership skills they never knew they had." Plus, the number of nurses with advanced training had increased. "We asked the leaders to seek out advanced certification in the first year, and we've gone from five CENs to 15," he reports.
The ED at the University of Kansas Hospital in Kansas City, KS, has virtually eliminated ambulance diversion; there were two diversions in June. It also has reduced its rate of patients leaving without being treated from 12% to 4%.Subscribe Now for Access
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