Patient flow team follows ED admits from first encounter to discharge

Access program provides 'a way for patients to connect the dots'

At Forsyth Medical Center in Winston-Salem, NC, patient flow representatives begin working to positively impact a patient's experience the moment he or she enters the emergency department (ED), says Kirsten Royster, MPA, director of patient access.

What takes the initiative to another level altogether, she explains, is that those employees continue to follow patients not only until they are discharged or admitted, but through the entire hospital stay for those who become inpatients.

Forsyth began the program in December 2005, Royster says, as a way to facilitate throughput and provide better care and customer service in the ED setting.

"It's challenging when patients are asked [for a customer satisfaction survey], 'How would you rate your admitting experience?' That's a pretty broad question. From the patient's perspective, it [covers] the moment you come in the door of the ED until you're actually in an inpatient bed," she points out.

"There are so many [factors] that have an impact on that experience," Royster adds. "We thought this would be a way for patients to connect the dots, so they weren't seeing two distinct areas of care."

To make the program a success, she says, the hospital needed "someone who was truly that person's advocate — not a nurse, not a tech in the ED, but truly outside that — who could focus on what to do to get from the ED to the nursing floor or discharged home."

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards regarding ED throughput and overcrowding were another impetus for the program, Royster says. "We thought this would be another way — in addition to throughput committees and tracking documents — of addressing that."

Three full-time equivalents (FTEs) — converted positions from the hospital's environmental services department — were designated for the program, she says. They were filled by a patient flow coordinator who reports to her, one full-time patient flow representative, and two part-time reps, Royster adds.

"We were trying to spread the hours so we'd have people there when the ED is busy, so the goal is 10 a.m. to 1 a.m., or even later," she explains.

The effort received a boost in June, Royster says, when the decision was made to incorporate existing ED guest services positions into the program and the number of employees went from four to 11. Patient flow representatives now perform the guest services role — check-in of patients before triage — in addition to working with patients in the treatment area, she adds.

"It's a nice collaboration," Royster notes. "The person in the lobby knows how many people are there, walking in the door and waiting to be seen, and can communicate that to their teammates in the back."

A patient flow representative may be in the lobby performing the guest relations piece for three hours, and then go to the back for the remainder of a shift, she says. "They have a fuller knowledge of the entire operation, and it has allowed us to have a lot more collaboration among all the areas of the ED."

In addition to providing more comprehensive service to patients, that step has been a real staff satisfier, notes Andrew Cox, the patient flow coordinator.

"The people who used to just work in the lobby love the fact that they are now rotating through," he says. "When I was up front [in guest services], I didn't have anybody to ask, 'Can you go to bed 12 and see if that patient can have the family come back?'"

Now, Cox adds, the person up front can make that call to a teammate in the back, who, for example, might respond, "No, they're still doing the assessment on that patient, but I'll let [the family] know when they can come back."

That teammate, he continues, might then come out in the lobby, introduce himself to family members as a patient flow representative, and say, "As soon as the patient's assessment is finished, I'll be glad to escort you back."

In the past, if the guest services representative checked on someone in the back, he or she risked missing other patients or family members who arrived in the interim, Cox points out.

Nursing staff like the new process, as well, he says, because during trauma and code cases they can depend on the patient flow representative to look out for arriving family members and inform clinicians when they arrive. Before, Cox adds, a nurse might have had to take the time to make those connections.

'Four-hour mark' is trigger

The Forsyth Medical Center ED is divided into a "major" area with critical cases, including those transported by emergency medical services; a "minor" area with less urgent cases; and a fast-track area, Royster explains. At present, she says, the patient flow staff work with any patient in the major or minor area who has been in the ED more than four hours.

"By the four-hour mark, there is usually the need for somebody to communicate," Royster says. "If there are not as many [patients], we do it sooner, and any trauma or 'code' [case] is outside the four-hour [rule]. We work with all of those.

"The intent behind [providing the service] is really to look at throughput, and the biggest issues are with the major or minor cases," she adds. "They are either about delays getting home or delays getting to the nursing floor."

From November through April, during the hospital's high census period, patient flow staff work with any patient who, after a determination to admit has been made, has to wait in the hallway for a bed because of overcrowding, Royster notes. "If they're not in a bed, they're already less satisfied. We help them understand how busy we are, why they're in the hallway, and what we're doing to get them where they need to be."

There are always two, and typically three, patient flow employees on duty, she says, and if there are three, one is in front and two are in the back of the ED.

The follow-through provided for those who come in through the ED and are admitted to an inpatient room is particularly effective from a patient satisfaction perspective, Royster says. "It's a nice thing, seeing a familiar face that they saw in the ED, not just for the patient but for the family.

"From the staff satisfaction perspective, it's also very good for the patient flow representatives," she adds. "In the ED, [typically] you may work with someone for six or eight hours and never know how they are after admission."

Under the guidelines of the Forsyth program, if a patient flow representative works with a patient in the ED who is ultimately admitted to the hospital, the rep tries to see that person every day until discharge, Royster says.

ED patients who are flagged to be admitted may start that process in the 10-bed emergency admission unit, where initial orders are carried out and inpatient beds may be requested, she notes.

If patients receive care in the unit, a patient flow rep follows them there and explains its purpose, Royster adds. Because the unit is located just off the ED, she says, patients otherwise might feel they are not making progress.

Patient flow reps don't stay with patients the entire time, she says, except during codes or traumas, when they are there "100% all the way through. That's part of the documentation that Andrew looks at for quality review and provides feedback on. [Staff] need to go back [and check on the patient] at least every hour, depending on the situation."

Consistency is key

The actions taken by the patient flow staff are monitored closely to help ensure the consistency and effectiveness of the program, Royster says. "We do a lot of documenting as to what steps they are taking with patients: Are they following our script? Are they introducing themselves the same way, describing the process the same way?"

Cox looks at such things as whether patient flow representatives are "throwing acronyms around" without explaining them. "Our hospitalists, for example, are called 'IPOFs' [internal physicians at Forsyth]."

Also noted, Royster says, is what steps are taken that could be characterized as "customer service," such as providing food or calling the chaplain, vs. those that are considered "patient flow intervention," such as working with environmental services to get a room cleaned STAT or contacting radiology or the laboratory to get results for a physician to review.

If they had it to do over, Royster and Cox say, they would have established the ground rules of the patient flow program with ED employees much earlier.

"It was an early challenge, making sure clinical staff knew who we were and when they should call us," Royster notes. "There was collaboration with them from the start, but when it got down to, 'When do you call me?' or 'When do you get involved?' we could have [clarified] that earlier."

Focus throughput, not customer service

"Early on, [patient flow reps] were doing more customer service-focused things, like getting blankets, but we wanted our focus to be on patient throughput," she explains. "We had some early issues with [clinical staff] wanting the patient flow team to take care of complaints and complete service recovery. They would call us and say, 'I've got a complaint — can you take care of that?' So we are clarifying for them, 'This is when we get involved, this is when we don't.'

"While we certainly do customer service activities, like getting blankets and escorting guests to our gift shop," Royster adds, "we set up the team to impact patient throughput."

Two months or so into the program, Royster and Cox did a presentation on the patient flow program to educate hospital leaders. "That helped us a lot," she notes.

In addition, new ED supervisors now meet with Cox as part of their orientation pathway to learn about the program and who the staff are, Royster says.

"About once a month," she adds, "we meet with the director and nurse manager of the ED to share experiences and get their thoughts on how we can be more helpful. Even though patient flow staff report through patient access, they really straddle the fence, as far as also being part of the ED staff."

With that in mind, Royster notes, patient flow staff attend staff meetings for the ED, as well as for the access department.

So that the patient flow team can be easily differentiated from ED clinical staff, members are required to dress in business casual attire or to wear polo shirts bearing the hospital logo and the words "Forsyth Medical Center Patient Flow Team," Cox notes. "If you have scrubs on, [people think] you're automatically a nurse or physician."

Patient flow employees also carry business cards with an e-mail address or telephone number, Royster adds, "so if a family member or patient needs to talk before we check back with them, they can contact someone."

Team members are 'designated requesters'

As an added service, seven members of the patient flow team have taken a class that allows them to be "designated requesters" for organ and tissue donation, she says, and an additional three were to receive training in December.

"If someone dies in the ED, whether from age or trauma, and we feel the person is a candidate, we will approach [the family member] and talk to them," adds Cox, who has received the training. "This is a huge help to the ED supervisor, because [the process] is very time-consuming."

People considering the option often have a lot of questions, he says, and patient flow staff can take the time to "get very in depth, very detailed." It also helps, Cox points out, that family members become familiar with the patient flow employees — which increases the comfort level — because they are so visible throughout the hospital experience.

Before patient flow staff took on this role, the responsibility for facilitating organ and tissue donation fell to the nursing supervisor, who had to handle it in the midst of myriad duties, he explains.

"[The nursing supervisor] would go in and talk to the family, get the paperwork on the record of death, and call Carolina Donor Services, which would call back and tell them if the person is eligible," Cox says. "By the time that call came, a lot of times the person [who could make the decision] had left."

Further discussion regarding the potential donation would then have to be done by telephone, he notes.

With patient flow representatives who have been trained as designated requesters handling the task, the turnaround time between making that call to CDS and having the agency call back with a response has been greatly reduced, Cox adds.

"When we place the call," he adds, "we already know what is required [for a person to be a donor]."

(Editor's note: Kirsten Royster can be reached at Andrew Cox can be reached at