Ambulatory Care Quarterly

'Attitude adjustment' is key to ED success

Presenting patients get a bed in three minutes

In the face of steadily increasing volumes (13,000 between 2008 and 2009), the emergency department (ED) at Peninsula Regional Medical Center in Salisbury, MD, has improved all of its operating statistics, achieving a door-to-bed time of three minutes and a door-to-doc time of 21 minutes.

While such a performance could not have been accomplished without more efficient processes, the ED leadership team insists that the single most important element in their success has been a change in the way physicians and nurses relate to each other.

"We had some leadership changes 18 months ago with a renewed emphasis on our relationship and teamwork with nursing and the hospital," says Clark Willis, MD, medical director of the ED. "Most of the positive changes that have occurred, in my opinion, are process, structure, and throughput changes that resulted out of that collaboration." Willis says it is "amazing" what can be accomplished when physicians and nurses link hands and work together, instead of blaming each other and pointing fingers.

Susan Castrignano, RN, BSN, nursing director, agrees. "A lot of it had to do with leadership," says Castrignano, who adds that she and Willis came to their positions about the same time. "When the staff saw we actually talked to each other and were on the same plan and shared the same ideas, and that we had support for each other, support from the physician group to nursing and vice versa, little by little people saw you as a leadership team and not me representing the nurses and he representing the physician team," Castrignano says.

One simple but important change involved the structure of staff meetings, she says. "Now we have one big meeting, whereas we used to have a staff meeting for nurses and a departmental meeting for doctors and some nurses," Castrignano says. "Now we are all in one big room together. We hear the same message at the same time."

Willis says, "We sat down and talked about what we thought made a difference." After an ED expansion, "we had more space, new servers to run the EMR [electronic medical record], but we both agreed that we had to make a renewed initiative of working together," he says.

In the past, there was much more division about who was responsible for different activities and whether errors were the doctor's fault or the nurse's, Willis says. "In trying to focus on how we could work better together, we eliminated job-title-specific details," he says. "Meetings were more about everybody seeing the bigger picture of where we were headed and what we were trying to do. The key questions became what was best for the patients and how we could best serve them, regardless of whose area it was."