Hands-on input is key to the design process

Experts agree that hands-on involvement from staff is essential for a redesign to be a success. When Northside Hospital in Atlanta was redesigning its ED in 1992, staff were involved from day one until the end of the three-year project. A design team of physicians, nurses, EMTs, and unit clerks was formed. "They were given instructions to design the very best ED they could, no holds barred," says Alison Wiebe, RN, BAN, the hospital’s director of emergency services.

Flow charts then were constructed with various patient presentations, from sprained ankles to ambulance cardiac arrests. "Staff looked at every single process a patient goes through from the minute they walk in the ED to the moment they’re discharged," notes Wiebe. "In each one of the processes, we looked at areas which were repetitive and areas which caused delay in treatment."

The idea was to paint an overall picture of a "dream ED" that was truly patient-focused. "At that point, it was still conceptual, but we had input from every member of the ED staff," she says. The next step was taking that concept and making it real. "The staff broke up into small work groups and focused on specific areas, getting input from all relevant parties, including the radiology department."

The findings were brought back to the main design team, which included representatives from management services. "They reviewed all the redesign flow charts and made some revisions. Any department which would be impacted was an ad hoc member of the design team," explains Wiebe.

It helped that hospital administrators had bought into the project from the inception. "The idea came from administration that people in the work area are the people who know what works, and they told the staff, ‘We want you to fix it," says Wiebe. "Then it was up to us to move ahead with this quality initiative of patient-focused care."

The next step was to determine if the conceptual design could be accomplished in the existing ED. "We realized it would be impossible to take the new model of care and implement it in our ED," says Wiebe. "We looked at the financial impact the ED had on the hospital, and our impact on the community, and the hospital decided it was time to build a new ED."

Staff was involved in selecting architects and working with them. "The architects designed a floor plan to support our new delivery of care, and staff worked with them to do that," she recalls.

Physical layout was only one aspect of the redesign. Staff roles also changed dramatically, with extensive cross training. Nurses’ roles expanded to include computers, telecommunication, aerosol treatments, fetal heart tones, and ECGs. The ED techs were cross trained in clerical tasks and ECGs, and clerks were phased out entirely, either becoming techs or communication liaisons out front.

Physicians learned the hospital’s tracking system, became more computer-proficient, and began carrying wireless phones to initiate their own phone calls. "They weren’t really used to doing that," says Wiebe. "Of any group, physicians were maybe more tentative or questioning of the benefits of the redesign, especially the concept of not having clerks any more." she says.

It took time for staff to adjust to their new roles. "Nurses took on more new tasks than anyone else, and initially some perceived their new role as taking on more clerical duties," says Wiebe. "The whole model is based on working as a team. The reality is, we’re not busy 100% of the time, so having people who can do everything gives you a lot of flexibility."

Once staff adjusted, they came to appreciate the changes. "We have nurses who were working per diem in other EDs, who won’t work there anymore because they’re used to putting in their own orders and making their own calls," she says. "Otherwise it creates a huge delay, if nurses have to wait for techs, for example."

The flexible roles save valuable time. "The beauty of working in a team is that you can do things yourself, or if you’re busy, you can delegate a task directly to someone else instead of going through one centralized clerk," says Wiebe. "Rather than wait for a respiratory therapist to come give an asthma patient an aerosol treatment or a technician to start an ECG, you can do it yourself."

Combining operational changes with physical redesign can be risky, so it’s important to have a flexible plan. Staff continued to assess the project’s success on an ongoing basis. After the new ED was operational, the design team got back together to work on problems in triage and patient flow. "Even after we’d moved into the new ED and had implemented changes, we found some of them didn’t work as well as they did on paper," Wiebe says. "You can’t be afraid to make changes at any point in the process and fix the problems."