Creativity catches on with ED staff

Triage, bedside admissions increase satisfaction

Bradley Memorial Hospital in Cleveland, TN, and Baptist Health in Little Rock, AR, used to have something in common that they’d rather not mention. Both hospitals’ emergency departments (ED) had low patient satisfaction scores: 40th and 52nd percentiles, respectively, on the Press, Ganey Associates patient satisfaction survey.

After a year of concerted efforts to raise those scores, the two hospitals again have something in common: They’re now at the top. Bradley is up to the 90th percentile, and Baptist is in the 92nd. Last year, both hospitals won honorable mentions in the South Bend, IN-based patient satisfaction measurement firm’s client competition.

At Bradley Memorial, the ED problem was getting bad enough that hospital administrators and board members were receiving periodic complaints, and public perception was so poor that some local residents were driving 45 minutes to a larger hospital for treatment, says Brenda Wynkoop, process improvement director. Quality improvement teams had failed to get staff buy-in until they hit upon the idea of a staff-driven task force called the "PIT Crew." PIT stands for performance improvement team. It’s a multidisciplinary group, and staff must apply for membership. Each PIT Crew member is responsible for getting input from other ED staff.

The PIT Crew began by doing a flowchart of the path a patient takes from arrival to discharge and found a potential of 30 waiting points for the patient, Wynkoop says. The project was divided into three phases: triage/registration process, treatment, and discharge. In the initial phase, the crew decreased the potential waiting points from six to one. Now, when patients arrive, a "guest service ambassador" does a mini-registration, getting name, date of birth, and complaint. The ambassador generates a chart and notifies the triage nurse, who evaluates the patient. Portable two-way radios are used to notify the team leader, and a room is assigned. When all 23 rooms are filled, patients are taken to a glass-enclosed inner waiting area where treatment can begin even before a room is ready. The total patient waiting time has decreased by 44 minutes to 137 minutes.

"Patients can also be monitored or wait for test results in the inner waiting room after they’ve seen the physician, which frees up treatment rooms for other patients," says Connie Martin, administrative director of the emergency center. "Patients are not tied to that exam room."

Martin says the key to the successful changes was communication among the staff. The emergency staff had an all-day session with a consultant where they were allowed to air grievances, and they learned how to reach decisions by consensus. Education sessions were also held, and a departmental newsletter was created to inform the staff of the PIT Crew’s plans.

Baptist Health also took a creative approach to get the staff motivated to improve the ED. Patient satisfaction scores had at one point been as low as the 33rd percentile, and the situation had come to a head with the hospital administration. Sandy Pryor, BSN, supervisor of emergency services, says the basic message was that the staff would improve the scores or their replacements would. So Pryor decided to draw on her Air Force experience to create a military-themed campaign to improve patient satisfaction. She went to staff meetings dressed in combat fatigues, brought an American flag as a prop, and played the theme music to the movie Patton as a backdrop for her presentation titled "D-Day: Don’t Drop or Die."

The plan was presented in military terms, as follows:

- Problem No. 1 — "unsynchronized deployment of personnel."

Because of a confusing entrance to the ED, patients were getting lost. They weren’t sure where to park, and some needed help getting to the door. The simple solution: Place a security officer in the parking lot to assist patients.

- Problem No. 2 "delay in staging area."

Because there were no standing orders from physicians for common problems, waiting times could be lengthy. So the ED developed protocols for such complaints as abdominal pain so nurses could initiate routine tests before the physician sees the patient.

Another improvement is bedside admissions, which allows patients to be taken to a room immediately. It might not get them to the physician any quicker, but it gives them privacy and the chance to lie down.

"They’re more comfortable, and that changes their whole perspective," Pryor says. "Some of this is pretty basic stuff. It just takes thinking it through."