Clinical team leaders provide added heft in driving improvements, moving the ED culture toward a patient-centered approach
Clinical team leaders provide added heft in driving improvements, moving the ED culture toward a patient-centered approach
Approach relies on 24/7 enforcement of new practices and policies
As the country moves toward full implementation of the Affordable Care Act, one issue that many safety-net hospitals are grappling with for the first time is market competition. While it is still not clear how many states are going to go along with the reform law’s expansion of Medicaid, the thinking is that in areas where newly insured patients have options for where to receive care, safety-net facilities are going to have to compete with other facilities to be the hospitals of choice.
The issue has not been lost on administrators at Truman Medical Center (TMC) Lakewood in Kansas City, MO. With another hospital less than two miles up the road, TMC is taking steps to re-engineer outdated practices and replace a safety-net-hospital mentality with a patient-focused culture that prizes efficiency and high satisfaction scores.
One primary focus of this effort is the hospital’s 20-bed ED, a department that treats just over 32,000 patients a year. Daniel Thompson, RN, BSN, CEN, MBA, was brought on board as the director of Emergency Services in 2011 to lead the improvement effort. And he immediately realized he wasn’t going to be able to make the needed changes without help.
“Any time you are implementing culture change, somebody has to be there to be the voice of why you are doing this and why it is important,” explains Thompson. “I can’t work 24 hours a day, seven days a week, so if we were going to establish a new culture of accountability, then we needed to do something that put real leaders at the bedside with the staff so that they could drive the change, hold people accountable, and give them the tools to be successful.”
Thompson could see that the way the ED was structured at the time, with a system of rotating charge nurses who would go back to their staff nurse roles on the days they weren’t taking charge duty, did not adequately empower or incentivize anyone to make needed changes. “They weren’t given the skills, the tools, or really the authority to make difficult decisions regarding behavior, performance, or even attendance,” he explains.
To address the problem, Thompson created a “clinical team leader” (CTL) position, a new role that would be given to four nurses who would work under Thompson, but have the authority to drive improvements and enforce changes in his absence. Thompson credits the approach with helping him to implement a number of difficult changes, ranging from immediate bedding and bedside triage to hourly rounding and bedside shift reports. Such changes are driving improvement on key metrics. The ED’s left-without-being-seen (LWBS) rate has been slashed by more than one-half, from 10% to 4.6, and the arrival-to-leave time has been reduced by more than 100 minutes, even while volume continues to rise by about 2,000 patients a year. (Also, see “To improve the patient experience, focus on team development first,” below.)
Solicit input from staff
While Thompson needed to receive approval from hospital leadership to implement the CTLs, the move didn’t require the addition of any new full-time employees (FTE). He used one open nurse position to bring in a CTL from the outside, but the other CTLs came from within the organization. To find the best candidates, Thompson queried staff about who they thought ran the floor best when they took charge duty. “I asked them who really ‘owns it’ when they are in that position,” he says. “I got a lot of staff feedback ... and then anybody who expressed interest in the position, I interviewed.”
Thompson infused the CLT position with some managerial responsibilities as well as charge nurse functions. “If the CTLs were just managers, then they would be far more administrative, and if they were just charge nurses, then they would be so close to the staff that I don’t think they would be able to have as much authority to discuss attendance, performance, or behavior,” he explains. “So I just hybridized the two. It definitely wasn’t easy to create the CTL positions, but I think it has really come together.”
For example, while the CTLs typically do not have patient loads, they are expected to take on patients if the department is short-staffed, says Thompson. Also, while they perform the responsibilities of charge nurses, they also do evaluations and have direct reports. “I oversee the evaluations to make sure they are written correctly and that they are accurate representations, but I also feel that the CTLs are the best people to say where [many of the employees] fit into our evaluation system. They are at the bedside with them,” he observes. The CTLs also perform extra administrative duties, such as audits, that are required on an ongoing basis, and some of them do scheduling as well as payroll. They do not, however, have the authority to hire or terminate employees, adds Thompson.
Establish 24/7 coverage
Having leaders with authority on the floor at all hours has helped Thompson implement changes, oftentimes in the face of considerable resistance. For example, one of the first changes that he implemented once the CTLs were in place was immediate bedding. A significant number of both physicians and nurses thought the approach wouldn’t work even though beds were often left empty in the ED when the department was overwhelmed with patients. “If it had just been me [promoting the practice], I would have said that we were going to do this, and then on nights, it wouldn’t have happened. Anytime I wasn’t around, it wouldn’t have happened,” says Thompson.
However, the CTLs were able to enforce the practice during all the shifts. “Once I stepped away from the table, they backed it up, and they just basically made sure that the beds stayed full and that nursing staff got used to the new model,” explains Thompson.
Next, to institute more equity in how the workload was distributed, Thompson established bed assignments. While staff members were more accepting of this change, it took time to implement because the beds in the department aren’t all contiguous. One nurse might have the beds numbered four, five, and nine, for example. Thompson and the CTLs were able to work through this problem by color-coding the beds and establishing a zone system. In addition to eliminating disparities in workload, the approach has also improved patient care, stresses Thompson.
One of the hardest changes to implement was bedside triage. Many veterans of the department saw triage as more of a place than a process, says Thompson. However, with enforcement help from the CTLs, the department has made significant progress transitioning to the practice. “We triage at the bedside now, and it works well,” he says. “We have really been going at it completely for about a year, and it is finally becoming the new normal.”
Other changes that Thompson implemented include a new bedside shift report, hourly rounding, and more accountability in the way time off for holidays is determined. “There was an issue where certain people got holidays off all the time, and there wasn’t a reproducible fairness to it, so we really had to reinvent the wheel in a way,” notes Thompson.
Identify resistance early on
With respect to all of these new practices, the CTLs have been particularly helpful at identifying pockets of resistance at an early stage, stresses Thompson. “Anytime you are instituting culture change, there is always probably going to be 20% who are with you, 60% who are on the fence but are complying with the change because they value their jobs and do it because they are told to, and then there is a small group at the bottom who really actively work against change and will spend a fair amount of time and energy attempting to undermine it,” he observes. When you catch this resistance early on, it is easier to control, adds Thompson.
The CTLs also act as key advisors who have their ears to the ground and can let Thompson know when processes or projects are not going well. For example, Thompson recalls a few occasions when the CTLs told him to hit the brakes. “We rolled out a huge amount of change, and it was very fatiguing to the staff,” says Thompson. “There were times when my CTLs came to me and said that we needed to slow down a little bit. And when they said that — because they were ‘A’ players and engaged in the process — I trusted them.”
Thompson has plans for further improvements. Next on the agenda is implementation of a fast track area — a move designed to drive the hospital’s LWBS rate down to a level more in sync with national averages. Thompson will rely on the CTLs to enforce process improvements, and he notes that the approach can work in other ED settings as well. But he has some advice, gleaned from having made a few mistakes along the way.
First, he recommends that ED managers take the time to get some alignment with the physicians before going live with changes. “I didn’t include the physicians on a couple of [our changes], thinking they wouldn’t care, and it really impacted them,” says Thompson. “Make sure you have formulated a reasonable goal and that you have communicated that goal as effectively and redundantly as possible so that everyone gets the memo.”
Also, Thompson says it is important to make sure that staff fully understand the reasons behind new initiatives. “You have to constantly preach the gospel of why something is necessary for the future of the organization and the care of your patients. They deserve this,” he says.
In cases in which expectations are not met, make sure that it wasn’t due to some type of communications failure or a failure to get buy-in from important stakeholders, advises Thompson. But if those issues aren’t to blame, then consider whether there was a lack of enforcement. “People do what they are held accountable for doing,” he says.
• Paul Spiegelman, Founder and CEO, The Beryl Companies, Bedford, TX. Website: http://paulspiegelman.com/contact/.
• Daniel Thompson, RN, BSN, CEN, MBA, Director, Emergency Services, Truman Medical Center Lakewood, Kansas City, MO. E-mail: [email protected].
To improve the patient experience, focus on team development first
Paul Spiegelman, founder and CEO of The Beryl Companies, a collection of organizations headquartered in Bedford, TX, that focus on improving the patient experience, makes the case that hospital leaders who want to improve patient satisfaction must first focus on their own teams. Spiegelman explains his reasoning in Patients Come Second: Leading Change by Changing the Way You Lead, (An Inc. Original, 2013) a new book on the subject, which he authored with Britt Berrett, president of Texas Health Presbyterian Hospital in Dallas.
Spiegelman says that the importance of internal development is particularly applicable to ED managers. “Make sure people feel fulfilled in their work and that they are bringing their passion and their best to work every day, obviously in a very stressful environment,” he says. “If the staff, the nurses, or the physicians don’t feel like they are being cared for beyond just having a job, then our hypothesis is that this is going to impact the quality of care, the patient experience, and, ultimately, the financial results of the organization.”
What can ED leaders do to nurture the right kind of attitude in subordinates? “Ways to do that are really common sense,” says Spiegelman. “It starts with making sure that staff connect with the mission, vision, and values of the organization. They need to understand what these are, repeat them, and make decisions based on them,” he says.
However, Spiegelman adds that leaders also need to demonstrate that they care about staff — not just their job performance. “That includes recognizing events in their lives that may be personal and not professional, such as a birth or a death, by sending a note card to the home or making a phone call,” he says.
In addition, leaders need to make time for rewards and recognition so that people feel valued for the work they are doing, and there should be an emphasis on training and development, adds Spiegelman. “People need to feel like there is a path to growth in the organization, and that leaders are not just focused on the job and the emergency of the day, the hour, or the moment, but also on growing their people so that they can achieve their personal goals,” says Spiegelman.
Not everyone is going to respond to such overtures by making requested changes or developing a positive outlook, acknowledges Spiegelman. And too often administrators make excuses for why they need to hang onto such malcontents, he says. “In health care, we do a very poor job of getting rid of people who don’t fit the culture. We hold onto them forever,” he stresses. “There will be people who are resistant, but when you have leaders or supervisors who become a negative influence on the organization, you need to make those tough decisions and move them out.”
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