National Health IT Week

A partnership to enhance outcomes through quality dashboards and action

It’s no small feat to create tools that help clinical nurses become data fluent and help leaders analyze and respond to data. That was the challenge we faced at our large academic medical center. To help prepare for our journey toward Magnet Recognition®, nursing leaders examined tools for data display and action planning—and realized improvements were needed. Bedside clinicians couldn’t access the electronic quality dashboard, and leaders who had access were challenged by inconsistent formats and data representation. The action-planning system was hard to use, and action-planning compliance was low.

The first step in correcting these problems was to convene the right group of people for a task force—nursing leaders, data analysts from nursing and the Quality and Performance Improvement (QPI) program, a senior applications system analyst from information technologies, and the QPI director. Initially, the task force met twice monthly to fully evaluate our organization’s needs and establish goals. Identifying goals helped to keep us focused during the initial phase, and continues to be helpful as tools and systems are refined. (See Task-force goals by clicking the PDF icon above.)

The next phase of work involved gaining access to the quality dashboard and improving the format of its home page and graphs. Restricted access to the dashboard posed a real barrier. How¬-ever, the chief nursing officer (CNO) and chief quality officers in the senior leadership team endorsed open access to the dashboard. As a result, all health-system employees can now view the dashboard using their secure log-on, with quality data protected by a firewall.

After reviewing how the data are organized, the task force decided to create dedicated organizational, nursing, and ambulatory dashboards. This would allow nursing leaders to navigate easily to nursing-focused metrics. Creating graphs with a consistent format and benchmark representation for all metrics greatly improved data interpretation. Units now have easy-to-understand graphs with color-coded data tables.

The next step was creating a mechanism allowing nurses to see and interact with the data posted in their clinical areas. Our CNO gave direction for all units to display specified data in public areas. The task force worked with internal marketing partners to create a nursing tagline and images for use on the quality bulletin boards. Unit staff were coached in creating posters that pinpointed improvement efforts for clinical and satisfaction levels, along with resulting outcomes. Once the poster content was complete, units received bulletin-board materials. The posters helped nurses to link their actions toward improvement with their accomplishments and to refine their understanding of what a patient outcome really is.

Overhauling electronic action-planning tools

After reorganizing data display and creating connections for clinical nurses, the next step was to overhaul the electronic action-planning tools. To gain a better understanding of the “lived experience” for those responsible for action plans, we held focus groups with unit managers. Conducted in a computer lab, these focus groups allowed us to gather feedback on current tools, as well as responses to the task force’s ideas on revisions. Focus-group results validated the need for easier-to-use tools and education on action planning.

The task force used this feedback to build an action-planning tool that walks users through evaluation of unit data and performance analysis, followed by a best-practice evaluation for each metric. Custom forms for key metrics, such as catheter-associated urinary tract infections and patient falls, provide a consistent structure and metric-specific best practices to address. Organizational content experts for each metric contributed to the material included on each form. Specific fields on the form populate a dashboard that upper management can access to view action-plan activity by unit and metric. Making reports available for action-plan completion supports a culture of accountability for this critical activity.

One-stop shopping

The task force identified “one-stop shopping” as an overarching goal to meet their original objectives. We wanted to ensure easy access to all tools that might be needed when staff evaluates and responds to unit-level data. We used Micro¬soft SharePoint, a content-management system, to centralize quality data, educational materials, audit tools, and links to such resources as procedures, protocols, and guidelines—along with the action-plan portal. We achieved this goal by linking resources to the home page of the electronic quality dashboard. Resources accessible from this single site include the educational PowerPoint used in training, clinical-practice audit tools, links to nursing and organizational clinical resources (such as procedures, protocols, and guidelines), and the action-plan portal.

The new action-planning tool was introduced in the computer lab setting. Managers were required to attend a 1-hour training session on action-planning principles and to experience a hands-on demonstration. Co-led by nurses and a QPI analyst, the training included dashboard navigation, basic quality methodology, SMART (Specific, Measurable, Attainable, Responsible person, Time-bound) goal development, and a guided tour of the new tools. Learners were able to begin drafts of their action plans using their own data during the class.

The quarterly process of data review and action planning is now well established. When new benchmarked data are posted, managers receive a notification that prompts them to update their unit bulletin boards and action plans. They have a 2-week window to update plans; directors and administrators can monitor that activity through built-in action-plan activity reports. Real-time awareness is supported through raw data counts of patient falls, infections, and pressure ulcers on the dashboard. This allows leaders to be nimble in monitoring unit performance.

We’re confident that we’ve established the right structure and process for data review and action planning, but we know there’s room to grow. Task-force members continue to engage in one-on-one coaching with managers as needed, evaluate tools and resources constantly, and collaborate continuously with other departments to maintain the best framework possible. Promoting clinical nurse data fluency and daily interaction with the data remains an important goal. Leaders now have better tools to analyze the data and monitor the response and action planning.

Our journey to improving quality outcomes has demonstrated the essential connections among nursing, quality improvement, and IT needed to support clinical excellence. Given the changing landscape of health care, meeting the demands for accessible and accurate data and the tools with which to respond to the data is a must for all healthcare organizations.

Selected references

Clutter PC, Reed C, Cornett, PA, Parsons ML. Action planning strategies to achieve quality outcomes. Crit Care Nurs Q. 2009;32(4):272-84.

Frazier JA, Williams B. Successful implementation and evolution of unit-based nursing dashboards. Nurse Leader. 2012;10(4):44-6.

Serb C. Effective dashboards. What to measure and how to show it. Hosp Health Netw. 2011;85(6):8 p following 40, 2.

The authors work at the University of Virginia Health System in Charlottesville. Jennifer T. Hall is the Magnet® Program Director. Christine M. Kelly is a system administrator and reporting analyst.

Technology, transformation, and the nursing workforce

Introduction of the stethoscope in the 1800s met great resistance among clinicians, who considered it invasive and contrary to current clinical practice. In 1834, The Times of London quoted a British physician’s opinion of the stethoscope: “That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.”

Today, few clinicians could imagine providing clinical care without the aid of a stethoscope. The tool has become so integrated with their practice that most clinicians consider it part of their standard uniform, wearing it proudly as a symbol of their knowledge and professional standing. But it’s not the tool itself that has transformed clinical practice. Rather, it’s the effective use of the stethoscope in the ears of an experienced clinician that can distinguish good sounds from bad and dramatically affect patient outcomes.

Similarly, in the 21st century, health information technology (HIT) has met resistance among some clinicians. Nonetheless, it’s fundamentally changing the skills and behaviors required in the workplace. No¬where is this change more profound than among the 3.1 – 3.6 million nurses, who make up the largest segment of the U.S. healthcare workforce.

Nursing informatics professionals at the leading edge

Since the earliest days of technology adoption in health care, nursing informatics professionals have been at the forefront of leading change. Early pioneers included nurses who effectively combined the science of nursing with computer and information science to support the clinical workflow, adding value to the organization as they began their journey to join the digital revolution. In 1992, the American Nurses Association formally recognized nursing informatics as a specialty. Since then, the field has grown and the demand for nursing informatics professionals has been increasing at unprecedented rates. Authors of the 2011 Nursing Informatics Workforce Survey from the Healthcare Information and Management Systems Society (HIMSS) noted that the average salary for nursing informatics professionals was almost 17% higher than it was in 2007 and 42% higher than in 2004.

Today, one of the key roles of nursing informatics professionals—and a role in which they add significant value—relates to clinical transformation. According to the HIMSS 2011 Clinical Transformation Survey, “Clinical transformation involves assessing and continually improving the way patient care is delivered at all levels in a care-delivery organization. It occurs when an organization rejects existing practice patterns that deliver inefficient or less effective results and embraces a common goal of patient safety, clinical outcomes, and quality care through process redesign and IT implementation. By effectively blending people, processes, and technology, clinical transformation occurs across facilities, departments, and clinical fields of expertise.”

Experience shows that simply overlaying technology atop existing processes doesn’t work. Yet many organizations, in their haste to become more connected or achieve government incentives related to electronic health information, are implementing technology without considering the need to transform clinical practice or the workflow. And in many cases, this is happening without qualified, experienced, and credentialed nursing informatics
resources. In organizations lacking a strong workflow and process advocate, the technology may take on a life of its own and begin to lead and inhibit clinical transformation rather than support and enable it. Ultimately, this results in significant resistance, workarounds, and unintended consequences.

Nursing informatics professionals also are helping to accelerate the changing skills and behaviors required for the 21st-century nursing workforce. Recognizing the need to adapt to an increasingly rich and technology-enabled environment, a group of nursing informatics leaders formed the Technology, Informatics, Guiding Education Reform (TIGER) Initiative in 2006. The goal of TIGER is to better define workforce competencies and effectively interweave evidence and technology into practice, education, and research. In addition to basic computer literacy, TIGER competencies include information literacy and clinical information management competencies for all practice levels. TIGER serves as a valued resource and continues to advance the integration of health informatics to transform practice, education, and consumer engagement.

Without doubt, technology-enabled tools affect every aspect of the nursing process in every care-delivery environment. From clinical documentation systems used to collect and store assessment data to closed-loop medication systems and wireless devices that promote adherence to the six “rights” of medication administration, these changes are occurring in all practice settings (including the patient’s home). Nursing informatics professionals stand ready not only to support but also to lead the transformation to a technology-enabled healthcare environment. With the right leadership an

Mark D. Sugrue is Director, Health Industries Advisory of Pricewaterhouse Coopers LLP in Boston, Massachusetts, and chair of the HIMSS Nursing Informatics Committee in Chicago, Illinois.

Enabling the ordinary: More time to care

Versions of this article appear in American Nurse Today (United States) and Nursing Times (United Kingdom) to acquaint readers with common goals, challenges, and advances in using health information technology to enable nurses to provide safer and more efficient care.

Around the globe, in every setting, nurses seek to provide care to patients and families to keep them safe, help them heal, and return them to the highest possible level of functioning. Nowhere is the struggle to achieve these simple aims more apparent than in hospitals. The tightrope of balancing what nurses believe to be adequate resources for high-quality care and the affordability of these required resources are often at odds. Disagreement among leaders in healthcare delivery systems as to how to allocate nursing resources has led to tension and discord. Despite decades of research showing that the amount of care provided by registered nurses directly affects mortality and morbidity, nurse leaders continue to have to justify requests for nursing resources.

Universally, the desire to make care more affordable has fueled efforts to make care more efficient and effective. The public recognizes this means examining all aspects of care in the pursuit of cost-reduction measures that will not reduce quality. In the United States, nurses continuously rank as the nation’s most trusted professionals by the Gallup Poll and have the public’s support whenever belt-tightening issues come to the forefront. On the other hand, in the United Kingdom (UK), the debate over resources that has been playing out in the media has caused confusion and public uncertainty as to whom to believe, undermining confidence in the system as a whole. The nursing profession hasn’t been spared this negative view and has needed to reassure the public of its core values and purpose—that caring and compassion are part of the core business of nursing.

Nursing is what nurses do, and what nurses do is coordinate and deliver care. So although the context, technology, and health needs of our populations have changed, nurses remain the foremost providers and coordinators of care.

Why state something so obvious? Showcasing the caring aspects of nursing in a technologically dominated world is challenging. Technology enables care and enhances safety by automating functions both simple and complex. It doesn’t replace nurses. As one expert cautions, automation should occur in nursing, not of nursing. The value of technology hinges on how it’s used and whether it helps or hinders care.

Changing nursing practice safely

So why do nurses have to struggle so hard to get the technology we need to support our practice? And when this technology is available, why don’t we reap the benefits we’ve been seeking for our practice?

For years, many in the healthcare community believed nurses were too slow to embrace new technologies and might disrupt or even obstruct the change process. Had they ever visited a neonatal or intensive care unit? Although their description of nurses and nursing wasn’t accurate, it had become a mantra within a wide variety of organizations.

What they failed to grasp, and continue to misunderstand, are the practical realities of how professions change and how to support innovation in practice. For generations, nurses have changed their practice successfully and have adapted to new challenges, such as coping with rising patient acuity, safely delivering dangerous drugs, and preventing adverse events. And they did this in a world where management theories were only beginning to address nursing and healthcare settings.

At times, the need for change has been critical and the response of the nursing profession has been swift. Of course, we can all acknowledge there are aspects of care we should have changed but have resisted. Nursing professionals have sought to understand how to change our practice and increase the available evidence on which to base our care. We understand how to change practice safely and how to sustain those changes.

Shared vision for technology: Enhancing care

The United States and UK share similar goals for technology innovation but differ in the economics and delivery-system configurations. (See Comparing the U.S. and UK health systems.) With the technology explosion, many healthcare organizations have sought to add new systems rather than integrate existing ones—usually without knowing if the addition would increase the workload or change work practices or whether it would be acceptable to patients. Organizations supported technology implementation to achieve business goals, whereas nurses saw practice development as the real goal.

The focus on the business case addressed primarily organizational benefits, such as the desire for technology to replace staff time and the ability to market to patients the use of “cutting-edge” devices and electronic record systems, not patient experience and outcomes. Many of these organizations treated technology to help nurses deliver care as a separate case, viewing it as an additional cost to services rather than a mechanism to enhance care. Thus, the possibility of being unable to sustain the technology was always real.

Increasingly, health technology projects have been seen as special projects that need special teams set up by senior managers, some of whom are unfamiliar with the care setting. These managers seem to struggle with focusing on supporting frontline practitioners to deliver care. Managers have failed repeatedly to enable ordinary day-to-day care with technologies.

The need for technology to support practice was demonstrated by findings from the Technology Drill Down project of the American Academy of Nursing’s Workforce Commission. Frontline nurses and other multidisciplinary care team members stressed the importance of involving direct caregivers in technology design, selection, and testing—steps often overlooked in the haste of acquiring systems or devices. (See Making care safer and more efficient with technology by clicking the PDF icon above.)

Technologies designed for and used by nurses at the point of care haven’t always been easy to use. A recent international survey seeking to identify priorities for nursing informatics research on patient care acknowledges that despite the growing evidence base on the design and evaluation of health information technology (HIT), these technologies focus mainly on medical practice. The study found that the two most highly ranked areas of importance were the development of systems to provide real-time feedback to nurses and assessment of HIT’s effects on nursing care and patient outcomes.

Agenda for leadership

We know how to support high-quality professional practice development and what conditions enable professions to change rapidly. If a profession is encouraged to annex new forms of knowledge and opportunities, it can rapidly develop appropriate practice to self-adapt. This is the route to successful, sustainable innovation. Nurses must address the leadership challenge of how to respond to and accelerate adoption of technologies to support practice. We need nurse leaders who see technologies as promising solutions, not problems, and are able to integrate technology into their vision for meeting practice needs. Nurse leaders need to model and promote examples of enabling technologies and demand systems that meet practitioners’ needs.

As technology matures, nurses and other healthcare professionals should be able to collect information only once and see it reused often. Management information should serve as a byproduct of excellent clinical practice and drive standards for high-quality data from nurses. The profession has made progress in dispelling the myth that nurses are slow technology adopters. With the help of nursing informatics experts, nursing leaders must continue to debate the issues that will help us leverage technologies to improve care and efficiency and achieve the promise that health technology can transform care.

Selected references

Aiken LH, et al. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011;49(12):1047-53.

Bolton LB, Gassert CA, Cipriano PF. Technology solutions can make nursing care safer and more efficient. J Healthc Inf Manag. 2008;22(4):24-30.

Cummings J, Bennett V. Compassion in practice: Nursing, midwifery and care staff:
Our vision and strategy. December 2012. www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf. Accessed September 27, 2013.

Dowding DW, Currie LM, Borycki E, et al. International priorities for research in nursing informatics for patient care. Stud Health Technol Inform. 2013;192:372-6.

Evenstad L. Cameron announces £100m nurse tech fund. E-Health Insider. October 8, 2012. www.ehi.co.uk/news/ehi/8109/cameron-announces-%C2%A3100m-nurse-tech-fund. Accessed September 22, 2013.

Hamer S, Collinson G. Achieving Evidence-Based Practice: A Handbook for Practitioners. 2nd ed. Baillière Tindall; 2005.

Newport F. Congress retains low honesty rating. Nurses have highest honesty rating; car salespeople, lowest. December 3, 2012. www.gallup.com/poll/159035/congress-retains-low-honesty-rating.aspx. Accessed September 22, 2013.

Plochg T, Hamer S. Innovation more than an artefact? Conceptualizing the effects of drawing medicine into management. Int J Healthcare Manag. 2012;5(4):189-92.

Simpson RL. The softer side of technology: How it helps nursing care. Nurs Adm Q. 2004;28(4):302-5.

Pamela F. Cipriano is a senior director for Galloway Consulting in Marietta, Georgia, a research associate professor at the University of Virginia School of Nursing, and editor-in-chief of American Nurse Today. Susan Hamer is the organizational and workforce development director at the National Institute for Health Research Clinical Research Network at the University of Leeds, England.

Collaborating on technology: A learning exchange between U.S. and U.K. nurses

Technology implementation in the clinical setting isn’t a project but rather a transformation of the delivery system. As healthcare services in the United States and United Kingdom (UK) embrace technology to drive reforms in quality and efficiency, growing opportunities exist to share experiences between the two countries. Today, many global nursing dialogues are sharing lessons about community-care delivery models, nursing governance and adoption, interprofessional communication tools, and patient portals.

Now is the time to share practices in nursing informatics globally. This is essential to the success of the journey toward health information technology (HIT)-enabled transformation. Although many nurses might focus on differences in payment models and delivery methods between the United States and the UK, significant commonalities and experiences exist that each country can share with the other. These were explored in June 2013 by a group of UK nursing leaders who visited the United States.

Nursing informatics immersion study

The 2013 UK Nursing Informatics (UK NI) Leadership U.S. Immersion Study was a joint effort by the Healthcare Information and Management Systems Society (HIMSS), HIMSS Europe, and Cerner Corporation. These partners launched a year-long initiative aimed at promoting UK nurses’ role in implementing and using information technology (IT).

A hosted nursing-leadership delegation trip to Chicago culminated the initiative. A 10-person delegation of nursing informatics leaders was selected from across the UK to meet with U.S. nursing informatics leaders, visit key U.S. healthcare facilities that use nursing informatics to deliver care, and meet with other providers, suppliers, and government leaders. The delegation explored innovative technology, met with nurse executives, and spoke with nursing informatics colleagues at three Chicago healthcare facilities, all of which have achieved Magnet Recognition® from the American Nurses Credentialing Center. Many Magnet® attributes became apparent to the delegates during these visits. (See Understanding the Magnet Recognition Program.® be clicking the PDF icon above)

Each of the three facilities had a specific focus:

  • Advocate Illinois Masonic Medical Center: Connecting the community through informatics
  • Northwestern Memorial Hospital: The connected patient
  • Ann & Robert H. Lurie Children’s Hospital of Chicago: Technology architecture and design.

Emerging ideas

Introduction of robust and sophisticated clinical information systems has prompted significant transformation in health care and focused greater attention on patient safety and outcomes. Healthcare systems are under increasing pressure to improve efficiency while standardizing and streamlining
organizational processes and maintaining high-quality care. The current knowledge explosion in health care requires clinicians to learn about and integrate information systems into their already demanding daily practice.

As part of the nursing informatics immersion study, several key concepts common to both the U.S. and UK nursing professions emerged. These include a culture of inquiry, shared governance and accountability throughout the organization, visible nursing leadership, and real-time data reporting through the use of quality dashboards.

Culture of inquiry

Working closely with bedside clinicians and the IT department, the nursing informatics team is responsible for development, implementation, and support of new systems. It’s also instrumental in fostering a culture of inquiry among the workforce. Giving frontline staff access to data provides a scholarly approach to change and transformation that emphasizes evidence-based practices and research.

Shared governance and accountability

The shared governance model gives clinical nurses a voice in determining nursing practice, standards, and quality of care. This empowers nurses to use their clinical knowledge and expertise to develop, direct, and sustain their professional practice. Interprofessional councils and committees allow the nursing informatics team to contribute to and share accountability for decisions made about patient-care delivery. Patients also participate in councils to bring their unique voice.

Visible nursing leadership

Presence of fully engaged nursing leaders with a shared vision aligns with the Magnet philosophy and the Magnet model component of structural empowerment. Professional practice flourishes under influential leadership, creating an environment where innovation is encouraged, adopted, and sustained. Although the three organizations the delegation visited had different leadership models, an underlying theme was the need for a clinical leader, such as chief medical information officer (CMIO), chief nursing information officer (CNIO), or director of informatics. Nursing informatics leadership is integral to help promote and drive the organization’s clinical vision and provide the underpinnings for a successful roadmap.

Real-time data reporting with quality dashboards

Quality data are informing practice at the bedside through real-time dashboards at each facility. The electronic systems were designed to monitor and capture adherence to indicators required by government and nursing standards. One of the facilities had unit-based quality message boards that informed patients and families of monthly quality outcomes.

Key findings

The immersion study found that organizations that empower their staff structurally by using interprofessional shared-governance models have the capacity and agility to deliver clinical decisions and transformation to keep up with technology. Another key finding was that supporting leadership roles, such as chief clinical information officer (CCIO), CMIO, and CNIO, champion the clinical voice and bridge the gap between the IT department and clinical staff. (See Delegates’ comments by clicking the PDF icon above.)

Clinical transformation is a continuous process that involves assessing and continually improving the way patient care is delivered at all levels. It occurs when an organization rejects existing practice patterns that deliver inefficient or less-effective results and instead embraces the common goals of patient safety, improved clinical outcomes, and quality care through process redesign and implementation. By effectively blending people, processes, and technology, clinical transformation occurs across facilities, departments, and clinical fields of expertise. Constant measurement and analysis of how practice has developed or changed from the point of delivery is crucial for ongoing quality delivery. Analysis of clinicians’ workflow is needed to determine if the current amount of direct care being delivered is enough to provide not only good outcomes but also compassionate bedside care.

Christel Anderson is director of Clinical Informatics at HIMSS in Chicago. Cathy Patterson is a nurse executive at Cerner in London, England.

Putting an end to patient overcrowding

Smooth and timely patient flow, or throughput, is critical to patient safety, patient and staff satisfaction, and hospital revenue. At our hospital, Provena Saint Joseph Medical Center (PSJMC) in , we saw firsthand what can happen when patient flow gets bottlenecked. We also learned that fixing a patient throughput problem is likely to require a system-wide approach—and perhaps a “cultural” transformation among employees.
Part of the six-hospital Provena Healthcare System, PSJMC is a 517-bed facility with a Level II trauma center. It’s located in a desirable area with one of the fastest growing populations in the country. But by 2004, our emergency department (ED) had become notorious for long wait times—so long that nearly 5% of patients left without being seen. Some patients who stuck it out wound up staying in the ED overnight.
The situation was getting considerable publicity and harming the hospital’s reputation. Public perception of the hospital plummeted.
At the same time, a new threat loomed: Other healthcare systems had announced plans to build hospitals in our market region, which would increase the competition for patients and could put PSJMC in financial jeopardy.

Emergency department woes
Our ED problem wasn’t unusual. EDs across the nation face significant overcrowding as the number of people seeking healthcare in EDs has risen. In 2003, national ED visits numbered 113.9 million—up from 90.3 million a decade earlier. But in the same period, the number of facilities capable of treating ED patients decreased.

Quick executive action
To improve patient throughput and repair the hospital’s reputation, our new chief executive took quick action. In local newspaper ads that PSJMC bought, he acknowledged the hospital wasn’t meeting the community’s needs, and he promised to fix the problem. He immediately directed the senior executive team to put together a patient flow initiative to bring about rapid change.

Transforming the culture
As the initiative got off the ground, team members realized their biggest challenge might be cultural. Having seen many failed efforts to change ED processes over the years, some employees thought nothing could be done about the long waits and patient bottlenecks. They simply accepted this situation as the norm.
The project team realized they’d need to alter this mentality and get all employees to take ownership of the throughput initiative. They gave the initiative a distinct identity and posted signs about it all over the hospital to help embed the cultural change.
To maintain the energy behind the project, the hospital held quarterly employee forums on throughput, published weekly employee newsletters, ran progressive ads in local newspapers, and added standing agenda items to meetings.

Taking a systems approach
Some hospitals deal with capacity problems by adding more beds, building out, or making costly capital investments. But these “fixes” may not address the issue of overloading one end of the system.
Although some PSJMC employees saw our patient flow problem as strictly an ED issue, other departments had capacity issues, too. The throughput redesign team decided the best solution could come from freeing up hidden capacity and using existing resources more efficiently and effectively. To fix our ED delays and gridlocks, we’d need to improve patient flow throughout the entire system.

Redesigning patient flow
First, the project team addressed space issues, recommending conversion of some offices to bed spaces to enlarge the ED. Then they assembled four multidisciplinary teams to redesign critical throughput areas and processes—ED, case management, patient placement, and patient transport. Each team took a systems approach.

ED redesign
Our ED throughput has been redesigned so drastically hat long ED waiting times are a thing of the past. Arriving patients go through quick registration; a surveillance nurse gathers only essential information before designating the patient to the “fast-track” or the mainstream ED process. Also, ED physicians now use short order forms instead of full order sets from admitting physicians.

Case management redesign
To yield additional beds for admissions and decrease bottlenecks experienced from every point of patient entry to the hospital, case management was redesigned to promote earlier-day discharges and reduce length of stay by 0.5 to 1 day. Case managers’ caseloads were adjusted to a ratio, and a physician dedicated to case management and utilization was recruited.

Patient placement redesign
To speed bed turnaround throughout the hospital, patients are now “pulled” into open beds rather than “pushed” from areas that need to free up beds. To get a bed assignment for an ED patient, the staff places a request through our Tele-Tracking system—the bed capacity management software that has replaced our old paper-and-pencil system. After identifying an appropriate bed, the bed control department conveys the assignment to the charge nurse in the unit, using a special cell phone; the charge nurse gives the name of the nurse who will accept the patient. The transferring nurse calls in the hand-off report; if the receiving nurse is too busy to take it, the report is recorded through a system called OptiVox. The unit nurse who gets the call from the ED knows that transportation has been called and the patient will arrive within 30 minutes.

Patient transport redesign
PSJMC now uses the Tele-Tracking system to electronically track patient discharges, notify environmental services of the need for bed cleaning, and list the open bed on the electronic board in the bed control office. When a patient is ready for discharge, the system notifies Central Transportation electronically. The transporter discharging the patient then informs Housekeeping electronically that the bed needs to be cleaned. After it has been cleaned, the Tele-Tracking system receives notice that the room is ready to receive a patient.

Progress report
Our patient flow initiative was fully implemented on May 23, 2005. Since then, we’ve made tremendous gains in patient throughput. We’ve significantly reduced overcrowding, increased patient safety, and enhanced the quality of care. Our ED patient satisfaction scores have risen to the 84th percentile—a steep increase from the 29th percentile registered in the fall of 2004.
At the same time, we’re seeing more patients than before. In the 10 months after our initiative was implemented, we saw 5,612 more ED patients than we’d seen in the 10 months before. This increase has had a significant positive financial impact.
Now, nearly a year and a half after our “go live” date, patient throughput continues to improve. We expect it will take another 2 years of evaluating the system, tracking outcomes, and revising processes before our new throughput process is fully embraced and showing sustainability.
Although we implemented our changes fairly quickly, it took a lot of effort to change the hospital’s culture to one dedicated to improving patient flow. If you’re tasked with improving throughput in your facility, we urge you to start by evaluating your facility’s culture and determining the best strategies for getting resistant staff members to “buy into” your redesign plan.

Selected references
Center on Budget and Policy Priorities. The number of uninsured Americans continued to rise in 2004. Available at: www.cbpp.org/8-30-05health.htm. July 13, 2006.

Emergency Department overload: A growing crisis. The results of the American Hospital Association Survey of Emergency Department (ED) and Hospital Capacity, April 2002. Available at: www.hospital connect.com. Accessed July 13, 2006.

Institute of Medicine of the National Academies, Advising the Nation, Improving Health, Report Brief, June 2006, Washington, DC. Available at: www.iom.edu/Object.File/Master/35/014/Emergency%20Care.pdf. Accessed July 13, 2006.

Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. January 2006, pp. 277-278.

Joint Commission International Center for Patient Safety. Issue 26, Delays in treatment. Available at: http://jcipatientsafety.org/show.asp?durki=9880&print=yes. Accessed July 9, 2006.

Kirby A, Kjesbo A. Tapping into hidden hospital bed capacity. Healthc Financ Manage. November 2003:38-41.

Kathleen A. Mikos RN, , is Vice President of Patient Care Services at PSJMC in and executive co-sponsor of the hospital’s throughput initiative. Jeffrey Brickman is Chief Executive Officer of PSJMC and executive co-sponsor of the initiative. Sharon K. Baranoski, RN, , FAAN, is Director of Nursing Acute Care at PSJMC.

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