NR631 Q-2 PICOT

Emergency Department Management

Introduction

As one hospital CEO put it “The emergency room is the front door to the hospital. As the ER goes, so goes the rest of the hospital”. Think about it…a typical emergency department can see 70,000 people walk through one of their doors (walk-in or ambulance) each year. Many of those patients will require diagnostics, treatment, and possibly surgery and/or admission to the hospital. In many cases, the ER is the primary means of generating revenue for the hospital or health system. True, elective and emergent surgery that bypasses the ER is a significant source of revenue. But left to that revenue stream alone, the hospital could not survive without the ER. This is even true in hospitals where there are lower or no trauma ratings.

The Chamberlain nurse executive specialty track seeks to prepare nurse leaders for senior and executive leadership positions. As senior leaders in the organization, you become responsible for the financial health and success of your hospital. Without a healthy and thriving ER, your hospital is at risk. Every senior nursing leader should have the finger on the pulse of their ER. Even if you don’t have a background or experience in emergency care, you need to be familiar with the health of your emergency department. For that reason, in this virtual or alternative practicum exercise, we will combine concepts of leadership and practice change project management and common ER metrics to help prepare you for your future leadership role.

Emergency leaders are faced with seemingly insurmountable challenges that test leadership and management skills daily. With the advent of the trend toward Evidence Based Practice (EBP), and a constant changing landscape of reimbursement strategies, leaders are forced to adapt and manage both clinical quality and financial issues as well. A director must have a thorough understanding of quality improvement principles, patient satisfaction initiatives, business skills, and service delivery. When problems exist in ED throughput, quality, or patient satisfaction, inconsistent, outdated processes are often the reason.

Let’s now move from the general to the specific. Below you will find the background information you will use to guide the development of a hypothetical practice change project. You’ll use this scenario for both the course and practicum aspects of the course. The Project Management (PM) process presented in the course is tied closely to the course text. The focus is on a more formal PM process that can be used to guide practice change projects that are at the systems level and are larger in scope. The practicum aspect will utilize a practice change model and process developed by Johns Hopkins University. The Johns Hopkins model is geared toward a more focused practice change. Both will be valuable to you as a nurse leader as you will be expected to lead change at various levels in your organizations.

Your mission (if you decide to accept it):

ADTALEM is a healthcare corporation that purchases struggling hospitals and smaller health systems and sends in teams of leaders and consultants to address critical issues and transform the hospital or health system into a thriving and profitable community resource. Prior to its acquisition by ADTALEM, Chamberlain Hospital was an independent full-service hospital with an emergency department and 500 medical surgical beds. Chamberlain Hospital performs general surgeries but is not nationally ranked or particularly known for a specialty area. There are other competing health systems and hospitals in the region including a nationally renowned level 1 trauma center and a top-10 ranked cardiac hospital. Chamberlain hospital has been losing market share to the competitors and its reputation has been slowly declining. The competing hospitals would be hard pressed to absorb all of Chamberlain Hospital’s patients if Chamberlain were to close. But, in its current state, Chamberlain Hospital must start turning a profit within the next two years or it will be forced to close, leaving the community without a valuable provider of care.

You are a part of a team of project managers from ADTALEM. After completing an assignment at another ADTALEM hospital, you are assigned to Chamberlain Hospital, along with two other nurse project managers. You have been assigned to Chamberlain Hospitals emergency department, a Level III Trauma Center that see’s approximately 70,000 patient visits per year. Your other two colleagues will be managing projects in the critical care and surgical services areas of the hospital.

Chamberlain Hospital is a fictitious hospital but the data you will see was based on data from a real hospital. The benchmarks presented were taken from the latest data available at the time the scenario was written. Chamberlain Hospital could be anywhere in the U.S. To make this more realistic, go to https://censusreporter.org to establish a community profile for YOUR Chamberlain Hospital. From that site, in the search box next to “Profile”, type in the name of the city you would like your Chamberlain Hospital to be located. Be sure to type the word “metro” after the city name as this will then provide you with demographics of the larger metropolitan statistical area around your city. For example, if you wanted Chamberlain Hospital to be located in Cleveland, OH, you would type “Cleveland metro” and then click on “Cleveland-Elyria, OH Metro Area”. This will provide you with a profile of the population that your ER serves.

Here is what you know:

You are part of a team of leaders who are tasked with turning around major issues at Chamberlain Hospital. You will be tasked with creating a practice change project to enhance throughput and reduce the LWBS rate in the ER. Other colleagues will be working on projects in the critical care and surgical services service lines. Your Senior Vice President (SVP) from ADTALEM shares the following background with you:

You are tasked with solving some important management issues. You need to assess problems as presented and apply management strategies to not only solve them but put processes in place to sustain them.

Chamberlain Hospital has been experiencing capacity issues in the emergency department (ED) due to high volume surges and boarding of inpatients in the ED. This has led to a higher than average walkout rate, lengthy waits for patients to see an ED provider, and declining patient satisfaction scores.

The SVP has requested your assessment of the emergency department as one of your first duties. She is hopeful you can improve front-end processes, improve bottlenecks in throughput, and work with all ED team members to consistently incorporate standards of behavior that promote positive patient experience. She would like you to implement evidence-based leadership methodology and practice change project management principles to sustain process improvement changes.

You have been initially allocated $1 million to use for the planning and implementation of your plan. This money must cover all personnel, training, capital, subscription and construction/reconstruction costs that may be part of your plan. If you find that more money must be allocated, you will need to submit a request to the project sponsor for consideration. Other projects are being undertaken in the hospital including in critical care services and surgical services and money for these projects is controlled very strictly. Every penny (literally) counts!

The concern is twofold: exposure to liability for the patients leaving without care, and the financial loss to the facility. She goes on to say the national benchmark for LWBS is 2.0%.

The Left Without Being Treated rate is high in this facility. It is calculated at 4.6%. Last year they lost 2013 patients. The average collected revenue on a patient in the ED is $668.55. This results in an average yearly loss of revenue upward of $1,345,791.00.

The ED is responsible for nearly all of the hospital’s admissions and 35% of surgical procedures. The hospital also misses out on revenue from diagnostic testing (labs, radiology, CT, MRI, etc.). Losing patients from the ED is financially tough on the hospitals bottom line. Currently, only about 29% of patients seeking care in the ED are admitted to the facility. The average collected revenue on each admission is 13,497.00. With a calculated 372 patients leaving before admission, a financial loss of 5,021,130.00 is calculated.

Total overall financial impact to the facility is roughly $6,366,941.00.

By comparison, if the rate were brought down to the national benchmark of 2%, only 880 patients would have been lost, resulting in a greatly reduced loss only of 588,333.00.

This would increase revenue by 757,478.00. If lost admissions were reduced to 163, the financial impact would be cut to 2,200,119.00. At 2%, the total patients lost would be reduced to 1043 and the total loss would be 2,788,451.00.

By reducing the LWBS (left without being seen) or LWBT (left without being treated) rate, the overall increase in revenue can be shown to be 3,578,489.00.

The CNO expects you to use your leadership and project management skills to solve this problem and keep Chamberlain Hospital from having to shut its doors to the community. She needs you to promote a culture of quality. She needs someone to take the reins and turn the department around. Are you up for the task?

Chamberlain Hospital Mission, Vision, and Values

Mission: To provide better care of the sick, investigation in their problems and further education of those who serve.

Vision: Our vision for Chamberlain Hospital is to be the best place for care anywhere and the best place to work in healthcare.

Our relationship to stakeholders:

· Patients: Care for the patients as if they are your own family

· Caregivers: Treat fellow caregivers as if they were your own family

· Community: We are committed to the communities we serve

· Organization: Treat the organization as your home

Core Values:

· Quality& Safety

· Empathy

· Teamwork

· Integrity

· Inclusion

· Innovation

Current Floor Plan:

Images of ER Lobby, Ambulance Bay, and Triage Areas:

Lobby:

Ambulance Bay:

Triage area:

Your Observations:

As you familiarize yourself with the current emergency room layout and practices, several questions emerge in your thinking:

1. What are the barriers keeping people from being seen or treated?

2. How are resources utilized?

3. Is staff utilized appropriately?

4. How is capacity managed and what plan is in place to manage patient surge?

5. How are resources utilized and are they utilized in the most productive manner?

6. Are there better ways to utilize licensed and unlicensed staff?

7. Is capacity managed effectively? Are there issues that limit access to safe care or service in the triage area.

Patients are queuing near the front entrance in the ED lobby. The physical space is limited, and the patient line often backs out the door. Pt’s are met by a registration clerk. Initial triage is done by a paramedic. The triage area consists of three “bays” separated only by a curtain. A solid partition which obstructs any view of patients coming into the lobby. The registration clerk is a trained medical assistant and is the first contact with the patient. If the registration clerk feels a medic or nurse should be notified of an urgent issue, they let her know via radio headsets. Otherwise the chief complaint is entered into the EMR and the patient is seen in triage in the order of their arrival time to the ED. After being triaged by a paramedic, patients are again instructed to have a seat in the lobby and will then be called back to be seen by a provider as soon as possible.

If the patient complains of chest pain on arrival, they are escorted by a paramedic to a side room and an EKG is performed. The paramedic attending to patients is off the floor during this time leaving patients arriving to be met by only the registration clerk.

Patients in the lobby are now on the board in the Electronic Medical Record (EMR). The Charge Nurse in the main ED watches the board and assigns patients in beds as they become available. The nurses in the main ED are not able to pull assigned patients from the lobby and the registration clerk from the lobby tries to move them back between new arrivals. When a registration clerk calls off sick, a paramedic is pulled from the floor for that role. If that paramedic is the only medic on duty, a nurse is pulled from treating patients to cover triage.

The lobby is crowded and due to limitations in staffing, it is impossible to round on lobby patients. Changing patient conditions are not noted unless they come back to the triage nurse. Last week, a man went into the bathroom and arrested while waiting for a bed in the ED.

Your Assessment:

1. You decide to follow the path of the patient. You begin by assessing how well patients move through the system. Your observations are to be both on a departmental process level, as well as to and from the department. What process issues exist, and how do they affect patient flow? Considering patient safety, is the ED Triage Nurse positioned ideally? Are you comfortable with the way patients are greeted?

2. The triage nurse completes a full triage when the patient is called to her booth. She assigns an Emergency Severity Index level (ESI). You notice all patients, no matter the complaint, get an Emergency Severity Index (ESI) level 4.

3. The triage nurse documents chief complaint, as well as full medical history including medications etc. The Electronic Medical Record is cumbersome, and each triage takes approximately 15 - 20 minutes. Triaged patients with assigned beds cannot be moved to the back effectively.

4. When the ED has open beds, patients are still required to stop in triage, no matter their complaint. You ask about immediate bedding and the triage nurse looks blankly at you.

Hospital Metrics

You observe the emergency department is suffering from throughput issues. The facility is spacious and well laid out. The hospitals reputation is suffering in the community as wait times have been increasing. The “Left Without Being Seen” (LWBS) rate is between 3% and 6% on most days with an average of 4.6%.

Many hospitals rely on benchmarks to determine optimal performance. We know that while benchmarks give an idea about how an organization compares to others, benchmarks (denoted in green) are inherently fallible. Departments vary in terms of physical layout, acuity, customer expectations, and physician practice patterns. The development of internal performance metrics is necessary for sustainable, achievable results.

Hospital Throughput Stats

	National Benchmark	Chamberlain Hospital
Arrival to Triage	2 minutes	17 minutes
Arrival to Bed	5 minutes	48 minutes
Arrival to Provider	20 minutes	61 minutes
Discharge Length of Stay	130 minutes	310 minutes
Admit Length of Stay	268 minutes	433 minutes
Overall Length of Stay	168 minutes	344 minutes

You examine the metrics and the following challenges are identified:

1. 4.6% of patients leave before their treatment is complete (Slow throughput once in the department leading to a failure to decompress the ED efficiently).

2. 48% of patients wait longer than 30 minutes to see a provider

3. 2013 patients per year leave prior to completing treatment

4. 68% of patients wait greater than 15 miutes for a bed (Contributary to high walk out rate and exposure of the facility to risk).

You realize these metrics are not encouraging. You notice these metrics are not posted anywhere nor are they shared at huddle. You realize losing 2013 patients last year was finacially devastating for the hospital and know this must be priority one to stop.

Departmental Flow Assessment:

Once the patient arrives in the ED treatment area, you note a delay in the provider seeing the patient. Patients are assigned to a room and the team leader for that pod is notified. Each pod has 10 beds with 3 nurses assigned. Ratio for the RN is either 3:1 or 4:1.

There is no verticle treatment area, all patients get assigned to a bed and occupy that same space until discharge. Advance practice providers (APP)such as Nurse Practitioners and Physicians Assistants see all patients rather than focusing on the ESI 4 and 5 patients. Because these patients are not seen by the APP’s, they bog the throughput down when they could be moved expeditiously if kept verticle. You notice critical patients are in the hallways on gurneys during busy times.

Emergency Department physicians are often frustrated by the inequitable distribution of patients. They feel assignments are nurse centric in nature and lack consideration of provider flow. They also feel there is no standardized work for throughput and bedding of patients. The patients are placed randomly in beds, without thought to acuity. Often times one pod receives multiple critical patients at once.

There are standardized nurse protocol orders within the electronic medical record and each nurse is encouraged to use these when a patient arrives with a complaint covered by a standardized nursing protocol. The theory behind this practice is to enable results to be in hand when the physician sees the patient. The hope is to expedite throughput. Nurses however are reluctant to use protocols as they are fearful of physician reaction as some of the physicians push back on their use.

Patient Experience

Chamberlain Hospital has been using the “ED Patient Experience of Care Survey”, created by the Center for Medicare & Medicaid Services (CMS) (copy of the survey available at https://www.cms.gov/files/document/edpec-50-2-column-survey-english.pdf). Although the survey has been administered for several years, nobody at Chamberlain Hospital was responsible for evaulating the survey results. Your review of the survey results over the last 12 months reveal the following means for each of the 43 questions (see actual survey for question wording):

Question #	Responses
Going to the Emergency Room
1	· Accident or Injury – 27% · A new health issue – 45% · An ongoing health condition or concern – 28%
2	· Yes – 22% · No – 78%
3	· Less than 5 minutes – 8% · 5to 15 minutes – 17% · More than 15 minutes – 75%
4	· 0 – 2% · 1 – 6% · 2 – 3% · 3 – 4% · 4 – 8% · 5 – 12% · 6 – 10% · 7 – 16% · 8 – 19% · 9 – 12% · 10 – 8%
During Your Emergency Room Visit
5	· Yes – 21% · No – 79%
6	· Yes, definitely – 10% · Yes, somewhat – 23% · No – 67%
7	· Yes – 27% · Don’t know – 44% · No – 29%
8	· Yes, definitely – 79% · Yes, somewhat – 10% · No – 11%
9	· Yes, definitely – 74% · Yes, somewhat – 19% · No – 7%
10	· Yes, definitely – 68% · Yes, somewhat – 21% · No – 11%
11	· Yes, definitely – 54% · Yes, somewhat – 27% · No – 19%
12	· Yes – 75% · No – 25%
13	· Yes, definitely – 52% · Yes, somewhat – 33% · No – 15%
14	· Yes – 88% · No – 12%
15	· Yes, definitely – 71% · Yes, somewhat – 22% · No – 7%
People Who Took Care of You
16	· Never – 4% · Sometimes – 5% · Usually – 44% · Always – 47%
17	· Never – 12% · Sometimes – 8% · Usually – 37% · Always – 43%
18	· Never – 9% · Sometimes – 6% · Usually – 39% · Always – 46%
19	· Never – 6% · Sometimes – 12% · Usually – 51% · Always – 31%
20	· Never – 9% · Sometimes – 22% · Usually – 31% · Always – 38%
21	· Never – 18% · Sometimes – 21% · Usually – 20% · Always – 41%
Leaving the Emergency Room
22	· Yes – 55% · No – 45%
23	· Yes, definitely – 76% · Yes, somewhat – 15% · No – 9%
24	· Yes – 38% · No – 62%
25	· Yes – 61% · No – 39%
26	· Yes – 64% · No – 36%
27	· Yes – 71% · No – 29%
28	· Yes – 43% · No – 12% · I did not need to treat pain – 45%
29	· OTC · Yes – 84% · No – 10% · Prescription Pain Meds · Yes – 72% · No – 18% · Ice pack or cold compress · Yes – 56% · No – 42% · Heating Pads or hot compress · Yes – 52% · No – 39% · Relaxation or meditation · Yes – 19% · No – 66% · Massage · Yes – 14% · No – 77% · Something else · Yes – 5% · No – 91%
Overall Experience
30	· 0 – 13% · 1 – 8% · 2 – 9% · 3 – 4% · 4 – 5% · 5 – 11% · 6 – 15% · 7 – 8% · 8 – 12% · 9 – 10% · 10 – 5%
31	· Definitely no – 7% · Probably no – 29% · Probably yes – 37% · Definitely yes – 27%
32	· 1 time – 36% · 2 times – 21% · 3 times – 12% · 4 times – 9% · 5-9 times – 15% · 10 or more times – 7%
33	· Yes – 86% · No – 14%
34	· None – 23% · 1 time – 42% · 2 times – 17% · 3 times – 10% · 4 times – 0% · 5-9 times – 5% · 10 times or more – 3%
About You
35	· Excellent – 9% · Very good – 18% · Good – 42% · Fair – 20% · Poor – 11%
36	· Excellent – 21% · Very good – 23% · Good – 26% · Fair – 18% · Poor – 12%
37	· 8th grade or less – 9% · Some high school, did not graduate – 12% · High school graduate or GED – 27% · Some college or 2-year degree – 31% · 4-year college graduate – 18% · More than 4-year college degree – 3%
38	· No · Yes, Puerto Rican · Yes, Mexican, Mexican American, Chicano · Yes, Cuban · Yes, other Spanish/Hispanic/Latino · NOTE (obtain this information from your demographic research above for your community)
39	· White · Black or African American · Asian · Native Hawaiian or other Pacific Islander · American Indian or Alaska Native · NOTE (obtain this information from your demographic research above for your community)
40	· English · Spanish · Chinese · Russian · Vietnamese · Portuguese · Some other language · NOTE (obtain this information from your demographic research above for your community)
41	· Yes – 12% · No – 88%
42	· Read questions to me – 31% · Wrote down the answers I gave – 35% · Answered the questions for me – 4% · Translated the questions into my language – 16% · Helped in some other way – 14%
43	· Yes – 58% · No – 42%

As you evaluate the survey results from the most recent twelve months you consider if there are any particular questions or sections that cause concern. Could these survey results help identify areas of need and drive needed change? Should I consider this as part of my evidence to help support my intervention? Could a particular question or survey section become one or more of my outcome measures for the intervention?

There is little to no leader rounding on patients or staff. No whiteboards are used in the patient care area. A culture of optionality is noted among the staff as there is a distinct lack of connection to purpose in patient experience tactics. Handover occurs in the nurses station and not at the bedside. Duration of care is not discussed and patients are on their call lights often.

The nurses are often on their personal cell phones, texting, and failing to round on patients. Call lights go unanswered and there have been several falls recently. Delays in lab results often occur and the average time for a CT interpretation is 120 minutes. You realize this is overlong as CT results are usually 60 minutes.

Patients get exasperated from the prolonged wait times during the treatment process, due to a to a lack of rounding and communication.

Lack of capacity management process results in the need to go on diversion from ambulance traffic, a majority of these runs are Advanced Life Support (ALS) runs which result in a significant loss of revenue. The department averages 118 hours per month in diversion time.

Patients marked for discharge are often delayed as nurses do not wish to take a new patient so discharges slow down at the end of the shifts. Unfortunately, these delays occur at peak flow times as nurses do not wish to start new patients. Rooms are often left uncleaned as there is no dedicated environmental services and there is a shortage of techs.

Shift huddle is unstructured and no metrics are shared. Shift changes/handoff are chaotic with nurses giving report at the desk.

Emergency Department Throughput

Further review of metrics reveals patients are moving slowly once bedded in the ED. Admitted patients are held in rooms in the ED and discharged patients become upset waiting long periods to receive discharge paperwork. Many leave before the nurse comes to sign them out.

Emergency Department Length of Stay

Admitted Patient Length of Stay 433 minutes

Discharged Patient Length of Stay 314 minutes

Overall Length of Stay 344 minutes

Daily Patient Volume by Day of Week

Patient Arrivals Per Hour

The busiest time of day is between 0900 and 2200 peaking at 1200.

Hour	Sun	Mon	Tue	Wed	Thu	Fri	Sat
12 AM	5.5	4.5	5.3	4.4	5.3	4.8	5.2
1 AM	4.2	4.3	3.8	4	4.1	3.3	4.4
2 AM	4.2	3.3	3.3	3.1	3.5	3	4
3 AM	3.6	2.8	3.4	3	2.9	2.9	3.5
4 AM	3.4	3.5	3.1	3	3.6	3.4	3.3
5 AM	3.7	4.1	4	3.8	3.9	4	3.7
6 AM	5	5	5.4	4.8	4.9	5	5.2
7 AM	6.7	8.3	7.2	6.8	7.3	7.8	6.1
8 AM	8.6	10.7	10.2	9.7	9.3	8.9	8.8
9 AM	10.3	13.4	11.9	11.4	11	11	11.3
10 AM	12.5	13.8	13.3	12.9	12.2	12.4	11.4
11 AM	11.7	12.6	13.2	12.3	12.9	13.3	11.6
12 PM	12.4	13.6	12.8	12.4	12.4	12.1	12.1
1 PM	11.6	11.9	11	11.9	11.6	12.1	11.7
2 PM	11.6	11.9	11.9	10.7	11.5	11.8	11.4
3 PM	10.6	11.8	12.4	11.2	10.9	11.9	10.8
4 PM	11.7	12.2	12	12.4	11.7	11.7	9.8
5 PM	10.9	12.8	12.1	12.2	11.7	11.7	11.2
6 PM	10.8	12.8	11.5	12.1	11.8	12.5	11.2
7 PM	11.2	12.3	11.6	11.9	11.4	12.1	10.5
8 PM	10.3	10.9	11.2	10.8	10.2	10.4	10.1
9 PM	9.2	8.7	8	9.3	7.9	8.8	9.1
10 PM	7.6	7.1	7.5	7.9	7.1	7.5	8.9
11 PM	5.8	5.8	5.9	6.1	5.8	6.6	7.4

Some questions begin to formulate in your head…considering the above data, how should staff be scheduled to handle the patient surge? Patients are sent back to the lobby after being triaged, no matter what the triage findings are. Beds fill up as the day gets busy. Less critical patients occupy beds while sicker patients are waiting in the lobby. There is no flow coordinator present. Patient distribution is random rather than methodical and ESI is not considered.

Other Delays in Throughput

You’ve been observing the ED for barriers to throughput and you notice in addition to the other problems previously noted, the following issues are also contributory.

Admitted Patient Flow

The ED admission process is cumbersome, and patients experience long delays after decision to admit. The practice of holding patients leads to ED saturation quickly.

In evaluating the admission process, you determine that while beds are assigned promptly, but due to difficulties with Environmental Services cleaning inpatient rooms, delays are often lengthy. In the last year, the average admission time, from decision to admit to bed was 187 minutes.

Delays in Discharge: Delays in discharge are often present as ED nurses are inconsistent in their sense of urgency to discharge patient’s home. The average time to from discharge order to departure is close to 1 hour. When the ED is the busiest, the nursing staff often drag their feet as they know their bed will be filled again shortly. The worst times are between 1700 and 1900 when the ED patient surge is peaking.

Turnaround Times

Labs:

Labs are often delayed > 1 hour as they are cancelled due to mislabeling, quantity not sufficient, or hemolyzed specimens. The ED is not notified of the issues consistently which causes extensive delays in care. The lab reports difficulty reaching bedside nurses or team leaders with critical values.

Imaging:

Diagnostic Imaging 240 minutes – Significant delays in final reads of plain films.

CT results take approximately 120 minutes. No point of care testing is available for BUN and creatinine prior to CT, resulting in delay to exam.

Question: Who would be the key stakeholders to invite to your first ED Steering Committee? What would your first agenda for this meeting look like?

Staff Turnover

The staff turnover rate is 31% for nurses in the Emergency Department. Many of the nurses appear to be suffering compassion burnout and there is bullying among the nurses.

The previous director could not align the staff with organizational goals. Many resisted any change or new initiatives. There is a strong “We/They” mentality as the staff felt administration asked too much of them as nurses.

The cost of recruiting, hiring, onboarding and training is upwards of 60,000 per nurse. Contract labor is currently occupying 70 % of the nursing spots and the cost is astronomical. The hospital is paying 84.00 per hour for contract nurses and the average full time nurse is compensated at 45.00/hour. The CNO has asked that you find a solution to re-recruit and retain nurses. You need to find a way to re-engage staff and the physicians in the importance of urgency in throughput regardless of volume.

You must round on staff and determine who your high, middle and low performers are. Evaluate your nurses by examining professionalism, teamwork, competence, knowledge, and ability to communicate. Determine how well each nurse adheres to policies and identify your level of commitment to the organization.

Some additional thoughts and questions:

You’re head is swimming with all of the data and the issues facing the ED. A number of questions and observations formulate in your head:

Question: How are low performers best dealt with?

Ultimately your goal at this organization will be develop a more patient centric environment. You must find a way to connect the staff to the “why” in patient care. You must educate the staff on leading practices to support the patient experience.

Question: What type of data would be meaningful to reconnect the staff to their purpose?

We know a lack of awareness contributes to the breakdown of operational efficiency. We notice pre shift huddles lack standard structure, key metrics, and changes in process are not shared.

Question: What is the best way to share data on operational efficiency? How often should these metrics be shared?

Your overall assessment of the culture reveals an apathetic view of new initiatives leading to a lack of sustainability in departmental improvement processes.

There is a strong link between engaged, satisfied staff and patient satisfaction. Both nurses and providers must recognize the importance of delivering a consistent positive patient experience in the ED.

Staff must have the full and complete support of management. Leaders must role model desired behaviors and be consistent in driving change. Sustainability is vital to the ED’s success.

From the C-Suite down, all must be accountable for creating that positive patient experience. Communication from the top down is essential. Leadership must recognize and celebrate consistency with organizational goals. Until now, a strong We/They culture has been present. Restoring staff morale is key to stopping turn-over.

Engaged staff will enable patients to feel as though they are moving through and efficient process from arrival in the ED to discharge home.

Conclusions:

You have your work cut out for you and you wonder what to do first. What can you do now that will make the biggest impact on both improving patient care quality and safety AND turn around the ED from a cost center to a profit center so that the hospital won’t have to close its doors and leave the community without this valuable resource.