Blog Posts

Patient Flow

Keeping Your Cool Amid the Chaos in the ED

Posted on Wed, Jun 29, 2016
Keeping Your Cool Amid the Chaos in the ED

By Ginger Wirth, RN

I’ve written about leading by example, and recently I had the opportunity to watch a fairly new leader do not only that but also lead from the front. I thought that I understood what that meant, but when I watched this medical director in action, it became even clearer to me.

I was observing processes in an emergency department and when I walked in at 10 a.m., things were clearly beyond the “norm.” I looked at the tracker and noted that names, numbers, different colors and flags filled the whole screen. There was nary a blank space to be seen. In the 24-bed department, the tracker told me that there were 18 patients waiting to be admitted and 11 of them were waiting for critical care beds. There also was a critical patient awaiting transfer. All of the other beds were filled with regular ED patients, and EMS was bringing more in the back door. I failed to mention that four of the critical care patients had been in the ED for more than 24 hours.

I saw the staff hurrying around the department, some looking more stressed than normal, while others maintained a smile despite the chaos. The medical director and I met in the ED at the same time. Without saying a word, she looked at me and I knew that she needed to fully assess the situation to determine the best way to help.

I watched her and was impressed. As many of us who have worked in emergency medicine know it’s frequently easiest to just grab the next chart and start seeing patients, go give the medication or provide the treatment. This medical director resisted that urge and she began making calls, activated the provider surge protocol, and assisted the facility and nursing leadership in implementing their capacity plan. The doctor remained in the middle of the nurses’ station directing the team, assisting advanced practice providers with reviewing discharges and turning over the low-acuity patients safely and rapidly. She also facilitated getting additional help for the hospitalists upstairs. They were able to get another hospitalist to come in and assist from the direction and notification from the ED SMD. She also made sure that the entire team was aware of the resources that were mobilized and what the plan was.

That entire scenario is exactly what I mean by “leading from the front.” Because of her leadership, providers and nursing staff were able to continue providing hands-on care to patients – and that’s exactly where we want them. The team felt comfortable knowing that the “administrative” stuff was being handled by the site medical director. By having the medical director there in the middle of the ED making calls, providing direction and supporting the staff, the team knew exactly what was happening and they were confident that relief was coming and beds would be found. While those calls could have been made in an office outside the ED, when action happens “outside” the chaos, many assume that nothing is happening. This frequently leads to dissatisfaction and low morale, and can have a negative impact on the care being provided.

On this day the team felt fully supported by the medical leadership in the ED. There was strong collaboration with nursing as well as the inpatient and administrative leaders. Frontline staff was able to focus on communicating with patients and their families about the delays and the plan going forward rather than making calls, assumptions and getting frustrated with the situation.

I know that this incident is nothing unique and there are EDs all over the country facing the same or similar days. I hope that they have nursing and physician leaders who can not only lead by example but also lead their departments and practices from the front.

Leadership requires collaboration, organization, planning and structure. It’s also important to be able to demonstrate the ability to stay calm in the face of stress, manage emotions – not only yours but at times the emotions of those around you – and to support and motivate the team. Be out there with your team, not only making sure that they believe you can do the things they are expected to do, but that you also are out there “in the trenches” with them.

“A true leader has the confidence to stand alone, the courage to make tough decisions, and the compassion to listen to the needs of others. He does not set out to be a leader, but becomes one by the equality of his actions and the integrity of his intent.”
-General Douglas MacArthur

Ginger Wirth

Ginger Wirth, RN, joined EmCare in 2013 as a Divisional Director of Clinical Services for the Alliance Group. Her goal is to make positive changes in healthcare by helping others focus on quality, excellence, and the overall patient experience. Wirth regards her role as Director of Clinical Services as the ideal opportunity to partner with nursing, physician and facility leaders to make positive changes to the entire patient care experience. Her 20-plus year nursing career has been dedicated to quality and excellence, promoting overall positive outcomes and safety for patients.


Hardwiring Patient Flow: Making Front-End Flow Work For You

Posted on Tue, Aug 04, 2015
Hardwiring Patient Flow: Making Front-End Flow Work For You

During last month's webinar, Hardwiring Hospital-Wide Flow To Drive Competitive Performance, Drs. Jensen and Mayer shared their secrets for streamlining processes, changing behaviors, and achieving sustainable advances in hardwiring flow throughout your hospital system. Here are a few tips from their presentation.

In healthcare, “flow” is defined as adding value and decreasing waste to processes, services or behaviors as patients move through the service transitions and queues of healthcare. This can be accomplished  by increasing benefits, decreasing burdens or both.

Thom Mayer, MD, FACEP, FAAP and Kirk Jensen, MD, MBA, FACEP, authors of “Hardwiring Flow” and “The Patient Flow Advantage” explored this topic further during a recent webinar.

Finding flow, according to Drs. Mayer and Jensen, requires:

  • Engaging staff from the beginning of the process to ensure they’re with you from takeoff to landing
  • Asking “Why?” and “Why Not?” incessantly about your processes, policies  and  procedures
  • Making your staff feel hopeful by decreasing constraints and finding ways to avoid burnout
  • Taking people out of their comfort zones – just because it’s the way you’ve always done it doesn’t mean it’s the right process for your facility now

Retooling Triage

It’s important to think of triage as a process, not a place. Triage in your ED is the “front door” to your facility for the majority of your patients, and how well your staff accomplishes this will drive flow as your patients  move through the system. Goal No. 1 is to get the patient and the physician (or the advanced practice provider) together as quickly and efficiently as possible.

To optimize the triage process, you must  forecast demand and define your ability to meet it with adequate capacity, whether it be having the appropriate level of staffing to handle patient influxes, or simply having enough clean, empty beds or treatment spaces available. This requires everyone to work together, including the ability to monitor flow in real time, set realistic patient expectations regarding wait times, eliminate bottlenecks and improve patient handoffs. Piece of cake, right?

You need to know:
  • Who’s coming?
  • When are they coming?
  • What will they need when they arrive?
  • Will your service capacity match the projected patient demand?
    • And what’s your plan if it doesn’t?

Knowing this information is essential in the Emergency Department, but also necessary in med/surg units and other inpatient areas. If a patient is horizontal, they think and feel like a patient. If they are vertical, he or she feels like and thinks like a customer. Keep your vertical patients vertical and moving through the healthcare system.  Horizontal patients value real estate (a bed or treatment area) and vertical customers value speed.

Your triage process should:
  • Improve throughput
  • Increase safety
  • Improve satisfaction
  • Improve quality
  • Provide adequate, patient-friendly information
  • Increase revenue

If it doesn’t, it’s time to analyze the triage and front-end processes and retool them, which may mean eliminating triage altogether and moving to direct bedding. The more complex that your healthcare environment is, the more complex unraveling and improving the issues will be. Weigh the benefits of your current system vs. the burdens it creates. Eliminate unnecessary steps and engage your staff from the ground up. Triage should move patients into value-added segmentation streams by putting the right patient in the right area at the right time with the right resources. It should never be simply determining who can wait. There is no value in that.

EmCare has a variety of resources and tools designed to help healthcare executives make informed decisions, including calculators to assess the financial impact of improving flow and to assess ED efficiency. Our partner hospitals have the benefit of the resources of Drs. Jensen and Mayer and innovative strategies to hardwire flow


Hardwiring Hospital-Wide Flow

Posted on Thu, Jul 02, 2015
Hardwiring Hospital-Wide Flow

Hardwiring Hospital-Wide Flow To Drive Competitive Performance
Thursday, July 9, 2015   |   2:00PM - 3:00PM  EDT
Presented by Thom Mayer, MD, FACEP, FAAP and Kirk Jensen, MD, MBA, FACEP, authors of “Hardwiring Flow” and “The Patient Flow Advantage”
Faster, friendlier, better service! We all want it.  At a restaurant, it means your food is delivered with a smile, piping hot, and perfectly in line with its preparation time.  You love to go to those restaurants because you know they are providing this excellent service just for you.  Of course it doesn’t hurt the restaurant’s business to give you great service. When you get your meal quicker, you finish your meal quicker and you leave quicker opening up that table for the next guest. It’s a win-win.
The same applies to healthcare and specifically a hospital emergency department. People enter the emergency department needing fast, friendly, quality service that treats their injury or illness and gets them on their way … or gets them into the hospital for further evaluation and treatment of more complex and serious conditions.  But, sometimes, there are just no open beds either in the ED or the inpatient units, and those patients who walked in the emergency department doors are simply not going to get the timely service they need or that you would like to give them. 
 Dr. Thom Mayer and Dr. Kirk Jensen know the challenges all too well.  With decades of experience in emergency medicine, clinical leadership and process improvement, they have uncovered the issues that result in slow patient flow. And, they have found the keys to addressing these issues with a deep sense of clarity and purpose. 
In the upcoming webinar, Hardwiring Hospital-Wide Flow To Drive Competitive Performance, Jensen and Mayer share their secrets for streamlining processes, changing behaviors, and achieving sustainable advances in hardwiring flow throughout your hospital system.
The presentation will help you distinguish value versus waste, moving from concept to execution, and their 7 successful strategies for hardwiring flow. The webinar will include a discussion of measuring and acting on demand capacity issues and will highlight common bottlenecks that can kill your hospital flow.  They will outline the initiatives that have consistently supported improvements in hospital flow including an in-depth look at triage processes.   You will walk through the process from the patient’s perspective, complete with a discussion of the psychology of waiting.  Then, they jump right into assessments of various approaches to flow.  They close the session with an intense discussion on changing physician behavior, engaging physicians, using data to achieve goals, coaching and mentoring and holding people accountable.
This event is free. You can register here.


Clinical Hot Topics: ABC Principle of Change

Posted on Wed, Oct 01, 2014
Clinical Hot Topics: ABC Principle of Change

Hosted by Al Sacchetti, MD, FACEP as moderator, Don’t Blink or You Will Miss It - Clinical Hot Topics can feel much like the “speed dating” of training presentations. The 12 hyper-paced presentations covered a wealth of information for the 2014 EmCare Leadership Conference attendees.  Each week, we’ll publish highlights from select clinical hot topics presented at the conference.

By Maureen Leckie, MSN, RN, Associate Vice President of Clinical Operations and April  Novotny, MSN, RN, CEN, Director of Emergency Services at Lakeland Regional Medical Center

Lakeland Regional Medical Center has experienced a transformation in efficiency, attitude and culture that is worthy of imitation. Change starts with a vision. “If you see it, you can find a way to get there!” It is propelled with communication that explains the need for change, expectations, and goals. It is nurtured with support and guidance.

The team summed it up in the “ABC principle of change” that requires: Accountability; Benchmarking Data; and Communication and Collaboration.

Want to get started?

Start by asking those on the front line to describe each process “in a perfect world.” This will help you understand the challenges and barriers to the change you are requesting. Then, monitor and provide frequent positive feedback regarding their compliance with new expectations until they become routine

For Lakeland Regional Medical Center, the changed culture resulted in a 2014 Gallup Great Workplace Award and a waiting list for ED RN applicants. The average turnaround time is now two hours 10 minutes. The number of patients who have Left Without Being Seen is less than two percent. And all this while the hospital that has seen exponential growth and an all-time high volume of 668 patients in one day.


INFOGRAPHIC: The True Cost of E.D. Inefficiency

Posted on Thu, Sep 04, 2014

Efficiency in the emergency department is always at the forefront of the minds of hospital leaders -- and for good reason. The infographic below reveals the true cost of inefficiency in the emergency department when it comes to patients who leave without treatment (LWOT) and why hospitals can't afford to leave this issue unaddressed.


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