What used to happen
A daily emergency department (ED) meeting was held every weekday morning at 8.30am to look at any breaches of the Government’s ‘shorter stay’ ED target.
The ‘shorter stay’ breach meeting had been in place for five years in response, in part, to the challenges of achieving the Ministry of Health shorter stays in emergency department target*. The meeting was attended by the ED manager, coordinator, clinician, service manager and hospital duty nurse manager of the day. It was a retrospective review of the previous 24-hour patient ‘breaches’ to investigate the causes of delay and to seek performance improvement.
The pros and the growing cons
The ED breach meetings were an integral part of the hospital-wide acute care reform programme and had been successful in identifying root cause problems.
However, over time, the focus of the ED breach meetings drifted towards a negative reflective lens in the face of the organisation failing to consistently achieve the ED shorter stay target.
The meetings were held in the main ED area to raise visibility, focus on the shorter stay target and to allow attendees a ‘feel’ of the department. But it became challenging to consistently engage meeting members and poor attendance demonstrated ineffectiveness.
Developing and installing hospital at a glance (HaaG) screens had improved organisational visibility hospital-wide and there was growing confidence that the screens reflected the real time ‘match’ between the clinical time needed to deliver patient care and the actual clinical hours and resources available. (Though often during busy periods the ED HaaG screen did not reflect a near-capacity ED as the staff busy with patients had less time to update the HaaG screen.) But the HaaG screen and ED electronic ‘whiteboard’ screen were not discussed at the daily breach meetings because of the meetings’ retrospective focus.
‘Light bulb’ moment
ED nursing staff indicated they saw little point to the breach meeting because things didn’t change. The meeting generated a lot of actions arising from historical, firmly embedded processes that failed to evolve with the organisation’s growing needs. In retrospect these actions could never be achieved without the ongoing quality improvement framework to provide structure and process.
As the group pondered the meetings’ effectiveness it became apparent that people wanted a more proactive approach to improving patient flow. This coincided with the development of a revitalised programme to improve the acute medical patient flow and reviewing the breach meeting process became part of that.
Then a light bulb moment occurred and it was decided to suspend the daily ED breach meeting and implement a daily ED huddle the following week. A simple email notification (available in the online version of this article) was sent on the Friday to acknowledge and thank the staff for their breach meeting contributions before starting the huddles on the Monday.
The positive aspects of the breach meetings were maintained, with the breach reports remaining in their current format and distributed via email. This ensures service issues associated with patient breaches can be actioned by the appropriate manager and breach themes actioned via the service improvement work streams.
Putting into action: plan, do, study, act
A PDSA (plan, do, study, act) cycle of improvement was created to test and evolve the new ED huddle which got underway in early May this year.
Meeting notes were initially taken but later discontinued to keep the focus on current
patient flow issues and not revert to using a retrospective lens.
A simple automated data feed – from the standalone ED whiteboard to the ED HaaG screen – was used to reflect ED activity and allow an appropriate organisational response.
A snapshot of the HaaG and ED whiteboard were recorded and used to demonstrate flow improvement as it took place; focusing on the successful flow of patients instead of the proportion of patient breaches. The ED reports were included in the notes so that a full situation of events was available in one place.
The overall feedback demonstrated the usefulness of the ED huddle and staff felt a sense of purpose in helping enable patient flow. The meeting no longer had a negative focus but helped to coordinate the day ahead as it integrated well within the hospital-wide care capacity demand management (CCDM) strategy.
The ED huddle could occasionally lack structure and it was agreed to follow a template of discussion and action so that there was a consistent approach irrespective of attendees.
What happens now?
There is consistent attendance at the 7.45am ED huddle. The winter pressure and patient volumes were challenging but the proactive approach to patient flow continues. The ED whiteboard and HaaG are no longer casually viewed during the meeting but are essential components to the group discussions.
What will happen next?
The ED huddle continues to evolve; further iterations include the attendance of the night medical registrar and attendance of the oncoming ED senior medical officer (SMO).
The ED huddle has not been developed in isolation but with other pieces of service improvement. The emphasis upon this initiative was the profound effect it had upon the group, and others, as it shifted our retrospective lens into a positive proactive approach to improving the flow of patients and ultimately the quality of care we deliver to our patients.
The process or system that we create can influence the culture and lens in which the world is viewed.
Peter Wood, RGN, MHSc, PG Dip, BA (Hons) Health Management is service manager of Emergency, Medical and Renal Services for Northland DHB.
*The Ministry of Health’s shorter stays in emergency department (ED) target calls for 95 per cent of patients to be admitted, discharged or transferred from an ED within six hours.
Firstly, I would like to thank you for your support as we progress our service improvement work on improving our patient flow and their experience. In response to comments received from staff involved in patient flow, the following has been decided:
- The daily breach meetings held in the emergency department at 8.30am will be suspended. These meetings discuss ED breaches that have occurred during the previous day, and do not deal with the pending issues of the day. The current format of the breach reports will still be distributed and will be revamped in the near future. Service issues associated with patient breaches should be picked up by the appropriate manager and breach themes will be actioned via the service improvement work streams.
- A new daily Emergency Department huddle, commencing on Monday 9 May 2016 at 07.45 in the Emergency Department, will focus on dealing with the issues of the day. Could I ask for the following attendees:
- Clinical Nurse Manager ED
- Duty Nurse Manager
- Service Manager
- ED Coordinator
- Medical Ward Coordinators
- The huddle will discuss and explore solutions to the acute patient bed requirements and ensure an appropriate action plan is developed. The largest proportion of bed requirements at this time is acute medical and at the moment I have not suggested that other specialities attend this huddle.
- The huddle will evolve in response to service needs, suggested improvements and patient flow.
Please accept my apology if I have not discussed this process with you personally.