To ensure optimal outcomes in the ED, there must be a focus on both systems and people. Organizational effectiveness requires those with a vested interest in success to meet regularly with a clear focus on improving clinical outcomes and perception of the ED experience. There must be a simultaneous focus on both performance processes and the creation of an environment in which providers want to work and patients want to receive care. Then alignment of personnel, clinical excellence, patient, and staff satisfaction can be successful; the providers will be engaged. Great and efficient systems fail without the “buy-in” of the healthcare professionals—the systems will either not be used or will fall into disarray. Conversely, great people without the great systems to support them will become frustrated and leave.
Rules of Effective Meetings
The second law of thermodynamics relates to entropy, implying that any system will move toward disorganization and chaos without a constant pressure toward order. The ED is similar. To continue to improve performance, pressure toward order, in the form of certain meetings, is crucial to success. Before discussing the type and content of these gatherings, it is important to review the rules of effective meetings (discussed in greater detail in Chapter 9):
Agenda: An “action” agenda should be sent out in advance so that attendees are clear about the content, meeting goals, and the particular responsibilities of each member present. The agenda should become the roadmap and guide to those present, focusing the discussion on the critical issues to be addressed.
SOT: Start on time. If a participant enters the meeting late, some leaders will interrupt the flow of the meeting to catch them up, thus wasting the time of those who arrived on time and rewarding inappropriate behavior. After the meeting, the leader should remind the late arriving member of the group's commitment to start on time. Out of respect for the team, each member should commit to arriving on time or alerting the leader in advance, if that member will be late or absent.
Begin with a positive orientation to the agenda: It may be helpful to start the meetings with a positive (eg, a patient compliment, recognition of a specific individual, or a great patient outcome), or a reflection that connects those in the room to the purpose of the group. Then always orient the participants to the purpose and importance of the work to be accomplished in the current agenda. The person conducting the meeting should describe how a successful conclusion will lead to improvement of a critical aspect of the ED, its operations, the patients' or providers' experience, and so on, showing those present the importance of the work to be accomplished.
Confirm action items: Always leave the meeting with a review of the next steps or action items, including who is responsible for the item and by when the item is to be accomplished. Without this step, there is no accountability. Alternatively, by establishing responsibility and gaining personal commitment of each of the participants, the leader and other members learn to expect task completion.
EOT: End on time. A meeting scheduled to last for 1 hour should conclude the major agenda items within 50 minutes, leaving the final 10 minutes to:
Evaluate the meeting (see point “6” later)
Travel to a subsequent meeting or responsibility
Address a critical off agenda or “parking lot” issue
By actually ending a few minutes early, those present will be pleased with the “gift” of extra time. By ending late, those present will be frustrated with the lack of leader management and the infringement on their time.
Final minutes of meeting: Some leaders spend 5 minutes at the end to have the participants grade the meeting on a 1 to 5 scale, with 5 being a great session which ran smoothly, invited input from all, and accomplished its goals. This final point is crucial to long-term success. It is all too common that a person walks out of a meeting with the stated or unstated feeling of “Well that was a total waste of my time!” Immediate feedback to the leaders of the session and to all attending engenders improved outcomes and more efficient utilization of everyone's time.
There are several critical meetings involving the ED and its leadership. A list of some of these meetings is provided next with examples of how often they may be necessary.
Quarterly (or Monthly) Meeting
Typically, the only times the C-suite (CEO, COO, CNO, CMO) hears about the ED are when there are unfortunate outcomes, patient complaints, or prolonged poor performance. In most organizations, the ED is the highest-volume department (or perhaps second to the primary care clinics). The reputation of the acute care facility in the community is substantially shaped by the experiences of patients in the ED. Regular meetings between executive leadership and ED leadership are essential.
The purpose of these meetings is to create alignment with the greater organizational strategy and to critically analyze the ED's associated strategy. Hospital administration and ED leaders must collaborate to set clear expectations about the ED's direction and performance. The ED leadership team should always be prepared to present information regarding the critical metrics and the resources required to carry out the goals of the organization. The ED leaders should also use this time as an opportunity to inform the executive team of the positive outcomes and performance of the department. This process provides balance to some of the negative comments that may be floated to the administration and is part of an internal public relations campaign to “manage up” the department.
It is important that the ED leaders begin by openly listening to the perceptions of the ED held by the administrative leaders. Once these issues, if any, are presented, the ED leaders can work to ensure that the chief executive officer and the chief nursing officer understand the challenges of the ED, how they are being met, and what is being done to overcome any obstacles to great patient care. It is essential that these obstacles are presented objectively and not as an excuse for not having accomplished the organizational goals.
Clear and frequent communication of concerns, expectations, and progress will prevent little fires from becoming catastrophic administrative conflagrations. It is recommended that formal meetings with senior leaders occur at least quarterly. In times of rapid change, major program development/implementation, or exponential growth, monthly meetings with senior administrators are necessary to ensure that the ED is
- Communicating progress
- Receiving necessary resources and assistance
- Establishing, measuring, modifying, and accomplishing defined performance expectations.
In addition to formal meetings, ED leaders should establish regular communication protocols with senior leaders, which might include
- C-suite walking rounds—occasional visits to touch base with the leaders.
- E-mail communications—to provide updates. It is important to determine if this is a preferred communication methodology of the administrative leadership. E-mail should never be used to “vent,” complain, or blame.
- Phone communications—to share quick critical information that is important to the recipient.
- Elevator speech—Occasionally, the ED leader finds him- or herself in a brief and unexpected interaction with the senior leadership. It is valuable to always be prepared.
Emergency Performance Improvement Committee
The ED patient experience involves many systems and departments. An operational meeting that reviews and refines all of these elements is crucial. If led well, this complex multidisciplinary meeting can have profoundly positive results and lead to great improvements. Various names for this committee include emergency performance improvement committee (EPIC), ED Joint Practice Council, Emergency Services Committee, ED Steering Committee, and others. While the name may vary, the goal of this team is always the same—to continuously coordinate and improve all aspects of care and caring provided in the ED.
The specific goals of the committee must be patient-centered and ensure that the work environment functions efficiently so that all ED staff can enjoy giving that care. This meeting should be led by ED leadership and ideally include representatives from the multidisciplinary team responsible for patient care, including (the)
- Inpatient units
- Laboratory services
- Diagnostic imaging services
- Admitting and registration staff
- IT/Informatics service
- Housekeeping/environmental services
- Residency programs (if an academic center)
Each service is given time to talk about its involvement and interaction with the ED and its approach to providing service to ED patients. To ensure coordination of care, it is important that each ancillary (“essential”) support service hears what the others are doing, rather than have each present and then leave. Efficiency is the key. The objectives are to ensure that
- All participants and systems function together as a seamless work system so that patients receive the highest-quality care
- Both the patient and the care providers are seen as customers or consumers of the services provided by the other departments
All members of the committee should consider what they and their divisions can do to most effectively meet the needs of the other parties as they are providing care to the patients. The goal is to break down the traditional barriers and create a collaborative partnership with all services focused on meeting the patients' needs. Some form of consistent and agreed-upon measurement method, such as an ED scorecard, can be reviewed at this meeting. It will help to ensure that those departments that provide diagnostic studies and other services to ED patients take responsibility for meeting the targets that have been mutually defined. The departmental action plan (see further information later) should also be reviewed at this meeting since broader perspective demonstrating how the work of this committee influences the outcomes of the department will engage, and demonstrate the importance of, all of the participants in this council.
Service Excellence Team (ED Work Environment Group/Combined Unit Council)
A Service Excellence Committee engages all of the staff and providers in the efforts to make the ED both a better place for patients to come for care and also a better place for staff and physicians to work. Whereas the cross-departmental, operationally focused, EPIC meeting focuses mainly on process and what should happen, the service excellence team places emphasis on the work environment and the patient experience. Defining how specific events are delivered and perceived leads to the formation of behaviors, patterns, and ultimately culture.
Many ED personnel believe that
- They must only demonstrate clinical competence.
- Patients will automatically be satisfied if appropriate care is provided.
- Someone else is responsible to create a great practice setting.
The reality is that only those who work in the environment can understand and provide what is necessary to create an optimal work system. Unfortunately, most ED clinicians either do not possess the knowledge and skills to make this happen, or if they do, may find themselves too busy and overwhelmed by clinical responsibilities to employ them. As such, this patient experience committee should comprise high-performing clinical staff and providers. Ideally, the ED leadership plays a facilitating role instead of directing the solutions and dialogue. As facilitators, the responsibility of the leaders is to ensure that the members remain aligned with the values of the organization/department and receive training relative to designing effective processes.
In this meeting, the group can brainstorm and consider “What would it take to generate the best place for us to work and the best place for our patients to come for care?” The process should be “freethinking,” without the constraints of current thoughts, processes, or resources. Then the committee can create a list of
What is working in the department?
What is not working?
What suggestions or solutions can be utilized and/or invented to make things better?
This committee can address and solve highly emotional, inefficient, or frustrating processes that ED staff deals with on a daily basis. Broad participation on this team empowers those who participate. Participants recognize and are inspired by the recognition that an efficient and caring work environment will not happen spontaneously, but rather through intentional and consistent effort.
The service excellence team should generate a list of suggestions, solutions, and recommendations and present them to the ED management team (EPIC) and to senior leadership. When staff transition from shift workers to engaged and empowered owners of processes, rapid change for improved quality and service are facilitated.
Participants may be chosen by ED leadership and invited, or staff may self-nominate representatives. Physician attendance at such meetings is mandatory. Committee membership should require a 1-year commitment. The schedule and time of the meeting should be developed so that people may arrange to be off for that meeting time.
A goal of any hospital senior leadership team is to create a consistent environment and process for all patients. Another goal is to create a workspace in which recruitment and retention of excellent people are paramount. In particular, many ED providers are by their very nature individualistic and have different “individualized” approaches to caring for patients and to working together as a team. However, to accomplish a consistent approach to the provision of excellent emergency care, a regular (monthly) discussion of uniform processes, outcomes, and behaviors is necessary.
Staff members must be well-educated about the design of the processes and the desired/expected outcomes. Sharing performance data including improvements and continuing gaps helps staff understand the impact of individual actions on the collective performance of the department. The agenda should be sent out in advance and typically include discussions of service and quality results, peer review, and operational efficiencies and opportunities. If these meetings include only single, rather than multiple, discipline(s), nursing leaders should be invited to a portion of the physician staff meeting and physician leaders invited to a portion of the nursing staff meeting.
A weekly or biweekly ED management team meeting ensures effective functioning and responsive management of issues and opportunities. An ED management team meeting is not a “catch-you-on-the-fly-while-you-the-medical/nursing-director-are-seeing-patients” get-together. It is a formal meeting where the agenda is consistently defined and minutes are kept in order to create accountability and define the action steps that are needed for the coming week(s).
The ED management meeting should be led by either the ED medical director or nursing director and attended by nursing and physician leadership, clerical/registration supervisor of the ED, and occasionally senior hospital leadership. Meeting frequency should be at least biweekly and weekly in an ED with patient visits more than 35,000. The purpose of these meetings is proactive management of department process rather than relying on retrospective attempts to solve problems. Topics covered may include
- Metrics—review of the scorecard (see later) including both clinical quality and service results
- Intradepartmental issues such as staffing, stocking of supplies, tools, and equipment
- Opportunities identified in rounding or in staff meetings
- Morale, relationships between different members of the team, recognition, and reward of high performers
- Interdepartmental subjects such as relationships with inpatient units (eg, acceptance of admitted patients)
- Flow issues related to lab or imaging, turnaround times, patient flow
- Information technology's assistance in concurrent and retrospective patient data
Some meetings should occur on a daily basis. These include staff huddles, “Medical Minutes,” tracking board rounds, and nursing supervisor rounds.
Huddles are stand-up meetings, which are held in the ED at the beginning of a shift. During the huddles, the current operational state of the ED and the hospital, as well as the areas of focus for the day are reviewed. Much like a coach meets with the team prior to the game, the ED team should regularly evaluate the current conditions, review the game plan, and receive some words of encouragement. Starting the shift as a team—with a huddle—aligns everyone and solidifies expectations.
It is important that the physicians attend these meetings whenever possible, even if their shift has already started. Integration of the nursing and physician work systems in the ED is vital to achieving operational excellence. If the ED nurse manager or clinical supervisor is not available to lead these meetings, the charge nurse manages the agenda. It is important that the manager of the department is present for these meetings several times a week, and that he/she interacts with both day and night staff members as they begin their shifts. There should be a standardized agenda so that the gathering remains short and accomplishes the goal of informing and motivating staff as well as reminding them about behaviors that are being coached. This agenda should include the following items:
Current state of the ED—how many patients in the ED, acuity, patients being boarded awaiting inpatient bed placement, and staffing/assignments for the day (shift)
Current state of the hospital inpatient services—how many available inpatient and specialty unit beds, occupancy, staffing issues
Current or expected concerns—IT outage, scheduled radiology maintenance, community events, etc
Current metrics review—patient satisfaction, door to provider, decision to admit to bed assignment, bed assignment to patient leaves the ED, etc
Recent patient wins, saves, feedback from callbacks of patients treated and released
Current focus (for the day or month)—processes and behaviors, for example, scripts, quick triage and immediate bedding on the front end, half-hourly rounding on patients, completion of whiteboards.
Other brief information that staff may need to know to help them have a great day and give patients outstanding care.
To start the shift off with a strong sense of physician and nurse collaboration, the concept of the “Medical Minute” may be incorporated into the stand-up meetings or huddles. At the shift change, an attending or senior resident gives a 60-second “lecture.” Anything goes, but must be limited to 60 seconds. Topics can include a new drug, PERC exclusion criteria for pulmonary embolus, NEXUS, TIA versus CVA, or a recent patient with an interesting clinical presentation and diagnosis. Staff is appreciative of this, and it may stimulate discussion later if a patient presents to the ED, whose care involves the topic of the day.
A culture of learning and innovation can be created in 60 seconds. This brief educational process sparks questions and reminds staff that the science of healthcare is continually changing. It also allows staff to see their peers as teachers and experts. This perception will inevitably impact patient interactions and promote “managing up” coworkers, which has positive impact on patients' perceptions of teamwork, competence, and communication. One physician wrote:
“The Medical Minute is also a great opportunity to gently steer staff in [positive] ways. For example, after discussing PID during our Medical Minute, I had nurses prompting me immediately to complete pelvic exams (instead of avoiding them!). Nurses, techs, and MUCs love getting medical teaching. They work in the ED because they are naturally drawn to this varied and fascinating patient population and pathology, but they haven't had the years and years of academic study that we have. Sharing what we know and how we think is good for morale and I believe will increase the quality of the care we provide.”
From a practical standpoint, the best way to start this process is to “hardwire” it by consistently presenting it at the 7 am meeting; it may be difficult to consistently implement this program at the evening stand-up meeting time as it is often much busier. Once the Medical Minute concept is introduced, nurses may be asked to create a list of topics they would like covered.
Periodic appraisal of the status of the ED's capacity, patient demand, and patient flow facilitates more efficient ED operations. The charge nurse (flow coordinator) and the emergency physician(s) review all patients currently in process (including potential admissions), in the waiting (reception) room, and ready for discharge. Patients no longer requiring a stretcher can be placed in alternative treatment spaces (including a results pending area). Note, when several physicians are staffing the ED simultaneously, many organizations pair the charge nurse (flow coordinator) with a charge emergency physician.
Either the charge nurse or charge physician may call for the analysis. One positive effect of this practice is that increasing physician awareness and involvement increases their sense of responsibility for patients not yet in rooms. This awareness generates proactive patient movement, decreasing the sometimes-overwhelming “tsunami” wave of patients waiting to be seen.
Nursing Supervisor Rounds
Most inpatient units are staffed for current census rather than for the expected number of admissions from the ED. Additionally, inpatient staff scheduled to work may be “called off” (told not to come in) 2 hours before the beginning of shift. To address potential incongruent inpatient demand-capacity needs, scheduled board rounds with the administrative/inpatient nursing supervisor
- Assists ED patient flow
- Identifies patients whose admission to the hospital is likely but not yet ordered
- Alerts the inpatient nursing leadership of probable admissions and the need for currently scheduled (or increased) inpatient staff
- Avoids inappropriately telling the staff to stay home
It is recommended that these rounds take place at a minimum of every 3 hours and 2½ hours prior to shift change.