The academic ED has many opportunities for change in clinical care, financial health, and quality programs. Change in any organization is difficult and managing and leading change in a 24 × 7, multidisciplinary operation can be daunting. Successfully implementing and measuring ED change requires the development of an organized structure involving both people and processes.
Setting up a leadership structure for change includes utilizing physician leaders, administrators, researchers, and educators as formal change advocates within the department and hospital. In the academic environment administrators should capitalize on the educational strengths and utilize an interprofessional team to develop an agenda for change. For example, an interdisciplinary performance improvement team could be cochaired by an ED physician and nurse. This team could review cases brought forward from the patient satisfaction committee, external departments, ED staff members, and so on, and then review and recommend ED processes to create improvements. Several steps are necessary to create effective change.
Steps to Effective Change
Data Collection and Measurement
A discerning review of data creates an objective impetus for change. For example, frontline staff may perceive the need for a faster lab turnaround time. Measuring and reporting lab turnaround times and comparing the information to widely accepted national benchmarks may convince staff that performance is or is not acceptable (if benchmarks are being met). However, a critical look at the specific components of laboratory turnaround times may reveal delays in multiple areas, including
- Provider order to specimen collection
- Specimen collection to sending to lab
- Sending to lab to receipt by lab (accession time)
- Accession time to results
- Results to reporting through the system
- Results reported to provider acknowledgment
When improvement is needed, having data helps “sell” the need for change.
ED change management is a process that requires those responsible for the change to share in the vision and the “why” of the change. Without understanding the need for change, the physicians, nurses, staff, and members of other departments are at best, unmotivated, and at worst, obstructive. Without accurate data, appropriate benchmarking, and a belief that change will improve patient care or their process, staff will typically believe that their current process does not require change, and state, “We've always done it this way, why do we need to change?”
Publishing statistics may help motivate some staff, but in order to make change relevant for others the message will need to reach a personal level. For example, improvements in LPMSE rates directly correlate to patient safety. Further, financially incentivizing physician and nursing staff also makes the change relevant.
After the change process is thoroughly planned and developed, goals are set, baseline metrics are defined, resources (human, financial, equipment, etc) are obtained, and staff “buys-in,” the process is ready for implementation. In order to encourage success, it is necessary to ensure high levels of leadership (nursing, resident, and physician administrative) presence during all aspects of the change process. Leadership presence during periods of change to pitch in, address complications, and reduce stress is seen as an immense motivator by frontline staff.
After execution, sustainability is perhaps the most important step in the change process and the most likely point of organizational failure. Money, time, and energy are spent formulating, implementing, and obtaining staff-buy, and yet processes often revert to baseline. One mechanism to preserve, validate, and improve upon new processes is to set specific metric targets related to the proposed change, track these metrics over time, report results for staff to review on a regular basis, and permit refinement of the process.
Several management processes and mechanisms take these change elements into consideration. Lean and Six Sigma are 2 popular approaches in healthcare that are widely used in industry. Lean operates from the perspective of the healthcare consumer and determines the components of the process that are valuable from the perspective of the consumer of the service. The primary principle of Lean is preserving value while minimizing waste. Six Sigma focuses on improving quality by measuring and controlling variability and error. Whatever method chosen to create change in the ED environment it is important that administrators maintain adherence to the clinical, research, and educational mission of the academic department and utilize an interdisciplinary team to create structure and processes for successful change to occur.
Measuring success can be difficult without clear definitions. Clinical outcomes, faculty retention, research grant dollars, and reputation of the residency program are all indicators of a successful academic EM practice. An ED-balanced scorecard can be a useful tracking tool to routinely monitor several key areas of the ED's operational efficiency and productivity. It is important to ensure that metrics on the ED scorecard are in alignment with institutional goals. One model of a scorecard uses key strategic values such as quality and safety, service, people, finance and operations, and growth.
A faculty scorecard can help align physician productivity with the ED scorecard and ultimately the hospital scorecard. Academic faculty may choose to divide their overall productivity between the areas of clinical, education, scholarly pursuits, and administration. Certain metrics on the faculty scorecard are benchmarked for the practice as a whole (ie, RVU/hour and patient satisfaction). Others will be individualized for specific physicians (ie, publication of a research manuscript). A faculty scorecard can be utilized to drive individual physician reimbursement.