Advancing the Safety and Quality of Care in the Emergency Department Over Time: A Story with Three Acts

By Nancy Shendell-Falik, Amy Doran, and Bernard J. Mohr

Complexity, Emergence and Appreciative Inquiry—Its Role In Complex Adaptive Systems

Improvement strategies within healthcare tend to be fragmented and linear—with some efforts focusing primarily on technology only, others focusing on patient care, others on cost reduction, and still others focusing on caregiver relationships. And in a fairly stable, structured environment, where the same simple processes and procedures are repeated over and over again, and where “we can know and predict in great detail what each of the parts will do in response to a given stimulus” it may be possible to study, analyze, and plan in great detail what the many “parts of the system” will do in a variety of circumstances.

But is an emergency department well described this way? Or is it more appropriately characterized as “a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents”? Our experience at Newark Beth Israel Medical Center (NBIMC) and elsewhere suggests the second description is more accurate—and this may help to explain why, in this setting, the challenge to achieve and sustain measurable outcomes for patients, caregivers, and the institution calls for an “out-of-the-box” approach to performance improvement.

One such approach is Appreciative Inquiry (AI)—which, in its simplest definition, is an umbrella term, describing a set of collaborative, relational practices that enable accelerated implementation of system innovations in ways that mobilize the human energy and commitment needed … for transformative change in complex adaptive systems.

Similar to most improvement strategies, the core practice sets that comprise Appreciative Inquiry include:

• Data gathering and sense making (the “Discovery phase”)
• Visioning/goal setting (the “Dream phase”)
• Innovation design (the “Design phase”)
• Implementation and measurement (the “Delivery or Destiny” phase)

However, it is AI’s distinguishing features that make it more suitable for systems that are more complex: AI places emphasis on:

• Multi-faceted ways of knowing and understanding a situation—AI invites wherever possible, the use of story/narrative rather than PowerPoint presentations as vehicles for data gathering and sense making.
• Inclusion—even when a representative group functions on behalf of the whole, AI encourages whole system “voice” through a simple, yet powerful activity known as “the appreciative paired interview.”
• Emergent engagement—recognizing that organizations are more like a constantly changing “river” flowing over constantly changing terrain, AI invites ongoing inquiry into new opportunities and possibilities rather than mechanically “sticking to plan.”
• Simultaneity—the power of information gathering as an interven­tion capable of generating BOTH good data AND also building the relationships and energy needed for execution—rather than assuming that the latter is something to be created down the road.
• Scalability and adaptability for many issues—recognizing that improvement challenges and opportunities come in many sizes and shapes, from one to one relationships to redesign at the scale of the whole, AI invites the use of whatever change activities and organizational forms respond to the need of the moment—be it strategic planning, organizational redesign, team building, or whatever.

Starting Small

Evolving something as complex as an inner city emergency department (serving 250 to 350 patients a day) from good to great, is a journey, not an event. Like a play with many story lines and characters, our own journey has so far included a first and second act, which we want to describe for you. The third act is yet to be written.

Our first act began in early 2005, when Newark Beth Israel Medical Center embarked on a journey to improve the patient handoff process for patients admitted to the telemetry unit from the emergency department. Our strength-based approach engaged the front-line nursing staff in designing and implementing a nurse-to-nurse handoff based on an analysis of times in which the process was deemed exceptional by the staff themselves. This generated a set of significant innovations and a personal level of commitment by the nurses involved, resulting in measurable outcomes and implementation house-wide. The most productive innovations have now been sustained over five years. Greater detail about this first act and the outcomes achieved is available in the Journal of Nursing Administration, 37(2), 95–104.

Taking a Bigger Bite

The success of this handoff project gave us the confidence to explore a broader and more complex initiative in 2008—the redesign of the whole emergency department. Emboldened, we undertook wider and broader participation from the start. Leadership of this “second act” project was by an eighteen-person group of ED nurses and doctors representing front-line staff and leadership along with the vice president of information technology (a key ally as it turned out). Nancy Shendell-Falik (at the time senior VP for patient care services) served as team member and the project sponsor. Amy Doran, assistant vice president, emergency department, and previously a member of our first core group, served as project leader. Bernard Mohr (a professional consultant in strength-based redesign) continued to serve as our thinking partner, coach, and journey guide.

We conceived the purpose of our work as “improving the quality of care, the patient experience, and the quality of life for the caregivers in the emergency department by focusing simultaneously and explicitly on both:

• The core clinical and operational processes that contribute to patient safety/quality in the emergency department
• The relationships (between and among physicians and nurses) surrounding that work”

Expanded use of Appreciative Inquiry within a healthcare setting has also been part of our intention.

Using Appreciative Inquiry—Again

With the experience of our first act successfully behind us and an increased comfort with focusing on the positive, we recommitted to the path we had learned. See Figure 7.1 for our design.

Definition: From the understanding that “the seeds of our future are planted in the questions we ask to understand the past,” Appreciative Inquiry begins with a thoughtful and often evolving exploration of what to focus on, what to study and seek an understanding of. In this project, we considered whether to focus on just the nurse-physician relationship or whether to take on the larger context of the functioning of the emergency department as a whole. Following the AI principle of “wholeness” (the recognition that the emergency department is a “whole” and that all its parts are entangled), we chose the latter. Based both on our own past experience (act one of our story) of redesigning our hand-off processes, a sixteen-person “core group” (representative of the various roles and levels within the emergency department) created a set of inquiry “prompts” which invited stories and narrative descriptions of moments in the emergency department when patient care, safety, and caregiver relationships were at their peak. We also developed our own “map” of the process flow in the emergency department and the activities within each key stage.

Discovery, Dream, and Design: In order to engage as many voices as possible in improving the practice environment, sixty of eighty RNs, ten of eighteen MDs, and thirty of forty ancillary personnel participated in an Appreciative Inquiry Interview. During the interview, staff described best practices and generated improvement possibilities. All participants reported this to be a positive experience toward promoting teamwork—even before any of the suggested changes had been implemented!.

Next came an intensive two-day workshop during which our repre­sentative “core group” worked with the “data” from our appreciative interviews to:

Discover the emergency department’s “positive core,” that is:

• Existing behaviors/practices/values to keep or expand
• Signature resources, assets, skills, or other strengths for building our future
• Opportunities for innovation in roles, processes, practices, technologies, etc.

Dream/envision (using skits, pictures, etc.) “our ideal future ED in action,” that is, How are patients being cared for differently? What do the relationships between nurses, doctors, and others look like? Etc.

Design new processes/activities, role shifts, and/or technology and/or procedural changes and or organizational changes. Using an activity called “Design Propositions” we generated and described the “innovations” at the intersection of what we most cared about and what we felt would have the greatest payoffs. We ended the workshop by generating and agreeing on the specific initiatives and projects that would bring our innovations into being. We developed our Implementation Roadmap, invited commitments for specific actions/steps and created a process for further involving those members of the emergency department not present at this session in shaping and prototyping the innovations.

Destiny: Our path beyond the two-day workshop was influenced by the concept of “rapid prototyping.” Many of the innovations (see following section) were implemented with a view to seeing how well they would achieve what we were hoping for and the anticipation that they might require evolution. We also realized that we needed to have an additional “deeper dive” day focused on “patient flow.” The innovations we generated from that day are included in the list below.

Some months later, in order to improve continuously, we conducted a one-day “celebration, review, reflection, and next steps” session to make sure that we:

Our Implemented “Quick Win” Innovations

These included:

• A designated section of the ED (called Expanded Care) was transitioned to a unit for admitted patients who are waiting for a hospital bed with staffing similar to the inpatient units.
• Pyxis was added to Expanded Care to provide medications similar to any other inpatient unit.
• Lower acuity patients are now treated in a designated area called First Care. Two nurse practitioners and a social worker were hired through a grant to expedite care to these patients.
• A voice-activated hands-free system that provides caregiver-to-caregiver communication without having to dial on a keyboard or look for a phone number is utilized to share radiology results with the emergency department physician.
• RFID tags were placed on essential expensive equipment in the emergency department to facilitate locating and tracking.
• Security was relocated from an enclosed booth somewhat removed from activity to the hospitality desk, which is central to the waiting room activity.
• Name and face boards using digital frames were created to identify the close to three hundred people who work within the emergency department.
• Phlebotomists now perform morning blood draws within the emergency department.
• A standing orders/protocols work team was formed to increase the number in use and promote timeliness and efficiency of care.
• An ED redesign web page accessible through the hospital intranet was created in order to provide updates and share progress on this project with all ED staff.

Additional and distinct initiatives from the day on “patient flow” included:

• Agreement that there are no hard and fast rules regarding a specific age of adolescent/young adult patients and whether they are placed in the adult or pediatric emergency department. As a team we embraced the provision of safe, quality patient care for the teenage/young adult population in the environment which best meets the patient needs.
• After triage the pediatric charts are handed off to the charge nurse to ensure children are safely managed while waiting to be evaluated by a physician. This can prevent a child from slipping through the cracks while waiting if the child experiences a change in condition.
• Commitment to a bi-directional patient entry, including patients waiting to be called and nurses and physicians actively moving patients in the system when ED flow permits.
• Collaboration between the charge nurse and lead physician to review the charts in the rack to facilitate necessary testing for patients waiting to be seen by a physician. This results in more information being available when the patient is evaluated and can decrease the time to patient disposition and improve patient satisfaction. This addressed the challenge that physicians are reluctant to give orders on patients who are not yet their responsibility.
• Communication by the nurse to the physician that all testing is complete and results are available. This promotes timely treatment and reduce waiting times as patients will not be “forgotten” when the emergency department is extremely busy.
• Projects that the team identified for future implementation included:
  • Utilization of a team approach to initially interview patients. This may include the RN, ED technician, physician, and patient access representative. This model would reduce the number of times a patient must share the same information and the team members could collaborate more timely on the plan of care.
  • Implementation of a code mobile alert system based on predetermined wait times for triage and the nurse and doctor rack. This could be a three-tier escalation response that mobilizes internal and external resources.

Outcomes

The ED staff turnover rate was decreased by 33 percent. This represents an approximate savings of $200,000 annually. Lower turnover also positively impacts patient care and clinical outcomes. Anecdotally, the staff has attributed this to teamwork and a more cohesive work environment. In essence, despite the heavy workload, they report that they enjoy working together. The time from walk-in to EKG has been reduced from thirty-five minutes to twelve minutes: door to balloon time for ST segment elevation myocardial infarction was reduced from sixty-five to fifty-three minutes.

Additional changes, based on New Jersey Peer Group Percentile Ranking, were:

Reflections

Our outcomes to date show some significant improvement in the quality of care, the patient experience, and the quality of life for the caregivers in the emergency department. In reflection, we see that by far most of the innovations identified during the process fall into the category of work flow/process improvements—sometimes called the “technical system” in the language of “sociotechnical systems.” This leaves a huge body of possibility, sometimes referred to as the “social system,” that is, the organizational context within which people work, including but not limited to the design of roles, levels of authority, departmental boundaries, reward systems, management processes for planning and evaluation, and so on.

Although participants in the process were invited to consider changes in the “social system,” we now believe that this important arena of innovation does not automatically or easily “come to mind,” perhaps because it is seen as an immutable given. With this operating assumption, the choices available in that domain are not easily visible. And yet, we know from decades of research that the organizational environment within which people function is hugely influential in both overall system performance and also the staff’s overall day-to-day experience of life at work. Bearing this in mind, we can imagine the possibilities of significantly leveraging the work done so far by undertaking several “next level” interventions, such as:

• Engaging all members of the emergency department in a process of explicitly re-imagining and redesigning the social system
• While at the same time supporting continuous innovation within the technical system by bringing in-house the skills and tools of Appreciative Inquiry for use in an “everyday” way.

Conclusion

The journey continues. The third act is unfolding. We have learned much in this process, both about the enormous untapped potential that exists within the collective hearts and minds of healthcare staff—a potential that is so much more easily unleashed when the process of improvement starts from a place of “collaboratively creating the future we want,“ rather than “fixing the problems of the past.” We continue to value the importance of continuously monitoring our plans for change and adapting them as new opportunities or challenges arise. And we are critically aware of the need for ongoing sponsorship at one to two levels above the organizational unit (in this case the emergency department) undertaking changes of this nature and would recommend to others considering this sort of journey to ensure that level of sponsorship as early as possible in the process.