Ncmb 418 RLE;

Quality and
Safe
Management in
the ER
Group 2 RLE
CASE SCENARIO
CASE SCENARIO: The Emergency Care Unit

A high-volume in the emergency department (ED) of a private health institution, Hospital XYZ,
was experiencing a variety of challenges related to key metrics as well as patient and staff
satisfaction. The ED unit has 16 bed treatment spaces. The patient population included a wide
range of acuities (refer to the table below) and, thus, variety of diagnostic testing and procedures.
The nurse administrators engaged further to understand the root cause(s) of their challenges
and identify recommendations for improvement. The increase in ED services’ costs associated
with increased use and patient influx, especially among individuals who are publicly insured and
low- income population groups, is of concern due to the patient and staff dissatisfaction and
potential decrease in the delivery of quality care and services.
 As the ED unit manager, from these data, use the PDCA
format to develop a report on how to improve ED services
in Hospital XYZ to increase patient and staff satisfaction;
hence continuous operation of the unit with quality care
and services.
PLAN #1: Create a strategy to track patient flow metrics
❏ Assign Patient Flow Coordinators to track patient movement
❏ Make use of Technology Strategy
Emergency departments (ED) face significant challenges in providing high-quality, timely patient care against a backdrop of increasing
patient numbers and limited hospital resources. A mismatch between patient demand and the ED's capacity to provide care frequently
results in poor patient flow and departmental crowding. These are linked to decreased care quality and poor patient outcomes. So, we
develop a plan to create a strategy to track patient movement inside the hospital therefore, improve the patient workflow by assigning
patient flow coordinators and have a technology strategy.

DO:
❏ Assign Flow Coordinator
There is an assigned flow coordinator that can assist the physician with researching and recording a patient’s PMH by assembling and
reviewing nurse’s notes, EMS reports, referral notes from other health care facilities, and hospital records. The floor coordinator will also record
onto the ED electronic medical record (EMR) the details of the patient’s visit as directed by the physician. Additionally, After the flow coordinator
and the physician leave a patient’s room, the physician will review the documentation entries recorded during the encounter, and will make any
and all necessary amendments to the patient’s medical record so that it is accurate and complete.In the study of (Murphy et., 2014), shows the
efficacy and effectiveness of having ED nurses act as flow coordinators to better expedite and facilitate the movement of patients through the
department. The results show that investing in a flow coordinator program can generate improvements to patient flow and can yield significant
financial returns for the hospital. Having this role allows for better communication among all staff in the emergency department, improved
patient care, and decreased length of stay.
❏ Use of Information Technology
Wireless phone or radio communication is used to have real-time communication in any area of the hospital, get extra support in
an emergency, contacting another department, quick answers for enquiries, and collaborate with other healthcare workers
decreasing the fatigue for the staff. Digital registration kiosks and bedside registration systems are used allowing patients to be
treated more quickly. An electronic patient tracking board will reduce wait times and improve turnover by helping caregivers to
monitor information critical to patient flow.

CHECK:
Assigned flow coordinator monitored and tracked patients’ journey through the hospital and ensured a timely manner from their
arrival in the emergency department, transfer to the ward, administration of treatment, tests, etc and up to their discharge. Using
technology, better communication among all staff in different departments are established as they were able to deliver information
efficiently. The new data of patient flow and the previous patient flow,resulted in efficiency and improved throughput of patients while
maintaining safe delivery of care and improved patient satisfaction.

ACT:
❏ The patient flow coordinators will continue to monitor and track the patients’ movement throughout the Emergency Department
and inside the hospital. They will follow-up, observe, and convey the identified and future problems in the patient flow to ensure
the effectiveness of the strategies and methods used and make changes in case improvements are needed.
❏ Flow coordinators’ workload should also manage and delegated appropriately to prevent burnout.
❏ Regarding the technologies used, in case of power shortage, the healthcare providers and hospital personnel should be prepared
and still will be able to provide continuous patient flow.
PLAN #2: Increase patient satisfaction, improve patient workflow, improve delivery of care and services,
decrease length of stay by 30 minutes, arrival to provider decreased by 10 minutes, and delivery of quality
care and services
❏ Develop methods and strategies to deliver quality care and services
❏ Develop strategy for patient discharge
❏ Make use of communication technique
Prolonged ED wait times are associated with increased morbidity and mortality, as well as lower patient satisfaction. It is difficult to
reduce ED wait times. The goal of this study is to see if implementing a series of interventions would help reduce the wait time to
consultation for ED patients. So, we develop a plan that will helpincrease the satisfaction of the patient, improve patient workflow, have
an improved delivery of care and services, decrease length of stay by 30 minutes, arrival to provider decreased by 10 minutes, and
delivery of quality care and services. Methods and strategies like triage, fast track, SBAR, bedside registration, coordinated patient
discharge, point of care testing, and full capacity protocols will be a big help in delivering quality care , services, and discharge of the
patient. (Shen & Lee, 2018 ).

DO:
❏ Triage
Triage is implemented where assessment is done to prioritize ED patients in need of immediate care, in accordance with clinical
severity and time urgency, compared with patients with non-urgent illnesses who can wait longer to be seen or who need referral to
a more appropriate health care setting (Porter, 1993). By applying a triage system, one can quickly and efficiently sort patients
according to clinical priority, thus aiming to manage patient flow safely when clinical needs exceed capacity. (Aarcharya, Gastmans &
Denier,2011).
 ● resuscitation — needs treatment immediately
● emergency — needs treatment within 10 minutes
● urgent — needs treatment within 30 minutes
● semi-urgent — needs treatment within 1 hour
● non-urgent — needs treatment within 2 hours
❏ Fast Track
There is a dedicated ED fast track area in or next to the ED that is specifically designed and designated for patients with minor
illnesses or injuries. It frees non–fast track ED resources to care for the most seriously ill and injured patients, moving them quickly
into appropriate inpatient units. In this way, fast tracks can reduce delays in care for both urgent and nonurgent patients, thereby
improving patient flow across the ED (National Academies of Sciences, Engineering, and Medicine, 2007).
❏ SBAR
SBAR comes from its acronym: Situation, Background, Assessment, Recommendation. The SBAR report is a utilized for effective
briefing of oncoming team members to rapidly get everyone on the same page so that they can efficiently move forward together in
a coordinated fashion (Shalini & Castelino, 2015). In the Emergency Department, especially, successful and the use of SBAR as a
communication tool plays a strong part in effective communication, minimizing errors and keeping the patient safe. Improving
communication with the use of SBAR will lead to positive patient outcomes in the hospital (Culkin, 2022).
❏ Point of Care Testing
POCT is done to perform diagnostic test administered outside the central laboratory at or near the location of the patient. Using
POCT, healthcare workers can perform, analyze, obtain, and act on test results at the bedside in a matter of minutes, significantly
faster than if samples were sent out to a central laboratory. If used effectively, POCT has the potential to decrease delays to treatment
initiation, increase ED efficiency, influence patient care positively, and alleviate the negative effects of overcrowding (Rooney &
Schilling, 2014)
❏ Bedside Registration
Patients are quickly triaged in the reception area and immediately moved to a bed in the treatment area, where they can be seen
immediately by a physician. In the treatment area, a staff registers the patient and collect insurance and other administrative
information at the bedside, even after treatment has begun. Bedside registration can help reduce long stays in the waiting room
(National Academies of Sciences, Engineering, and Medicine. 2007).
❏ Coordinated Patient Discharge
There is an assigned “discharge coordinator” positions and “discharge resource rooms.” A discharge coordinator monitors charts
to determine which patients are ready for discharge and work to expedite the disposition process. A discharge resource room is an
area of the hospital where staff help patients prepare for their home care after discharge in a comfortable, central location. Through
coordinated patient discharge, hospitals can alleviate discharge-related patient flow impediments(National Academies of Sciences,
Engineering, and Medicine., 2007). The process of discharging patients requires the coordination of multiple different groups
including physicians, nurses, ancillary service staff, patients, their families, and in some settings the finance/billing department (El-Eid
et al., 2015).
❏ Full Capacity Protocols
Full-capacity protocols are put in place by to improve the treatment of patients and patient flow in conditions of extreme
crowding due to full inpatient units. According to the Institute of Medicine (2007), rather than keeping patients in the ED, perhaps in
hallways and unsafe areas, full-capacity protocols allocate patients to inpatient beds in alternative units on a temporary basis.
❏ Enhanced Operational Efficiency
Tools derived from engineering and operations research have been directed successfully at the problem of hospital efficiency in
general and ED crowding in particular. Efficient patient flow can increase the volume of patients treated and discharged and minimize
delays at each point in the delivery process while improving the quality of care.
Efficient patient flow can increase the volume of patients treated and discharged and minimize delays at each point in the
delivery process while improving the quality of care (Board on Health Care Services, 2007).

❏ Feedback Form
A feedback form is handed to the patient or the person accompanying the patient. The feedback form allowed the healthcare
providers to gather feedback from patient regarding their overall experience. Feedback forms are collected in a dropbox.
CHECK:
The flow of patients is monitored and tracked from the implemented triage, fast track, point of care testing, bedside registration, and
coordinated patient discharge and was compared from the previous data and flow. The effectiveness of SBAR was proved as proper and
clear communication was established between the healthcare providers which result in effective and efficient patient care and prevent
mistakes. On the other hand, full capacity protocols enabled all departments to share the responsibility for addressing overcrowding in
the Emergency Department as the pressure is minimized in the department.
Additionally, the quality of care, services, and performance of the healthcare providers improved as these are evaluated through the
feedback of the patients.

The methods and strategies resulted in significant positive outcomes. Even with patient volumes remaining at or above the previous
averages, the length of stay decreased by 30 minutes, arrival to provider decreased by 10 minutes, the availability of the laboratory
services was improved which improved patient satisfaction.

ACT:
❏ Reason for overstay of patients should be discussed frequently during the Unit Staff Meeting.
This is to emphasize and inform the staff regarding the existing problem therefore help to prevent this from happening.
❏ Continuous education to all ED staff regarding the methods and strategies in order to implement and maximize the function of
the said methods and strategies.
❏ These methods and strategies should be maintained in order to provide the patient a safe, effective, efficient, and quality care
and continuous patient flow in the Emergency Department.
❏ Continuous observation and evaluation in the Emergency Department especially the patient flow should be implemented in
order to make changes and improve the condition in the department.
❏ Continuous evaluation of the strategies and methods should be implemented to determine the effectivity overtime.
❏ Feedback form and suggestions from patients and staff should be taken to have a better outcome of care and services.
PLAN #3: Improve Healthcare Providers’ Satisfaction
❏ Develop efficient and effective schedule
❏ Manage workload
❏ Propose incentives and employees of the month
Patient satisfaction is used to assess healthcare reform efforts that focus on patient-centered care. The satisfaction ratings for
emergency departments (EDs) are frequently the lowest. Since the emergency department is the patient's first point of contact for
receiving primary care, we aimed to develop a plan to improve healthcare providers satisfaction by developing an efficient and effective
schedule and managing workload that is composed of staffing and scheduling depending on the patient arrivals, zone nursing, unit
assessment tool as well as giving incentives and employees of the month (Abass, et al., 2021 )

DO:
❏ Staffing and Scheduling Depending on the Patient Arrivals
The number hospital personnel are scheduled depending on the previous data of patient’s arrival based on the day, week, month,
season, or holiday, The highest expected patient arrival is used as a basis in order to staff each shift in each ER by physicians
and nurses to accommodate the patients.
❏ Zone Nursing
Nurses’ patients are located in one area to eliminate the need for nurses to traverse a unit to provide care (JCAHO, 2004; Wilson
and Nguyen, 2004).

❏ Unit Assessment Tool

Unit assessment tools, based on the traffic light concept, is used to determine and monitor the capacity of various units throughout the
hospital system. The tool comprises graded, color-coded indicators that note the “workload tolerances” of each unit, based on a preset range of
numerical scores. Under the system:
Green (go) indicates the unit is working at 85 percent of maximum capacity
Yellow (early caution) indicates the unit is working at >85 percent capacity
Orange (late caution) indicates the unit is working immediately below its maximum capacity
Red (stop) indicates the unit is at full capacity
❏ Incentives and Employees of the Month
The head nurse reviewed staff performance and gave acknowledgement for nurses who displayed an exceptional performance. Employees
of the month are given incentives, rewards and privileges that motivate employees to meet goals. They are provided monetary or non-monetary
incentives that may be cash bonuses, gift cards, etc. to encourage employees to uphold excellent behavior and job performance.
❏ Rightsizing/Re-aligning staff to meet arrival demands
Emergency medicine requires relatively high levels of staffing, provided by a multidisciplinary team,
working on a 24/7 basis. The ED provided a suitable environment for ED staff and also for those who work
episodically in the department (Skinner, Higbea, Buer, & Horvath, 2018).
○Direct patients with less acute conditions to a more appropriate setting. This involve less healthcare
providers for they can initially assist by consulting physicians or nurse manager that would address their
concerns
○Remove patients from the general ED milieu.
○Developed special units or high dependency units for patients presenting with acute illnesses that
needs urgency and involve majority of the healthcare provider including specialist physicians in this
area.
❏ Room assignments for staff so providers know who to approach
Having layout or blueprint of infrastructural requirements that are considered as the clinical areas
(including direct clinical care and clinical support areas) and non-clinical areas required in ED. This
includes relationship and interaction between areas (Tarawneh, 2018). Reference on next slide.
❏ Reducing the workload of the physician while maintaining patient safety
Workload management reduce confusion, maximize employee performance, and the health
care team feeling content rather than overwhelmed at the end of each day (Martins, 2020).
●Workload management enables you to more efficiently allocate work among your team members
●Reducing stress-related employee burnout while also preventing them from feeling overworked in the first place.
❏ Maintaining and improving relational climate to be able to address patients satisfaction
○Relational climate assessed by measuring employee perceptions of policies (eg, support for diversity), organizational procedures (eg,
conflict resolution), and interpersonal practices (eg, cooperation and knowledge sharing.
○Effective teamwork among providers becomes critically important in the presence of growing workload pressures. When providers
face severe time constraints, they often rely on rapid or nonverbal communication with other providers and to coordinate patient
care (Mohr, Benzer, & Young, 2013).

CHECK:
The arrivals of the patient on the previous data are studied and the nurses are schedules based on these data. The new schedule
of the nurses are shown to be effective as overstaffing and understaffing was prevented. Along with this, workload of the nurses
are managed and reduced as capacity of each unit is indicated which also prevented the closing of the unit due to the workload.
The healthcare providers seems to express their satisfaction with the new strategies and methods. The quality of care and
services seemed to improve based on the feedback form from the patients. The nurses also expressed gratitude for the
incentives and recognitions.

ACT:
❏ The patient population should be frequently observed and monitored as this can be changing, in order to make an effective
schedule for the staff to prevent understaffing, overstaffing and excessive workload.
❏ Ensure to apply nurse-to-patient ratio based on the patient arrival.
❏ Conduct timely discussions on the problems in work processes to make corresponding revisions.
❏ Leader and managers should always reach out and listen to the staff and take into considerations their suggestions as they will
always convey the problems they are experiencing.
❏ Encourage the patients to show gratitude to their healthcare providers especially in giving quality care.
●
References
Aacharya, R.P., Gastmans, C. & Denier, Y. Emergency department triage: an ethical analysis. BMC Emerg Med 11, 16 (2011).
https://doi.org/10.1186/1471-227X-11-16
● Culkin, C. (2022, April 20). SVMC Emergency Department Handoff Reinforcement Using SBAR. DigitalCommons@SHU. Retrieved September 8, 2022, from
https://digitalcommons.sacredheart.edu/cgi/viewcontent.cgi?article=1202&context=acadfest
● Diesing, G., & Eagle, A. (n.d.). Hospitals use technology to improve emergency room performance | AHA Trustee Services. AHA Trustee Services. Retrieved
September 11, 2022, from https://trustees.aha.org/articles/954-hospitals-use-technology-to-improve-emergency-room-performance
● El-Eid, G. R., Kaddoum, R., Tamim, H., & Hitti, E. A. (2015, March 27). Improving Hospital Discharge Time - PMC. NCBI. Retrieved September 9, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4554014/Rooney KD, Schilling UM. Point-of-care testing in the overcrowded emergency department--can it
make a difference? Crit Care. 2014 Dec 8;18(6):692. doi: 10.1186/s13054-014-0692-9. PMID: 25672600; PMCID: PMC4331380.
● Institute of Medicine. 2007. “4 Improving the Efficiency of Hospital-Based Emergency Care ." Hospital-Based Emergency Care: At the Breaking Point.
Washington, DC: The National Academies Press. doi: 10.17226/11621.
● Shalini, Castelino, F., & T., L. (2015). Effectiveness of protocol on situation, background, assessment, recommendation (SBAR) technique of communication
among nurses during patients' handoff in a tertiary care hospital. International Journal of Nursing Education, 7(1), 123-127.
doi:10.5958/0974-9357.2015.00025.2
● Al-Najjar, Sabah & Ali, Samir. (2011). Staffing and Scheduling Emergency Rooms in Two Public Hospitals: A Case Study. International Journal of Business
Administration. 2. 10.5430/ijba.v2n2p137.
● Standford Health Care. (n.d.). Patient Flow Coordinator in SAN JOSE, California, United States of America | Administrative Support at Stanford Health Care.
Stanford Health Care jobs. Retrieved September 8, 2022, from https://careers.stanfordhealthcare.org/us/en/job/R2215705/Patient-Flow-Coordinator
● National Academies of Sciences, Engineering, and Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National
Academies Press. https://doi.org/10.17226/11621.
● Chang AM, Cohen DJ, Lin A, et al. Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study. Annals of Emergency
Medicine. 2018;71(4):497–505.e4. doi:10.1016/j.annemergmed.2017.07.022.
● Janssen MP, Rautmann G. The collection, testing and use of blood and blood components in Europe. Strasbourg: European Directorate for the Quality of
Medicines and HealthCare (EDQM) of the Council of Europe; 2014 (https://www.edqm.eu/sites/default/files/report-blood-and-blood-components-2014.pdf,
accessed 26 July 2019).
● WHO guidelines for safe surgery 2009: safe surgery saves lives. Geneva: World Health Organization; 2009
(http://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng.pdf?sequence=1, accessed 26 July 2019).
● Julia Martins, how to effectively manage your team’s workload. July 29th 2020. https://asana.com/resources/effectively-manage-team-workload
●
References ● Board on Health Care Services. (2007). Hospital-Based Emergency Care: At the
Breaking Point. Washington, DC: The National Academies Press.
● Martins, J. (2020, July 29). How to effectively manage your team’s workload.
Retrieved from asana:
https://asana.com/resources/effectively-manage-team-workload
● Mohr, D. C., Benzer, J. K., & Young, G. J. (2013, January). Provider Workload and
Quality of Care in Primary Care Settings. Retrieved from Researchgate:
https://www.researchgate.net/publication/233880484_Provider_Workload_and_
Quality_of_Care_in_Primary_Care_Settings
● Skinner, J., Higbea, R. J., Buer, D., & Horvath, C. C. (2018, January 31). Using
Predictive Analytics to Align ED Staffing Resources With Patient Demand.
Retrieved from Healthcare Financial Management Association:
https://www.hfma.org/topics/hfm/2018/february/59165.html
● tarawneh, W. (2018, January 28). Main Considerations in Design and Planning of
Emergency Department (ED) Part -1. Retrieved from Linked in:
https://www.linkedin.com/pulse/main-considerations-design-planning-emergen
cy-ed-part-tarawneh
THANK
YOU
GROUP MEMBERS:

● DUEY, LORIE MAE

● ESPLEGUIRA, AIRA
● LANDERO, JANELLA MAEGAN
● PEMPENA, NIKKA SHAINE
● BERONGOY, CHRISTIAN JAY
● CONCLARA, SARAH
● CUSTODIO, JEHERSON ART
● MARCELO, JANIEL CYNTH
● MACARUBBO, PRINCESS ALLIAH