Many healthcare organizations today are plagued with patient flow problems. One sign of this kind of problem occurs when patients are being boarded or held in the emergency department (ED) while waiting for an open bed in the hospital. Some may be children waiting for a pediatric intensive care unit (PICU) bed and needing very specific types of care. When children do not get the intensive care they need, adverse events can take place (Healy-Rodriguez et al., 2014).
Another aspect of the patient flow problem is seen when parents come to the ED with a sick child but get impatient during times of overcrowding and simply leave. Most are planning to either come back later or go elsewhere for care. This problem is known as “left without being seen” (LWBS) and annual rates related to this issue are being tracked by the Centers for Medicaid and Medicare services (CMS) (Healy-Rodriguez et al., 2014). CMS realizes the importance of lowering these rates to ensure hospitals are giving safe, quality patient care.
Boarding and LWBS can both lead to negative impacts on the patients while leaving surrounding communities with a very poor impression of the care available within the organization. No hospital wants this kind of negative publicity. It is important to find appropriate interventions that can help change these problems.
Several organizations have found that creating centralized bed management centers within their hospitals can help improve overall patient flow or throughput. This solution allows for improvement in ED overcrowding, which lowers boarding and LWBS rates. It takes innovative leadership using proven strategies to bring about such a change to a pediatric acute care hospital in the Midwest.
There are many challenges facing the DNP- prepared nurse when leading any process improvement project. The first decision concerns what must be accomplished with this process. A plan must be developed to allow needed improvements in the patient flow process. That includes making sure it is feasible to accomplish what has been planned. When all this information is in place, the plan must move forward toward implementation. Creswell, Bates, and Sheikh (2013) advised that not only are high-level administrative and clinical leadership involvement necessary, but physicians, nurses, managers, and various administrative staff must be involved as well. This ensures buy-in from all stakeholders, increasing the chance for a successful change process. Being a DNP- prepared leader means demonstrating positive leadership qualities to successfully lead a team (Starck & Rooney, 2015), since there are many lives at stake. Not only do changes affect the patients being treated in the hospital but also the employees.
There are certain ethical dynamics to acknowledge when dealing with any type of change in today's complex, ever-changing healthcare organizations. Effective leaders must take into consideration the ethical components involved while being prepared to address any legal challenges that might arise. Trying to implement a major change in the way a hospital is run takes dedicated and ethical professionals . “The nurse leaders’ ethical behavior can promote the care quality by affecting the nurses’ performance and bringing up several positive consequences for the organization.” (Barkhordari-Sharifabad, Ashktorab, & Atashzadeh-Shoorideh, 2018, p. 21)
Committed leaders want to show that they can be trusted to do what they say they are going to do for the benefit of the staff and the patients. Nurses have long been recognized as being one of the most trusted professions in the world. Employees often do not like to see change coming because it disrupts the status quo and decreases their feelings that all is right in their world. It takes strategic leadership planning to model the type of behavior needed to promote excitement among the staff. This can lead to positive expectations of bigger and better things to come for the company.
There needs to be change from the old to new ways of doing things, which requires transition (Day-Calder, 2017). According to the Transition Model, there are three main stages of change that all people go through. Ending, losing and letting go, is the first phase when staff hear about a change and think about how it will impact them. Next is the neutral zone, a sort of in-between stage. Staff no longer experience the old ways, but do not yet understand and feel familiar with the new way yet . Last is the new beginning stage. This is where employees know what they are doing and feel good about where they are at (Day-Calder, 2017). Employees need to be convinced that things are going to be better once the new process is in effect (Porter-O’Grady, & Malloch, 2015). Staff are encouraged to be accountable for their own positive, ethical behaviors. They do this better when they can see and feel how the process improvement can bring about desired changes. They also want to see leadership follow these ideals as well.
It is up to those in leadership positions to engage employees in having a say in what is happening within their workplace (Porter-O’Grady, & Malloch, 2015). That will have a positive effect on the organization and lead to sustainable changes and is necessary for improved outcomes. By improving the teletracking system so that it functions the way it was intended to, the organization will be able to ensure that the right patient will be in the right place at the right time. This improvement will also allow staff to make sure they are using the right resources necessary to bring about system changes while keeping within their allowable charge reimbursements .
T he leader needs to review the current situation and look for waste and inefficiency (Leming-Lee, Terri, & Betsy, 2017). Any process that does not add value should be removed. It is important for staff to see willingness from the leader plus ample amounts of courage, passion, energy, discipline, and trust (Porter-O'Grady & Malloch, 2015). Having these inner qualities while following the planned steps to improve the system can allow for the work to progress smoothly and create hopefulness among the employees. It will also give staff a willingness to work on improving the organization.
More collaboration can take place as people learn how to work together as leaders exhibit positive and collaborative behaviors. Fischer (2017) noted that nurses need to work alongside their coworkers as they all focus their efforts on “preserving the safety of those receiving care” (p. 54). It is the safety of the patients that should be first and foremost in everyone’s minds (Porter- O'Grady & Malloch, 2015).
When teletracking is used correctly, their real-time solutions have helped hundreds of hospitals and health systems around the globe drive measurable, sustainable and impactful outcomes (Teletracking, 2017). It costs money up front to create a central operations center and train extra staff to work there, but it is well worth the cost. That value will be realized when the organization can exchange the cost of all the inefficiencies found for correct behaviors that allow the system to function as intended.
Leadership needs to invest the time and money that it takes to see that positive return on their investment that can last for many years to come. The TeleTracking Inc. consultant h recommended to the hospital studied during this implementation plan that staff have 120 hours of training and education. This preparation was needed to have a successful launch of the Teletracking XT program that was added to the Teletracking software already in place (Klein, 2010).
The organization required this upgrade along with advanced training on the use of the newer technology to see better results with their patient flow problems. The suggested education necessary for all the staff who will use the system includes both the XT and Transport Tracking applications that can be tied together to create a central operations center where all staff will work. Super-user training sessions for registration/admitting, nursing, environmental and transport department staff should be followed by train-the-trainer programs. Hospital education support staff will maintain this training following successful implementation.
Table 1 (Klein, 2010) illustrates are the direct costs of Teletracking XT set up. These costs cover hotel accommodations, meals, and travel for consultants from the Teletracking company who will be staying at the hospital during the start-up training and initial go-live time.
Table 1: Direct costs: TeleTracking Technology Inc. (Reprinted with permission)
Table 2 (Klein, 2010) shows approximate costs that the study hospital incurred during staff training sessions. The same approximate costs will be seen for this similarly sized organization.
Table 2: Direct cost for Hospital A staff’s training (Reprinted with permission)
Finally, in Table 3, are the indirect costs of supplies like copy paper and printer ink (Klein, 2010). The organization supplying these data is in another US S tate but it is also an academic medical center affiliated with a teaching hospital that serves approximately the same number of patients.
Table 3: Indirect costs for Teletracking XT supplies. (Reprinted with permission)
One other hospital implemented a centralized patient logistics center where all the departments were housed together so everyone could use the system. T he cost for creating the main space was $1.2 million, including construction , computers, phones, and furniture (Lovett, Illg, & Sweeney, 2016). The hospital hired additional staff to ensure around-the-clock clinical coverage.
These investments allowed the program to place the right patients on the right units at the right times, creating better efficiency overall for the hospital. The additional salary and benefits for the extra nurses cost $700,000. What followed was an increase in admissions, transfers and ED visits. The ED diversion rate went down, as well as the LWBS rate. Looking at the profits that came from a lower LWBS rate, the return on investment was already at $2.1 million (Lovett et al., 2016). This is the kind of outcome that can be attained when teletracking is used as intended, with staff following dynamic leadership who are dedicated to seeing improvements for the good of the staff and, more importantly , the patients.
Changing a healthcare organizational process by using a teletracking program will involve a large-scale operation with many people affected by the changes. Success depends on the quality level of the use of innovative leadership strategies. Getting all staff involved and excited to see the beneficial changes that can come about for the organization when this process is complete can indeed make a huge difference in project outcomes. DNP-prepared leaders can ensure that all people who take part in process improvement will feel pride when they see how their input was sought and used to decide on ways to introduce and then finalize the planned changes. A dedicated team working in this manner can create the kind of quality, safe care that they can all be proud of when they go home at the end of the day.
Citation: Wyatt, L. (November 2018). Leading A Process Improvement in a Pediatric Acute Care Hospital. Online Journal of Nursing Informatics (OJNI), 22(3), Available at http://www.himss.org/ojni
Powered by the HIMSS Foundation and the HIMSS Nursing Informatics Community, the Online Journal of Nursing Informatics is a free, international, peer reviewed publication that is published three times a year and supports all functional areas of nursing informatics.
Lori Wyatt MSN/INF, RN
Pediatric Case Manager at The Children’s Hospital, OU Medicine Inc.
I received my LPN license in May 1977.
I received my Associates in Applied Science in nursing in 1998.
I earned my Bachelor of Science in Nursing in 2008.
I received my Master of Science in Nursing with an emphasis in Nursing Informatics in 2010.
I began my DNP program in June of 2016 at the University of Oklahoma Health Sciences Center College of Nursing and plan to graduate in May 2019.
Barkhordari-Sharifabad, M., Ashktorab, T., & Atashzadeh-Shoorideh, F. (2016). Ethical competency of nurse leaders: A qualitative study. Nursing Ethics, 25(1), 20-26. doi:10.1177/0969733016652125
Cresswell, K. M., Bates, D. W., & Sheikh, A. (2013). Ten key considerations for the successful implementation and adoption of large-scale health information technology. Journal of the American Medical Informatics Association: JAMIA, 20(e1), e9–e13. http://doi.org/10.1136/amiajnl-2013-001684
Day-Calder, M. (2017). Showing strong leadership during a period of change. Nursing Standard (2014+), 31(42),37-38. doi: http://dx.doi.org.contentproxy.phoenix.edu/ 10.7748/ns. 31.42.37.s42
Fischer, S. A. (2017). Developing nurses' transformational leadership skills. Nursing Standard
(2014+), 31(51), 54. doi:10.7748/ns.2017.e10857
Healy-Rodriguez, M., Freer, C., Pontiggia, L., Wilson, R., Metraux, S., & Lord, L. (2014). Impact of a logistics management program on admitted patient boarders within an emergency department. Journal of Emergency Nursing, 40(2), 138-145. http://dx.doi.org.contentproxy.phoenix.edu/10.1016/j.jen.2012.12.008
Klein, M. (2010). Practicum portfolio (Unpublished master’s thesis). University of Phoenix, Phoenix, AR.
Leming-Lee, S., Terri, D. C., & Betsy, B. K. (2017). The lean methodology course: Transformational learning. The Journal for Nurse Practitioners, 13(9), e415-e421. doi: http://dx.doi.org.contentproxy.phoenix.edu/10.1016/j.nurpra.2017.06.022
Lovett, P. B., Illg, M. L., & Sweeney, B. E. (2016). A successful model for a comprehensive patient flow management center at an academic health system. American Journal of Medical Quality, 31(3), 246-255. doi:10.1177/1062860614564618
Porter-O’Grady, T. & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health (4th ed.). Burlington, MA: Jones & Bartlett.
Starck, P. L., & Rooney, L. L. (2015). Leadership for the integration of comprehensive care and interprofessional collaboration. Clinical Scholars Review, 8(1), 43-48. doi:10.1891/1939-2095.8.1.43
Teletracking. (2017). Internalizing the transfer center process: The Oklahoma University medical center story. Retrieved from http://go.teletracking.com/oklahoma-university-case-study