Is the integration of urgent, emergent, inpatient and
care of patients with
acute medical conditions.
By Sam Jones RN, BSN, Director of Emergency Services, Mercy Hospital, Roseburg, OR
Walking into Mercy’s ED as the Director of Nursing more than a year and a half ago, I was tasked to meet three specific outcomes; improve patient satisfaction, increase overall productivity, and decrease staff overtime. After spending the first several months collecting and reviewing data, as well as collaborating with the medical director, I began building a process known as “team care” in our department. While we did experience great success in the three aforementioned areas, we also managed to reduce our turn-around time to discharge (TAT-D) by 20%.
The first step in this process was to rebuild our shift times. We discovered that we had a number of staff on at various times of the day when our census was low. We eliminated and re-created shift times so that we could have more staff available when we were busy, and less when we were not. A simple enough plan, but this concept really paved the way for our team care model by putting our staff in a position to succeed as a team.
In our old system, one nurse was assigned to three or four patients, while techs served 12-14 patients apiece. We developed a system in which every 8 patients have two nurses and one tech caring for them. This allowed more people to interact with each patient, improving the patient’s perception of teamwork in our department. Additionally, we began having a team member, preferably an RN, available and at the bedside with the provider during the initial evaluation and during the disposition of the patient. While this was originally developed so that patients would experience us working together as a team, we unexpectedly found it has also reduced our TAT-D time by 20%.
The 20% drop in TAT-D appears to come from many different sources. Patients are rarely left alone and thus get their questions answered more quickly. In addition, engaging the nurses raises their participation and understanding, and helps them to both anticipate patient needs and to gather data that the provider requires for treatment and disposition. Finally, being at the bedside with the providers during patient evaluation and disposition raises the nurses overall awareness of patient needs, which allows the nurses to be more efficient and to manage their time more effectively.
When we began team care more than a year ago, we developed a very structured process and expected staff members to follow it. But what were hoping for in the long run was a culture change. We wanted to create an environment that would enable staff to help whichever patient was most in need at that moment. Today we are seeing that change take place. While staff members are still assigned to teams, they now go beyond their assignments to help other staff members, providers, and patients to whom they are not assigned. We are beginning to see a change in culture which will allow us to grow as a department, as a hospital, and as leaders in health care, while providing safe quality care and excellent service to our patients and community.
Sam Jones RN, BSN
Director of Emergency Services
Trackback from Perspectives on the Acute Care Continuum
By Phil Piccinini, MD
As health reform moves forward, we will need to work with fewer resources and find innovative ways to streamline care. One such solution is what my group calls “Team Care”—medical personnel working together to... ...
Thank you Katherine, we have worked very hard here and are seeing really good fruit come from it for our patients and our hospital.
Certainly adjusting shift times was a factor in our success; however, it was integral to our team care process as well. Not only do we have more staff on when we need them, but we staffed so that we can work in teams of 3 for every 8 patients plus a provider; this was not a possibility in our previous staffing model. Also, I believe the real key to our TAT-D is having the provider and RN at the bedside together during disposition. Instead of a provider going over disposition with the patient, leaving the room to type discharge instructions, placing the chart in the unit clerks pile, who then places it in the rack for the RN - who of course is busy as does not know there is a discharge waiting, and 20 minutes later they make it into the room only to find the patient has more questions, so now the RN must find the provider.... and on and on we go. These cases are frequent which lend to lengthy wait times for discharge. In our team care process, the RN and provider are at the bedside together, all questions are answered, and the nurse is fully aware of the discharge. Because of this, we rarely have patients waiting lengthy amounts of time to be discharged from our department. This is where we have made a difference in TAT-D. The team process simply allows for more people who know the patient to be available to be at the bedside with the provider when the primary clinician is busy. As far as cost goes, certainly leadership, development, education and training can be expensive; however, so can missing core measure times as well as receiving poor patient satisfaction scores. Prior to beginning this venture most of our patient satisfaction scores where in the 1st and 2nd percentile with a composite score in the 10th percentile. Barely 8 months later we had many scores in the 70th plus percentile with a composite score over the 50th percentile. Today, we are nearing a composite in the 60th percentile changing the face of our organization. As you are well aware, these types of scores are invaluable and thus worth every penny to make needed changes in our hospitals. Finally, by structuring our department in teams, we actually improved our productivity further saving money. The culture change, while difficult to accomplish, was necessary. Ultimately we are here to provide the best possible care and service to all of our patients, and without a culture change, in my opinion, we are accepting mediocrity and cannot truly profess "it's all about the patient" - which is exactly why we do what we do. When we started this process there wasn't a lot of buy in - maybe only 10 or 15 percent of staff and providers alike; however, after witnessing what it has done to our patient satisfaction scores, to our TAT-D, and listening to the patients praises for how well we work as a team and provided them with the best possible experience - staff morale is higher than it has ever been, and most everyone sees the benefit of team care in our department creating this change in culture.
I think this is a great example of implementing the powerful suggestions in the article Dr. Ruben cited on this blog, by Dr. Atul Gawande: http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html Congratulations to Sam Jones for his success emphasizing teamwork (I'm not a doctor, but I do measure TAT-D among other things, and we love to see reductions because we know how good it is for patients AND hospitals).
Good article. However, I think the observed outcome is a combination of "team care" and simple shift time adjustments so "(we) have more staff available when we were busy, and less when we were not". Anyway you can quantify more accurately the effect of team care? As you pointed out, team care requires culture change (whcih is very difficult and expensive); I would also think it is associated with a higher maintenance cost that is critical for successful teamwork (training, leadership, etc). Is this approach practical/worthwhile for a specific ED? How can one find out the answer?
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