A short-term acute care hospital in the Midwest with more than 300 beds contracted with Compass Clinical Consulting to provide interim leadership to fill the director vacancy in the approximately 80 FTE Emergency Department, as well as to deal with significant leadership changes, improve processes and overall staff and physician relationships, and stimulate an environment of change.
Over the last several years, the hospital had experienced a succession of ED managers and high turnover in leadership. Prior to beginning the engagement, the hospital’s ED leadership structure consisted of: one nurse manager, two assistant nurse managers, and a part-time educator. However, just prior to the start of the Interim’s engagement, the nurse manager and one assistant nurse manager resigned, and the second assistant nurse manager began a 12-week medical leave. Because of the lack of leadership, the Interim ED Director had to take a different approach to this engagement—instead of focusing initially on high-level concerns, she concentrated first on the day-to-day operations of the department.
Therefore, it was important that the Interim ED Director hit the ground running, be present in the daily operations of the department, and earn the trust of staff. The Director of Nursing served as the interim’s key contact to quickly assimilate into the department and get to know the staff and their systems.
Cultural Barriers in the ED
Immediately, the Interim encountered a conflict: the hospital’s traditional physician culture. Initially, the medical director was not the most collaborative leader, making decisions regarding the department that vastly affected nursing practice without input from nursing leadership. Different staff members needed to approve processes and plans before they could be implemented, and the Interim’s access to reports and materials was limited at the start of the engagement. As a result, the Interim had to develop a project plan to share with current leadership (the Director of Nursing and the CNO) to gain approval.
Another obstacle was earning the acceptance of the Emergency Department staff. Because they felt a lack of visibility with previous leaders, staff members did not immediately trust new leaders. In addition, the hospital had never used interim leadership before, which also caused initial distrust. A major barrier in previous leadership/staff relations was the failure to communicate why changes occurred. As such, it was important that the Interim Director proactively communicate changes to the staff to begin to open the lines of communication.
Recognizing the nuances of the hospital’s culture, the Interim worked to fit into the culture rather than challenge it or ignore it. This traditional culture did slow down the process, but the Interim’s approach helped her to earn the staff’s trust and acceptance.
In addition to the cultural barriers impeding the department’s efficiency, the Interim Director quickly identified another problem area: staffing. The department had a significant vacancy rate that stemmed from a large turnover of staff; typically, people inexperienced in the ED were hired to fill those gaps. Following a hire, there was no official education or onboarding process, so there was no mechanism to ensure competencies.
Furthermore, scheduling practices had been stagnated for many years, rather than being updated to be more efficient. Staff schedules did not account for patient volumes to ensure that the busiest times of day were fully staffed.
Data and Process Discrepancies
The Interim also identified discrepancies in the department’s data and processes. For example, the hospital was not collecting data points correctly according to the requirement from the Centers for Medicare and Medicaid Services (CMS) that hospitals track their boarding times. The Interim was told their boarding hours were zero – a seemingly impossible number. However, following observations, the Interim realized staff members were entering the admission time as the time the patients left the department, not the time the admission order was written, resulting in times mistakenly being labeled as zero.
Emergency department staff members also suffered from a lack of accountability. For example, triage rapid improvement processes were developed, but no one had put these plans into action or monitored that this process had been accomplished.
To account for the organization’s more traditional culture and smaller leadership staff, the Interim ED Director worked to establish a tactful balance between following the existing policies while still making recommendations and illuminating areas of opportunity for improvement. The Chief Nursing Officer welcomed the Interim’s insight, and staff as a whole were ultimately extremely receptive.
Education and accountability were key in affecting sustainable change within the department. For example, the Interim discussed the collection of data points with the Director of Nursing and the CNO and provided education to them as to the correct process. With their approval, a group was pulled together including staff from the IT, Quality, and Medical Records departments to improve their understanding of the ED metrics and make corrections to the data points.
The interim took initiative in this engagement by creating an initial list of about 15 priority areas for improvement. Over the course of four months, the Interim ED Director met regularly with the Director of Nursing to discuss the engagement’s progress and reprioritize the project list as needed. This technique proved extremely effective in creating change.
Soon, improvements were seen throughout the department, including improvements in accountability, flow, triage, and throughput metrics, as well as door-to-doc time. The program for sexual assault patients was better organized, and patient care practices and processes were improved.
Relationships between leadership and staff in the ED and the interim improved through the gradual development of trust. The physician-nursing relationship became much more positive and conducive to a professional atmosphere, while the interim’s relationship with the medical director did improve through the engagement, and he expressed gratitude for the help and adopted a more receptive attitude towards changing some ineffective practices. Additionally, expectations were re-established, and overall department morale increased.
Following the Interim’s departure, the Emergency Department staff and leadership continued to achieve significant improvement in several processes. Additionally, the interim established a much smoother scheduling process, changing shifts and implementing self-scheduling guidelines that people began to follow. Staffing vacancies were filled, and overall scheduling of staff increased to account for patient load, as new guidelines were implemented.
Staff members responded positively to the open lines of communication the Interim had established. With an understanding of how changes would affect them and the benefits of the changes, staff became more receptive to new efficient processes and developed greater trust in leadership.
Both leadership and staff of the Midwest hospital were very receptive to recommendations that the Interim provided and changes the Interim initialized. The Director of Nursing has stayed in touch with the Interim following the end of the engagement to express appreciation and share the good news that staff and leadership alike continue to work on plans toward implementing efficient processes and safe practices in the Emergency Department.