cutting-edge discussions of management, policy, and program issues in emergency care
TRANSCRIPT
CUTTING-EDGE DISCUSSIONS OF MANAGEMENT,POLICY, AND PROGRAM ISSUES
IN EMERGENCY CARE
Authors: Jeff Solheim, RN, CEN, CFRN, FAEN, and AnnMarie Papa, MSN, RN, CEN, CAN, FAEN,Doylestown, PA, and Keizer, OR
STAFF ACCOUNTABILITY
How have you as a leader been successful in holding
staff acountable against goals of the department
and hospital?
Answer 1:A clinical leader role (with compensation) was initiated. Thisrole requires the nurse to run the shift, mange flow, make as-signments, and to coordinate and collaborate with all levels ofstaff, providers, supervisors, and in-house units/departments.The clinical leader also must take on a performance improve-ment project, be responsible for one of the national patientsafety goals, and participate in budget preparation. Clinicalleaders are responsible for variance reporting and follow up.They are members of the interview team for new staff. Theclinical leaders are expected to be actively involved in newemployee orientation. They are able to offer overtime, call, andincentive pay to staff in those often urgent staffing situations.
The team meets monthly to determine priorities, iden-tify issues, determine a direction, and monitor success or theneed to tweak. One of the toughest challenges for the clinicalleaders was delegation to other members of the ED team.“Crucial Conversations” and other resources are provided.The empowerment has been the incentive for most. Theywere carefully chosen, received mentoring, and are recog-nized for the unique qualities each brings to the table andfor their individual efforts in the organization. The old adageremains true: Set the bar high and the performance will behigh, set it low and there is no need to strive any further.—Judy Street, RN, BSN, Administrator of Emergency and Peri-operative Services, St Joseph’s Hospital, Bangor, Maine; e-mail:[email protected]
Answer 2:I have been moderately successful using Press Ganey re-ports as well as quarterly reports on National Patient SafetyGoals. These results, along with department goals, are re-ported weekly and quarterly through the use of a weeklye-mail update to the staff that includes the registered nurses,physicians, mid-level providers, ED technicians, and registra-tion staff. The results include suggestions from this manageras well as suggestions from caregivers on how to improve thescores or set new goals. Most of the solutions are evidence-based practice from other institutions and publications.Credit is given to those who produced the solution, andthis acknowledgment encourages others to participate inmaking a positive contribution.—Darin Durham, RN,BSN, ED Manager, St Charles Medical Center, Bend Ore;e-mail: [email protected]
Answer 3:As a leader, I believe in supporting one’s staff and remind-ing them that they are professionals and with that designa-tion comes autonomy and empowerment. I believe today’snurses have forgotten that they are professionals and havelost their sense of entitlement. They need to be remindedthat they are special and have a gift and that their commit-ment is appreciated and respected. If you want to be respectedand treated as a professional, then you have to behave andportray a professional environment and attitude.
As a leader it is my responsibility to be fair and con-sistent and to lead by example. You are only as good asthose around you. I need to be just as clinical as theyare; then I can hold them accountable. As a leader, youneed to be able to relate to their concerns and the balancethat they need to have.
Our staff is involved in decision making through anED focus group created to promote accountability. The fo-cus group is an interdisciplinary group of team membersincluding ED nursing staff, physicians, an administrator,and personnel from the laboratory, imaging, customer ser-vice, information services, and performance improvementdepartments. A rapid cycle is done and each team memberis responsible for carrying out the task and followingthrough with the outcome. This approach promotes group
The opinions expressed are those of the respondents and should not be con-strued as the official position of the institution, ENA, or the Journal.
J Emerg Nurs 2009;35:371-4.
Available online 28 May 2009.
0099-1767/$36.00
Copyright © 2009 Emergency Nurses Association. Published by Elsevier. Allrights reserved.
doi: 10.1016/j.jen.2009.04.005
M A N A G E R S F O R U M
July 2009 35:4 JOURNAL OF EMERGENCY NURSING 371
buy-in and develops a working collaboration. Staff mem-bers are compensated by being able to participate in certi-fications that the hospital pays for, along with publicacknowledgement and the satisfaction that they are a profes-sional.—Shari McDonald, RN, BS, Director, Cayuga MedicalCenter, Ithaca, NY; e-mail: [email protected]
CONSISTENT LEADERSHIP
What types of effective strategies do you use to ensure
consistent leadership around the clock within your
department (ie, how do you provide incentive for
charge nurses to carry out expected performance)?
Answer 1:Monthly charge nurse meetings are mandatory. At eachmeeting, we discuss our triumphs and challenges with anopen mind and encourage open discussion with specific ex-amples. Newer charge nurses tend to bring current trendsand seasoned charge nurses bring experience. I also encour-age charge nurses to use the philosophy of “Ask for for-giveness instead of asking for permission.” This approachempowers the charge nurses and forces nurses to thinkabout their decision prior to making it, rather than notthink for themselves and simply call the manager at home.Cases are presented at the charge nurse meetings to critiquethe problem and solutions.—Darin Durham, RN, BSN,ED Manager, St Charles Medical Center, Bend Ore; e-mail:[email protected]
Answer 2:The most effective method is to provide information to alllevels of staff, be it regarding the budget, the state of the or-ganization, new technologies, projected changes, or regulatoryrequirements. Knowledge is power. Recognizing the numberof intelligent brains at one’s disposal, identifying the specialgifts each one brings, and providing support for innovationeven if you know it might not work lends itself to staff“owning” the success of a department and an organization.
Recently we needed to reduce costs by 3%; the staffwas provided the data, considered options, and chose todo a temporary, voluntary reduction of hours. They saved171 hours in the first month. They evaluated inventoryand found ways to eliminate redundancy. The staff gets ex-cited about taking on challenges and discovering they canexceed their own expectations. It is important to note theexpectations are set by the team once the issue and stan-dards are clear.—Judy Street, RN, BSN, Administrator ofEmergency and Peri-operative Services, St Joseph’s Hospital,Bangor Maine; e-mail: [email protected]
Answer 3:We have consistent clinical resource coordinators (chargenurses). We have 3 on days and 3 on nights, and theydo three 12-hours shifts, each rotating weekends. Two daysa week they overlap and one takes a patient care load. Byhaving this consistency in the person in charge, the messageremains the same and isn’t deciphered differently betweensomeone just filling in. What we have found, however, isthat their work load is getting extremely heavy and com-plicating how they function in a leadership role. We also havefound that by having them in that role and one day a weekworking on the floor, it is very difficult for them to hold theirpeers accountable only part of the time. We are in the processof hiring 4 separate supervisors who do nothing but rovethe department, trouble shoot problems, provide in-serviceprograms, perform evaluations, initiate disciplinary action,provide customer service, service recovery, and audits, andperform similar tasks.—Terry Sipola, RN, BSN, MHA, EDManager, North Colorado Medical Center/Banner Health,Greeley, Colo; e-mail: [email protected]
Answer 4:We use the team leader role to promote individual account-ability. In addition, either a team leader or a director is oncall to provide support for the charge position wheneverneeded around the clock. Whomever is in the leadershiprole is expected to regularly make rounds, interacting withpatients, families and staff members. The expectation tomake rounds is required of charge nurses, managers, andmembers of administration equally. Rounding helps pro-mote leading by example. Staff members also are assignedto committees, which helps nurses understand the impor-tance of the roles they will be growing into as they move frombeing a novice nurse to an experienced nurse. This approachallows the staff nurse to have a better appreciatiation for thecharge nurse, and the expectations are clear. Staff memberswho consistantly participate are rewarded with conferencesand paid certification examinations.—Shari McDonald, RN,BS, Director, Cayuga Medical Center, Ithaca, NY; e-mail:[email protected]
DEPARTMENT SECURITY
What efforts have you implemented to improve security
for patients and staff in your emergency department?
Answer 1
• We have an unarmed security officer in the departmentmaking rounds 24 hours a day, 7 days a week. At 8 PM,when the main hospital doors are locked, we have sec-
MANAGERS FORUM/Solheim and Papa
372 JOURNAL OF EMERGENCY NURSING 35:4 July 2009
ond security officer at the main entrance to the emer-gency department stationed as a visual for visitors.
• We have a security dog that is in service during week-end hours, which is a huge deterrent for our psychiatricpatients as well as gang members.
• We have bullet-proof glass at the triage windows and abadge proximeter access.
• We have panic buttons in the triage bay as well as atthe charge nurse desk that allows us to directly get thepolice department.
• We are finalizing and implementing a visitor policy thatonly allows 2 visitors per patient, and they must have aspecial tag to get in and out.
• We are installing all badge-in and badge-out proximeterbadge access at every entrance and exit of the emergencydepartment. This practice eliminates anyone from justgetting into the department along with keeping ourelopements down.
• Video cameras are in place at all entrances and are mon-itored by security dispatch. We also have a video cameravisible to the charge nurse for the ambulance bay as wellas the waiting room.
• We have sitters available around the clock for any sui-cidal or homicidal patient or any patient on a hold.
• We have implemented crisis intervention training forall staff in de-escalation.
• If a patient has a known gang-related injury, law en-forcement always arrives immediately and stay in thevicinity until the patient is discharged or admitted to en-sure safety in and around the emergency department.—Terry Sipola, RN, BSN, MHA, ED Manager, North Colo-rado Medical Center/Banner Health, Greeley, Colo; e-mail:[email protected]
Answer 2:We maintain support officers in our department nearly allthe time, in combination with our ED technicians and se-curity. All of our rooms have intercoms and panic alarms.We also have buttons that go directly to the city policefor assistance in the department. If needed, we have poli-cies in place to lock down our department or even the en-tire hospital.—Anna Zumpella, RN, Patient Care Manager,Jameson Health System, New Castle, Pa; e-mail: [email protected]
Answer 3:ED leaders should be at the table with hospital security andlocal law enforcement to assess the threats to the emergencydepartment and to evaluate the current systems in place.Cliché security cannot be achieved merely with locks andguards; it starts with each employee. Employees should beeducated to be aware of their surroundings and be alert to
signs of escalation and threats from patients and visitors.This education includes how to first enter an examinationroom, how to position yourself at triage to give yourself anescape route, and knowing what might be used against you(eg, stethoscope, trauma shears, and intravenous pole).Consider badge swiping for door access 24 hours a day,7 days a week. This practice might pose an issue with pre-hospital personnel, but a key pad might be the alternativefor the ambulance bay. Additionally, the ability to lock downthe emergency department with a single trigger is important:the goal is to keep the threat out or contained and still giveothers a chance to escape.—Fred Neis, RN, MS, FACHE,CEN, Senior Director, H*Works Consulting, The AdvisoryBoard Company, Washington, DC; e-mail: [email protected]
Answer 4:We have Management of Aggressive Behavior training forall of our staff as well as security available around the clock,7 days a week. We have fostered an atmosphere of respectfor all patients regardless of socioeconomic status, physicalpresentation, behavior, substance abuse, or mental capacity.Staff members have reduced the need for restraints from3 per week to 2 or 3 per quarter with this new philosophy.Helping staff consider inappropriate language as beingsimilar to a foreign language and a normal means for acertain patient population to communicate needs or sig-nal an inability to cope has changed the way staff ap-proach the patient and resulted in far fewer confrontationalsituations.—Judy Street, RN, BSN, Administrator of Emer-gency and Peri-operative Services, St Joseph’s Hospital, Bangor,Maine; e-mail: [email protected]
Answer 5:A fairly strict visitor policy was introduced a little over ayear ago, allowing only one visitor at the bedside. Thereare times when additional visitors are allowed and timeswhen no visitors are allowed, depending on the patient’ssituation and the volume in the department. We also haveincreased our security guard coverage to 24 hours a day,7 days a week for the emergency department alone. Priorto this change, the security officer left the emergencydepartment to make routine patrols around the hospital.There is now a dedicated guard in the emergency depart-ment and one that patrols the rest of the campus. Withinthe past year, our contracted security service was changedto a company with guards who have extensive training. Amajor front entrance remodel is about to begin and includesbullet-proof glass around the ED registration and triagearea. All staff are also required to attend 4 hours of behav-ioral health and assault response training every year.—DarinDurham, RN, BSN, ED Manager, St Charles Medical Center,Bend, Ore; e-mail: [email protected]
MANAGERS FORUM/Solheim and Papa
July 2009 35:4 JOURNAL OF EMERGENCY NURSING 373
DESIGNING YOUR NEW EMERGENCY DEPARTMENT
What suggestions do you have for those of us who
are designing, remodeling, or building new
emergency departments?
Answer 1:We have been in our new emergency department for morethan a year now. We went from 26 to 51 beds and morethan tripled our space. One very important piece of the puz-zle is to get loads of staff input!
Things we love: The emergency department is de-signed in 4 sections we call “zones” and are color codedfor easy identification. Every room is the same size, exceptfor 3 resuscitation rooms and 3 “safe” rooms for psychiatricpatients, and the 12-bed Minor Care area.
Built-in alcoves in the hallways for carts and suppliesare strategically located for easy access. This feature makesthe hallways open and free from equipment. Be sure to putplenty of outlets where your electrical equipment will bestored. The design allows you to look down the 2 mainED halls and see from one end to the other, with the workstations in the middle for each zone. We also put the medrooms close to both ends of the department, with a win-dow so staff can see in and out. There is no cabinetry inthe rooms, but we have portable storage carts and specialtycarts. One double-wide supply cart is in each room; oursupply technicians take them to our central supply roomevery day to clean and restock them. If they are depletedduring the later shifts, the staff can take the used cart tothe central supply room and grab a fresh one. We have spe-cialty carts for orthopedics, casting, eye, ear, nose and throat,sutures, point of care, airway, and obstetrics and gynecology,so the carts go to the room.
We have a patient care area that opens from the backof the triage room for flu season or when the emergencydepartment is full. We included a family view room and2 family rooms away from the mainstream of the emer-gency department, which we use frequently.
I can’t say enough about having secure access to thedepartment and dedicated radiology rooms in the emer-gency department. Most of the outlets are at 48 inchesso staff members do not have to constantly bend down toplug things in.
Things I would change: We built the new emergencydepartment in phases, taking in an existing doctor officeand the old parking lot of the emergency department. Thisphase came first so we could move into that new area whilethe space we were in was completely redone. Thus the newentrance, triage, and part of the waiting room were the firstphase. If I could redesign I would move the 3 triage roomsto be directly across from the main area of the ED waitingroom. We tried to design the triage so you could see thewaiting room, but in the end we have limited vision ofthe waiting room. I also would move the location of staffbathrooms. The location of these bathrooms never pleaseseveryone; we took them out of our lounge because staffdidn’t like it when the door opened while they were eating.Now they are in a location where visitors can walk past,and they do not hesitate to use them. I would design a typeof anteroom inside of the lounge and put the bathroomsback in the lounge area if I could do it again.
It is important to pay attention to the small details.Some of the irritations we are stuck with: the ceiling wasraised in several areas by 6 inches, but no one coordinatedlowering the wall cabinets. This was a challenge and therewas an extra cost to have the cabinets lowered so we couldactually use them. Also, some of the book cabinets are notdeep enough to hold 3-ring binders straight in. The filedrawers can only hold papers vertically; the engineers some-how overlooked this issue.
We need more storage for wheelchairs. We had to havea lot more electrical outlets put in after we went live. Nomatter how many you plan for, it’s not enough.
Lastly, have plenty of signage and budget to add moreafter you move in.—Eileen Bohannon, RN, CEN, Directorof Emergency Services, Providence Health Center, Waco, Tex;e-mail: [email protected]
MANAGERS FORUM/Solheim and Papa
374 JOURNAL OF EMERGENCY NURSING 35:4 July 2009