HA425 Unit 7 ED Evening Flow Improvement Proposal Example

Move One Shift Four Hours Later and Free the Rooms: An Improvement Proposal for a Composite Community Hospital Emergency Department Pairing an 11:00 to 23:00 Nursing Shift With a Six-Recliner Results-Pending Area, Each With an Owner, a Price and a Start Date

[Student Name]

Purdue University Global

HA425: Operational Analysis and Quality Improvement

Unit 7 Improvement Proposal

[Instructor Name]

[Date]

The department, the costs and every target are composite and bracketed; the proposal is a course model built on the earlier units' analysis.

Background

Earlier units found that evening arrivals at this composite hospital's emergency department need about [22] occupied rooms, yet only [20] remain open once the clock passes 19:00, because a day nurse's shift ends at the peak. The evening median door-to-provider time is [64] minutes, against [29] in the day, and [6.4] percent of evening arrivals leave without being seen. The root cause analysis traced the pattern to a staffing template set six years ago.

Question 1: What Are We Trying to Accomplish?

Aim: For patients arriving between 19:00 and 23:00, reduce the median door-to-provider time from [64] minutes to under [45] minutes, and cut evening walkouts, now [6.4] percent of arrivals, to under [3] percent, within [12] weeks of the first change. The aim is specific to the evening because the data showed the evening is a separate operation. An aim for the whole day would dilute the effect.

Question 2: What Will Show Us the Change Helped?

Outcome measures: evening median door-to-provider time, weekly; evening left-without-being-seen rate, weekly. Process measures: staffed rooms by hour; median time in room for patients moved to the results-pending area. Balancing measure: the morning median, door to provider, for patients who arrive between 07:00 and 11:00, since moving a shift later removes a nurse from the morning, when arrivals average about [2.5] an hour. Every measure goes on a weekly run chart, annotated on the day each change begins (Langley et al., 2009). The balancing measure watches the morning, because a change that fixes the evening by quietly breaking the morning has not improved the department.

Question 3: Which Changes Should Lead to Improvement?

Change 1: The 11:00 to 23:00 Shift One of the four day nursing shifts moves from 07:00 to 19:00 to 11:00 to 23:00. Total nursing hours stay the same. From 07:00 to 11:00 the department runs with three day nurses plus the charge nurse, which matches the low morning arrivals. From 19:00 to 23:00, the shifted nurse keeps [24] rooms open. Owner: Emergency Department Nurse Manager. Cost: the evening differential of [$3.00] an hour applies to the whole shift under the hospital's policy for shifts that end after 21:00, about [$13,140] a year. Start: the first schedule period after approval, about six weeks, with a volunteer test before then. Change 2: The Results-Pending Area Six recliners in an existing consultation space hold patients whose evaluation is complete and who are waiting only for laboratory or imaging results. A nurse already assigned to the area's adjacent rooms monitors them. Each move frees a treatment room. Owner: Emergency Department Director, with Facilities for the space and Information Systems for the tracking board. Cost: recliners and monitors about [$18,000] one time; a tracking-board location change. Start: after the facilities work order, about [four] weeks.

Why These Two Changes

The capacity model showed two levers: more staffed rooms in the evening, or less time per patient in a room. The shift change raises staffed rooms from [20] to [24]; the results-pending area lowers time in room by about half an hour for eligible patients. Together they move evening room demand well within capacity. Matching staffing to the arrival pattern has been shown to reduce patients leaving without being seen in emergency departments (Green et al., 2006).

Changes Considered and Not Proposed

A fourth evening provider would address the next constraint but costs far more; it will be reconsidered if provider utilization exceeds [90] percent after the room changes. A second triage nurse addresses a smaller problem.

Testing Before Spreading

Each change will be introduced through plan-do-study-act cycles, starting small. A review of how the method has been used in health care found that many projects skipped the small-scale testing and learning that make it work, so the plan states predictions and decision rules for each cycle (Taylor et al., 2014).

How Staff Were Involved

The proposal grew from the root cause review, where evening nurses described the 19:00 room closures as the worst hour of their shift. Three day nurses have said they would consider an 11:00 start; two cited childcare that suits a later shift. The evening providers asked that the results-pending area have clear criteria so they are not asked to move patients who are still being worked up. Both points are built into the plan.

Eligibility for the Results-Pending Area

Patients may move to a recliner when the provider's evaluation is complete, the patient is stable and can sit, no further procedures are planned and the patient is waiting only for results or a ride. Patients on cardiac monitors, receiving intravenous drugs that need close titration or at risk of falls stay in rooms.

Risks

Morning waits may rise. Nurses may resist a later shift. The results-pending area may be used for patients who are not ready, creating safety concerns. Each risk has a measure or criterion: the balancing measure, a volunteer-first approach and written eligibility criteria for the recliners.

Budget Summary

The shift change adds no hours; only the differential is new. Recurring: about [$13,140] a year. One time: about [$18,000]. If the walkout rate falls from [6.4] to [3] percent, about [180] more patients a year would be seen, recovering an estimated [$60,000] or more in revenue, as well as serving patients who now leave.

What Success Would Look Like on a Tuesday Evening

At 20:00 on a weekday after both changes, the charge nurse would have [24] staffed rooms and two or three patients in recliners awaiting results. The waiting room would hold perhaps [eight] people instead of [20], most triaged within the last half hour. Patients like the one in the root cause analysis would be roomed within an hour and would have labs drawn at triage.

Approval Requested

Approve the shift change and the results-pending area, with the implementation plan to follow in Unit 8. A decision by [date] allows the volunteer test to begin in the next schedule period.

Conclusion

Two changes aimed at the evening constraint, a later shift and a space that frees rooms, address the root cause the analysis found at modest cost. The measures, including the morning balancing measure, will show whether they work.

References

Green, L. V., Soares, J., Giglio, J. F., & Green, R. A. (2006). Using queueing theory to increase the effectiveness of emergency department provider staffing. Academic Emergency Medicine, 13(1), 61-68. https://doi.org/10.1197/j.aem.2005.07.034

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862