Best Practices

Resources in this article:

Original patient flow coordinator responsibilities
Final patient flow coordinator job description
Full Powerpoint presentation of PCMC's flow initiatives

As the only pediatric hospital in the state of Utah, Primary Children's Medical Center (PCMC) serves children in the local Salt Lake City community and five surrounding states - Utah, Idaho, Wyoming, Nevada, and Montana. PCMC's emergency department (ED) is a designated level I trauma center that has seen a steady increase in patient volume since 1994, reaching almost 40,000 patients in 2003. With increased volume came more patients leaving without treatment (LWOTs), a decrease in patient satisfaction and lowered staff morale. Knowing they needed to fix these problems, Donna Thomas, R.N., M.S.N, director of the ED's rapid treatment unit, and her team asked hospital administration for help.

Hospital administrators assigned a member of their re-engineering team to work with Thomas in the ED to:

Decrease wait times

Decrease LWOTs

Improve resource utilization

Improve patient and family satisfaction

As a first step, the consultant performed a detailed process analysis and found a long delay between when they came in the door to when patients first saw a doctor and in the time it took for a patient to see the doctor once they had seen the nurse.

"We didn't identify the exact cause of the bottleneck in patient flow, but we did notice one, important thing: no one was responsible for patient flow," said Thomas. "What we had was organized chaos."

Using PCMC's patient tracking system, a data analysis showed triage was not the cause of the delay, the consultant made several recommendations to help the ED reach its goals. One of these was to adapt the charge nurse role to that of a patient flow coordinator (PFC). Since no one was specifically responsible for patient flow, Thomas and her team decided to first focus on this recommendation before the others. Other recommendations included standardizing the triage and discharge process, finding ways to better use the tracking system and improving coordination of ancillary services.

Thomas opened the position to everyone, not just existing charge nurses, by posting the job opening internally within the hospital. Everyone had to apply and be interviewed, including existing charge nurses.

Once the new PFC position was implemented, several problems quickly surfaced:

The charge nurse was used to being the clinical expert in the ED, working directly with doctors on patient care. PFCs were instead expected to stay at the desk and found it hard to give up their role as clinical experts.

Charge nurses never had to assign nurses to patients, which was now the responsibility of the PFC. This caused an imbalance in workload - nurses who were good and fast found themselves slammed with patients, while others didn't have a heavy load.

"Our biggest mistake was that we didn't change anything else except to implement the PFC," Thomas said. "There are so many other variables in patient flow, and the PFC was responsible for so much - this person was literally going crazy. It was too huge of a job without other changes, which meant no one wanted the job."

See slide of original PFC responsibilities

However, there were some successes with the first try at making the PFC work. PFCs became responsible for their own schedules, which gave them more autonomy over their hours, and they received a pay increase.

Armed with a new perspective on the role of the PFC, Thomas and her team took another look at the role. They worked with the director of system improvements, who helped them focus on other system improvements.

"We found that the real bottleneck was the doctors, so we wanted to work closely with them. We won their respect because we shared the data - we could show them that it wasn't another problem within the department," Thomas said.

PCMC used Rapid Cycle Testing to implement other changes to improve patient flow, including a two team approach to staffing. An East Team and West Team were created within the ED, each team with its own PFC. Teams were assigned to a block of rooms, instead of individual nurses being assigned to patients. This alleviated some of the staffing responsibility of the PFC and created a less stressful environment for nurses, since they are only responsible for a few rooms.

Now, instead of being overwhelmed, the PFC is able to concentrate on patient flow management, which includes making sure patients are seen, ensuring nursing coverage, overseeing hospital admissions, directing physicians and serving as a role model for the entire department.

Thomas says there are certain attributes that are important for the PFC to have. "It's important for the PFC to have experience within the ED, excellent customer service skills and to be viewed as a role model by other staff. Cindy Royall serves as the coordinator of the PFC staff here, and she can motivate staff to do anything. She is positive, creative, innovative and has really grown professionally in this role."

Results

The PFC role has been in place for about three years, and staff love it. Thomas says that staff morale and patient satisfaction has greatly improved.

PCMC's "door to doctor" times have gone from more than 100 minutes in February 2003 to just 80 minutes in February 2004 (their busiest month).

Average LWOT went from seven percent in February 2003 to just over three percent in February 2004.

Thomas says all of the improvements and changes that the ED has made are dynamic, and are constantly being evaluated and updated. "You quickly learn that you're never done. We'll never be done trying to make improvements."

Lessons Learned

Although Thomas points out that what may work for one hospital may not work for others, she does feel that the PFC system could work for others and notes that it's not specific to pediatric facilities.

Thomas said, "Our biggest lesson was that anytime you are going to make a change, do an experiment first; people are always willing to try something. You need to get your staff involved, then you need to be there to see it and experience the change with them." She added, "You have to be willing to make hard changes and decisions. Just be sure to involve your staff - reward them and hold them accountable."

Donna Thomas, R.N., M.S.N
Director, ED Rapid Treatment Unit
Primary Children's Hospital
Salt Lake City, UT