In 2011, the Wisconsin Federation of Nurses and Health Professionals (WFNHP) and the management of St. Francis Hospital in Milwaukee, Wisconsin, collaborated on a joint project designed to improve patient care and patient satisfaction, focusing on the Emergency Department. The project was supported by the Shanker Institute and the Foundation for St. Francis and Franklin. The project was led by the RN/MD Committee, which includes managers, doctors, nurses and techs from the department, and which has experience working together on making improvements within the department.

The hospital's Labor-Management Committee, whose membership includes top leadership from both the union and management,  oversaw the project. In addition, an outside consultant experienced in labor-management committees and hospital improvement efforts, and staff from the AFT and from the Wheaton Franciscan Healthcare System, supported the effort. 

Getting Started

In August 2010, members of the RN/MD Committee surveyed staff and managers in the Emergency Department (ED) to identify "What is the biggest obstacle to consistently delivering the highest quality care in the ED?" The responses focused on seven key issues. The issue they selected to start with was:

"How can we transport patients more efficiently from the ED to procedures and to the floor without pulling staff away from other more important responsibilities?"

Members of the committee chose this issue because of its potential to improve patient satisfaction by reducing wait times, and because of its potential to improve staff satisfaction by freeing up time to address other high-priority issues identified in the survey responses.

To get a better handle on what issues were affecting the transport process, ED staff collected data for a two-week period in late September and early October to determine:

• • How often do ED patients require transport to and/or from another department?
  • Are there particular times of the day or particular days of the week that are busier than others?
  • How much time do ED staff spend out of the ED transporting patients?
  • Which ED staff are most involved in providing transport?

Key Findings

The data collected by ED staff suggest that over 90 percent of transports are for ED patients being admitted to the hospital or for ED patients that require CT scans. Of those, roughly half are to inpatient floors and the other half are to Radiology.

As a reality check on the data collected by ED staff, those data were supplemented by hospital data showing the actual number of ED patients admitted to the hospital during the same two-week period, as well as the actual number of ED patients that required transport to the Radiology Department.

The hospital data showed that, on average, 36 patients a day required transport from the ED to Radiology or to an inpatient floor. The data collected by ED staff showed that an additional 4 patients a day, on average, required transport from the ED to other areas of the hospital, primarily Labor and Delivery. The ED data also showed that 5 patients a day, on average, require transport to the ED from another area of the hospital by ED staff. That adds up to an average of 45 transports per day.

The hospital data suggested that half of these transports occur on the evening shift, and that the other half was split between the other two shifts. There did not appear to be any particular pattern regarding days of the week.

Data collected by ED staff suggested that each transport took 12 minutes, on average. Therefore, ED staff were spending roughly 9 hours per day transporting patients (12 minutes/transport x 45 transports/day). For the most part, this burden felll on the ED Techs, except on the night shift, when it is shared by RNs.

The committee considered using the hospital-wide transport service for all or part of these transports. However, hospital-wide transport staff were not available to handle this load, nor was the hospital-wide transport system designed to consistently meet the needs of the ED for a quick response time.

At an earlier time, it may have been possible for the ED to handle patient transports on its own. However, the volume of patients in the ED had increased significantly over the past 5 years, and was expected to continue to increase as health insurance coverage expands, while primary physicians remain in short supply. At the time of the study, more than half of all patients admitted to St. Francis came through the ED. In addition, an even greater number of people from the community were treated in the ED and form an opinion about the quality of care available at St. Francis. At a time of increasing competition among hospitals based on quality of care and patient satisfaction, a substantial portion of the hospital’s reputation in the community hinged on what happens in the ED.

Resolution

The RN/MD Committee met with the hospital’s top executives to explore ways to address this problem. They agreed that the hospital-wide transport staff would be increased by 2 Full Time Employees (FTE) to create a new position dedicated to the ED during peak times. Those additional transport staff would free up ED staff to spend more time with patients, and to work on other improvements, such as making sure that the right supplies are in the right rooms at the right times, getting an earlier start on, and being more timely in, testing new patients, and developing a more cohesive multi-disciplinary team in the ED. In addition, they agreed that in future, a CT scanner will be located in the ED. The  hospital agreed to explore options that would accelerate the purchase of that equipment.

Over time, freeing up ED staff to spend more time with patients and to make other improvements was expected to make a noticeable difference in the core metrics for the ED -- patient satisfaction, throughput, and employee satisfaction. The RN/MD Committee agreed to develop and conduct  a survey of ED staff satisfaction to establish a baseline,and to repeat the survey on a regular basis to track progress. They also agreed to continue to measure patient satisfaction and throughput using a scorecard that will be developed to track overall performance of the ED. The RN/MD Committee agreed to meet with the hospital’s top executives within six months of the study's completion to determine whether the additional transport staff were making the expected difference in performance.

Next Steps

Based on the success of the pilot in the ED, the union and the management have agreed to continue the effort in the ED. The RN/MD Committee identified the next issue: ensuring that translators are more available when needed to better serve the growing number of non-English speaking patients that are being seen in the Emergency Department. In addition, the union and management at St. Francis agreed to expand this effort to another unit in the hospital, and began the process of identifying which unit would have the greatest likelihood of success.