BHA FPX 2110 Assessment 1 Performance Improvement Plan: Challenges and Opportunities

Identify Issues and Assess Concerns

What are the key issues facing the emergency department (ED) at Green Valley Hospital (GVH)?

Response: Green Valley Hospital (GVH) already has a number of critical problems that impact patient care, staff workload, and affect the functioning of the hospital in its Emergency Department (ED). As a small rural Critical Access Hospital (CAH), with only 30 hospital beds, and a small community with limited access to health care resources, the ED is an important resource for GVH. The long waiting times and a high number of patients are among the most pressing issues. Patients’ stay is usually for four and a half hours on average, with an initial time of up to 45 minutes for their first examination and 90 minutes for them to see a doctor.

Reducing time delays will not only result in frustration and dissatisfaction amongst patients (which is already at 68% patient satisfaction), but could also pose patient safety risks including late identification and/or treatment of critical conditions. The other thing that comes to mind is how many staff members are going to be in the ED at the peak times; they only have two nurses and two doctors to staff. As the workers work at the same time on triage, patient care, and administration, they may have less time to devote to patient care. This is also related to the more obvious stress faced by the healthcare industry at large, which is the lack of quality healthcare in EDs due to heavy workloads (staff fatigue, burnout, risk of error).

The lack of effective processes at the ED, particularly in triage, also blemishes the ED. Repeatedly signing in and out patients is a time-consuming process, and even the sign-in/out part of the administration process requires employees to make decisions as to which patient gets the treatment room, and which patient gets the delay.

The poor inventory management is another aggravation for that inefficiency, as it causes waste in resources and the cost of operational inefficiency. The requirement of value-based purchasing also puts financial pressure, and that’s why there is also value on quality patient outcomes and quality improvement; they’re tied to the reimbursement.

How do these impact patient care, staff workload, and hospital operations?

Response: These problems in the Emergency Department at Green Valley Hospital directly affect the quality of care, workload for the workers, and the operation of the whole hospital. Wait times and overcrowding can impact the timely assessment and treatment of patients, leading to poorer clinical outcomes and causing anxiety, especially for patients requiring urgent and/or complex treatment. In the staffing aspect, the constant and heavy workload on nurses, physicians, and support workers also exerts additional stress on their work and allows them to deal with multiple tasks simultaneously with a limited number of resources, further compromising nurse and physician health and leading to increased fatigue and risk of burnout.

From a business standpoint, these circumstances affect patient flow, reduce bed availability, and reduce the efficiency of the hospital’s resources, resulting in longer hospital stays and decreased patient satisfaction. These factors all demonstrate the impact of delays in the ED on the individual patient journey, on staff performance, and on the hospital’s ability to provide safe, high-quality care.

How are the issues at GVH related to issues in the broader healthcare industry?

Response: The problems encountered by Green Valley Hospital are typical of those of many other hospital facilities in the country, especially those that are remote and/or have limited resources. The Red Cross is reporting that many hospitals across the country are under pressure due to the high number of patients, long waiting times in the emergency room, as well as staffing reductions. The high number of emergency visits to rural hospitals can be difficult to manage as they have limited bed capacity and limited access to specialty services like GVH.

The growing challenges associated with reimbursement structures and increasing operating expenses add to the challenges of increasing staffing or enhancing the facility. These common challenges show that the healthcare scenario at GVH is not unique, but is part of an overall movement in the healthcare industry to meet the increasing requirements, limited resources, and need to ensure patient safety, quality outcomes, and employee well-being.

Role of Evidence-Based Medicine and Value-Based Purchasing

What role does evidence-based medicine have in helping to improve this situation?

Response: The problems currently faced in the Emergency Department (ED) of Green Valley Hospital (GVH) are dealing with waiting times, staffing, ineffective triage, and financial difficulties. Evidence-based medicine (EBM) and value-based purchasing (VBP) are potential solutions to such issues. EBM is a goal of integrating the best clinical research with the knowledge and experience of the health care provider and the patients’ preferences to affect clinical decision-making. EBM in GVH ED would make the job of triage easier in that setting; nurses and physicians would know immediately how to prioritize what to do for the high-risk patients.

This would help to lessen the waiting time of patients, enhance safety, and boost satisfaction scores, as they will be receiving high-quality care that will be consistent. It can be illustrated with the establishment of a common procedure for the assessment and intervention in routine emergencies to reduce the variability of care delivery and reduce mistakes, which is very beneficial in a small rural hospital with the limited number of employees it has.

What role does value-based purchasing have in helping to improve this situation?

Response: Value-based purchasing is a side show to EBM – the reimbursement of hospitals is not based on the number of services provided, but rather the outcomes of the services and their quality. By using certain performance measures like AHS, TFA, patient satisfaction, and resource usage, GVH can take certain interventions to minimize inefficiencies and waste. This not only improves patient care but also helps in ensuring financial sustainability by following reimbursement incentives.

For example, management of the inventory and elimination of unnecessary triage procedures can save costs and improve efficiency of care, which can directly impact financial and operational issues. EBM and VBP provide a continuous improvement cycle whereby clinical decisions should be based on evidence and be cost-effective, consistent with the broader trend in the healthcare industry of quality-focused, affordable care.

Stakeholders

Response:

The key stakeholders at Green Valley Hospital (GVH) Emergency Department are the nursing staff, medical staff, nursing leaders, hospital administrators, financial officers, patients and family, and outside agencies or entities including regulatory bodies and insurance companies. Nurses, such as Sarah, perform the functions of triage, direct care and treatment coordination, directly affecting patient prioritization, patient safety and patient satisfaction. Dr. Adams and Dr. Johnson are physicians, and they have the ability to diagnose and treat their patients even in the face of a lot of volume, and are also able to follow evidence-based guidelines to deliver high-quality, consistent care.

Mrs. Garcia is one of the nursing leaders who is responsible for staffing, digitization of workflows, and coordination of clinical and operational priorities with resources available in the hospital. Hospital administrators like Mr. Lee keep an eye on how well the ED works, determine the workload, and direct improvement efforts; financial officers like Ms. Thompson manage expenses and make sure that money is spent wisely, including connecting financial decisions to results on quality measures via value-based purchasing.

Immediate outcomes of the engagement and feedback from patients and families, and reimbursement and compliance policies and standards from external stakeholders such as insurance providers and regulatory bodies, impact outcomes. The stakeholders work together and are interconnected, requiring collaboration and coordinated decision-making to enhance patient care, operational efficiencies, and financial sustainability.

How might each stakeholder’s role impact overall decisions and outcomes?

Response: All Green Valley Hospital stakeholders have a role to play – and an impact to make – in the decision-making process. The leadership and administrators of the hospital are tasked with determining priorities, focusing available resources, and approving policies that have a direct impact on the number of workers, the patient flow, and quality improvement programs. Their choices will help decide whether investments are made in evidence-based practices, staff support, or operational changes that decrease the wait time and improve care.

The clinical skill, knowledge, and adherence to evidence-based guidelines, plus the communication with the patient and team, are clearly significant factors for both physicians and nurses in patient outcomes, but heavy workload and time pressures can diminish their ability to deliver the best care. Support staff, including registration clerks and technicians, can contribute to delays by the volume, timeliness, and accuracy of information transmitted, which can either decrease or increase delays.

Patients and families also contribute to the process in many ways, such as involvement, symptom communication and feedback, which can inform patient care decisions and quality improvement. Last but not least, outside actors (payers, regulatory agencies) affect outcomes through reimbursement policies and expectations, which can help or hinder the hospital’s capacity to undertake actions designed to enhance its sustainability, quality, and safety.

Operational vs. Strategic Issues

What are the important differences between strategic and operational issues?

Response:

The key distinction that needs to be understood between operational and strategic problems is in terms of their objectives and/or the time horizon. These can be operational issues, which are day-to-day problems affecting the efficiency and effectiveness of day-to-day activities, or strategic issues, which are issues that require longer time horizons, look forward, and will determine the hospital’s development, sustainability, and its direction towards meeting the hospital’s aims.

In fact, both types are interconnected, and operational improvements can help achieve strategic objectives, while strategic planning assures sustainable operational changes, which are consistent with the hospital’s mission. Improving the care that is delivered to the patient, as well as the effectiveness of staff performance and overall organisational effectiveness, requires a holistic approach to tackling both simultaneously at GVH.

Explain whether each issue you’ve identified is operational or strategic and why.

Response:

 The problems found in the Green Valley Hospital (GVH) ED can be either operational or strategic in nature as a function of their scope, duration and significance to the hospital. Operational problems are those that occur on a day-to-day basis and have an impact on daily hospital activities, staff performance, and patient care. Some examples of these problems at GVH are lengthy waiting times, inefficient triage process, unequal staff workload, and lack of treatment room availability. All of these problems are ones that need to be addressed immediately through workflow changes, employee scheduling, and/or the implementation of evidence-based protocols that will improve workflow processes, patient safety, and patient satisfaction.

Strategic issues are associated with longer-term planning and decision-making, which will impact the hospital’s sustainability and the organization’s objectives. The challenges at GVH revolve around funding sustainability, risk of being rewarded based on value, and allocation of resources between the departments. Leaders making choices to address these challenges can mean pursuing investment opportunities such as investing in employee training, technology investments to enhance long-term patient care and hospital performance, or cost-saving operational decisions to balance the costs of good outcomes.

Tools for Problem Solving and Decision Making

Describe three problem-solving or decision-making tools that could be useful in addressing issues identified in the narrative.

Response: The Green Valley Hospital (GVH) Emergency Department (ED) is plagued by problems, and these needs can be solved with the help of a structured problem-solving and decision-making process. Root Cause Analysis (RCA), Plan Do Study Act (PDSA) cycle, and SWOT analysis are three tools that may be useful here.

Discuss the importance of using these tools to make decisions and solve problems in healthcare.

Response: RCA is a methodical process for analyzing problems to seek their root causes and not just their symptoms. For the GVH ED, issues to which RCA could be applied include long patient wait times and too many patients being brought into the ED without being triaged. Leadership can identify the issue at hand by going back to the source problem, such as a staffing problem, unnecessary administrative steps, or a late room assignment, and take targeted measures to solve the root cause, which will help improve patient flow and staff efficiency.

Another valuable tool that can be used to assist with continuous improvement in health care settings is the Plan-Do-Study-Act (PDSA) cycle. Plan, Do, Study, and Act is a powerful tool for implementing continuous improvement in health care settings. Using PDSA gives the GVH team the chance to make a small change, do it, learn about what happens, and then take action. For instance, a PDSA cycle might attempt a modified triage process, track wait times, patient satisfaction, and other metrics of the process, and tweak the process before it is fully adopted. This is an iterative process that helps mitigate risk and improve operational efficiency through an evidence-based experimental process.

Last but not least, SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) is a strategic decision-making tool that helps an organization analyze internal and external influences that impact the performance of an organization. Using SWOT for GVH’s ED would enable leadership to examine the pros and cons of their current services, such as the capacity to easily implement telehealth, as well as the cons, like a lack of extra treatment spaces, and threats like limited financial resources or a growing patient population.

This overall perspective makes good use of operational and strategic planning and provides direction towards operational improvement or long-term strategic planning, with interventions congruent with the priorities and resources of the organization. Combining these three tools together can be a complete package, as it can help in addressing the root causes and help in iterative testing of solutions with PDSA, and it will provide a broad strategic perspective with SWOT. Together, they allow GVH to inform the decisions made by its leadership, improve patient care, reduce staff workload, and improve operational efficiencies and finances within the ED.

Recommend one tool to address one specific issue described in the narrative and explain why it would be useful.

Response: The most useful tool to solve this pressing problem of inefficient triage and long wait times for patients in the Green Valley Hospital (GVH) Emergency Department (ED) is the Plan-Do-Study-Act (PDSA) cycle. The PDSA cycle is an evidence-based process of change that is iterative and gives the health care team the opportunity to test out small changes, learn about the effects, and make necessary adjustments before applying the change on an organized scale. If PDSA was used in GVH’s triage process, it would involve: Planning the new streamlined triage process, implementing it during peak hours, collecting data on patient turnaround time, room usage efficiency, and staff load, analysing the results, and then making changes to the process.

For GVH, this method is especially appropriate since during peak periods there are only 2 nurses and 2 doctors working in the ED; large-scale interventions are risky and could be disruptive. The PDSA approach enables changes to be introduced step-by-step, to help reduce risk and to help ensure that measurable improvements are realised. A small pilot could be used to trial other administrative tasks out of the reach of Nurses during triage, or other standardised checklists that would eliminate unnecessary tasks. Researching results on the ground, like throughput and client happiness, can enable leaders to help make informed choices about permanent implementation.

Also, PDSA supports ongoing improvement, and all staff (physicians, nurses and administrators) can give input after each cycle to make sure the change is implemented in a feasible, sustainable manner. This not only boosts efficiency but also minimizes the stress of staff members, thereby ensuring better care for patients, and supports overall efforts for efficiency, safety, and value-based care in healthcare. Triage efficiency via PDSA is a highly targeted and practical solution that allows GVH to get more patients assessed quicker, ensure patient satisfaction, and optimise the limited resources available.

Additional Questions

Identify additional questions to ask to help set goals and to develop key performance indicators.

Response: The answer is to provide a set of focused questions to inform goal setting and the creation of key performance indicators (KPIs) needed to enhance performance in the Green Valley Hospital (GVH) Emergency Department (ED). Good questions are related to care for the patient, workload of the staff, effective operation, and financial viability. Understanding the average wait time for patients at each triage level, for instance, will inform you of potential delays in patient assessment and help set up a tangible KPI for reducing wait times.

Questions like Where are there bottlenecks in patient flow, and how could staffing be better optimized during peak hours?” directly inform staffing and resource allocation decisions. Once identified, points of congestion within the hospital can be used to create KPIs that include issues relating to staff efficiency, patient flow, and the use of treatment rooms. One more important query is, “How well is the stock controlled to avoid shortages or waste?” This is a question that will encompass both operational and financial considerations, and will support “value-based purchasing” efforts to use resources optimally to lower cost.

Last but not least, the question “What are the most frequent reasons for dissatisfaction and how can they be reduced?” brings up aspects of the care such as communication, comfort, and responsiveness, which are important factors that determine patient-centred care. All of these questions together will help to set measurable and evidence-based goals and KPIs, with which continuous improvement can be achieved in the ED.