The Multidisciplinary ED Performance Improvement Team

In previous articles we have reviewed how to recognize a broken ED, how to identify whether the “front door” or the “back door” is the bigger problem, and the ED performance scorecard. Improvement in any of these areas require not only strong administrative support and effective data collection systems, but also a team of individuals that can be tasked with objectively looking at all the data, reviewing benchmarks and goals, exploring feasible improvement solutions and developing and implementing a strong improvement plan. The focus here is to discuss the multidisciplinary team, the teams’ leader, members and support structure, and the tools and measures to guide and measure their success.

Who Is The Team Leader

The decision to appoint a team leader should be carefully considered during the improvement process. The performance improvement team leader sets the tone of the team, coordinates and ensures task completion, and must have the skills and leadership ability to communicate, coordinate, negotiate, delegate and appreciate the insight, perspective and competence that each of the team members bring to the table. Should the leader of this group always be the department director or the medical director?

In my experience, the best leader for the team is someone with good people skills, a working knowledge of the issues, and the ability to see the big picture. The team leader should have the ability to lead the team without having a direct stake in the outcome of the improvement effort. If an improvement action fails, the failure should not affect the team leader’s ability to continue in the leadership role. The team leader must weigh successes and failures in the context of the overall objectives of the improvement initiative and continue to move the team despite success or failure. Selection of the team leader can have a significant impact on team performance. Whether it is the ED director, the performance improvement director, or an outside independent consultant, make sure that the team leader understands the importance of team leadership as well as the goals and objectives of the improvement initiative.

Choosing Team Members

The team should be comprised of internal ED staff and staff from ancillary departments and nursing departments that take admitted patients from the ED. This multidisciplinary approach ensures that there is a good cross section of viewpoints, integration of process analysis across departmental lines, and complete understanding of the basic causes of current process failures. The team must come together to see the ED as a facility wide problem, not just an ED problem. The following positions should be considered as members of the ED performance improvement team:

• ED Medical Director or Designee
• Administrative Advisor (DON, COO)
• ED Nursing Director
• Performance Improvement Manager/Director
• ED Nurses (two per shift )
• ED Tech (one per shift)
• Nursing Supervisor
• Admissions or Bed Control Supervisor
• Inpatient Nursing Director (Med/Surg)
• Inpatient Charge Curses (1 Med/Surg, 1 Critical Care)
• Environmental Services Shift Supervisor
• Lab and Radiology Supervisors or Lead Techs

This group may seem larger than most performance improvement teams, but the complexity of ED issues warrant representation from many hospital departments. It also integrates improvement efforts into departments that traditionally have been outside the performance efforts of an ED, but are integral to their success. As improvement efforts proceed, an effective team leader will evaluate the need to change the group according to ongoing needs of the team.

Developing a Results Oriented Team Philosophy

For the team to be successful, the team must adopt a results oriented team philosophy. The team must work toward common goals set collectively by the team. In order to ensure the team has a clear direction, the initiative must be formalized and well communicated to team members and their peers in their respective departments.

First, a team charter must be developed. The team charter provides structure for the improvement initiative and the team. The charter should outline the purpose of the team, the facility level goals for the team, and provide an understanding of the level of administrative support that will be provided to the team. When team membership is finalized, the team members’ names should be place on the document and each team member should sign it as a show of commitment.

Second, a standard team meeting agenda should be used that focuses on action and results. Always review the status of past assigned actions, review data or scorecards as available, identify new issues for discussion and design new strategies as appropriate. Use the team meeting agenda to keep the team focused on the issues, subsequent actions and the results of those actions as evidenced by the data. The team should frequently review and revise the “master issues” list. Brainstorming by the team should elicit a list of issues for the team to address. The team will prioritize the list to develop a starting point but as the team completes its work, the issues will probably need to be reprioritized.

Third, reward the team for incremental successes. This is critical to the ongoing commitment of each team member. Be sure to reward the staff of ancillary departments as well; they are the end users of new and improved processes and their continued compliance will ensure that changes are hardwired. Also be sure to share the team’s accomplishments with the entire facility. This sets the foundation for facility-wide performance improvement participation and steers culture change.

Measuring Success

As discussed in previous articles, there is no magic pill that will instantly improve ED performance. Therefore, there is no magic strategy that can be developed by the performance improvement team. With this in mind, measures of success will be incremental, supported by data and monitored over time. Success comes in two stages, initial improvement (when strategies seem to have made an immediate positive change) and ongoing improvement (when changes have been hardwired into daily practice). Both are equally important to the success of your team. Avoid deflating team efforts by hastily identifying successes without the supporting data. Make sure the team understands what the goals are for each strategy and what the measure of success will be before they are implemented. And again, share the successes with the entire facility. As with any performance improvement effort, some strategies my not accomplish intended goals. How the team leader and the team handles these missteps will determine the ongoing team efforts. To ensure the team stays on track despite missed strategies, use the following tips:

• Every strategy implemented is called a pilot until its appropriateness is ensured.
• Set incremental, obtainable goals.
• Look for “low hanging fruit” to provide some quick wins for the team.
• Assure the team that if an improvement action doesn’t work, it can always be redesigned.
• Use data to determine effectiveness, not anecdotal comments.

The ED performance improvement process can be very complicated and the multidisciplinary team will be asked to guide improvements is just as complicated. Each team member brings a different viewpoint of issues to be tackled and these different perspectives must be harnessed to provide a comprehensive view for the team to use to its advantage. The leader of this talented team must mesh the different levels of representation within the organization into a well-oiled team that using data, knowledge, and perspective to develop facility wide strategies that will have lasting improvements for the patients that you serve.