Flow Hacks 10 – An ED Model of Care©.

In Education & Quality Improvement, FLOW Hacks by Laila NasserLeave a Comment

To continue our FLOW Hacks series, Mary Van Osch (RN, MSN, ENC) discusses her team’s new Emergency Department Model of Care (ED MOC ©) at Fraser Health in British Columbia. 

Setting

The model was implemented at Fraser Health in British Columbia, across 12 emergency departments (ED) with a total of 720,000 visits per year.

Description of Innovation

The ED MOC © was developed at Fraser Health by the Emergency Network core team after conducting an extensive literature search on best practice emergency care along with an environmental scan on current practice in the Fraser Health emergency departments. The intention was to support improved quality care, patient and staff experience and create standardization across the 12 departments. 

The ED MOC © has four key areas:

  1. Foundational: Involves development of local ED quality improvement teams comprised of clinical leadership, frontline staff, patient representatives and inter-regional partners. A regional metrics dashboard was created to track and evaluate improvements in the departments.
  2. Environmental: Care zones were developed based on patient acuity and care needs after identifying commonalities in the then-current functional space in the 12 departments. The 6 zones are: patient check-in, acutely-ill, sub-acute, minor treatment, paediatrics and mental health.
  3. Access: Streamlining of the triage and registration process with the goal of initial triage assessment within 10 minutes followed by relocation to the appropriate care zone.
  4. Throughput: Focus on creating waiting areas within each care zone where treatment and re-assessments are optimized. 

Was a quality improvement methodology used?

The Prosci Change Management methodology was implemented.

What data was used?

Patient information data was taken from the electronic medical record, Meditech. Initial data to incite change was based on the environmental scan of Fraser Health. 

Who was on the team?

The Emergency Network core team (composed of clinical nurse specialists, regional medical director, previous director) in addition to local ED managers, physician leads and frontline staff. 

What performance measures were used?

  1. Time to physician initial assessment
  2. ED length of stay
  3. ED left without being seen

How was it implemented?

Implementation is currently underway across the 12 Fraser Health EDs. Emergency Network clinical nurse specialists support the local QI teams and share resources across the sites. Frontline staff were also empowered to generate solutions with a key approach “locally actioned, regionally enabled solutions”.

How did you get buy in from physicians, nurses, administrators and other allied professionals?

Using our “locally actioned, regionally enabled” approach, a culture was created where all the departments were working toward standardized targets, we encouraged solutions to come from frontline staff to reflect the specific needs at each site. We then had sites collaborate to share their learning to further promote the culture of continuous quality improvement and celebrate learning and success. 

What was the impact on your department?

From the time ED MOC © was launched in May 2018 to February 2019, all EDs had formed a local QI team and had ongoing QI projects. Specific improvements included decreasing patient arrival time to triage by up to 36%, decreased ED length of stay for moderately ill patients by up to 1 hour, and a decrease in rates of patients leaving without being seen by a physician. 

What were some of the barriers to success?

There were limited to no resources for completing individual QI projects. In addition, overcrowding within the ED made shifting priorities a challenge as well. 

If you could do it all over again, what changes would you make?

The team would develop a clear well-resourced communication plan that focuses on engaging front life emergency staff including physicians. 

This post was copy-edited by Jung-In Choi.

Laila Nasser

Dr. Laila Nasser is a resident physician in emergency medicine at McMaster University. She has strong interests in quality improvement and resident wellness.

David Savage

David Savage is a resident in the FM/EM program at NOSM, Thunder Bay. His interests include EM policy and the application of analytics techniques to physician scheduling, patient forecasting, and capacity planning.