Reference no: EM133514808

Case Study: The New Department Director As a new director of ambulatory care at the Kennedy Medical Center, Dr. Grant started to review issues in the hospital; it was clear that something was wrong. Every day, a large crowd of patients and families waited for hours in the emer-gency department. Although the outpatient ambulatory practices seemed to be running smoothly, the emergency department, which was within Dr. Grant's responsibility, seemed to be a mess. The hospital was typically going "on divert," meaning they would divert ambulances from the emergency room, sending them to another hospital in the city because Kennedy Medical Center did not have the beds and staff to accept more patients. Dr. Grant was embar-rassed by the situation and was surprised that no one higher up in the administration had noted this as a concern. When he asked about it, his boss, the chief operating officer of the hospital, said it had been this way for a while. Dr. Grant approached Ms. Downs, the nurse manager of the emergency department and a nurse with 25 years of experience at the hospital, about the issue. She also reported that the situation was no worse than usual and, while it was not ideal, Kennedy Medical Center did better than other hospitals in the area. Still, the situation bothered Dr. Grant, and he made a promise to himself that he would fix it, setting a goal of having 90 percent of the emergency department outpatients in and out of the emergency department in four hours and having the emergency department be on divert no more than once per month. He was not sure what the current percentage meeting this goal was, but given his previous experience at other hospitals, he aimed to accomplish these objectives in six months. With his problem identified and clear objectives set, Dr. Grant set out to implement a new strategy, which involved (1) teaching the staff about root cause analysis, (2) reengineering the triage work flow to speed access to a clinician, and (3) making what he viewed as a minor fix to the current electronic registration system to improve team communication. This approach had worked well in his former hospital, reducing wait times by more than 30 percent within six months. After much planning, Dr. Grant held a staff meeting of the nurse manager and the three emergency department supervisors who reported to her to discuss the new strategy. He described the new processes, which were supposed to smooth out redundancies and save time. The staff seemed to like the reengineering process ideas best, so Dr. Grant decided to start with those. He suggested that they could begin the new workflow in two weeks, after staff education and training. The staff meeting was friendly, and no one said much. Ms. Downs had to leave slightly early to pick up her son from school, but the supervisors said that training should be no problem and that two weeks gave them plenty of time. They agreed as a group to start two weeks from Monday. On the "go live" Monday, Dr. Grant had a morning of meetings outside the hospital but was comforted that Ms. Downs was there and in charge. Unfortunately, two clerks had days off requested months earlier, and the charge nurse for the day had a family emergency over the weekend and was late to work. The staff members remaining were thankfully the most efficient. When Dr. Grant returned to the hospital after his outside meeting, Ms. Downs was waiting in his office and upset. She said that the new workflow process had fallen apart and that the crowds were worse than ever. She raised her voice and then turned quickly away to go back to her work area, saying, "You have not fixed anything. You have made it worse here. Look at the mess we have today. And it will be just as bad tomorrow. We need to go back to the way it used to be." Dr. Grant was surprised at how angry Ms. Downs seemed to be. He looked in at the emergency department triage area, and it did look very crowded. The efficient registration clerks were there working, but they could not keep up with the crowds. The beds in the emergency department were already full, and the medical director was suggesting it was time to divert ambulances already even though it was only Monday at noon. Dr. Grant went back to his office and wondered what he should do.

Question 1: What problem(s) does Dr. Grant face? Think about the root cause problem. See Table 2.4 for examples of writing effective problem statements.

Question 2: Consider individual-level, team-level, and system-level problems. For each, set an objective that is SMART. Note: objectives should follow the SMART format (see page 43.) Objectives should be structured to follow the SMART mnemonic. CHiME Competency Domain 2 Standard 2.2