Running head: QUALITY IMPROVEMENT PROJECT 1

Quality Improvement Project

Cara Lucy

Bon Secours Memorial College of Nursing

NUR 4144 Professional Role Development

March 28, 2017

I have neither given nor received aid, other than acknowledged, on this assignment, nor have I

seen anyone else do so.

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Quality Improvement Project

In the past decade, the workload and demand for emergency care in hospitals has steadily

grown, causing a nationwide problem known as Emergency Department (ED) crowding. The

Emergency Nurses Association defines crowding as a situation in which the identified need for

emergency services outstrips available resources in the emergency department. This situation

occurs in hospital emergency departments when there are more patients than staffed emergency

department treatment beds, and wait times exceed a reasonable period (2006). The

development and implementation of a quality improvement (QI) project is vital to improving

patient flow through the ED, and ultimately reducing overall crowding. As a nurse manager,

there are multiple options that could be implemented in an effort to decrease crowding in the ED.

Regardless of which strategies are used, this QI project should be undertaken using the four

domains of leadership: the heart, head, hands, and habits (Blanchard & Hodges, 2005).

Additionally, the nurse manager should also utilize the five practices of exemplary leadership:

modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and

encouraging the heart (Kouzes & Posner, 2013).

For a nurse manager to lead with the heart, they must assess their own inner character to

determine their motivation; are they a self-serving leader or a servant leader (Blanchard &

Hodges, 2005)? A nurse manager that truly leads with the heart will place the well-being of the

patients and staff above all else. While crowding in the ED poses many operational and profit

based issues for hospitals, the nurse manager should not be focus on these self-serving problems.

Instead, those with the true heart of a servant leader will be motivated to serve others by ensuring

that all patients receive the care they deserve. Studies have shown that ED crowding can lead to

delays in critical treatment, higher rates of complications, increased negative outcomes of patient
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care, and higher mortality rates. Overcrowding in the ED has also been associated with a higher

occurrence of preventable medication errors (Kulstad, Sikka, Sweis, Kelley, & Rzechula, 2010).

While implementing a quality improvement project designed to reduce overcrowding and

boarding of patients in the ED, the nurse manager should gather input from the staff regarding

any current issues or flaws in their patient flow methods. By embracing the opinions of others

while accepting feedback and suggestions, the servant leader can stay grounded in Gods

unconditional love while finding truth and value for improving their leadership (Blanchard &

Hodges, 2005).

Once the servant leader identifies their motivation through the heart, they must move

towards leading with the head. Blanchard and Hodges explain that a servant leader must have a

clear and compelling vision of the future (2005). This means that the nurse manager must guide

the journey by providing a purpose, expressing their values, and implementing their vision. In

order to do this, we must first recognize that ED crowding is actually a hospital-wide problem.

There are many external factors that contribute to ED crowding such as staffing shortages during

peak volume times, delays in diagnostic testing, inadequate coordination of procedure

scheduling, and patient boarding due to lack of inpatient hospital beds. A nurse manager that

leads with the head should effectively communicate their purpose, values, and overall vision to

the entire hospital in order to build a culture of transparency, promote interdisciplinary

involvement, and accomplish their overall goals.

After the internal aspects of servant leadership are addressed by the domains of the head

and heart, the hands domain can begin setting clear goals, observing performance, praising

progress, and redirecting inappropriate behavior (Blanchard & Hodges, 2005). During this

phase, the nurse manager will start to implement their ideas while working as both a servant and
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a leader themselves. The servant leaders role during this phase is arguably the most important:

to equip the learners so that together, they may extend their services for the common good. The

nurse manager should create an action plan using SMART goals: specific, measurable, agreed

upon, realistic, and timely. It is also imperative to establish the desired expected outcomes, as

well as how to evaluate them. In addition to using measurable data to evaluate the changes being

made, the servant leader should also seek input from the staff in order to build trust and honor

teamwork. Involving the opinions of the staff allows team development through empowerment,

and maintains staff support throughout the process. According to Blanchard and Hodges,

individuals in the group will not empower each other to accomplish an assigned task if they do

not trust each other. Failure to empower is one of the key reasons that teams are ineffective

(2005, p. 27).

The final domain of leadership, habits, is imperative for the health of the nurse manager,

staff, and hospital as a whole. Blanchard and Hodges described the five key habits as solitude,

prayer, study and application of Scripture, accepting and responding to God's unconditional love,

and involvement in supportive relationships (2005). Solitude and prayer are essential habits that

should be practiced by everyone when guidance is needed in order to avoid stress and caregiver

burnout. It is also important that a servant leader applies Scripture to everyday life, as well as

never forgetting that Gods love is unconditional. By leading with these habits, the servant

leader can continue to lead

To be an effective servant leader, Kouzes and Posner state that one must first model the

way (2013). Modeling the way is the foundation of servant leadership. The nurse manager

should set a clear example of their expectations and determine whether or not these values alight

with the values of others. They will help others achieve their greatest potential, and will always
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follow through with the promises and commitments they make. During times of ED crowding,

the servant leader is present and engaged, working with the staff at the front of the line in an

attempt to improve patient flow. Servant leaders must also inspire a shared vision, showing

others what they are capable of accomplishing together. Once they share this vision, they must

be willing to challenge the process in order to accomplish their goal (Kouzes & Posner, 2013).

In this situation, the nurse manager cannot simply sit back and observe as the ED struggles to

function effectively. Instead, they must show people what the future should look like, and then

take initiative to try new ideas. Part of challenging the process means that the nurse manager

should look to external sources for advice, and take in all suggestions with an open mind. Once

this information is converted into an actual plan, the servant leader must enable others to act

(Kouzes & Posner, 2013). This involves more than simply providing others with physical

resources. It means embracing the diverse ideas of those you work with, being respectful

towards others, and allowing people to make their own choices in regards to how they do things.

A true servant leader will always be willing to jump in and help. Whether theyre providing

support and education to employees, triaging patients as they walk in, re-stocking patient rooms,

transferring patients, or even performing housekeeping duties after patients are discharged, they

always strive to empower others through teamwork. Once the ED staff has been enabled to act,

it is important that the nurse manager reflects on the changes that have been made, and

encourage the heart. To encourage the heart, the servant leader should constantly encourage

others, offering praise and appreciation for contributions they have made. By encouraging the

heart, servant leaders are able to maintain a positive outlook as they stimulate, focus, and

rekindle peoples energies and drive (Kouzes & Posner, 2013, p. 120).
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In addition to the practices described above, there are many implications for professional

practice that the nurse manager should use to reduce patient crowding in the ED. For example,

the nurse manager may implement the use of an ED fast track area for patients with less severe

injuries and illness in order to keep the main areas open for more severe patients. Fast track

areas have been shown to reduce delays in care for both urgent and non-urgent patients, thereby

improving patient flow across the ED (IOM 2006). Another option would be to coordinate

elective surgery schedules so they are move evenly distributed, creating more available beds

during peak times in the ED. The most effective option, in my opinion, is to begin board patients

in hall beds on inpatient units instead of boarding them on hall beds in the ED. If there are ten

patients being boarded in hall beds while waiting to be admitted, it makes much more sense to

distribute those ten patients among ten different inpatient units, resulting in one hall bed per unit,

rather than having 10 hall beds confined to the ED alone.

If this QI project was successful in reducing ED crowding, it would significantly benefit

all patients and employees across the entire hospital. In order to determine whether or not the

project is successful, the nurse manager must ensure that proper data is collected and analyzed.

The data should consist of information such as door to triage times, triage to diagnosis and

treatment times, average length of stay, number of patients boarded each day, and how often the

hospital goes on ambulance diversion. If this data shows that the SMART goals have not been

met, then the project should be adjusted and new measures should be taken until the final vision

has been reached.

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References

Blanchard, K. & Hodges, P. (2005). Lead like Jesus: Lessons from the greatest leadership role

model of all times. Nashville, TN: Thomas Nelson.

Blom, M., Jonsson, F., Landin-Olsson, M., & Ivarsson, K. (2014). The probability of patients

being admitted from the emergency department is negatively correlated to in-hospital bed

occupancy - a registry study. International Journal of Emergency Medicine, 7(8). DOI:

10.1186/1865-1380-7-8.

Emergency Nurses Association. (2006). Emergency Nurses Association position statement:

Crowding in the emergency department. Journal of Emergency Nursing, 32(1), 42-47.

doi: 10.1016/j.jen.2005.09.023.

Institute of Medicine. (2006). Hospital-Based Emergency Care: At the Breaking Point.

Washington, DC: National Academy Press.

Kouzes, J. & Posner, B. (2013). The Student Leadership Challenge: Student Workbook and

Personal Leadership Journal. San Francisco, CA: Jossey-Bass.

Kulstad, E., Sikka, R., Sweis, R., Kelley, K., & Rzechula, K. (2010). ED overcrowding is

associated with an increased frequency of medication errors. International Journal of

Emergency Medicine, 28(3), 304-309. http://dx.doi.org/10.1016/j.ajem.2008.12.014