Running head: QUALITY IMPROVEMENT PROJECT 1

Quality Improvement Project

Kaitlyn M. Spence

Bon Secours Memorial College of Nursing

NUR 4144 – Professional Role Development

March 15, 2018

Pledge: “I have neither given nor received aid this assignment.”

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Quality Improvement Project

The emergency department (ED) is where most patients begin their medical care at any

given hospital. With the growing population and aging generations, the influx of patients who

seek care in the ED continues to rise. This fact, along with the current nursing shortage, adds to

overcrowding in ED’s across the country. According to the Agency for Healthcare and Research

Quality, “Nearly half of ED’s report operating at or above capacity, and 9 out of 10 hospitals

report holding or “boarding” admitted patients in the ED while they await inpatient beds”

(McHugh, Van Dyke, McClelland, Moss, 2014, p. 5). From a nurse leaders’ perspective, there

are many causes and factors that contribute to ED overcrowding, and each needs to be evaluated

to improve the issue on a large scale. An efficient and effective way to begin solving an issue

like overcrowding is to implement a quality improvement (QI) project.

Nurse leaders play a vital role in identifying needs for change on their unit and initiating

improvement tactics. There are two models for leadership that a nurse manager should follow in

order to implement changes in their workplace. The first is a servant leadership model that

includes the heart, head, hands, and habits of a leader, with each representing different qualities

that a leader should possess in order to thrive (Ellcessor, n.d.). The second model is the five

practices of exemplary leadership; these include model the way, inspire a shared vision,

challenge the process, enable others to act, and encourage the heart (Blanchard & Hodges, 2005).

These represent things that a nurse manager or leader can implement to ensure that the unit and

staff is working successfully.

A nurse manager must begin by leading with the heart. The heart of a leader represents

their motivation. According to Blanchard and Hodges, the heart of a leader represents the choice

of weather to be “motivated by self-interest, or by the benefit of those you are leading”

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(Blanchard & Hodges, 2005). Overcrowding in the emergency department affects the entire

hospital and how it operates. A self-serving leader would only be concerned with how the

overcrowding affects their specific job and workload. On the other hand, a leader who leads with

the heart would be concerned about how to improve the issue, in order to provide the best care to

the patient population. A servant leader is one who views their power as a “loan to those whom

they serve” (2005). This view would ensure that the leader values the input from those who work

under them. As far as the issue of overcrowding, feedback from the nursing staff would be very

beneficial. Nurses are the individuals who deal with the direct effects of an increased workload,

and therefore are able to clearly see where room for improvement lies. A servant leader who

leads with the heart should be willing and grateful to receive feedback from the staff, whether it

be good or bad.

The next step to evaluate in the journey of servant leadership is the head of the leader.

The head represents the “belief system and perspective on the role of the leader” (Blanchard &

Hodges, 2005). To lead effectively with the head, a leader must have a purpose and vision. In

order for the issue of overcrowding in the ED to resolve, the leader should have a clear higher

purpose. In this case, the higher purpose would be to be able to effectively provide safe care to

all patients, which is difficult to do with a high volume of patients coming in each day. The nurse

leader should ensure that their team understands the higher purpose and the vision for the future,

because only then will the staff be motivated themselves to accomplish the goal of reducing

overcrowding as well.

After the heart and the head of the nurse leader are established. The next step is to

evaluate the hands of the leader. The hands of a leader are one of the most important parts,

because while the heart and the head may be in the right place, the hands are what actually make
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the difference by taking action. This includes being a performance coach, which means

increasing the responsibilities of the team, letting others make decisions, and increasing

confidence (Blanchard & Hodges, 2005). In relation to overcrowding, the servant leader should

empower the team to plan the course of action and begin to implement it. The leader must be

able to promote a sense of togetherness among the team, and enhance teamwork strategies.

Another aspect of the hands of a servant leader includes leading through coaching. The leader

should have enough experience to be able to assist team members through the stages of learning:

novice, advanced beginner, competent, proficient, and expert (Ellcessor, n.d.). After the leader

assists with the learning of the team member, the servant leader should be able to evaluate the

effectiveness of the coaching strategies in order to improve in the future.

The last domain of a servant leader is their habits. The five habits of a servant leader

listed in the book, Lead Like Jesus include: solitude, prayer, study and appreciation of scripture,

accepting and responding to gods unconditional love, and involvement in supportive

relationships. For those leaders who follow Jesus, these habits will aid in keeping their practice

aligned with their mission and values. Practicing things like solitude and prayer will increase the

leaders focus, and strengthen their ability to push through difficult and treacherous times with

their faith. For those who follow a different faith or belief system, there are similar methods of

refocusing to ensure that the leader keeps their motivation. Some of these things include

meditation, exercise, and self-care routines. With either direction that the leader takes, these

habits are important because others will recognize the centeredness and focus, and be motivated

by it to do the same for themselves.

To be an effective leader you must follow the five practices of exemplary leadership. The

first practice is modeling the way. Modeling the way means that the leader should be committed
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to being a role model for the rest of the team, and ensuring that their words and actions are

consistent. “The leaders who are admired most are those who believe strongly in something and

are willing to stand up for their beliefs. You can be authentic only when you lead according to

the principles that matter most to you. Otherwise, you’re just putting on an act. You will not have

the integrity to lead” (Ellcessor, n.d.). In reference to overcrowding in the ED, the leader can

model the way by being available to help the team with getting patients triaged and discharged,

and being passionate about solving the issue. If the leader is engaged and involved in the day to

day tasks to work towards the goal, the team will be more motivated to follow the leaders path to

success.

The second practice of exemplary leadership is to inspire a shared vision. The leader

should be able to look towards the future, envision a new system, and share their vision with

their team. “When visions are shared they attract more people, sustain higher levels of

motivation, and withstand more challenges than those that are yours alone. People want to

follow those who can see beyond today’s problems and clearly visualize a brighter tomorrow”

(Ellcessor, n.d). The leader must be able to have a positive outlook on the future, and not get

bogged down by the daily struggles that come along with the leader role. This will enable the

team to have positive outlooks as well.

Once the leader can share their vision with their team, they must be able to challenge the

process. One of the main assets of leadership is being able to be innovative, and make changes

where there are opportunities to do so. The leader should be able to assess their surroundings,

and figure out where there is room for improvement. “Learning happens when people feel

comfortable in talking about both successes and failures, about what went right and what went

wrong. Leaders don’t look for someone to blame when the inevitable mistakes are made in the
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name of innovation. They ask instead, what can be learned from the experience” (Ellcessor, n.d.).

In the ED this would mean evaluating things like nursing satisfaction, patient care timelines,

length of stay, and effectiveness of triage. Because of the leaders’ open-mindedness and

innovation, they will be able to find opportunities for change and improvement within these

areas of evaluation.

The next exemplary practice that will aid in becoming an effective leader is enabling

others to act. With being a leader, it is important to recognize that one cannot take on all the

responsibility themselves. The leader must be able to aid in team building and collaboration, in

order to foster and open and communicating environment. The leader must also be able to trust

their team and be accepting of others’ capabilities and drive to take leadership roles for

themselves. In the ED, trust is very important because the entire staff is working as a team to

care for the patients. A leader should ensure that every team member is empowered and has a

role in accomplishing the overall goal of the unit (Ellcessor, n.d.). It is also important for the

leader to recognize and acknowledge positive contributions from the team members. This

practice of exemplary leadership is called encouraging the heart. “Personalizing recognition

sends the signal that the leader took the time to notice achievements, and makes certain that

others realize you are paying attention to behaviors that are consistent with shared values”

(Ellcessor, n.d.). By giving praise, the leader can reinforce that the team is working well together

to complete a goal, and this leads to increased satisfaction amongst the staff members.

Along with effective leadership strategies, there are many ways that overcrowding in the

ED can be addressed and reduced. For example, emergency departments can begin or increase

use of a “vertical flow” or “fast track” process. A vertical flow system is a few rooms set aside in

the ED that are for minor injuries that can be treated quickly like small lacerations, fever, or
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dental pain. A study entitled The impact of a fast track area on quality and effectiveness

outcomes: A Middle Eastern emergency department perspective, found that “A fast track system

appears to be an effective method by which a busy ED can efficiently maintain patient flow in

light of restricted resources, space constraints, limited manpower, and an escalating patient

census” (Devkaran, Parsons, Murray, Drennan, & Rajah, 2009). Another option for reducing

overcrowding is ensuring that the ED is adequately staffed with nurses. By fixing the nursing

shortage, the team would be able to quickly and effectively treat and discharge patients. This

would decrease the amount of time that each patient stays in the ED, which in turn increases the

number of patients that are able to be seen.

One strategy that could be effective is patient education. Many patients that come into the

ED are seeking care for non-emergent issues. Within the vertical flow section of the ED, there

could be parameters for educating those specific patients. The patients in fast track are always

non- emergent patients, therefore educating them on basic medical care like how to treat a fever,

or how to effectively care for a small cut will prevent these patients from returning for similar

issues. This will reduce the overcrowding issue and enable emergent patients to be treated more

promptly. Nurses could also explain to these patients that the best place for non-emergent

medical care is a primary care physician, or an urgent care facility like Patient First. Education is

the beginning of solving many of the issues in the health care setting today.

With this QI project, overcrowding in the ED could be significantly decreased. This, in

turn, would lead to better nursing satisfaction. It also would ensure that most of the patients

being seen are truly emergent, and can be treated effectively. The main concern is that each

patient is receiving the treatment that they need, and with patients seeking the appropriate facility

for their care, this would reduce overcrowding and improve patient outcomes. In order for a QI
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project to be successful, the leader must analyze and evaluate its data and outcomes. After

evaluation if the problem has not improved, the leader must continue to challenge the process A

good leader is motivated, and continues to search for a solution that improves the ultimate goal,

quality patient care.

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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.

Devkaran, S., Parsons, H., Dyke, M. V., Drennan, J., & Rajah, J. (2009). The impact of a fast

track area on quality and effectiveness outcomes: A Middle Eastern emergency

department perspective. BMC Emergency Medicine, 9(1). doi:10.1186/1471-227x-9-11

Ellcessor, B. (n.d.). Five Practices of Exemplary Leadership [PowerPoint Slides]. Retrieved from

https://bsmcon.blackboard.com/webapps/blackboard/execute/displayLearningUnit?course

_id=_3707_1&content_id=_214218_1

McHugh, M., PhD, Van Dyke, K., MMP, McClelland, M., MN, RN, & Moss, D., MPA. (2014).

Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for

Hospitals. Agency for Healthcare and Research Quality. Retrieved March 20, 2018, from

http://www.ahrq.gov/research/findings/final-reports/ptflow/index.html