From Invisible to Invincible: An ED Engagement Journey

Added on Mar 21, 2016

From Invisible to Invincible: An ED Engagement Journey
By Audrey Doyle
From Industry Edge March 2016

The emergency department at Moses H. Cone Memorial Hospital has long been known as one of the busiest EDs in North Carolina’s Piedmont Triad metropolitan region, providing care to more than 100,000 patients annually. Until recently, the designated Level II trauma center had also been known for having low patient experience scores and low quality-of-care outcomes.

Realizing that strong employee engagement results in behavior that improves performance and the patient experience, leadership at the Greensboro-based medical center initiated significant changes in April 2013 that have transformed the ED culture and resulted in sustainable improvement. Employee engagement scores improved considerably, rising from the 19th percentile in 2012 to the 82nd percentile in 2015, and the hospital experienced a surge in survey participation rates from 54% to 90% during the same period.

An Ailing ED

A 501-bed, tertiary-care facility, Moses Cone is one of six hospitals in the Cone Health network and one of only three Level II trauma centers in North Carolina. The facility’s acute-care services include a children’s emergency department and neuroscience, heart and vascular, orthopedics and stroke centers of excellence. For several years, however, the hospital’s ED had struggled to achieve acceptable levels of productivity, efficiency, quality, safety, service and clinical outcomes. By 2012, the department had reached a crisis point: Its patient experience score was in the 22nd percentile, and several of its CMS core measure scores were low. Among the most egregious were 75% compliance in Door to EKG, 30% compliance in Stroke Protocol Documentation and 0% compliance in Specimen Labeling Policy & Procedure.

When Misty Freeman, RN, MHA, CSN, NE-BC, was named the ED’s director of nursing in April 2013, she learned that employee engagement was in the 19th percentile and survey participation rates were only 54%. What’s more, those scores had remained flat the preceding five years, indicating that the staff had been disengaged for some time. “In any organization, but especially in a busy ED like ours, it’s crucial to have strong employee engagement,” Freeman said. “That’s what drives behavior that supports high-quality care.”

Freeman knew that transforming the Moses Cone ED culture from woefully disengaged to highly engaged would be difficult. “Our ED is very big,” she said. “There are 250 staff members — including RNs, nurse techs, EMTs, secretaries and phlebotomists — and only one director.”

Her first step toward rectifying the problem was to meet with a core group of level III RNs who had been with the ED for some time to identify why the staff members were so disconnected. According to Freeman, several years of high employee turnover and instability had damaged their morale.

There also was a perceived lack of support. For instance, the staff felt leadership hadn’t increased staffing to accommodate sharp increases in patient volume and acuity level, which caused burnout. “The staff was already dissatisfied, so when the department got busier and the work got harder, people got burned out and left,” Freeman said. “When I started, the ED had a 54% vacancy rate.”

Also contributing to the high vacancy rate was the fact that the ED wasn’t fully equipped with the tools the staff needed to do their jobs. For example, they didn’t have a bladder scanner to assess patients for post-void residual urine volume. “That’s a crucial tool for any ED,” Freeman said. What’s worse, when staff members made a mistake — as with specimen labeling — they weren’t held accountable for their errors. “You must have accountability, because if you don’t hold the low performers accountable, your high performers will leave,” said Freeman.

Measurable Gains

Once she had diagnosed the problem, Freeman formed an engagement team and asked the level III RNs to help her lead it. Then she spearheaded some changes, including hiring some assistant directors. “That’s when the staff saw I was serious about improving their environment,” Freeman said. “They began to trust me, and their morale shot right up.”

Four months after Freeman started at Moses Cone, the staff took their August 2013 Employee Engagement survey. The results were impressive: Employee engagement had increased to the 28th percentile, survey participation had risen to 70% and patient experience had increased to the 49th percentile. “That’s when I knew the staff was committed to high patient satisfaction and the provision of high-quality patient care,” Freeman said.

To ensure continual gains, Freeman set goals for the next two surveys: Finish 2014 and 2015 with employee engagement and patient experience at the 90th percentile and survey participation at 90%. Although she knew those goals were high, she felt that setting them lower would send the wrong message to the staff. “Setting goals that are high tells a staff they’re qualified. Sometimes if you set a goal too low, it doesn’t push staff to try harder, because they don’t think they can do any better.”

The strategy paid off: In 2014, employee engagement rose to the 55th percentile, patient experience rose to the 69th percentile and survey participation increased to 88%. And in 2015, the staff scored in the 82nd percentile for employee engagement, with a survey participation rate of 90%. Although patient experience slipped from the 69th to the 59th percentile in 2015, Freeman attributes the decline to a 12% increase in patient volume that resulted in a temporary increase in wait times, an issue that has been resolved through adjustments in physician staffing.

Freeman notes that the increase in employee engagement has led to further improvements. In addition to 100% compliance for Specimen Labeling Policy & Procedure, the department’s most recent CMS core measure scores were 90% compliance for Door to EKG and 95% compliance for Stroke Protocol Documentation. Meanwhile, the staff turnover rate has dropped from 18% to 6%, overtime has dropped from 13% to 3% and the staff vacancy rate has dropped from 54% to 18%. Overall, the department scored so well on their 2015 Employee Engagement survey that their results earned them a Tier 1 rating, indicating that minimal action planning was needed to increase engagement.

To evaluate progress toward engagement goals and sustain improvements, the organization pairs the Employee Engagement survey with the National Database of Nursing Quality Indicators (NDNQI®) survey to measure job satisfaction and evaluate the practice environment, and it conducts midyear surveys to determine ahead of the next Employee Engagement survey whether the staff is on track to achieve their goals.

Strategies to Reengage

According to Freeman, the Employee Engagement survey results drew a clear picture of staff members’ attitudes toward the organization as a whole and their managers in the ED, as well as their feelings about their jobs, their co-workers’ performance and their work unit’s performance. Freeman and the assistant directors were able to use this information to devise a creative action plan that has helped reengage the staff.

To increase survey participation, for instance, the engagement team set up within the department a group of booths, similar to voting booths, where staff can take the survey, along with a schedule where staff can volunteer to cover for their co-workers. “They had indicated they didn’t take the survey because they couldn’t access it from home and were too busy to complete it at work,” Freeman said. “This makes it easy for them.”

Through the practice of Shared Governance, staff members have a voice in administrative matters, thereby empowering them to be more engaged with the department and the organization. A peer-elected Shared Governance Council consisting of front-line leaders conducts activities designed to increase employee engagement and reviews staff suggestions. “Previously, if a staff member wanted to suggest a change they felt would improve the work environment, they didn’t know who to go to or, if they did find someone, what became of their suggestion,” Freeman said. “The engagement survey results indicated they wanted to know they’re being heard and that they play an important role in our decision making.”

So, in the staff lounge, a board was hung with a graphic on it that resembles a highway. Staff members attach to the board slips of paper onto which they’ve written problem and solution sets. The Shared Governance Council selects those that best meet the department’s needs and tries the solutions for 100 days.

According to Freeman, this has driven numerous positive results. “For example, this is how we reduced mislabels of blood specimens to zero,” she said. “An employee submitted an idea to keep the labels at the bedside so that they remain with the patient at all times, thus reducing distractions. We tried the solution for 100 days, and it worked.” Additional changes include a return to team nursing, more clearly identifying where pulse oximeter cables should go for recycling and ensuring that trash cans in patients’ rooms have lids to shield the contents from view.

Additional solutions that have been spearheaded along the engagement journey include the following.

  • The development of a Mission Control Team comprising ED front-line leaders and the Shared Governance chair. Each leader takes ownership of their goals by creating action items to support improvement, and the team meets monthly to share progress and discuss barriers they may be facing. Administration attends these meetings to provide resources, help the team overcome barriers and monitor success.
  • The formation of Executive Listening Cafes in which hospital executives meet with staff informally to discuss staff concerns.
  • Celebrations of staff performance milestones, patient saves and individual accomplishments.

For 2016, Freeman set goals of 90th percentile for employee engagement and 90% for survey participation, and she says the staff members are well on their way to achieving them. “In January, patient satisfaction was in the 92nd percentile, so I know they can do this — they’re that good,” she stressed. “And it’s because they’re highly engaged and truly invested in their jobs now.

“Employee engagement is about ownership,” she concluded. “They own their team, not me. And that’s the way it should be.”