Strategies to Overcome Barriers and Leverage Facilitators in Implementation of a Quality Improvement Program in Emergency Departments


Nahid Rahimipour Anaraki, Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland

The implementation of effective quality improvement eHealth interventions in emergency departments (EDs) is challenging. Prior research has identified barriers and facilitators to the implementation of such interventions in the ED (i.e., management strategies, availability of key resources, the obvious need for change, etc.). However, prior research has often overlooked how to develop strategies to address these factors when implementing large-scale interventions in EDs. This study identifies a set of management strategies to guide the implementation of SurgeCon, an eHealth quality improvement program, in the dynamic environment of two rural and two urban EDs in Newfoundland and Labrador, Canada. SurgeCon aims to improve ED wait times and ED efficiency while ensuring high-quality patient care and enhancing clearer communication among healthcare providers. The implementation of SurgeCon involved changes throughout the ED, including: the installation of eHealth system, organizational restructuring, and the establishment of a patient-centered environment. We utilized semi-structured, in-depth interviews with 33 healthcare providers (e.g., physicians, nurses, managers), discussions with the implementation team involved throughout the implementation of SurgeCon in the four EDs and in the implementation at a pilot site, and structured observations of the EDs. An interpretive description approach was utilized to analyze the data. A set of seven management strategies to overcome barriers and leverage facilitators emerged from our analysis. 1- Train staff to cultivate engagement in the intervention. The SurgeCon implementation team developed a 4-hour FLOW Course to foster a holistic approach —an interactive simulation module to provide practical insights into connecting software to process improvement, an eHealth platform module to familiarize staff with the digital whiteboard application, and a patient centeredness module to reinforce core values related to patient care. 2- Appoint and train a dedicated frontline champion by ED management to act as a crucial liaison between staff and the implementation team, ensuring effective communication and ongoing support. 3- Continuously measure and report performance to improve the operational efficiency of EDs by offering meaningful data. Prominently displaying department-level data in the ED and providing individual performance reports to physicians, focusing on key performance indicators (KPIs) such as time to physician initial assessment (PIA), length of stay (LOS), and the rate of patients leaving without being seen (LWBS). However, post-COVID staffing shortages prompted changes in reporting protocols, as KPIs do not reflect staffing allocations and are inappropriately assuming ideal operating conditions. Providing individual physicians with performance reports may not offer a fair assessment in the presence of staff shortages, leading the implementation team to opt for aggregated department-level reports. The primary goal is to boost physician motivation to use SurgeCon. 4- Highlight successes. To motivate physicians, the research team highlighted the success of SurgeCons implementation in the pilot site, presenting it as a model for other sites. 5- Encourage engagement in the intervention. Executing interventions is a collaborative effort requiring dedication from all members. To encourage engagement, compensation, including full payment for attendance, travel, and meals, was provided for participation in training sessions and interviews. Additionally, refreshments in the form of snacks and beverages were offered at every training session. 6- Assign a clinical or non-clinical staff member to manually enter department-level data into SurgeCons cloud-based application to assess the level of busyness in the ED based on patient demand and availability of resources. The SurgeCon score that is calculated once an algorithm has analyzed all the inputted data provides a set of actions the ED team can carry out to improve patient flow. The data entry process takes less than a minute and collects information related to the number of patients, the level of acuity assigned to those patients, the number of patients with special care requirements, bed availability, staff shortages, among other relevant variables. 7- Employ demand and capacity analysis to optimize staffing models. The information collected through SurgeCon’s eHealth platform can be used to advocate for improved staffing levels during peak times of the day and week. This could come in the form of double physician coverage, the addition of a nurse practitioner to the team, or an increase in the number of registered nurses. This study expands upon current knowledge providing comprehensive management strategies to overcome obstacles and leverage facilitators when implementing quality improvement eHealth interventions in the ED.

Non-presenting authors: Holly Etchegary, Memorial University ; Meghraj Mukhopadhyay, Memorial University; Jennifer Jewer, Memorial University; Christopher Patey, Memorial University; Paul Norman, Eastern Health, Carbonear Institute for Rural Reach and Innovation by the Sea, Carbonear General Hospital; Oliver Hurley, Centre for Rural Health Studies, Faculty of Medicine, Memorial University; Shabnam Asghari, Centre for Rural Health Studies, Faculty of Medicine, Memorial University

This paper will be presented at the following session: