Introducing Rapid Change Escalades to Adjust Organisational Issues in Clinical Practice

Background: Running clinical facilities implies facing many challenges, as neat time management and fluid care processes. A method that warrants small changes and an interconnected and collaborative proceeding is convenient for adjusting clinical processes and avoiding unwanted side effects. From an organizational perspective, a smooth clinical process translates also into a levelled occupation of team members as reflected by over-time and absenteeism. Methods: The policlinic nurse team introduced weekly mini-huddles of maximum 15 minutes to discuss work organizational issues, with structured access to collaborating professionals and their hierarchies. The team selected the topic of patients presenting without a planned appointment. Nurse’s over-time stock and absenteeism were assessed before and after the intervention. Results: The clinical process had six steps, of which the patient’s waiting room period was transformed into a nurse’s evaluation and triage period followed by a transmission note to the physician. The new process decreased the average stock of nurse’s team over-time from 65.5 to 46.8 hours (-29%), and the nurse’s absenteeism from 4.6 % to 1.97 % (-57%). Conclusion: By cautious and collaborative proceeding, and the choice of an earnest issue by front nurses, we levelled the nurse’s workload and pleased patients and professional teams.


Introduction
In hospital organizational terms, timely and smooth patient management is not only reflected by patient's satisfaction, but also by employee's satisfaction as they are concerned about resource utilisation, unnecessary waiting imposed to patients, difficulties in transmission, and availability of colleagues [1][2][3][4]. This satisfaction bounces back to the teams, influences its overall well-being end efficiency, and therefore deserves careful attention, often unfolding over time [5][6][7][8][9][10][11][12][13][14]. Enthusiasm for organizational change is often present, especially if the targeted improvement is well defined. Eventually, success of implementation and obtained results are often lagging behind initial intentions [15][16][17][18][19][20]. This reality is linked with the complexity of hospital systems with their numerous interfaces and interstations in the patient's journey, and common pitfalls inherent to a project life cycle even independent of the hospital setting [12,[19][20][21][22][23][24][25][26]. Different redirections, as the publication of new protocols and standards, or new legislative requirements, add a permanent source of perturbations to an organizational change process [27]. Hence, exploring swift robust ways of achieving dextrous and lasting adjustments of clinical organization is mandatory or recommended [18,19,[28][29][30][31][32][33][34]. Our goal was to experiment with an organizational change practice that would take little time and effort for the team when attempting to improve a collaborative patient care process.
The focus of this article is not the content of the clinical change itself, but the economic and sustainable way by which dissatisfaction was addressed and a transfer of physician's responsibility to nurses was achieved in a short lap of time. The local problem worked concerns the organization of care given to non-scheduled patients that arrive at the outpatient clinic in a prompt but not vital need of care.

I Clinical Unit
The clinical unit is part of the ENT department, which in turn belongs to our tertiary teaching hospital's surgery department. The outpatient section of the ENT clinic has a volume of 15312 annual patient visits. A dedicated nurse team assists physicians during outpatient visits in the policlinic and has an activity of its own (2600 visits per year), for example for post-surgery care like removing stiches or changing bandages. This nurse team is attached to a chief nurse directing three policlinics in the surgery department.

II Team and Approach
The entire nurse team is composed of a head nurse, two staff nurses, two nurse assistants, partially two nurse students, and all participated in the mini-huddles. The huddles focussed on follow-up of ongoing change initiatives or the discussion of new issues. There was, for example the distribution of tasks for treating an issue: determining who is collecting which data, who is going to contact another member of the policlinic. The huddle is animated and concluded by the chief nurse or head nurse but otherwise very democratic as any nurse staff member was equally invited and active to propose and discuss. The policlinic's team of secretaries and the ENT clinic physicians were not involved on a regular basis but solicited occasionally (see section "project phases"). The trial was accompanied by an expert in operation management and process (OMP) improvement. The head of the ENT clinic, the chief nurse as well as the head of ENT clinic administration gave their consent, adhesion and support throughout the trial. Care was taken to keep the head of secretaries' team and the chief nurse informed by informal quick exchanges. The head of ENT clinic was formally contacted three times, once for approving starting the trial, once for presenting the solution and requesting approval of its application, and once for presenting the results. The head of ENT clinic ensured that physicians be informed about the existence of the nurse's trial. The final version of the new document that became part of new patient care process was shared with whole administrative (via the head of administrative team) and physician's team (via the referent physician). Since the whole nurse team participated, no further communication effort was necessary.

III Project Phases
The very first nurse's mini-huddle took place in November 2018. The first few weeks were devoted to assimilate the principles, figure out its mechanisms, and get some practice by making the first improvement actions concerning mostly the nurse's team only. The trial described in this article was the first improvement action of a large scale since it implied the involvement of two other professions, the administrative team of the outpatient desk and the physician's team (Table 1). This trial was the largest however, only one amongst other initiatives treated by the nurse team in the mini-huddles. Since the beginning of the nurse mini huddles, 25 initiatives were undertaken, and 14 of them finished by now.

IV Clinical Process
The old process had two main problems ( Figure 1). [1] When the patient arrived at the desk, the physician on-call was informed. The delay until arrival of the on-call physician regularly created important waiting time for the patient, for example when the physician was in the operation theatre. [2] It regularly occurred as well that several patients were presenting without appointment. The physician on-call had to spend time upon his arrival for the patient assessment in order to decide which patient should be seen first.   The clinical process after the intervention. The nurse involvement was split into "Nurse evaluation", placed before the physician on call arrival, and "Nurse care" to carry out the doctor's advice and prescriptions. Nurse evaluation was completed by a patient triage. A newly created triage transmission sheet was exposed in the nurse's office and was consulted by the physician on call on his arrival. This sheet provided a rapid assessment and helped to prioritise between often multiple patients present.
Two adjustments of the process were undertaken, responding to both main problems of the process (Figure 2). i) Upon patient arrival, in addition to the physician on-call, the nurse team was also informed. Rapidly, a nurse or nurse assistant went to see the patient, assessing the patient. ii) The patient information to be collected and the criteria for patient triage were agreed with the referent physician beforehand and settled on a triage document to be used. These triage sheets were a new element introduced through this process adjustment. The sheets were attached to the wall in the nurse's office and clearly marked with order of priority. At his arrival, the physician on-call went to the nurse's office to fetch the triage sheets, run through them to confirm (or revise) the order of priority and then address the patient of first priority. As a result, the nurse's work part was cut into two pieces, allowing them to execute their autonomous nurse evaluation before the arrival of the physician (instead of after the physician visit). The triage of patients as a result of this nurse evaluation was new item to this process. The second part of the nurse's work was after the physician's visit and was done as before the intervention. Thus, the duration of nurse's intervention did not really change, but the part of the nurse work that is independent from the physician's appreciation of the patient was displaced forward in time and allowed the nurses to finish their day earlier (that means without creating over hours).

V Measurement, Data Processing and Outcomes
The following data were collected: overall nurse's clinical activity volume (number of patient visits), unplanned clinical activity volume (number of patients presenting without appointment), stock of over-time (number of hours remaining at the end of the month after compensation leaves), rate of absenteeism. Nontangible appreciation and collaborator satisfaction and patient complaints expressed at the desk or to nurses was collected by staff interviewing.
The quantitative analysis of clinical activity volume, stock of over-time hours and rate of absenteeism from January through May 2019 provided a baseline value. The period of June through December 2019 was used to evaluate the impact of the intervention (post-intervention process). All consecutive patients presenting without appointment at the ENT policlinic were included. The primary outcome measure was the average rate of absenteeism, in percent. The secondary outcome measure was the stock of over-time, and team's appreciation.

Results
Patients may present from Monday through Friday. A total of 2600 patient visits with nurse involvement were included (1011 visits from January to May 2019; 1589 visits from June to December 2019). Of those, 285 visits and 417 visits, respectively, were patients presenting without an appointment. This corresponds to an average of 57 and 60 visits per month, respectively, a 5% increase between the two periods.
The intervention was well prepared during two weekly mini-huddles, of which the chief nurse was invited to the second one. The involvement of the two other collaborating professions could be limited to one meeting with the head of administrative team, one meeting with the referent physician followed by three emails settling the triage sheet and procedure, and a quick exchange of the nurses with the administrative team to decide on practical issues. The administrative team checked the proposition for problems in one of their weekly mini-huddles.
Team satisfaction increased in all professions. None of the professional groups did encounter any difficulty with the new procedure. The administrative team occupying the outpatient desk and overviewing the waiting area had to deal with fewer patient reclamations. Nurses much enjoyed patient's appreciation of the nurse's expeditiously assessment and care on patient's arrival. Patients had practically no waiting time upon their arrival. Nurses could finish part of their job before the physician's assessment, be anticipative and were therefore less occupied after the physician's assessment, where they merely executed physician's orders. By this forward shift of the nurse's occupation, they were able to finish their day with fewer over-time hours, which in turn had direct positive feedback on the entire nurse team. Physicians appreciated the nurse's patient evaluation and triage, availability of needful information and nurse's anticipative actions.
With the new process, the accumulated average stock of over-time hours decreased by 30% and the average rate of absenteeism by almost 60% (Figures 3 & 4). The weekly mini-huddles were continued all along the trial and thereafter. No further adjustment of the process was necessary, and the new procedure was quickly adopted.

I Statement of Principal Findings
We successfully experimented with an organizational change practice that would take little time and effort for the team when attempting to improve a collaborative patient care process.

II Interpretation within the Context of the Wider Literature
To the best of our knowledge, there is no report on a method of quick improvement measures that are universal and robust enough to apply to the whole hospital context, to detailed process analysis and improvement, handling chained initiatives as well as introducing change across different professions [18,20,29,[35][36][37]. Grimshaw et al. stated in his work "that despite 30 years of research in this area, we still lack a robust, generalisable evidence base to inform decisions about strategies to promote the introduction of guidelines or other evidence-based messages into practice" [28]. That was in 2004, and progress has been made, like Braithwaite's call for considering complexity science and UK NHS member's efforts to engineer better care in 2017 [24,31,[38][39][40].
We reported a deep interprofessional process analysis on discharge letters earlier, where the focus was on finding root causes for a broken process and to come up with new ideas to remedy it across professions [41]. The presented case was successful and of larger scale, asking for the determination of a project team to work on the discharge letter process.
Here, we tried a method involving the whole team and solving relatively easy but important issues. We abstracted the idea of discussing organizational issues during the daily clinical huddles to dedicating a mini-huddle once a week to organizational issues. It is embedded into the possibility of escalading for a structured access to chiefs and heads of other professional groups [42]. This ensures to keep simple and treat matters at their organizational level within respective circle of autonomy and to have easy and defined access to next organizational level in case the matter exceeds own team or unit decision level. This approach recognises the complexity of even small organizational changes and is open to interaction with any profession in the hospital or central services. The importance of decentralisation was pointed out by West et al., and of leadership at all levels by Ferlie et al. [21,43]. We also paid much attention to regularity and to not to exceed 15 minutes. The regularity ensures a follow-up and that processes are not forgotten in the speedy daily business, and the respect of 15 minutes duration cheers adhesion to the habit [37]. By now, these mini-huddles processed twenty matters in the nurse's team and twelve in the administrative team, most of them being already completed.
Generally, an improved interprofessional collaboration and team dynamics was perceived and appreciated. Patient management, clinical reasoning and decision making as well as well-defined roles are the core of nurse-physician collaboration [44]. They found good support through this initiative and helped the team to move forward and experience common goal setting [45,46]. This improvement action needed no further attention and both nurses and administrative team discussed other matters during their weekly mini-huddles. The way of proceeding by mini-huddles and selective meetings was well accepted because subjects were prepared, information transparent and profession's responsibilities respected. Trust was built through this proceeding, and residents adopted the new procedure quickly, even though only their referent physician was actively participating in the development of the triage sheet. Chiefs and teams were easily accessible to each other. Launching the system of mini-huddles in nurses and administrative team facilitated their interprofessional exchanges and collaboration for organizational issues. This was helpful for responding quickly and keep control.
The habit of the mini-huddles might have helped the nurse team absorb two realities: i) an increase of five percent in the clinical work load related to increased number of patients, and ii) the departure of the head nurse at the end of October 2019 due to evolving professional plans. For a transitory period, the nurse team remained without formal head for the rest of the trial, due to the delayed arrival of a new head nurse for administrative reasons. Nurse team was staffed with a new nurse, who arrived in December 2019. The nurse team had the possibility to address issues related to this change during this mini-huddles, especially because the chief nurse participated every second week.
As an outlook, it will be worthwhile to close the quality circle loop and manage the new process as a procedure by revising, updating and archiving. After streamlining a few more organizational issues, thereby saving some time, such task may be attributed to one member of the nurse's team. Another desired evolution would be extending the minihuddle's habit to the physicians. For the moment they do not have a minihuddle of their own, but are readily available for requests from nurse or administrative staff as shown in this example.

III Strengths and Limitations
A strength of the presented study is its real-life character. From the early beginning, the initiative was run as a new current activity of the team, and not as a 'project' having a beginning and an end. Accountability and organization of emails, meetings and documents was carried by the team and not by the accompanying expert.
A limitation of this study is that we did not formally assess the level of satisfaction of patients and staff, as is sometimes requested for approval of the introduction of a permanent change at the end of an improvement project [47]. We had no available time. As patient's and staff's satisfaction were however rather evident, we decided not to investigate further this fairly complex domain [48][49][50][51][52]. Staff's satisfaction was backed by their wish to continue mini-huddles because they achieved real change, promoting interprofessional collaboration and giving them a voice.
Evidently, absenteeism is a multifactorial phenomenon and hardly depending on a single intervention. Here we have however indications that make confident to associate the positive effects to the huddles and the intervention. The combination of evident staff satisfaction, the stock of over hours that fell the spite that more work was done over the year, the absorption of additional issues related to the rotation of medical staff, overcoming the departure of the head nurse that was not replaced (and that was known), the lack of other interventions that could contribute to the result and the weekly accompaniment during more than a year of the small team give rise to thoughtful interpretation and appreciation of the results.