Continuous Quality Improvement

Case study: Barriers to an Effective QI

District Hospital is a 260-bed, public, general acute care hospital owned by a special tax district. Its service area includes five communities with a total population of 180, 000 in a southeastern coastal state in one of the nation’s fastest growing countries. It is one of the three hospitals owned by the special tax district. The seven other hospitals in District Hospital’s general service area make the environment highly competitive

District Hospital has a wide range of services and a medical staff of 527 representing most specialties. The emergency department (ED) is a major source of admissions. Last year, 26,153 patients visited the ED and 3,745 or 14.3% were admitted. This was 42% of total hospital admissions. Some admissions were sent to the ED by private physicians, and some came by ambulance, but most were self-referred.

The hospital chief executive officer, W.G. Lester, noted that the number of visits to the ED was decreasing. Over a 3-year Period, they had declined from a high of 29,345 to the current low of 26,153. Only part of this reduction seemed attributable to competition. Lester was also concerned about an increasing number of complaints concerning the quality of ED services. The complaints related to waiting time, poor attitudes of physicians, and questions about the quality of care. Investigation found that many complaints were justified, but the causes of these problems were difficult to discern.

Register nurses (RNs) employed in the ED want a larger role in triaging and treating patients, but the dominance of ED physicians limits the RN’s duties and frustrates other staff, as well. This is manifested among RN staff by high turnover, low morale, and difficulty in recruitment and retention.

Another factor is the emergency medical technician (EMT) program started in the county few years ago. The EMTs are an important community medical resource and are very influential in deciding the hospital to w...