Dear Director,
Our ED patient flow is not working, and we cannot keep up with our patient arrival and disposition patterns. This has resulted in extended patient wait times and an increase in our LWBS rate. How can we implement sustainable changes to our processes while not overwhelming our staff or compromising quality and/or safety?
Although the ER never sleeps, and the administrative responsibilities rarely slow down, I hope you had the opportunity to enjoy the energy and excitement of the Paris Olympics. Athletes, each at the peak of their physical and mental abilities, came together from across the globe, prepared to put their years of tireless training and preparation to the test. As I watched both the individual and team events, I thought about the similarities between ED operations and Olympic events where every second counts, and every decision impacts the outcomes.
In some cases, as in a sprint event or a cardiac arrest, time is of the essence and alternate approaches and change needs to occur almost instantaneously. In other cases, such as responding to administration’s ‘request’ to develop a performance improvement plan to reduce ED length of stay and improve patient experience scores, change is best implemented incrementally, over time as if competing in the triathlon. Implementing small changes along the path to improvement and reaching the goal is at the core of the Rapid Cycle Testing method of performance improvement.
What Is Rapid Cycle Testing?
Rapid Cycle Testing is a performance improvement tool to help teams make small but meaningful changes quickly and efficiently. It’s a process where you test a new idea on a small scale, see how it works, make adjustments, and then test again. The cycle then repeats, with consideration given to successes, barriers, and other factors you would like to do differently. This repeat of the PDSA cycle allows for continuous improvement through quick feedback and adjustment leading to the team finding the best solution.
Key steps in rapid cycle testing:
A good starting point is to answer three questions:
1) What do we want to accomplish?
2) What changes can we make to result in an improvement?
3) How will we know an improvement has been made?
Healthcare has historically used the PDSA methodology of process improvement, and that model can serve as an effective strategy to facilitating effective change.
Plan: Identify the problem, define the goals, and plan a small-scale test based on your expected outcomes and predictions.
- Communicate the purpose of the test and the expected benefits
- Determine all stakeholders (ancillary departments) who may be impacted during the test of change. Include them on the change team and develop a mechanism to keep them informed of progress during the test
- Create consistent vernacular among the change team to optimize communication
- Brand your change initiative with a compelling, motivating moniker and visual symbol to represent what you wish to achieve
- Flowchart the change process and develop standard work documents
- Obtain baseline data and create data collection forms
- Develop roles descriptions and educate personnel to their roles and the roles of others on the change team
- Identify an appropriate date and range of time for your test
- Gain endorsement of the plan from your Executive Sponsor
- Anticipate resistance and develop talking points to respond to nay-sayers
- Schedule a follow up meeting to review data, identify successes, and review/respond to obstacles
Do: Implement the change on a small scale
- Follow the plan as it has been outlined, minimizing ad hoc changes
- Observe objectively and support operations
- Ensure compliance of the change team based on their assigned roles and responsibilities
- Monitor for patient safety issues that may require ad hoc changes to the plan (communicate any ad hoc changes throughout the change team and the rationale for altering the plan)
- Provide ongoing emotional and resource support for the change team members and other staff that may be affected by the test
- Provide positive reinforcement and encouragement
Study: Collect
- Analyze with a critical eye to avoid misinterpretation with an awareness of the limitations of your data (sample size or external variables)
- Ensure that conclusions are backed by statistically significant evidence.
- Determine if the data have moved in the direction you were anticipating
- Identify and discuss breakdowns in flow, communication, compliance, resources, etc. and the cause and effect of these breakdowns
Act: Determine your next steps based on your new knowledge and analysis of whether the change was beneficial.
Based on what they learn, the team decides whether to keep the change, tweak it, or try something different.
- Adopt – Document the changes and their effects by updating your data charts and determine if you are ready to incorporate the change into your standard work.
- Adapt – Establish what should be done differently in your next testing cycle
- Should the scope of the test be decreased/increased?
- Do steps need to be eliminated/added?
- Should the test be carried out under different conditions?
- Different time of day/day of the week
- Using different staff members
- Abandon – only if adoption or adaptation is impossible due to unresolvable resource constraints or if patient safety will be compromised
Again, using the PDSA model, the change cycle begins again
Characteristics of Rapid Cycle Testing
Speed and Efficiency
One of the most exciting aspects of rapid cycle testing is how quickly you can see improvements. Imagine being able to try out a new approach today and see meaningful results within days or weeks. In the ED, it’s not about gold medal speed although speed is a crucial element. Rapid cycle testing helps the team make quick, small changes to improve efficiency. By testing new ideas on a small scale, they can see what works best and implement those changes rapidly. Testing can be as simple as making one intervention in one nursing zone for a four-hour window with a pre and post interval evaluation.
Continuous Improvement
A continuous improvement mindset is central to rapid cycle testing in the ED. The team doesn’t just make one change and call it a day. Instead, they’re constantly looking for ways to refine their processes. One intervention will likely not solve your issue. It’s a combination of interventions that will drive improvement over time.
Teamwork and Collaboration
Change is a team sport, and it requires front line players. When you involve staff in the process of testing and refining changes, it creates a sense of ownership and engagement. People are more likely to buy into changes that they’ve had a hand in developing. This not only improves the likelihood of success but also fosters a culture of continuous improvement, where everyone is always looking for ways to do things better. where the entire team works together seamlessly to achieve their goal. Success is dependent on inclusivity, communication, and each team member understanding their roles and the roles of other team members
Training and Preparation
ED caregivers and athletes spend years training, preparing, and honing their skills. They study their craft, learn from their mistakes, and practice relentlessly. Build a strong foundation by assuring that your staff is well-trained and ready to adapt quickly when new changes are tested.
Adaptability and Resilience
New challenges emerge, technologies evolve, and patient needs shift. With rapid cycle testing, you can quickly adapt your approach to meet these changes. It’s not a rigid process; instead, it allows for constant adjustment and fine-tuning based on what’s happening in the real world allowing the team to quickly test and implement new solutions as situations evolve.
Ad hoc changes during a test of change are discouraged. Deviating from the plan and making ‘on the spot’ changes usually results in miscommunication, frustration, and inefficient use of resources. Rather, make sure that the change team and observers make note of challenges and opportunities during the test and address them in subsequent tests.
Evidence-Based Decisions:
In healthcare, decisions must be grounded in evidence. Rapid cycle testing ensures that every change is backed by data. Each cycle involves collecting and analyzing data to see if the changes are actually making a difference. This way, you’re not relying on hunches or assumptions but making informed decisions based on real-world evidence.
Cost-Effectiveness:
Implementing a large-scale change can be expensive and time-consuming. Rapid cycle testing, on the other hand, is generally more resource-efficient. Because you’re testing on a small scale first, you’re not committing large amounts of time, money, or personnel to changes that might not work.
Scalability:
Once a change has been proven effective on a small scale, you can feel more confident about rolling it out on a larger scale. This step-by-step approach helps prevent the kinds of large-scale failures that can occur when untested changes are implemented across an entire organization.
A word of caution…. just because a change works well in a small test doesn’t mean it will automatically succeed on a larger scale. The broader context might introduce new variables that weren’t present in the initial test, thus the importance of validating findings and making necessary adjustments before rolling out changes more widely.
Iteration and Refinement
“Tradition is the illusion of permanence” according to Woody Allen. Athletes don’t reach the top by doing the same thing over and over again. They go through various cycles of training and refining their techniques. Your ED change team must follow a similar pattern of planning and implementing a change, making revisions, studying the results, and then refining the approach based on what they’ve learned. As the process repeats over and over, each successive cycle brings your team closer to the best possible solution.
Balancing Risk and Reward
Athletes often have to make tough decisions about how much risk to take. A gymnast might attempt a more difficult routine for a chance at a higher score, knowing that the risk of failure is also greater. The key is to find the right balance between pushing the limits and playing it safe.
In the ED, balancing risk and reward is a daily challenge. Implementing a new process can lead to significant improvements in patient care but carries the risk of unintended consequences. Rapid cycle testing helps manage this balance. By allowing the team to test changes on a small scale, they can minimize risk while still aiming toward better patient outcomes.
Handling Pressure
Although the whole world isn’t watching, the expectations are sky-high. Lives are at stake; rapid cycle testing helps manage this pressure by breaking down the process into manageable steps. The team can focus on one change at a time, analyzing the results and making adjustments without being overwhelmed by the need for immediate large-scale changes, reducing the incidence of burnout and change fatigue
Learning from Failure
Failure will occur. It’s part of the game. Lest you give up and quit, consider your lack of success as wins nonetheless. As Henry Ford stated, “Failure is simply the opportunity to begin again, this time more intelligently.” If you are leading the change initiative, this philosophy is invaluable and must become part of the change team’s culture. Believing that, in failure you win by learning, your team will remain engaged and become even more innovative in future iterations.
Putting Theory into Practice
Once you have identified your improvement opportunity, whether it’s developing and implementing nurse-driven protocols during the triage process, innovating a means to initiate provider contact with patients more quickly upon arrival, optimizing physician efficiency by implementing waiting room medicine when your ED exceeds capacity, or developing a vertical care process to expedite the care of lower acuity patients, this structured methodology can guide your multidisciplinary team through the change process.
Consisting of key stakeholders including, at a minimum, physicians, advanced practice providers, nurses, aides/techs as well as personnel that may be directly impacted by the change, such as patient registration, radiology, laboratory, and other ancillary services, it is imperative that your change team understand the problem and goals, and agree that all members have an equal voice, regardless of title.
The role of the team’s facilitator, often an objective, outside source, is to consistently communicate the compelling vision to team members in terms of benefits to patient care and/or staff engagement. Although challenging, make sure to find value in the input from resistors and laggards–doing so will often convert the naysayers into your champions for change.
Meeting on a weekly basis, with the option to join virtually to optimize participation, helps to keep decisions, opportunities and barriers at front of mind. Providing agendas to team members prior to meetings and meeting follow ups/minutes is imperative to maintain the momentum and assure consistent sharing of knowledge and ideas.
Conclusion:
The need for change has no expiration date. There is a constant need to keep up with external pressures (population aging, technological advancements, regulatory initiatives and political reform) as well as internal motivations (financial, customer experience, patient safety, staff burnout, etc.).
Rapid cycle testing is a powerful tool for driving continuous improvement in emergency departments. By allowing teams to make small, data-driven changes quickly and efficiently, it helps create a more responsive, adaptable, and effective healthcare environment.
Its ability to deliver quick, data-driven results makes it an invaluable tool for driving positive change. By being aware of the potential risks and taking steps to mitigate them, organizations can harness the full potential of rapid cycle testing while avoiding common pitfalls.
Whether it’s reducing wait times, improving patient safety, enhancing communication, or managing resources, rapid cycle testing provides a structured approach to problem-solving.
Like any tool, it’s important to use it wisely. Success depends on careful planning, accurate data collection, and a willingness to learn from both successes and failures. It also requires a commitment to involving the entire team in the process and fostering a culture of continuous improvement.
