Unprecedented times in the emergency department: are "board rounds" and leadership the missing links to improve patient flow?

Abstract

Purpose: National Health Service (NHS) Emergency Department (ED) attendances are at the second highest level ever recorded, (RCEM, 2021a) and as they soar, performance plummets, putting patient safety at risk (RCEM, 2021b). Managing patient flow in the ED is critical to reduce patient safety incidents and crowding, however, this needs effective leadership (Jensen and Crane, 2014). This paper aims to introduce an innovative form of managing patient flow in ED, which is a two hourly "Board Rounds", providing a managed process to pull patients through the system meeting pre-determined time critical standards and preventing patient harm. Board Rounds combined with effective leadership can play a contributory role preventing crowding in the ED.

Design/methodology/approach: An evaluation of two hourly ED Board Rounds was undertaken using the hospitals' ED Board Round Standard Operating Procedure to develop a series of short questions. As leadership is the responsibility of all clinicians (Darzi, 2008; Moscrop, 2012), a separate survey was undertaken for clinicians of all grades and managers to self-assess their own leadership styles using the Path-Goal Leadership Theory (House and Mitchell, 1974; Indvik, 1985; Northhouse, 2013). Findings were reported to the team to explore ideas for improvement not only to develop more effective leadership in the ED but also to raise awareness of how to optimise leadership in Board Rounds.

Findings: In total, 27 (n = 27) clinicians and managers reported support for a 2 hourly Board Round, for a period of 15 min, in both minor and major injuries departments in ED. A multi-disciplinary Board meeting, led by the lead nurse with support from the Emergency Physician in Charge, was preferred, locating it at the nurse's station. A validated Path-Goal Leadership survey instrument was returned (n = 24). The findings reveal that leaders and managers are using a high level of the directive leadership style, where there is more potential to use the supportive, participative and achievement approaches to leadership.

Research limitations/implications: This was a small sample, returned from a Hospital ED located in a semi-rural location, department requiring "improvement" from the Health Regulator. This research would benefit from being undertaken in a medium/large NHS ED department to identify if the findings report on a wider leadership culture in the NHS ED. The implications for this study are that improvement interventions such as a "Board Round" can be usefully evaluated alongside a review of leadership styles and approaches to understand the wider implications for continuous improvement and change in the ED.

Originality/value: NHS EDs are facing unprecedented challenges and require innovative evidence-based solutions combined with leadership at this time. The evidence base for improving patient flow is limited, however, this study provides some initial findings on the positive perception and experience of staff to Board Rounds. Board Rounds combined with leadership has the potential to contribute to the wider strategy to prevent crowding in ED. This paper is the first of its kind to evaluate perceptions of Board Rounds in the ED and to engage clinicians and managers in a self-assessment of their own leadership styles to reflect on optimum leadership styles for use in ED.

Keywords: Board round; Doctors; Emergency department; Leadership; Path-goal theory; Patient flow.