Name
Western Governors University
D226 BSNU Capstone
Prof. Name
Date
This document addresses the first task of the BSNU Capstone Course by presenting a detailed healthcare change proposal aimed at improving operations within the emergency department of Mike O’Callaghan Military Medical Center (MOMMC). The proposal identifies an organizational sponsor who will review and approve the suggested changes. It incorporates feedback from the sponsor, evidence-based rationale, and explains how the proposed change will enhance value-based care delivery. Additionally, the paper outlines key stakeholders, provides a structured implementation plan, and concludes with a personal reflection on the author’s role as a change agent throughout the process.
The change proposal targets Mike O’Callaghan Military Medical Center (MOMMC), a military hospital under the Defense Health Agency (DHA) and the Department of Defense (DoD), located at Nellis Air Force Base in Las Vegas, Nevada. The author is a civilian contractor and registered nurse working in MOMMC’s emergency department.
MOMMC’s emergency department consists of twenty beds and two trauma bays, staffed by a multidisciplinary team comprising military personnel, civilians, and contractors. This team includes doctors, nurses, medics, and administrative staff. Although the hospital primarily serves military members and DoD beneficiaries, its Trauma Level III designation has led to increased emergency transports from the surrounding civilian community.
Staffing at MOMMC is generally stable due to the blend of personnel, but temporary shortages occur when military staff are deployed. Civilians and contractors represent about 40% of the emergency department workforce, providing continuity during these periods.
What is the current process for patient registration in the emergency department?
At present, patients check in at the front desk of the emergency department, where two registration technicians perform full patient registrations before triage occurs.
What change is being proposed?
The proposal recommends relocating registration technicians to the back of the emergency department to handle unit clerk and registration duties. At the front desk, a medical technician and a registered nurse would replace them, responsible for rapid patient registrations and immediate symptom assessments.
What is the purpose of this change?
The main goal is to reduce the door-to-EKG time, particularly for patients presenting with symptoms indicative of ST-Segment Elevation Myocardial Infarction (STEMI). Currently, the non-medically trained registration staff delay symptom recognition and timely EKG acquisition, which should ideally be completed within 10 minutes according to national guidelines. By positioning medically trained personnel at the initial patient contact point, the change aims to accelerate symptom identification and treatment initiation, thus improving outcomes for high-risk cardiac patients. Meanwhile, registration technicians will concentrate on their strengths in administrative responsibilities.
| Aspect | Current State | Proposed Change | Expected Outcome |
|---|---|---|---|
| Staffing at Front Desk | Two registration technicians | One medical technician and one RN | Faster symptom recognition and quicker EKGs |
| Door-to-EKG Time for STEMI | 40%-60% compliance within 10 minutes | Target 100% compliance | Improved patient outcomes and accreditation |
| Patient Flow | Delays due to non-medical staff | Streamlined registration and triage | Enhanced throughput and patient satisfaction |
| Role of Registration Technicians | Full patient registration | Back-end registration and admin support | Better alignment with staff expertise |
According to the American Heart Association and the American College of Cardiology, a 12-lead EKG should be performed within 10 minutes of arrival for patients presenting with chest pain or cardiac symptoms (Dechamps et al., 2016). Coronary artery disease causes approximately 500,000 deaths annually in the United States (Butt et al., 2020). Aligning personnel capabilities with clinical priorities through this staffing modification is expected to promote timely care, potentially lowering cardiac morbidity and mortality.
Brian Hubbard, RN, BSN, MPA, was selected as the organizational sponsor due to his extensive experience as an ICU nurse, cardiac catheterization nurse, and nursing supervisor at MOMMC. He emphasized the critical role of data-driven decision-making and acknowledged challenges related to staffing.
Mr. Hubbard recommended implementing a 60 to 90-day pilot period to trial the new staffing model before making permanent changes. This period would require nurses and medics to work an additional 1-2 shifts monthly, which may encounter resistance.
He highlighted the necessity of engaging staff early in the process, communicating the benefits focused on improved patient care and sustainable staffing practices to gain their support.
| Barrier | Description | Mitigation Strategy |
|---|---|---|
| Staff Resistance | Increased work hours and training demands | Transparent communication, education on patient benefits, and staff involvement in planning |
| Administrative Resistance | Reluctance from DoD and DHA to increase staffing | Use of statistical evidence and accreditation requirements to justify changes |
| Skill Gaps | Lack of familiarity with rapid registration | Targeted training programs and ongoing support |
Staff buy-in is essential for overcoming resistance. Providing education that emphasizes improved patient outcomes and compliance with regulatory standards will be critical to success.
This proposed change advances value-based care by fostering interdisciplinary collaboration to improve outcomes. Placing medically trained staff at the initial point of contact facilitates:
Reduction in door-to-EKG times for STEMI patients
Enhanced early recognition and intervention during emergencies
Improved patient throughput and overall satisfaction
This approach benefits all emergency department patients by minimizing wait times and ensuring timely treatment initiation.
| Stakeholder | Role |
|---|---|
| Staff Nurses and Medics | Implement the change and provide patient care |
| Registration Technicians | Manage registration and administrative duties |
| Emergency Room Nurse Manager | Oversee nursing operations and staffing |
| Emergency Department Medical Director | Provide clinical oversight and guidance |
| Registration Director | Manage registration processes |
| Chief Nurse | Provide nursing leadership and resource support |
| Hospital Commander | Authorize organizational resources |
| Staffing Chief | Approve staffing document changes |
Monthly meetings will be held to monitor progress, review data from the Genesis charting system, and address staff feedback. Metrics such as door-to-EKG times, length of stay, and patient satisfaction will inform ongoing decision-making.
This plan leverages existing internal resources such as management, charge nurses, and staff cooperation. Since military personnel are not paid hourly, adjusting staffing roles will not increase payroll expenses. No additional external funding or resources are required.
| Phase | Description |
|---|---|
| Planning | Engage stakeholders continuously and finalize the proposal |
| Milestones | Collect weekly and monthly data on door-to-EKG times and patient flow |
| Implementation | Roll out after briefing staff and training on rapid registration |
| Evaluation | Continuously monitor data with a 90-day review to validate staffing changes |
Ongoing monthly evaluations will ensure sustained improvement and inform future adjustments.
| Outcome | Description |
|---|---|
| 100% Compliance | All eligible patients receive EKGs within 10 minutes |
| Improved Patient Outcomes | Faster treatment reduces complications |
| Increased Patient Satisfaction | Reduced wait times improve patient experience |
| Financial Benefits | Higher civilian patient volume may increase revenue |
| Accreditation Maintenance | Meets or exceeds chest pain center standards |
The proposal aligns with nursing ethical principles, including nonmaleficence (avoiding harm) and fidelity (commitment to patient care).
The Genesis electronic charting system will be crucial for tracking door-to-EKG times and other key performance metrics in real time. Data-driven success stories can be used to enhance internal communication and support community outreach efforts aimed at increasing patient utilization.
Success will be evaluated through:
Continuous improvement in clinical performance metrics
Patient satisfaction feedback regarding registration and care processes
Staff morale and acceptance of new workflows
Positive staff engagement is vital to cultivate a culture of compassionate care and ensure the sustainability of the proposed changes.
With over two decades of emergency nursing experience, the author identified critical gaps impacting patient care and leveraged clinical expertise alongside best practices to propose a viable solution. Acting as a change agent involves using professional credibility, evidence-based rationale, and collaboration with stakeholders to advocate effectively for improvements that enhance patient flow and outcomes.
If successful, this staffing model and rapid symptom recognition protocol could be adapted across the Department of Defense healthcare system. This model may become a standard for enhancing emergency cardiac care in other military treatment facilities, thereby improving patient outcomes and operational efficiency on a national level.
Butt, T. S., Bashtawi, E., Bououn, B., Wagley, B., Albarrak, B., Sergani, H. E., Mujtaba, S. I., & Buraiki, J. (2020). Door-to-balloon time in the treatment of ST segment elevation myocardial infarction in a tertiary care center in Saudi Arabia. Annals of Saudi Medicine, 40(4), 281–289. https://doi.org/10.5144/0256-4947.2020.281
Dechamps, M., Castanares-Zapatero, D., Berghe, P. V., Meert, P., & Manara, A. (2016). Comparison of clinical-based and ECG-based triage of acute chest pain in the emergency department. Internal and Emergency Medicine, 12(8), 1245–1251. https://doi.org/10.1007/s11739-016-1558-8
