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Table 3 Full capacity protocol implementation barriers and recommendations to overcome those barriers

From: What is full capacity protocol, and how is it implemented successfully?

Barrier Recommendations
Inability to reach the consensus about the criteria for activation of and actions in each FCP level •Collect and analyze operational data to create a predictive model and patient flow map. A predictive model and patient flow map gives a hospital the opportunity to appropriately plan resource allocation and prepare to address patient flow variability. Adapt the criteria for activation of each FCP level based on hospital unique flow variation [31] and identified hurdles.
Lack of knowledge and information about FCP •Disseminate knowledge and train various stakeholders about the FCP. Hospital stakeholders should be aware of the protocol and their new operational responsibilities. For example, clearly defining that once an admitting physician has accepted a patient, that admitting physician is responsible for the patient throughout the admission, regardless of patient location.
•Key staff members such as nurse managers should be trained to participate in FCP implementation. These trained staff members can then become champions and coaches for others in the hospital.
Limited resources •Provide adequate staffing and resources to inpatient units. Some examples of resources necessary to successfully implement FCP may be central telemetry monitoring, privacy screens, a wireless call system, portable monitor/defibrillator, portable suction equipment, and appropriate bathroom facilities for transferred patients. Remember, “adequate staffing” is relative to the patient’s viewpoint. Moving a patient upstairs may yield less than optimal ratios; but it may improve patient satisfaction. Reorganize hospital resources (e.g., EHR modification), revise existing operational procedures, and/or create new structures in line with FCP.
Lack of leadership support and commitment •Ask hospital leaders to personally visit the ED to view the crowding first-hand.
•Tell a compelling story about what is going on with boarded patients and why they are not getting the care they need—how they are suffering because of crowding.
•Change some of the verbiage when sending information to the executive team and across the hospital. Describe the problem as a hospital capacity issue instead of an ED crowding problem.
•Take responsibility; do not blame other parts of the hospital.
•Make crowding a priority for hospital leaders.
•Present hospital leadership with studies that demonstrate financial opportunities lost due to crowding and ED profitability. Emphasize that crowding could indirectly damage the hospital by hurting the hospital’s reputation, increasing hospital length of stay, adversely affecting mortality and clinical outcomes, putting the hospital in danger of losing other certifications, and decreasing atient satisfaction. Many of these can affect CMS reimbursement.
•Hospitals tend to abandon the entire idea of FCP because of concerns about placing patients in inpatient hallways. Try to include inpatient hallway placement in the protocol, but do not sacrifice the entire FCP for this component.
•Outline the pros and cons of FCP over other known ED crowding interventions.
•Remind leaders that adopting both FCP and other ED crowding interventions are not mutually exclusive. One option could be to implement a combination of ED crowding interventions based on the hospital culture, needs, and resources.
•Do not oversell FCP. Be clear that it is not ‘the solution’ for crowding. Rather, FCP has been demonstrated to successfully reduce crowding.
•Hospital leaders should provide a consistent message about adhering to the protocol by providing tangible assessment and appreciation. Hospital administration should offer a modest but visible reward program. Reward systems may include informal celebrations, small denomination gift certificates, and senior leadership personally thanking staff on the floor for their efforts.
Cultural resistance •Explain the benefit of FCP to all providers, specifically inpatient nurses.
•Involve all hospital members in FCP planning. Pre-implementation involvement helps reduce barriers to change by creating psychological ownership, promoting the dissemination of critical information, and encouraging employee feedback for fine-tuning the change during implementation.
•Let key stakeholders know the appropriately assigned thresholds. For example, the higher level of FCP should rarely be activated (if ever).
Inpatient nursing resistance •Listen to, acknowledge, and respect the concerns of nurses. Common concerns have been a lack of monitoring and threats to patient privacy and safety.
•Emphasize that transferring patients to inpatient hallways is a last resort in dealing with crowding. The main purpose of FCP is for patients, not the ED. It is designed to optimize patient care in suboptimal circumstances.
•People are more receptive to participate in change when they perceive potential for personal and organizational benefit after weighing the strengths and weaknesses of change [32].
•Ask nurse managers to help you address the problem. Show them that their efforts will not only help patients but also improve the work environment for ED nurses by more evenly re-distributing the workload throughout the hospital.
•Emphasize that FCP is not about room versus hallway; it is about which hallway.
•Work with CNOs to create an environment in which the floor nurses “pull the patient up” rather than the ED nurses “pushing the patient to the floor.”
Concerns about domino effect •Communicate with local organizations. Consider inviting competitors to observe your processes.
•Host town halls with community hospitals to present your metrics and process improvements.
•Educate local community hospital directors and nursing leadership about FCP. Ask them to join you.
External policies and regulations •Before officially adopting FCP, address relevant regulatory guidelines that would have an impact on hallway boarding policies, such as those from the Joint Commission and the appropriate state regulatory bodies. It may be necessary to obtain approval from relevant regulatory bodies prior to FCP implementation. Joint Commission has not typically required prior approval, as long as fire safety regulations are addressed.
•Work with the local fire marshal to determine how to safely implement the FCP. It is only through consulting with the fire marshal that one may determine how to overcome regulatory obstacles to inpatient hallway boarding.
•Justify FCP to fire marshals with two key concepts. First, describe how patient safety concerns are equally as critical in the ED as in the inpatient setting. Both should be viewed as acceptable. Second, describe how the risk of keeping a patient in an ED hallway is much greater than transferring that patient for a short period of time to an inpatient hallway.
•Conduct fire drills that involve transferring patients, how transfers are to be carried out, and actions to take in the event of a fire.