NR 447 Week 6 Admission Order Team Improvement Plan Example

Naming the Next Admission at the 1400 Huddle: A Team Improvement Proposal for a Medical Unit

Student Name

College of Nursing, Chamberlain University

NR 447: Collaborative Leadership in Healthcare

Instructor Name

Month Day, Year

Naming the Next Admission at the 1400 Huddle: A Team Improvement Proposal for a Medical Unit

The Irritation

On a composite 30-bed medical unit, the same argument happens almost every afternoon. A bed request comes through from the emergency department between 1500 and 1800, the charge nurse looks at the board, and two or three nurses explain at once why they cannot take it: one is expecting a transfer back from the procedure area, one has a patient going bad, one took the last admission. The conversation takes five to fifteen minutes while the emergency department waits, and it usually ends with the admission going to whoever objected least, which is often the newest nurse. In a two-week tally, 19 afternoon admissions produced 14 of these negotiations, with a median delay from bed assignment to report of 22 minutes. The nurses dislike it, the emergency department dislikes it, and it produces the least considered assignment of the day.

The Change and the Moment It Happens

At the unit's existing 1400 safety huddle, which already reviews high-risk patients and staffing, the charge nurse will add one question: who takes the first, second and third admissions between now and 1900? The order is decided in the room, with every nurse present, using three rules the unit agrees on in advance: a nurse with an unstable patient or a patient returning from a procedure after 1400 is skipped for the first admission; a nurse who took an admission already that shift goes to the end of the order; and a nurse in the first six months after orientation is not first unless everyone else is skipped. The order is written on the whiteboard next to the huddle notes. When a bed request comes through, the charge nurse assigns it to the next name on the board, unless something has changed, in which case the charge nurse decides and says why. Goldenhar et al. (2013) describe huddles as a way of building shared awareness of risk before it becomes an emergency, and the admission order is a small, predictable risk that fits that purpose.

What It Costs, in Minutes

The added question takes about two minutes at the huddle, spent by every nurse present, which is roughly 12 nurse-minutes a day. The charge nurse spends another minute writing the order on the board and updating it if someone is skipped. Against that, the tally suggests the current negotiations cost 5 to 15 minutes of three or four nurses' time on most afternoons, or 20 to 50 nurse-minutes, plus the emergency department's waiting time. The change removes a step rather than only adding one: it replaces the afternoon negotiation with a morning decision. The owner of the new minutes is the day charge nurse, who runs the huddle and keeps the board, and the proposal names that role explicitly so the order belongs to someone.

Walking It Through an Ordinary Shift

On an ordinary Tuesday, the 1400 huddle sets the order as nurse C, nurse A, nurse E. At 1530 the emergency department calls with a patient with pneumonia. The charge nurse looks at the board, sees nurse C, checks that nothing has changed in the last ninety minutes, and gives nurse C the report. The whole exchange takes under a minute. The second admission at 1720 goes to nurse A in the same way.

Walking It Through a Bad Shift

On a bad Thursday, two nurses have called out and the unit is running with four nurses instead of six, each with seven or eight patients, and the house supervisor has told the unit it must still take admissions. At 1400 the huddle is short and tense. The order is set, but every nurse is at the limit. At 1450 the first admission comes, and nurse C, first on the board, has just had a patient become hypotensive. Under the rules, something has changed, so the charge nurse decides. The rule helps here too: the charge nurse does not reopen the negotiation with everyone but moves to the second name, nurse A, and tells nurse C to focus on the hypotensive patient. At 1640 the second admission arrives when nobody on the unit can safely take one. The huddle order does not solve that problem, and the proposal does not pretend it can. What it does is make the charge nurse's call to the house supervisor, saying that the unit cannot take this admission safely, a clear escalation rather than the end of a failed negotiation. On a bad shift the change saves less time, but it still removes the argument, and it keeps the newest nurse from absorbing the admission by default.

The Colleague Who Carries On as Before

Nothing in this proposal can be required of anyone, and some nurses will not like being named in advance. The likely objection is that it is unfair to be first when the afternoon turns out to be heavier than it looked at 1400. The answer built into the proposal is that the charge nurse can always change the order when the situation changes, and must say why. For the charge nurse who simply does not ask the question at the huddle, the proposal relies on two things: the unit educator adds the question to the printed huddle script, and the night charge nurse asks at 1900 handoff whether the order was used. If after a month the question is being skipped on more than a third of days, the change has not taken, and the unit should decide whether to drop it rather than pretend it exists. Missed care research identifies breakdowns in teamwork and communication, alongside staffing and supplies, as antecedents of care left undone (Kalisch et al., 2009), and an admission that waits twenty minutes while nurses negotiate is a small, daily instance of that pattern.

How We Will Know

The measure is observable and already partly collected: the time from bed assignment in the electronic record to report called to the unit, for afternoon admissions, which the emergency department tracks. The baseline median is 22 minutes. The target is a median under 10 minutes over the first month. A second measure is simpler: the charge nurse marks on the huddle sheet whether the order was set, and the unit reviews the percentage each week. Marquis and Huston (2021) note that staff accept assignment systems they helped design and see applied consistently, so the unit will vote on the three rules at the next staff meeting before the change begins.

References

Goldenhar, L. M., Brady, P. W., Sutcliffe, K. M., & Muething, S. E. (2013). Huddling for high reliability and situation awareness. BMJ Quality & Safety, 22(11), 899-906. https://doi.org/10.1136/bmjqs-2012-001467

Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517. https://doi.org/10.1111/j.1365-2648.2009.05027.x

Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.