A few weeks ago, one of our customers called to ask that we add the role “Nursing Supervisor” to the third level of escalation for nurse call alerts presented on their Vocera badges. By that point, their integration between their Rauland nurse call, Connexall, and Vocera systems had been operational for almost two and half years—and they’d long abandoned the inclusion of “Nursing Supervisor” in the patient alarm workflow. There were clearly some breakdowns occuring on site, and nursing leadership was trying to adjust.

In the original design, the thought was that placing the Nursing Supervisor alongside the Charge Nurse in the escalation chain would not only provide a fail-safe, but it would also provide a level of managerial insight into what was going on at a patient level. After the initial roll out, leadership recognized that providing patient response backup to the Nurses and Charge Nurses was not a practical use of that role’s time. The sheer volume of “escalated” alarms that were showing up on the Supervisor’s device was not manageable and was extremely distracting.

Institutional memory can often be short… In the ensuing six weeks since the request was made to change the escalation, here’s what’s happened:

Workflow Modification	Result
Added Nursing Supervisor to 3rd Level	Supervisor begins to receive 200+ escalated calls during a typical day/night shift (peaking at 279 calls/per day). Prior to this change, they’d received zero calls. I met with one of the Supervisors and quickly understood that this was not a workable situation.
Removed Supervisor from 3rd Level and Placed at 4th Level	Nursing Supervisor call volume significantly reduced (average of 49 calls/per day); however, overall volume of calls escalated to Level 3 (and beyond) stay at historically consistent levels. Nursing Supervisor still isn’t happy, but call volume and call response to patient are not better.
Removed Supervisor from 4th Level and Placed at 5th Level	Even with reduced levels of calls to the nursing supervisor, call levels are still considered intolerable, and it is deemed that the Nursing Supervisor be the last possible point of escalation (between 3–5 minutes, depending on severity of call). In the first 24 hours since the change, we’ve seen a slight reduction in calls received by the Nursing Supervisor.

Make no mistake—we’re outsiders here, and there are organizational and situational factors beyond our view. My observations are purely via the data. As I see it, this is a “caring” organization with good people trying to do right by their patients. That said, what the data is showing us is that there are many calls that are not being answered expediently and staff don’t quite have a handle on how to fix it. It will be interesting to see how this correlates with their HCAHPS scores, but we’ve seen a lot of inconsistency in the time since we’ve been working with them.

Our customer is not unusual in regard to its ability to react and adjust. As I look at trying to advise them, here are some things I’m thinking…

1. Alarm workflow is definitely NOT “set it and forget it.” Being agile is key. You may have had a very expensive initial implementation with extensive planning and set up, but it is possible that there were erroneous assumptions going in. More likely, there has been a lot of evolution to how you use your systems. It can be tough to revisit these initiatives; however, it’s essential that you do. Be careful about knee jerk adjustments.
2. Have the systems in place to baseline before you start, measure after you deploy, and be ready to revisit your measurements. Obvious disclaimer: We are in the analytics business and we are promoting the notion of embedding analytics into daily practice. But, putting our selfish interests aside, knowing where you’re coming from and where you want to go just makes sense. The Nursing Supervisors may be getting the short end of the stick, but the fact remains that consistency of care is not what this organization wants it to be. When we began our work together two and a half years ago, the customer had targeted certain standards—but it’s been difficult for them to keep their eyes on the prize.
3. Someone who matters needs to own the data and its interpretation. In the case of our customer, no one truly owns the data and there isn’t anyone organizationally prominent enough to advocate on its behalf. From our experience, this really can’t be a business analyst or technical person, but rather someone involved in the outcomes. It also needs to be someone who truly understands the end-to-end workflow from both a patient and staff perspective (including a functional understanding of the technology).
4. Who gets the calls is always a hot potato issue. By far, one of the most contentious issues of mobile device integration with alarming systems (like nursecall and patient monitoring) is who gets the calls and what happens when the calls are not responded to. In spite of this customer’s best efforts to provide enabling technology and copious backups, calls are still not getting answered.
5. Don’t be reactive. At best, the reshuffling of escalation responsibilities have been reactive “band-aids” to mollify already overburdened roles. There may be staffing issues, HR issues, and/or technology problems that are causing this, and the causes are not malevolent. We advise our customers to look at the entire spectrum in context: your hourly, shift, daily, weekly, monthly data can raise the right questions.

What other workflow modifications have you implemented recently?