Table 1.
Fishbone for in-hospital phase crosswalk. Abbreviations: advanced practice nurse (APN); multi-disciplinary rounds (MDR); discharge (D/C); physical therapy (PT).
| Obstacle | Potential Solutions |
|---|---|
| Orders Incomplete | |
| Non-hospitalists give limited phone orders | Increase use of hospitalists/unit-based APNs |
| Variability in physician practices | Hospitalists/APNS/MDR rounds |
| Failure to use order sets | APNs |
| Lack of available order sets/care pathways | Develop orders sets/pathways |
| Testing Delays: Physician Related | |
| Inappropriate tests: not indicated | APNs/MDR |
| Inappropriate tests: Could be done as O/P | APNs/MDR |
| Duplicate testing | APNs/MDR |
| Consultant-related order delay | APNs |
| Poor communication among team members | MDR/APNs |
| Delayed results: echo and stress | Remote reading/APN stress model |
| Testing Delays: System Related | |
| Wasted transport time due to poor test coordination | Command center |
| Limited Capacity/Machines, Techs, Hours | |
| MRI (hours) | Staff MRI 24/7 |
| Cath lab (rooms/staff) | Improve capacity and efficiency |
| Ultrasound (hours) | Increase evening staffing |
| Stress test (weekend hours) | Institute APN stress model |
| Transport Delays | |
| Patient/nurse not ready | Command center |
| Lack of transporters | Staffing issue |
| Lack of equipment | Purchase wheelchairs/stretchers as needed |
| Delayed Entry of D/C Orders | |
| Competing priorities | MDR/APNs |
| PMD rounds AFTER office hours | APNs |
| Handoff issues (Weekends) | MDR/APNs |
| Delays 2/2 Rehab Placement | |
| Failure to ambulate | OOB initiative |
| Poor communication among team members | MDR/APNs |
| Delayed PT evaluation | Increase PT staffing |
| Family decision making | MDR/APNs |