Table 1 Action plan of ED providers’ identified issues for improvement, respective measures, and implementation status at follow-up

Work system factor (SEIPS)

Identified problems and issues for improvement

Solutions and respective improvement measures

#HCM / #SCM

Implementation status at follow-up

Organization

Lack of personal breaks during work time (i.e., limited opportunities to take breaks while on duty; short duration of breaks; multiple short breaks instead of longer pauses)

Schedule additional nursing staff for short-term replacement of nurses taking breaks

HCM#2 / SCM#2, SCM#4

Not feasible and declined after discussion in steering committee

Short-term rotation across ED units to replace nursing staff in breaks

HCM#2/ SCM#2, SCM#4

Partially completed

Supervising physicians coordinate residents’ breaks

HCM#2/ SCM#2

Fully completed

Shift supervisor coordinates temporary replacement of nursing staff in breaks on a daily basis

HCM#2/ SCM#2, SCM#4

Declined after discussion in steering committee

Task

Unclear work agreements (i.e., lack of mutual agreement between ED units concerning patient transfers and admissions; unclear agreements with ICU and adjacent care units concerning specific care obligations, e.g., timing of transfusions)

Revise agreements for interdisciplinary occupancy of ED observation unit

HCM#3 / SCM#2, SCM#4

Discussed with consulting physicians and head nurses; not implemented

Agreement on transfusion process in ED observation unit

HCM#3 / SCM#2

Discussed among attending physicians; completed

Organization

Meeting with ICU representatives and revision of patient transfer agreements from ED observation unit

HCM#3 / SCM#2

Not implemented

Organization

High pressure environment - point of triage (i.e., poor and narrow design of triage area; understaffing; lack of qualified personnel for triage; ongoing project on redesign of triage process and assisting technology)

Repeated discussion of various solutions for point of triage in ED management meeting (with the objective to manage exceeding work load during triage)

HCM#4, HCM#5, HCM#7 / SCM#3, SCM#4

Few completed (e.g., blocking of external phone calls); but most solutions considered not feasible (e.g., separate room, free of distractions, permanent staffing of two qualified nurses at triage)

Leadership (e.g., staff’s need for enhanced participation in meetings and ongoing reorganization)

External moderator for ED nursing staff meetings to allow for enhanced discussion and opportunities to ask questions

HCM#6 / SCM#3, SCM#4

Agreed, but not implemented at follow-up

Ad hoc meeting for ED providers concerning reorganization of triage process

HCM#6 / SCM#3, SCM#4

Completed

Lack of staff information (i.e., lack of status information concerning ongoing projects and reorganization activities in the ED)

Provision of Q&A sheet on reorganization of triage process for nurses in intranet

HCM#6 / SCM#3, SCM#4

Completed

Staff shortages (i.e., permanent understaffing, particularly during times of high patient load)

Schedule additional nursing and medical providers in shifts

HCM#8 / SCM#4

Not implemented

Realistic HR planning of ED personnel and shift staffing levels of ED nurses and physicians

HCM#8 / SCM#4

Not started at follow-up