Toyota-style management helps hospital cut ER wait times

Excerpt from the Ottawa Citizen

In 2008, the Montfort Hospital emergency room was one of the province’s worst. Its sickest patients waited up to 20 hours to be admitted. Patients complained and nurses quit. Morale was low and turnover was high. The nurses who remained were overworked and burnt out.

Occasionally, staff frustration boiled over; patients either left without being treated, or went public with stories about rude behaviour and substandard care. The hospital became a focus of negative headlines. “It was a crisis,” admits François Lemaire, Montfort’s clinical director of the ER.

These days, Montfort is no longer a laggard among Ontario’s busiest ERs. Its wait time for the sickest patients is 10 hours — half of what it was in 2008 — even though the volume of patients continues to rise. From 35,000 patients in 2008, the ER now treats 52,000 annually. Many of them are sicker and harder to treat than patients in the past. Yet despite these challenges, Montfort’s wait time continues to fall.

A recent survey of Ontario hospitals indicated that nine out of 10 patients would recommend Montfort’s emergency department to their family and friends. And the turnover in ER nurses is so low that there are currently no full-time openings — a dramatic change from 2008 when there were 15 vacant positions.

The turnaround, aided by $3.7 million in provincial funding since 2008, is one example of how Montfort says it has improved patient care by using practices made famous by Toyota. With the hospital-wide introduction of checklists, streamlining, standardization and non-stop brainstorming with front-line staff, Montfort has joined a growing number of acute-care centres in bringing the efficiency of a factory floor to health care.

The approach, known as lean, has long helped the auto and aerospace industries reduce waste and boost value for customers through continuous small improvements. With a cash-strapped government trying to rein in health spending, Ontario hospitals are catching up, spurred by provincial directives to do more with less.

Nowhere is the need for improved efficiency more critical than in emergency rooms, where speedy care is a key component of good care.

Montfort’s transformation began in January 2009, to teach its staff the lean principles. The hospital paid for the lean consultants with some of the $687,000 it received that year for ER improvement.

The money was part of a four-year, $400-million provincial program called Pay For Results. When it was launched in 2008, Montfort was among 23 of Ontario’s poorest-performing ERs to receive the funding, which gets clawed out of their annual budgets if they don’t show improvement.

Hospital staff deconstructed every aspect of how patients moved through the ER, from the time they arrived by ambulance or car until they were discharged. They examined the “flow” of patients — how they were assessed at triage, how they got their lab tests and diagnostic scans, how they were discharged or admitted and how information moved with them at each stage. They attacked the problem in the same way that factory managers studied the parts of an assembly line.

“We were a whole bunch of people with Post-it notes on the floor that showed all the different steps,” recalls Sophie Audet, an ER nurse. “After it was done, everybody looked at each other and started saying, ‘Oh my God. No wonder we’re so tired.’ There were so many steps. When you see it, you actually realize that.”

Audet and her colleagues worked to simplify the journey for patients and reduce unnecessary tasks for staff. To their surprise, the best ideas were not necessarily flashy, or expensive to implement.

Among other things, a daily activity report was introduced that gave every hospital worker — from the chief executive to department heads, physicians, nurses and housekeeping staff — a snapshot of the traffic in and out of Montfort. It listed the number of patients waiting to be admitted and discharged.

For the first time, staff got a bird’s-eye view of where the hospital’s bottlenecks were. They could also see which departments needed extra help to move patients along. “You see the big picture, not just your own little department,” says Audet.

In the ER, a low-tech whiteboard was introduced. It tracked the location and status of every patient and listed what services they were waiting for. For the first time, method and transparency were imposed, allowing the nursing team to manage patients more quickly and effectively. The approach also reduced the chances of patients being lost in the shuffle.

“Before, we used to write down everything by hand,” says Johanne Gougeon, the ER’s lead nurse. “Now, we write on magnets. If we have a patient go somewhere, we just move the magnet around. It’s on the board, it’s written out, it’s all standardized and everybody can see what’s happening.”

In addition, the triage process was simplified for patients with minor complaints. And the workflow of the diagnostic imaging department as well as the work schedules of housekeeping staff were adjusted to conform with the ER’s busiest times of the day.

Other changes related to inconveniences in the physical layout that added up to hours of lost productivity every day.

For example, the storage and labelling of medical supplies were standardized so that nurses did not waste precious time searching for surgical dressings or catheters. A method was introduced to manage wheelchairs, which were never available when staff needed them, leading to longer-than-necessary delays for patients waiting to be moved or discharged.

“We (drew) a line on the floor and we put up a sign: ‘Three wheelchairs here,’ ” says Lise Vaillancourt, director of clinical services. “All of a sudden, when somebody was done with a wheelchair, they knew what to do with it.”

Even a simple procedure like urine analysis often kept patients waiting because the fridge where the samples were stored was far from the nursing station. “We calculated that the nurse had to walk something like 150 steps and another 150 steps back an average of 75 times per day,” says Vaillancourt. “So we just took the fridge and put it under the counter. Now, it’s zero steps.”

Based on these seemingly minor improvements, ER wait times at Montfort fell by 10 per cent within three months.

Meanwhile, other changes happening hospital-wide also helped to ease some of the ER congestion. Physicians and nurses started to emphasize discharge planning almost as soon as patients were admitted. In the past, discharge planning only took place toward the end of a patient’s stay, which often led to extra days spent unnecessarily in the hospital. The resulting bed shortages triggered a backlog of patients waiting in the ER to be admitted.

Another change involved introducing a system of early-warning signs that flagged hospital staff about imminent overcrowding, giving them more lead time to plan for a higher number of patients.

By 2010, two years after Montfort introduced lean, its ER was among three that were recognized as the most improved in the province. That year, the department was awarded a $200,000 bonus under Pay for Results. By then, the ER had left its cramped and aging space for a brand new facility that was double its previous size, part of the hospital’s $300-million expansion of its premises on Montreal Road.

The new space allowed for even more ER efficiencies to be introduced.

These days, when patients walk into the Montfort’s ER, one of the first things they see are signs telling them what the estimated waiting time is. Based on how serious their illnesses or injuries are, they are directed to different waiting areas and treatment zones. They take a number to wait so they know how many patients are ahead of them.

Instead of having nurses or porters accompany the walking wounded to get their diagnostic scans, there are colour-coded lines on the floor that guide patients to where they need to go. In the past, patient care suffered in part because staff spent so much time shuttling patients back and forth.

Hospital officials say patients, especially those with minor complaints, are now so savvy that they’ll call ahead to check Montfort’s wait times against those of The Ottawa Hospital or Queensway Carleton. “Now, people are shopping around,” says Lemaire, the ER director. “This is our reality.”

Excerpt from the Ottawa Citizen
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