Leadership and Improvement Conference-Toronto 2017 Series: Part 1 of 5

Canadian Emergency Departments Post Rapid Improvements in Key Indicators

Patient Flow, Wait Times, Patient Satisfaction and Cost Per Case

Canadian Emergency Departments are facing multiple and serious pressures. During the winter of 2016-17, many EDs saw some of the highest and most persistent demand levels ever recorded, as issues like seasonal flu, increasing patient complexity, and gaps in primary care combined to create unprecedented overcrowding at the “front doors” of our hospital systems.

Studer Group has a long-standing program aimed specifically at solving the problem of contemporary ED management. Emergency Department Intensives are comprehensive programs through which specialized ED coaches work closely with ED leadership to implement evidence-based practices that optimize facility layout, flow management, hospital integration, and the experience/engagement of patients, staff and physicians.

The ED Intensives are a fast and efficient way for leaders to access and adapt ED best practices developed through real-world application in hundreds of hospitals worldwide.

Two Canadian hospitals using ED Intensives were featured at the Healthcare Leadership and Improvement Conference in Toronto. Both launched programs to address a host of challenging ED issues, and both have since posted rapid improvements in key performance indicators. They offer practical, real-world insights into how seemingly overwhelming demands can be managed efficiently, so all patients get the care they need, when they need it.

Collaboration and continuous improvement

Hawkesbury and District General Hospital (HGH) is a community hospital in Eastern Ontario that is now in the process of expanding into a full-service regional health centre. The ED handles about 50,000 visits per year in a space designed for about 12,000 annual visits, while a new facility is under construction.

In a report on progress to date, Dr. Yacine Adjaoud, ED chief at HGH, described how existing ED facilities have been re-designed and advanced flow management systems have been implemented to produce immediate results.

Within two weeks of implementing a rapid access zone (RAZ), along with “pull-to-full” and other flow optimization tactics, average wait time to initial physician assessment was reduced from 4 to 1.7 hours, and left without being seen (LWBS) rates were cut from 4 to 0.53 percent.

All of this has been supported by a strong nurse-medical dyad leadership model and a focused effort to build a fully coordinated interdisciplinary team. Physician engagement has been another key factor as the ED team evolved from family doctors to dedicated ED physicians.

Denise Picard-Stencer, VP of patient care and CNE at HGH, summarized key lessons learned. She stressed the importance of involving frontline staff and all other hospital teams involved in ED service delivery, and recommended an open, transparent process of continuous improvement. Results are shared, celebrated and constantly re-evaluated so that changes can be made as needed.

Not doing more, but doing it differently

The Emergency Department at Hôpital Montfort in Ottawa, ON receives roughly 55,000 visits per year, with about 130 ED staff. Montfort has had a long history of coping with ED challenges, including patient complaints, poor staff engagement and posting some of the longest wait times in Ontario. After some promising but temporary improvements, the hospital launched an ED Intensive in 2014.

Sophie Parisien clinical director of emergency department, critical care and ambulatory care at Montfort, cited a long list of improvements achieved in the two-year period from 2014 to 2016. Highlights include reductions in time to triage from 27 minutes to 2 minutes, time to inpatient bed from 13.6 hours to 4.7 hours, and length of stay (LOS) for admitted patients from 22 hours to 18 hours. These results have been recorded while cutting the cost per visit from $172 to $161, and increasing both patient experience and employee engagement ratings into the 80 to 90 percent range.

Montfort has implemented many of the best-practice facility design and flow management strategies that have proven effective at HGH and many other EDs. Also highlighted in this case were rigorous communication practices and careful integration with other hospital departments – the required efficiency improvements cannot be achieved by the ED alone.

Many of Ms. Parisien’s comments focused on staff and physician engagement practices aimed at creating a culture that enables and leverages the transformations underway. She spoke about the importance of involving staff in planning so they are part of the solution. Staff was asked questions such as “What would your ideal ED look like?” What would make you want to come to work?” and “What would make you say we are living our values?” ED champions have played an important role in helping to build connections between leaders and frontline staff.

The ED improvements at Montfort represent a fundamental process of change management and a new way of doing things, not simply another one-off project or initiative. According to Ms. Parisien, “the message to staff was that we are not asking you to do more. We are asking you to do it differently and to think about the why as you are providing patient care.”

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