Emergency Department Process Improvement Program - PIP

Executive Summary

Objectives, Scope and Metrics

PIP is one component of the Ontario Ministry of Health and Long Term Care Emergency Department – Alternative Levels of Care Strategy. This strategy has three main aims: to reduce ED demand, increase capacity and improve ED processes, and faster discharge processes for ALC patients. The mandate for PIP is specifically to improve the quality and efficiency of ED processes.

In addition to improving ED metrics such as average length of stay for all patients, PIP has 4 other objectives:

1. to build capacity in hospital staff to sustain long-term change
2. to improve patient and public satisfaction with emergency care
3. to improve the staff working environment
4. to create provincial and regional networks to share information across hospitals

Approach

Based on lessons learned from health care transformation programs in Ontario and UK, PIP uses an approach grounded in Lean. We support sites in three main areas – operational improvements, performance management and culture and capabilities. All sites move through the 4 stages of the program at the same time – from diagnostic, to solution design, pilot and finally roll-out. At the end of each phase, hospitals meet in large provincial forums to share their results and best practice, which provides important opportunities for peer learning, and networking.

Sites are supported by a designated coach, experienced in Lean and health care transformation work. Coaches provide both on-site and remote support, ensuring that the hospital team leads have all the skills and confidence to lead the change.

PIP also offers sites a simple “Daily Access Reporting Tool” (DART) which uses the hospitals existing data collection to pull daily snapshots of metrics. This excel-based tool is relatively easy to implement, and whilst it does not replace the clean, accurate data supplied by provincial data reporting systems, it does provide hospitals with a timely tool to evaluate and manage the impact of improvement initiatives.

What’s different about PIP?

Site-specific solutions: PIP does not provide a ‘to do’ list to hospitals participating in the work – all sites are encouraged to find solutions specific to their organisations, based on data and considering the expertise of staff involved in the processes. Whilst many sites do find similar solutions, this approach ensures that change is owned by the staff, and tailored to the culture and needs of each organisation.

Improvement work is lead by hospital staff: building the capacity of hospital staff to lead this work had 2 important benefits – the work is owned by the people involved in the processes; and the knowledge and skills remain at a provider level. After PIP finishes, those staff can support or lead improvement work in other units, and become an important organisational resource. We hope this will reduce the reliance on external consultants, keeping skills and knowledge ‘in-house’.

Focus on sustainability: from the moment we begin work with hospitals, we discuss sustainability. We use champions from previous waves, or pilot sites, often asking physicians and front line staff to speak to their peers about the importance of planning for long-term change. Lessons learned from previous health care process improvement work indicate that many programs’ results are short term- our solution to that is to focus senior leaders on leading transformational change, and performance managing results. We facilitate and train on sustainability planning, which includes making specific individuals accountable for specific metrics, regular reviews and Steering Committees, and an organisational focus on continuous quality improvement.

Regional sharing of best practice: knowing that the emergency care issues cannot be solved by focusing just within the four walls of the ED, we support LHINs to promote regional sharing of best practice. We encourage hospitals to involve CCAC and LHIN staff in their teams and Steering Committees, and leverage existing LHIN-wide health care provider meetings to share solutions to patient flow issues.

Wave 1 results and lessons learned

The brilliant news from our five wave 1 sites is that all hospitals saw improvements in their ED and inpatient average length of stay (ALOS). For some sites, there were dramatic improvements, for example where ‘See and Treat’ models of care were implemented, 3 hospitals reduced their ALOS for medium acuity patients from over 7 hours to around 1.5 hours.

All sites also improved the numbers of patients being discharged before 11am, significantly improving the capacity for sites to find beds for admitted patients and reduce ALOS for inpatients.

We saw improved patients satisfaction scores at the sites too – both satisfaction that the ED waits had decreased, but also satisfaction with better communication. In particular, patients were happy to learn more about when their expected date of discharge was, so they could ensure they were ready to go home. Lastly, over 5 hospitals, 70 staff were trained in Lean and quality / process improvement tools and techniques.

Next steps

PIP will be working with another 17 sites from now until May of next year. By the middle of 2011, we should have worked with up to 90 hospitals across Ontario, and engaged with up to 100.

What, in your experience, ensures quality and process improvement work is sustained? - Kate Pengelly