CASE STUDY 3
Making the Case for Quality
Six Hospitals Combat Regional Emergency Department Congestion With Lean
• Representatives from six urban hospitals in the Canadian province of British Columbia that partner to serve mental health and addiction patients worked together to curb emergency department congestion by deploying a single care model across all sites.
• More than 80 staff from the hospitals assisted with this effort by employing lean tools, obtaining benchmarking data, and standardizing work activities.
• Recognizing that the technical side is only one piece of the puzzle, leadership and the project team turned to a formal set of critical success factors to engrain the change into the culture.
At a Glance . . . Canada’s Centre for Addiction and Mental Health estimates one in five residents will experience a mental illness in their lifetime. Concurrent disorders—cases in which a person has both a mental health and substance use problem—are common, with more than 50 percent of those seeking help for an addiction also experiencing a mental illness, and 15–20 percent of those seeking help from mental health services also living with an addiction.1
At Vancouver Coastal Health (VCH), one of the six publicly funded healthcare providers in the Canadian province of British Columbia (B.C.), approximately 11 percent of total inpatient admissions per year (12,500 of 116,000 patients) are mental health and addiction (MH&A) patients. Over 75 percent of admit- ted patients enter through the emergency department (ED) at any of the 13 hospitals within VCH.
On several occasions, patients had to wait in the ED until an inpatient psychiatry bed became available in the hospital. This not only led to congestion in the ED, it also put tremendous pressure on the care delivery system to discharge patients in order to make beds available for new patients.
Representatives from six urban hospitals collaborated on a project to address the issue of ED conges- tion and patient flow through acute inpatient adult psychiatric units. The project allowed VCH to move to a regional care model through the support and participation of all six hospitals. This new model, based on best practices and evidence-based care, gave patients timely access to acute care beds and increased utilization of beds across the region.
About Vancouver Coastal Health2
VCH delivers direct health services to more than 1 million B.C. residents—25 percent of the B.C. popula- tion—living in Vancouver, Vancouver’s North Shore, Richmond, the Sea-to-Sky Highway, Sunshine Coast, the tiny communities of Bella Bella and Bella Coola, the Central Coast, and the surrounding areas. VCH also provides adult tertiary and quaternary services for the entire province of B.C. While many of VCH’s services are offered in the 13 hospitals it operates, it also provides a number of other services including:
• Primary care • Community-based residential and home healthcare • Mental health services • Addiction services • Public health services • Hospital care • Research
by Sumeet Kumar
November 2012
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During early stages of the project, three full-day regional kaizen sessions and additional working group sessions at each hospital site were staged. More than 80 staff participated in these work- shops, undergoing training in lean tools to learn the concepts of flow, pull, buffer, and supermarket. Initially, their intent was to understand patient flow at each hospital and identify areas of com- monality and variance by mapping the current state. Figure 4 shows Sumeet Kumar, the VCH workflow improvement coordina- tor, explaining the current state of patient flow to the project team.
Through additional analysis, the teams discovered that the aver- age acute inpatient adult psychiatric bed occupancy rate across the six hospitals varied from 83.6 percent to 110.1 percent. This indicated that while some hospitals were at overcapacity, other hospitals had underutilized beds.
The team agreed to establish a process that would move all six hospitals to a single, harmonized process for transferring MH&A patients to a site with an inpatient psychiatric bed available. The team intended to develop and implement a new, evidence-based care model within four months (December 2010 to March 2011).
Orchestrating the Change
A regional project team composed of 18 representatives from the six hospitals was established to focus on this improvement. This cross-functional team included psychiatrists, nurses, oper- ations leaders, and frontline staff. A steering committee, comprising the executive sponsor, project champion, LTS sponsor, and LTS project facilitator, met every two weeks to ensure that the project was on track.
Mapping the Current State: Trouble With Triage Teleconferences
The first step was to map the current state. The team discovered that an approach to handle patient transfers had already been in place. For years, hospital representatives had participated in half-hour long triage teleconferences every weekday morning to report on inpatient psychiatric bed inventory and anticipated patient transfers. However, there were several issues with these teleconferences:
1. Representatives from all six hospitals were often missing from the calls.
2. Correct information on bed availability was not on hand at the time of call.
3. If inventory changed, the other hospitals were often not alerted. When hospital representatives did make an effort to keep other hospitals informed, it required several calls.
4. The authenticity of the data often could not be validated. 5. Staff did not have the authority to accept or decline transfers
while on the call. Transfers required a case evaluation by a psychiatrist at the receiving hospital, which took considerable time.
VCH is committed to enhance care for MH&A patients and to continu- ously improve using lean as its approach. Objectives 1.2 and 4.1 in the VCH strategic framework, depicted in Figure 1, affirm its commitment to patients and quality.
Lean Transformation Services (LTS) was estab- lished in 2007 to undertake process improvement projects across the organization. Some members of the LTS team have been assigned to work with the MH&A Regional Council, which is composed of VCH’s MH&A senior management team, to identify opportunities for improvement and imple-
ment projects that would enhance care for this patient population.
LTS’s approach to implementing lean has evolved over the years based on experiential learning and literature, including, but not limited to, the book Toyota Kata, by Mike Rother, published in 20093. The LTS lean approach is a four-stage process—set the vision, understand the current state, identify the ideal state, and set the target condition/develop future state. The journey from the current state to the ideal state is endless, facilitated by plan- do-study-act on a continual basis to come closer to the ideal state. The LTS approach is shown in Figure 2.
Figure 3 provides a project timeline and lists key accomplish- ments the team achieved at each stage of the LTS lean approach.
Six Disparate Processes
Six urban hospitals in the region (Vancouver General, UBC, Richmond General, Lions Gate, St. Paul’s and Mount St. Joseph’s hospital) provide services for the MH&A population. Each hospital had created its own processes to deliver care since there was a perception within each setting that the needs of its patients were unique. Staff at these hospitals acknowledged that most issues staff faced during the patient journey were common, and they agreed to collaborate and change together. VCH led the effort to improve emergency department congestion and patient flow through the acute inpatient adult psychiatric units at a regional level.
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Quick Statistics
• $2.8 billion annual funding
• 22,000 staff (full time, part time, and casual)
• 2,500 physicians
• 5,000 volunteers
VCH annually supports:
• 3 million+ patient days of care
• 308,000+ emergency department visits (one person every two minutes)
• 640,000+ clinic visits
• 81,000+ same-day surgical visits
• 116,000+ inpatient discharges
• 2.3 million+ residential care days
• 1.9 million+ home support hours
• 199,000+ home nursing visits
Mental Health and Addiction
• 197 inpatient psychiatry beds
• 12,500+ patient admissions per year
Vancouver Coastal Health in Figures
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Figure 2—Lean Transformation Services’ approach for implementing improvement projects
Target Condition/
Next Future State
Target Condition/
Next Future State
Target Condition/
Next Future State
Target Condition/
Next Future State
Target Condition/
Future State Ideal State is avalue add
process from the customer’s
perspective
Step 1: Set the Vision
Step 3: Identify the Ideal State
Step 4: Set the Target
Condition/ Future State
Step 2: Understand the Current
State
Plan /do/
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utur e Sta
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We are committed to supporting healthy lives in healthy communities with our partners through care, education, and research.Mission
We will be leaders in promoting wellness and ensuring care by focusing on quality and innovation.Vision
People FirstLens
Use a standardized,
rigorous process to accelerate the creation and broad use of evidenced- based protocols in all clinical areas and programs.
Develop a regional program
for Mental Health and Addiction and Cardiac Sciences to improve quality of care.
Build a regional medication
reconciliation system across the continuum.
1.1
1.2
1.3
Reduce health inequities in the
populations we serve through focused improvements in core public health programs.
Build on VCH integration
strategies to support implementation of the MoHS directive to deliver integrated primary care, home and community care, and community mental health services.
2.1
2.2
Enhance workforce
utilization and match staffing to clinical volumes and patient acuity.
Recruit and retain the best people by
fostering a culture of excellence, recognition, and respect.
Build organizational
capacity by strengthening leadership and management competencies.
3.1
3.2
3.3
O bj
ec tiv
es
Embed LEAN thinking at all
levels to fulfill objectives and to deliver quality outcomes.
Develop and implement best
practices in care management to reduce unnecessary days of stay.
Deliver administrative and
support efficiencies through the shared services organization and consolidation.
4.1
4.2
4.3
Respond to provincial patient-
centered funding model.
Develop service agreements with
funders and service providers.
Develop and implement a
strategy to secure increased capital funding.
Continue our commitment to
“Green Care” alternatives by reducing waste and our carbon footprint.
4.4
4.5
4.6
4.7
Provide the best quality of care.
Promote better health for our communities.
Optimize our workforce and prepare for the
future.
G oa
ls Use our resources efficiently to sustain a viable healthcare system.
Patient/Community Focus Engaged TeamDrivers Financial SustainabilityOperational Excellence
ServiceValues SustainabilityIntegrity
Figure 1—Vancouver Coastal Health strategic framework
Adapted from the book Toyota Kata, McGraw-Hill, 2009, by Mike Rother.
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Figure 3—MH&A regional acute inter-hospital transfer journey
Dec. 2010 March to May, 2011 June to Oct. 2011 June 2011Feb. 2011Jan. 2011
O ut
co m
es
Timeline
Project De�nition
Current State
Future State Implementation
Audit/ Re�ne Sustain
■ 26 Pts transferred from unfunded to funded beds in �ve months, resulting in 94% regional bed utilization
■ Regional bed inventory is updated 87% of time
■ 100% accuracy of bed inventory updates
■ More SOPs created ■ Google Docs
platform established for sharing regional bed inventory information
■ New forms created for the inter-hospital transfers
■ Pilot for 12 weeks (March 1–May 31, 2011)
■ Project rolled out regionally on June 1
■ Regional SOP ■ Standard transfer
and repatriation forms, and transfer checklist
■ A system to share their bed inventory levels twice daily across sites
■ Maintain accuracy of bed inventory
■ Different process at each hospital
■ Different terminologies
■ No roles and responsibility
■ Different forms ■ Person-dependent
process ■ Not all hospitals
participated in triage call
■ Information of bed inventory not known at each hospital during the day
■ Establish a standard regional system for inter-hospital transfers of mental health & addiction acute patients (across six hospitals: VGH, UBC, RGH, LGH, SPH and MSJ)
■ The Regional Issues Resolution Group meets every six months to address issues
Figure 4—Sumeet Kumar, workflow improvement coordinator at VCH, explains current state patient flow to project team
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Mapping the Ideal State: Exploring Best Practices4, 5, 6, 7
The next step was to map the ideal state that would be applicable to all six hospitals. Before mapping this ideal state, the regional team benchmarked ways other healthcare providers maintain bed inventory and inter-hospital transfers. The team also looked to the retail industry for how they managed and communicated inventory levels.
A summary of the team’s benchmarking findings:
• It is important to standardize communication, as 80 percent of serious medical errors point to miscommunication during handovers and transfers.
• Standard forms, tools, and checklists are ways to hardwire the system.
• Allow the opportunity to ask questions and provide direct contact information as staff at receiving hospitals may need more details about transferred patients.
• Reinforce quality and measurement—monitor compliance and hold staff accountable.
• Educate and coach—teach staff how to complete successful handoffs and provide timely performance feedback.
• Use electronic tools. • Use internal buffers to manage sudden surges in demand. • Build supermarkets at critical bottleneck processes to create
flow.
Creating a Regional Future State
Using lean, benchmarking findings, and considering ideas gen- erated during brainstorming sessions during the workshops, the regional team created a standard regional future state process map. See Figure 5: Regional standard inter-hospital transfer process map. The new process included the following changes:
1. The triage call would be replaced with a Web-based tool or customized software to allow staff to access data in real-time.
2. The patient would be medically cleared according to a standardized checklist before being presented to psychiatry.
3. Care teams and psychiatrists would agree to standard regional criteria—situation, background, assessment, recommendation (SBAR)—for accepting or declining transfers if beds are available. SBAR is a technique for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action.
4. Instead of faxing records of all patients that may need a transfer, information will only be transmitted if the patient is deemed a good candidate for transfer based on the SBAR outcome.
5. To ensure proper handoffs to transportation during patient transfers, a regional checklist will be used.
6. Ambulances would be reserved for transferring “involuntary” patients. “Voluntary” patients would be transported by a family member or an authorized private service provider.
7. Two forms of identification would be used to ensure the correct patient was transferred.
8. A process owner would be assigned to each process step to avoid communication gaps.
Real-time Tracking
The steering team selected Google Docs for the online bed inven- tory system because of its ease of use and short implementation.
An inventory template was created using its Excel Spreadsheet tool. See Figure 6: Hospitals share bed inventory using Google Docs. Most cells in the template are formulae based and change colors automatically to provide a visual cue to the user: red (no possibility of transfer), yellow (hospital at buffer bed level), and green (transfer possible). To ensure confidenti- ality, patient details are not referenced on Google Docs.
Hospital representatives agreed to report their inventory twice daily, including weekends. The only downside of Google Docs is that the data feed is still people-dependent.
To meet unexpected demand for mental health services, hospitals were provided with a number of buffer beds to help maintain flow through the system. If bed inventory at one hospital reaches utilization of the buffer beds, the hospital would not offer beds to other hospitals. Representatives now share the actual bed inventories and accommodate transfers.
Standardized Regional Documents
Four working groups were established with individuals who had the appropriate expertise for the areas of focus. Their task was to develop standardized forms to support the new approach for transferring patients:
1. Standard operating procedures 2. Inter-hospital transfer form based on SBAR and transfer
checklist 3. Repatriation process form 4. Issues resolutions process
Once the documents were drafted by the working groups, they were reviewed by the regional team. Their feedback was inte- grated prior to implementation. These forms were approved by the Forms Committee and became a part of patient health records.
To ensure common understanding across all sites, teams were trained on the new standard regional process as well as on the use of standardized forms during the pilot testing phase.
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QUALIFY TRANSFER COORDINATE TRANSFER ACTUALTRANSFER
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Patient in ED
admitted to psychiatry
service (medical clearance complete)
Is there an inpatient
psychiatric/ OCP bed
available in the
hospital?
Discuss if patient is an appropriate
transfer candidate with team.
Does team feel that
patient is an appropriate transfer at this time?
Discuss the possibility of transfer with the
patient and family if
appropriate.
Is patient and/or family
agreeable to transfer if patient is accepted by outside facility?
Access regional
online bed capacity inventory to check
bed availability
Is there an inpatient
psychiatry bed
available at the outside hospital?
Patient stays in ED
Sending transfer
coordinator (TC) calls potential patient’s receiving
TC
Fax patient information to outside
hospital for review by potential receiving
psychiatrist
Psychiatrist to
psychiatrist phone call
Does outside
psychiatrist accept
patient?
TC organizes
appropriate transportation
Psychiatrist tells the TC that patient has been
accepted by outside facility
Is there a signiƒcant
delay in the arrival of
transportation?
Transfer coordinator
calls outside/ accepting
hospital to tell them about
delay in transportation
Transportation arrives to
take patient
Nurse to nurse verbal report
Patient physically
leaves hospital
along with necessary documents
Patient arrives at receiving hospital
TC TC TC TC TC TC TC TC Sending
nurse calls receiving
nurse
Receiving nurse
receives patient
Inter- hospital transfer checklist
Sending psychiatrist to contact potential receiving psychiatrist
Sending psychiatrist
Refer to SOP document for list of
documents to be faxed
Refer to SOP document for
criteria
Medical clearance
form?
Refer to SOP document for list of
documents to be faxed
TC/admitting psychiatristTC discusses with psychiatrist and
RN caring for patient
TC = Transfer coordinator (The term transfer coordinator is used in place of the many dfferent terms used at the various facilities for the person responsible for coordinating transfers.)
Yes
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Version 1.3
Date: February 23, 2011
Createad by: Sumeet Kumar
Owner: Lean Transformation Ofƒce
Correlate the numbers indicated within the SOP. If patient becomes agitated or condition changes then the transfer can be cancelled.
Steps that directly involve patient
Figure 5—Regional standard inter-hospital transfer process map
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Results
The regional team piloted the inter-hospital transfer process and the online bed inventory system at the six hospitals over a three- month period. After testing and making minor modifications to the process and Google Docs templates, the approach was launched across all hospitals under VCH and Providence Health Care in June 2011.
Between June and October 2011, 26 patients were transferred. These patients went from emergency beds in hospitals that did not have inpatient psychiatry beds available, to other hospitals with psychiatry beds available. This resulted in an average of 94 percent utilization of psychiatric beds regionally, smoothing the outliers (highs of 110.1 percent to lows of 83.6 percent).
Electronic bed inventory has enabled staff to access real-time bed inventory data, validated by the decision support team as 100 percent accurate. Bed inventory was updated 87 percent of the time on average between June and October 2011. During September and October 2011, the average frequency of updates reached 96 percent.
Sustaining the Gains
The region’s psychiatrists and operations leaders formed an issues-resolution process. This group meets every six months to evaluate the effectiveness of the regional inter-hospital transfer process; address any specific issues arising from regional inter- hospital transfers; share knowledge within the region in order to competently handle unexpected situations; ensure sustainability of the process; and provide ongoing quality review.
If an issue requires immediate attention or if compliance to the online regional bed capacity inventory falls below 80 percent, the group meets to prepare corrective actions.
Strengths That Led to Success
Taking on this improvement project was like venturing out into the unknown. With careful planning and strategic use of resources, the hospitals involved were positioned to overcome some of the typical hurdles inherent with cultural change, turning what could have been snags into successes. Examples are below:
1. Clear direction and vision: Projects do not succeed if leadership does not provide enough clarity and direction to the project team. In this project, the sponsor and the
Hosp D
Hosp E
Hosp C
Hosp F
Hosp A+ B
Figure 6—Hospitals share bed inventory using Google Docs
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champion provided clear expectations; the charter was developed promptly; and teams attended weekly meetings with key stakeholders to keep the project on track. Realizing the importance of keeping physicians engaged, a regional medical director was included in the regional steering committee meetings that were held biweekly.
2. Communication: Teams from the six hospitals were brought together in a series of workshops to develop a common regional approach. This provided an opportunity for the teams to engage face-to-face, discuss site-specific issues, and learn best practices from each other. Also, staff were now able to appreciate challenges faced by the teams at other sites. A dedicated communications representative provided assistance during the project. This enabled timely updates via memos, intranets, and staff newsletters to help inform the entire team and regional staff not directly involved in the project.
3. Hands-on Approach: The process owners at each hospital were nominated as representatives for their sites for updating the bed inventory data and coordinating transfers. As the project got under way, all transfer cases, whether accepted or declined by the receiving hospital, were faxed to the project champion who would resolve issues in a timely manner. This helped overcome change resistance in the teams and standardize the process.
4. Project Management: The project was executed effectively and efficiently using proven project management approaches and tools: a charter was developed; teams were formed and responsibilities were assigned; a planning committee and steering review committees were established along with additional support functions and working groups; and timelines were agreed upon in advance.
Change Management: Critical to Project Success
Change management is key to project success. It doesn’t matter how many Six Sigma Black Belts and Green Belts an organiza- tion has—ultimately, success depends on how the people side is handled. The more we acknowledge this, the more effective improvement efforts at VCH will be.
The following critical success factors (CSFs) are the criteria VCH used to guide this project and all cultural changes, whether at the system, organization, process, or individual levels:
1. Establish leadership visibility and stakeholder engagement. Employees should see their leaders/supervisors completely involved and engaged in improvement projects. It is important for leaders to demonstrate their commitment by
“walking the talk” so staff can understand and appreciate the importance of working on the project. Leadership has the
ability to “spark a wildfire” and spread cultural change across the organization.
2. Clear direction and visioning the future state creates buy-in. Leaders should provide staff with direction so they know exactly what is expected of them and encourage frequent, honest, and open communication. Employees should be involved in decision making, especially if the change directly affects them. Involving staff helps attain their buy-in since they feel they contributed toward the future vision and they will be more comfortable with impending changes.
3. Communicate. Communicate. Communicate. Communication is the key to success in almost anything that involves human intervention. Naturally, this is also true for cultural changes. Clear communication from the right person to the right audience using the right medium is essential.
4. Define success, recognize people, and celebrate wins along the way. Defining project goals, metrics, scope, deliverables, and timelines for any project is crucial to help the team keep focus. After wrapping up a project, recognize and celebrate team members and wins before moving on to the next project. Acknowledgement spreads positivity across the entire organization and builds momentum for future change.
5. Trust and empower teams. Create as many change agents in the organization as possible so that the Black Belts and Green Belts do not have to facilitate change all by themselves. Leaders should nominate team members to participate in education sessions, encourage the formation of project teams, empower the team to make decisions, support them in their decisions, and help them by removing roadblocks.
For More Information:
• Contact Sumeet Kumar, VCH Workflow Improvement Coordinator, at sumeet.kumar@vch.ca
• Learn more about Vancouver Coastal Health at http://www.vch.ca/.
• Find more real-world examples of quality applied in a healthcare setting at http://asq.org/healthcare-use/why- quality/case-studies.html.
About the Author
Sumeet Kumar is a mechanical engineer, MBA, and Certified Lean Six Sigma Black Belt with 16 years’ experience in the automotive, fast food, chemicals, consumer durables, and health- care industries. At Vancouver Coastal Health, Sumeet helps spread lean culture and promotes operational excellence across eight hospitals that provide mental health and addiction services.
Sumeet formerly served Trident Group as vice president and quality deployment leader and led a team of 17 Black Belts and
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25 Green Belts as he built an infrastructure to support cultural change. He has copyrighted a customer relationship model, and leverages domain expertise, technology, and knowledge in per- formance excellence models to stimulate new business growth, increase revenue and profit, and reduce overhead.
References
1. www.camh.ca 2. www.vch.ca 3. Toyota Kata, Mike Rother, McGraw-Hill, 2009 4. Protocol for the Inter-hospital transfer of patients and their
records, Crest, 2006 5. Applying Toyota production system principles to a
psychiatric hospital: making transfers safer and more timely, Young, J.Q, Wachter, R.M., 2009
6. Communication during patient handover, Joint commission center for transforming healthcare, 2010
7. Inter-hospital patient transfer – a thematic analysis of the literature, Victorian Quality Council, 2009
Acknowledgements
1. Yasmin Jetha, regional director, Mental Health & Addiction Service Program – for providing leadership support to the project
2. Dr. Peter Gibson, medical director, Richmond Mental Health & Addiction – for providing clinical insight to the process and engaging the physician group across all hospitals
3. Rena Van der Wal, executive director, Lean Transformation Services – for providing lean resources and chairing the project steering team
4. Melissa Pearson, workflow improvement advisor, Lean Transformation Services – for providing best practice documentation support and imparting education to the team on standard operating process
5. Jennifer Hamilton, communications – for providing various stakeholder communications support
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