Hotel Dieu Grace Hospital

Hotel Dieu Grace Hospital used value stream mapping and other lean techniques to transform its emergency room, and now it is looking for even deeper changes, as Keith Regan reports Not long ago, the emergency room at Hotel Dieu Grace Hospital (HDGH) in Windsor, Ontario, was a study in inefficiency. Given its downtown location and proximity to the border, the ER can be a very chaotic place. Patients endured long waits to be seen by doctors and nurses and often became angry as a result. Physicians and nurses alike suffered from low morale, says Nicki Schmidt, an ER nurse at the facility, and many senior nurses were looking for positions outside of the ER. The turnover rate was high as a result of the constant stress. ÔÇ£There was very much a feeling of hopelessness,ÔÇØ Schmidt adds. ÔÇ£We were constantly in crisis mode.ÔÇØMaking matters worse was competition from across the border, where hospitals were advertising that patients would wait no more than 30 minutes to see a doctor. So when the idea of using value stream mapping and other principles of lean borrowed from the manufacturing world arose, there was, despite some of the usual resistance, a strong sense of needing to give it a try, says Schmidt, who became a facilitator for the lean effort and is now a member of a core team spreading lean throughout the hospital. The lean work began in October 2005, and by March of the following year, significant improvements were being seen.A slew of changes were made, including simple workplace organization tweaks that eliminated the need for nurses to walk long distances to obtain frequently used medicine or apparatus. One key change came in the way patients were handled by triage nurses in the ER. In addition to using the traditional 1 to 5 scale of urgency, the hospital decided to test out a system by which nurses made a judgment call on whether patients would be admitted or sent home. While the most acute cases were still seen first, the shift meant that patients could quickly be moved through the ER and beds made available. The same change eliminated an inefficient process of having head nurses batch patients together, handing out several charts to nurses on duty at a time, creating times of intense work pressure followed by down time. ÔÇ£Now the nurses were controlling the work and having a level workload instead of getting two or three patients at a time,ÔÇØ says Schmidt. ÔÇ£That change was a big heads-up for the organization in terms of how powerful this could be,ÔÇØ says Claudia den Boer Grima, integrated vice president of clinical support services at the hospital. ÔÇ£We saw that this way of tackling problems was bringing about significant and measurable change.ÔÇØOthers in the hospital noticed as well, with other departments asking for help implementing the same types of changes. Before long, senior management recognized the opportunity to make deeper changes and set out to raise the stakes through a program known as the Transformational Plan of Care (TPOC). This uses rapid improvement events (RIE) and a structured program of preparationÔÇöwhich includes extensive use of value stream mappingÔÇöand follow-up in which participants report their experiences and their improvements. RIEs occur at the rate of two to three per month, with a seven-week cycle for each one that includes weeks of preparation work during which senior management helps explain to participants how specific programs might fit into the bigger picture. Ways of auditing the events after they take place are also designed, often with a heavy emphasis on using visual techniques. The hospital also has instituted ÔÇ£transformational roundsÔÇØ in which the core team and senior managers visit departments that have been through the RIE process to see first-hand how things are different. The presence of those senior managers sends a key message, says den Boer Grima. ÔÇ£We all can get wrapped up in our daily responsibilities, but having us there emphasizes that we are behind this on a corporate level in a very committed way.ÔÇØ As in any organization, getting broad acceptance is key to the success of a lean journey. That may be especially true in healthcare, where many nurses and doctors have been following certain procedures for years, if not decades. To break down resistance, several techniques were used. In the ER, as new approaches were used, the hospital created what it called ÔÇ£Suck it up Wednesday,ÔÇØ when new ideas could be put into practice. The idea was to create a negativity-free window of time to try out new approaches, says Schmidt, with nurses and doctors told they would have a chance to provide feedback once it was over. ÔÇ£We were trying to get across the idea that we could try anything, as long as it was safe, and that we could get people to set aside their resistance for just that short time.ÔÇØ ┬á┬á┬á There was also early acceptance because the focus was never on saving money or cutting costs, Schmidt adds. ÔÇ£The focus was on improving the care we delivered and just being more efficient.ÔÇØEarly successes have built more momentum, meanwhile, and helped make it easier to propagate even deeper change. But the journey will continue, den Boer Grima says. A key component has been involving as many people as possible who are impacted by changes, a major shift from the former approach of using top-down mandates, with ideas put in place by leaders, who might not understand all the implications of doing things in a new way. ÔÇ£WeÔÇÖre now at the point where it is really getting some traction in a very meaningful way,ÔÇØ she says. ÔÇ£WeÔÇÖre at that point where maybe now we need to look at how the changes impact each of our roles. Maybe some of the things we did under the old culture made sense then but now have a different focus. Maybe part of a managerÔÇÖs job will be to focus on sustaining the improvements that have been made, for instance. There is still potential for significant changes to occur.ÔÇØ ÔÇô Editorial research by Dan Finn