Need help preparing a lean management project proposal/ presentation.
ICYC – dental ranking #1 in customer service complaint
Complaints: low moral in staff, burnout/ staff shortage, scheduling difficulties, wait time/access to care, and ineligible for dental care -Veteran must be 100% service connected to receive this care.
New Implementations: Extended hour clinics (Wed- open access clinic, Saturday morning clinic ending at 1:30, and afternoon clinics on Wed& Thurs. We hired 2 dentist, 1 hygienist, and 4 dental assistance to assist with burn out, the criteria for dental care can not be change it comes from the VISN, ICYC initiative and rewarding employees for excellent customer service (incentive for employees like compensatory time. Wait time / access – Kiosk check in system and community care for veterans who qualify
Possible examples I researched:
There are numerous examples of completed Six Sigma projects across a wide range of applications in healthcare. Some examples include using the methodology to improve service cycle time, reduce patient wait time, reduce medication errors, streamline nursing workflow, optimize the use of technology, reduce length of stay, improve the billing process and increase capacity for patients.
It is difficult to provide a great deal of depth in an email response, but at a very high level, here are a few projects and results:
-Midwest hospital reduced patient wait time in ED by over 40%
– To improve perioperative services, one hospital focused on scheduling, length of stay and pre-admission testing. Projects resulted in turnover times reduced by 50-60%, higher surgical staff satisfaction and 6% increase in case capacity yielding $1.7m annually.
– 500 bed hospital improved MR capacity adding 5 slots per day with potential for $437,500 annually in additional revenue
-East Coast health system reduced average CHF length of stay from 6 to 4 days, also improving patient education and chart consistency as part of the project
I would be happy to provide more detailed information on projects and results via email at
@med
.ge.com”>carolyn.pexton@med.ge.com.
With that in mind, the Shark Tank requires a project you completed. We will conduct a face to face video conference by skype or MS Teams. And, you will discuss your A3 and or any other supporting documents. It is a “pure pitch”, with nothing but the value of your project. Please prepare a 10 minute presentation for the interview panel. Select members from the Steering Committees may also be present. However, Only the interview panel will ask questions based on PBI questions and your presentation.
Medical Center Improvement Coach
The Michael E. DeBakey VA Medical Center
This is a face to face video conference
One of the essential skills for Medical Center Improvement Coach is communication. Without this, everything else fails. Communication is the life and blood of any Executive.
Honesty and trustworthiness are of utmost importance in HealthCare. Improvement Coach brings about critical responsibilities, processes, deliverables and resources such as material, money, and human resources. They also represent the organization to employees, customers, and stakeholders. They are role models for their facility.
Improvement Coach is responsible for understanding the need of the customers and proactively responding in a timely, efficient manner in ways that meet customer expectations. Improvement Coach is also responsible for establishing and maintaining effective relationships and gaining the trust and respect of customers and stakeholders.
Medical Center Improvement Coach
The Michael E. DeBakey VA Medical Center
Getting through the MEDVAMC “SHARK TANK”:
Please be prepared to present no more than 10-minutes to support your presentation to the Shark Tank.
• You are free to choose your own PowerPoint template, A3 and graphics, but ensure they are easy to visualize.
• The presentation has a time limit of 10 minutes
• Visual aids are allowed (this includes PowerPoint presentations, etc.)
• A brief question/answer session will follow the presentation.
• The content and delivery of the presentation will be scored
Medical Center Improvement Coach
The Michael E. DeBakey VA Medical Center
Instructions:
This is a face to face video conference
Present your last project for your Shark Tank presentation. (Must contain a signed charter & A3 within your slides) During the presentation, identify why you selected this project for the Shark Tank.
2. How you managed and lead the projects through to completion/ sustainment.
3. How did you manage resistance to change throughout the project?
4. How did you monitor and review the delegated responsibilities, if used?
5. What tools and resources you used to implement your plans and manage the activities of your team?
6. What are some best practices you’ve used to develop relationships within the project teams?
7. How did you ensure sustainability once the project is deployed and implemented?
Medical Center Improvement Coach
The Michael E. DeBakey VA Medical Center
Question you must address in or during your presentation:
Instructions–
Seeking to Understand Problems, Big and Small
Lisa Segerstrom
10/02/2018
De-Mystifying a simple tool
• A3 simply refers to a paper size (11×17 aka A3).
• Mainstay of the Toyota Production System for:
• Proposals
• Status Reports
• Problem Solving
A3 is an approach to problem solving that grew out of Lean Manufacturing at
Toyota. The A3 report condenses project information onto a single page in an
easy-to-read, graphical format. This A3 template provides sections for describing
background information, current conditions, root cause analysis, target
conditions, implementation plan, and follow-up.
• Basic methodology to:
• Identify problem, gap, or need
• Understand current state
• Develop simple target
• Understand root cause
• Brainstorm or identify countermeasures
• Create action plan
• Check results of corrective actions or improvements
• Sustain results
No standard template – your organization or department
may have preferred template.
A3 Report: Project name
Project mission statement
What is the team trying to accomplish?
Background
• Problem background
• Why the problem needed to be fixed
• Importance of identifying solution
Original state/problem statement
• Use a diagram if possible
• Show where the problems exist with Kaizen bursts, i.e. graphic
indicators of opportunities for improvement
• Extent of the problem (e.g., metrics or measures of success that
are below target)
Problem analysis
• Why does the problem exist?
• Does asking “why?” five times help identify the root cause?
• What influences caused the problem?
Team
Executive sponsor:
Champion:
Team lead(s):
Project team: List names and departments
Solution
• Describe recommendations of team
• Show diagram or map of new process
• Measurable targets to achieve within determined timeframes
Implementation plan
• Use a diagram if possible
• Who is responsible for which tasks?
• What resources are required?
• What targets have been identified? Timeline for achieving?
• How regularly will the improvement team connect while the
change is underway?
Graph results
Show improvement over time
Sustain
Implementing a project doesn’t guarantee long-term success. How
does the team plan to continue to make the improvement part of daily
practice, long after the “project” as ended? Determine metrics to
track, feedback loops for staff, and maintain regular A3 updates to
share with the team and supporting leadership.
0
10
Source: AMA. Practice transformation series: starting lean healthcare. 2015.
6) Check: (Summary of the solutions’ results, overall goal success, and any supporting metrics)
1) Problem Statement: (description of the problem and its effect)
Project Lead:
Project Champion(s):
Date Updated:
Project Team:
2) Current State: (depiction of the current state, its processes, and problem(s)
Best Practices/Literature Search:
3) Goal: (how will we know the project is successful; standard/basis for
comparison)
4) Root Cause Analysis: (investigation depicting the problems’ root causes)
A3 Project Title
5) Solutions: (action plan and findings of tested solutions)
7) Act: (Action taken as a result of the Check, and the plan to sustain results)
Goal & Metrics Baseline Target Current
Goal
Supporting Metric
Supporting Metric
Root Cause Tested Solution Responsible Due Finding
*A3 is a UCLA Operating System 11×17 template used to document and communicate complex problem-solving using the Plan Do Check Act (PDCA) method: Steps 1-4 (Plan), Step 5 (Do), Step 6 (Check), Step 7(Act)
A3 PROBLEM SOLVING TOOL: Date:Contact:
SOLUTIONS
What solutions will solve the root causes? (Tools: Brainstorming and Affinity Diagram)
• What solutions are best and we should recommend?
Tool for a few primary options: Impact/Difficulty Matrix
Tool for many options: Criteria Decision Matrix
Consider including an evaluation of the status quo (no change) option
• What impacts (positive and negative) may result from implementing the solutions? (Tool:
Impact Wheel, FMEA)
• How will we mitigate or resolve negative impacts?
• What communication or stakeholder engagement is needed? (Tool: Communication Plan)
• What training is needed?
ACTION ITEMS
• What tasks or actions do we need to take? Who will be responsible for the task? When
should the task be completed? (Tools: Action Plan, Gantt Chart)
• What support and resources are needed for each task?
METRICS/FOLLOW-UP
• What metrics will we use to track progress and performance? How will we validate results?
• How and when will we check progress and performance (e.g., daily, weekly, 30, 60, 90-
days)?
• What processes will we use to enable, assure, and sustain success?
• How will we communicate results and share what we learn with others?
Task Owner Proposed
Date
Actual
Date
BACKGROUND / BUSINESS CASE
• What issue or problem do we need to solve?
• Why is this issue important to solve now?
• What benefits do we anticipate from solving the problem (e.g., quality, timeliness, cost,
customer/employee satisfaction)?
STAKEHOLDERS
• Who are internal and external customers?
• Who are team members that will complete the A3 Problem Solving Tool?
CURRENT CONDITION
• What do we know? What customer, process, program data/measures do we have on the
problem (location, patterns, trends, frequency, factors)? Answer questions like: What
errors are occurring? Who is making the errors? Where are the errors occurring? When are
the errors occurring? How are the errors occurring?
• What don’t we know and need to find out? We may need to develop a Data Collection Plan
that includes: The information/data we need to collect, who will collect the data, data
sources, who will prepare the visuals (bar chart, trend, pie chart), when and who will be sent
the data.
• What is the Problem Statement? What specific performance measure needs to improve?
We need to understand the scope and nature of the problem before we can create a
problem statement. More analysis may be needed if the team cannot write a problem
statement.
Example: Reduce/Increase the number/percent of > from
ANALYSIS/ROOT CAUSES
• What are root causes? Why are the errors occurring?
If the root cause is not obvious, use a root cause analysis tool. Use the simplest
tool to show cause-and-effect down to the root cause(s). The root cause should be
specific – not vague like “poor communication”.
Tools: 5 Whys, Fishbone diagram, or Affinity and Relations diagrams
• Does our data verify the root causes? – a team may need to collect additional data to
verify the root cause(s)
Problem Statement (Describe the Problem)
Historical Trend/Background (Current State of the Situation)
Target/Goal(s)
Implementation Plan/Countermeasures/Outcome
WHAT will be done By WHOM By WHEN What was the OUTCOME
Summary/Wrap-Up/Next Steps
Root Cause Analysis
A3 TITLE: Owner: Sponsor/Manager: Version #: DATE:
• Unlike many other quality improvement tools, it doesn’t require
much instruction or orientation to the process – it’s fairly intuitive.
• Helps focus on process issues or common human error rather than
individual performance.
• Helps shift focus from symptoms of defect to causes of defect.
• Helpful when data isn’t available to identify exact root causes.
• Can help identify other process issues that can be relatively
hidden.
• Allows for identification of all possible causes.
• Allows for clear visual representation of the problem and causes
and process used to come to improvement actions.
• When using the cause and effect or fishbone for
problem solving, identified causes are based on
perception and should not be considered quantitative
analysis. It is best suited for problems that do not have
hard data to use to discover causes.
• Some potential causes identified during the exercise
will be worthy of further analysis or verification.
• It is possible to focus on solving problems that
ultimately have little effect on the problem.
• Best when the exercise involves representatives of all
stakeholders.
• Clearly identify your problem – what are the “bookends”.
• Consider impact to patients as a compelling argument to
get attention to the problem.
• Make sure there is appropriate leadership support for
working on this problem.
• Identify stakeholders – this exercise is best when all
stakeholders have a representative at the table (think
outside the box about who this might be).
• Identify a facilitator and, if resources allow, a note-taker.
(My preference is for both not to be direct stakeholders)
• Schedule an appropriate space and amount of time
(typically at least 90 minutes).
• Provide a paper copy of the template to everyone but use a whiteboard
or flip chart to capture potential causes.
• Facilitate effective brainstorming – no idea is bad or criticized, all offered
causes are recorded and included.
• Ask probing questions to dig deeper into potential causes and to clarify.
• Instruct the group to ignore the categories (Human, Training, Equipment,
Policy/Procedure, Process, Equipment)
• These are suggestions and can by modified as necessary including excluding
some or adding others. (there is no set number required)
• Trying to categorize causes as they are shared will derail your facilitation as
well as limit participants ability to think about all potential causes.
• Once all possible causes seem to be exhausted, ask the group to identify
which of the causes seem to be the most important to solve first (ask if
any need additional data or validation).
• Transfer everything to the template after the session and send to
everyone to review for accuracy.
January 24, 2014
The ‘Do’s’ and ‘Don’ts’ of Effective Brainstorming
• As with any quality improvement project, you want to have a
solid work plan, method for assessing if the improvements have
had the desired effects (or not), and a plan for sustaining
improvements.
• Once you have completed Step 4 with a high level action plan,
create a more detailed work plan for actions/improvements that
are complex, multi-phased, involve multiple departments, or
require significant resource.
• Use your organizations preferred tool. Should, at a minimum,
include:
• One person responsible for completing or overseeing completion
of each task
• Target date for completion for each task
Problem Statement (Describe the Problem)
• We experienced 50 patient identification errors last month with the majority being
mislabeled or unlabeled specimens. This can result in delayed diagnosis, wrong
diagnosis, or patients having to come for repeat testing which is dissatisfying for
them and costly for us.
Historical Trend/Background (Current State of the Situation)
We experienced an unexpected increase in the number of mislabeled or unlabeled
specimens last month. We brought together stakeholders from the nursing staff, lab,
and medical staff to complete A3 problem solving to better understand what may be
contributing to these defects. We prioritized our findings to focus on:
• Ensuring all patients are wearing identification bands.
• Increasing font size on specimen labels to make it easier to see.
• Replacing current specimen labels with a new product that better adheres to
containers
• Improving staff training, clarifying expectations, and developing process to monitor
practice.
Target/Goal(s)
• At least 50% reduction in two-patient identification errors in Q4
Implementation Plan/Countermeasures/Outcome
WHAT will be done By WHOM By WHEN What was the OUTCOME
Each detailed action step Name Target Date
Summary/Wrap-Up/Next Steps
• We will continue to monitor defects as we make these improvements to be sure
they are having the desired effect.
Root Cause Analysis
A3 TITLE: Owner: Sponsor/Manager: Version #: DATE:
- A3 Problem Solving
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 23
What does A3 Mean?
The A3 Method
Why Use A3?
Same Idea, Different Templates
Benefits of Using A3 Fishbone
A Word of Caution
How to Use A3/Fishbone
The Nuts and Bolts of Facilitating Fishbone Problem Solving
Problem-Solving Story
Example: Two patient ID
Easy Enough, But Now What?
1. Personal Mastery :Tell us your experience when leading a group of people to coordinate work. How did you approach the task, what specifically did you do, what was the response to my efforts, describe in detail the outcome and if you would do anything differently?
Success story: Challenge-Context- Action-Result (CCAR) Model
Position: Patient Advocate- Dental ranked #1 in customer service complaints
Challenge: How to best reward and recognize employees in order to improve quality of care for our Veterans and improve their outcome.
· The goal is to increase morale, improve patient experience, and business outcomes.
I caught you caring initiative – to reinforce extraordinary customer service behavior through peer or Veteran recognition. This contains two folds
· Increased attention to the contribution of co-workers.
· Enhance collaboration and teamwork.
Focus Area/ Piolet Clinic: Dental
I shared my vison with the top administrators in the Dental Clinic-Operative Care Line team. I met weekly with these officials and presented key components to increase customer satisfaction and build morale in the Dental section. I created a PowerPoint presentation from data produced by the VEO showing dental ranking #1 in customer service complaints. I successfully argued that launching the Caught you caring initiative/campaign that will boost the morale, improve patient satisfaction, and the veteran experience. My Vision for ICYC initiative includes recognizing individuals who demonstrates our hospital values, the values expressed by our patients/community, and our vision to deliver excellent customer service. I proposed, lobbied for, and succeeded in including the ICYC initiative as part Dentals award/recognition segment in quarterly meetings.
My ability to communicate my expectations of the ICYC initiative allowed me to garner the support of upper management administrators. The Dental clinic employees rallied and provided positive feedback on how this initiative made them feel recognized and this award drives the dental team to provide the best customer service to our Veterans. Management backing was key in obtaining support from executive leadership and the award ceremony was a success and vital to increasing customer satisfaction.
Within the next 6 months I would like to establish the ICYC as an important program that give us the opportunity to recognize an individual who demonstrates compassion, care and contributes to delivering an excellent care experience. The goal is to recognize the employee with the most compliments every quarter. That employee will get to select a gift or compensatory time, get to take a professional headshot photo, be recognized in employee newsletter.
Example of A3 (lean management ) model
Example:
Toyota is known for its continued commitment to improving operational performance. How does a company with close to 350,000 employees consistently, rapidly improve? With a Lean thinking tool called the A3 process. See how the A3 process and problem solving approach helps organizations practice continuous improvement.
The A3 process and problem solving approach helps organizations practice continuous improvement.
What is the A3 Process?
The A3 process is a problem solving tool Toyota developed to foster learning, collaboration, and personal growth in employees. The term “A3” is derived from the particular size of paper used to outline ideas, plans, and goals throughout the A3 process (A3 paper is also known as 11” x 17” or B-sized paper).
Toyota uses A3 reports for several common types of work:
· Solving problems
· Reporting project status
· Proposing policy changes (policy meaning rules agreed upon and enforced by the group)
Why Use an A3 Process?
In most organizations, on most teams, we aren’t collaborating as strategically as we could be. We leave meetings with ideas half-baked. We often move hastily to begin working on implementing a solution, without aligning around important details. Projects move slowly due to rework and duplicate effort, two symptoms of a lack of alignment.
The A3 process allows groups of people to actively collaborate on the purpose, goals, and strategy of a project. It encourages in-depth problem solving throughout the process and adjusting as needed to ensure that the project most accurately meets its intended goal.
The A3 process prescribes to the famed quote by Abraham Lincoln: “Give me six hours to chop down a tree and I will spend the first four sharpening the axe.” The A3 process helps an organization sharpen its proverbial axes by fostering effective collaboration, bringing out the best problem solving in teams.
Collaboration between talented people is critical for innovation and speed. Using the A3 process to foster collaboration can help organizations and teams invest their time, money, and momentum most effectively.
Steps of the A3 Process?
There are nine (well, ten) steps in the A3 process.
0: Identify the problem
Since the purpose of the A3 process is to solve problems or address needs, the first, somewhat unwritten, step is that you need to identify a problem or need.
1: Capture the current state of the situation
Once you align around the problem or need you’d like to address, then it’s time to capture and analyze the current state of the situation. Toyota suggests that problem solvers:
· Observe the work processes firsthand and document your observations.
· Gather around a whiteboard and walk through each step in your process. You can use fancy process charting tools to do this, but stick figures and arrows will do the job just as well.
· If possible, quantify the size of the problem (e.g., % of tickets with long cycle times, # of customer deliveries that are late, # of errors reported per quarter). Graph your data if possible; visualizations are really helpful.
2: Conduct a root cause analysis
Now that you see your process, try to figure out the root cause of the efficiencies. You can ask questions like:
· Where do we suffer from communication breakdowns?
· Where do we see long delays without activity?
· What information are we needing to collaborate more effectively/smoothly?
Document these pain points, then dig deeper. The 5 whys is a helpful tool for
conducting a thorough root cause analysis
. The basic idea is that you begin with a problem statement, and then you ask “Why?” until you discover the real reason for the problem. You may or may not have to ask why exactly five times – this is simply an estimate.
3: Conduct a root cause analysis
Countermeasures are your ideas for tackling the situation; the changes to be made to your processes that will move the organization closer to ideal by addressing root causes. Countermeasures should aim to:
· Specify the intended outcome and the plan for achieving it.
· Create clear, direct connections between people responsible for steps in the process.
· Reduce or eliminate loops, workarounds, and delays.
4: Define your target state
Once you’ve selected your countermeasures, you are able to clearly define your target state. In the A3 process, you communicate our target state through a process map. Be sure to note where the changes in the process are occurring so they can be observed.
5: Develop a plan for implementation
Now that you’ve defined your target state, you can develop a plan for how to achieve it. Implementation plans should include:
· A task list to get the countermeasures in place
· Who is responsible for what
· Due dates for any time-sensitive work items
Most teams choose to document their implementation plan in their A3.
6: Develop a follow-up plan with predicted outcomes
A follow-up plan allows Lean teams to check their work; it allows them to verify whether they actually understood the current condition well enough to improve it. A follow-up plan is a critical step in process improvement because it can help teams make sure the:
· implementation plan was executed
· target condition was realized
· expected results were achieved
These first six steps are captured in the A3 report. Most teams use a template for their A3.
7: Get everyone on board
The goal for any systemic improvement is that it improves every part of the system. This is why it’s vital to include everyone who might be affected by the implementation or the target state in the conversation before changes are made.
Building consensus throughout the process is usually the most effective approach, which is why many teams choose to include this at each critical turning point in the A3 process. Depending on the scope of the work, it might also be important to inform executives and other stakeholders who might be impacted by the work.
8: Implement!
Now it’s time for implementation. Follow the implementation as discussed, observing opportunities for improvement along the way.
9: Evaluate results
In far too many situations, the A3 process ends with implementation. It’s critical to measure the actual results and compare them to your predictions in order to learn.
If your actual results vary greatly from what was expected, do research to figure out why. Alter the process as necessary, and repeat implementation and follow-up until the goal is met.
A Strategy to Reduce Emergency Department Wait Times
in Newfoundland and Labrador
2012
Minister’s Message
The Government of Newfoundland and Labrador is committed to
investing in the health and well-being of all of our residents and
ensuring that health care programs and services are available to
everyone. A key piece of that commitment is enhancing access
and reducing wait times for patients in emergency departments
throughout the province. As Minister of Health and Community
Services, I am pleased to present the Provincial Government’s
Strategy to Reduce Emergency Department Wait Times.
Our vision through this Strategy is that all our residents will
receive appropriate and timely access to services provided in
emergency departments. This will help individuals, families and communities to achieve optimal
health and well-being.
Enhancing the way emergency departments function for both health care professionals and
patients is a main goal of the Strategy. The health care providers who work in the emergency
departments in our province are well-trained, highly-skilled professionals. They come to work
each day committed to providing the best possible care to their patients. By taking actions to
reduce patient wait times, both the patients and health care providers will be better served.
Implementation of the goals and objectives of the strategy will be a long-term process and require
a coordinated approach, with departmental, regional health authorities’ and health professionals’
cooperation and input. We are committed to this process, which will be led by the new Access
and Clinical Efficiency Division within the Department of Health and Community Services.
We recognize that health care affects each and every individual in our province and we will ensure
that our investments result in improvements to the health care system for everyone. I look forward
to reporting to the public on our Strategy to Reduce Emergency Department Wait Times.
Sincerely,
Honourable Susan Sullivan
MHA, Grand Falls-Windsor-Buchans
Minister of Health and Community Services
A Strategy to Reduce Emergency Department Wait Times
in Newfoundland and Labrador
Map of Newfoundland and Labrador
showing the location of the 13 Category
A emergency departments
INTroDuCTIoN
For many individuals the emergency room or department represents
the “front door” to the province’s health care system. In Canada, almost
60 per cent of admissions to hospital are through an emergency
department.1 With a population of approximately 512,000, in 2010-11,
520,000 patient visits were made to the 33 emergency departments
in Newfoundland and Labrador. Of the 33 emergency departments,
13 are larger, have the highest number of patient visits each year and
are most often the sites where patients may experience long wait
times.2 In 2010-11, a total of 180 physicians and 344 staff, including
nurses, nurse practitioners, licensed practical nurses, and clerks,
provided coverage in the larger emergency departments.
The Provincial Government knows that the public expects more
timely access, shorter wait times and better communication and
information regarding emergency department wait times. In 2011,
the Provincial Government made a commitment to address wait
times in emergency departments.
Recognizing the need for health care system enhancements, the
Provincial Government has invested over $140 million over the past
eight years to improve wait times throughout the province, but
more needs to be done. This Strategy builds on that recognition
and furthers the commitment to ensure Newfoundlanders and
Labradorians receive appropriate and timely access to services
provided in emergency departments.
1 Canadian Institute for Health Information report, 2008
2 This province has 13 emergency departments that are designated as Category A and
20 designated as Category B (refer to Appendix A for a list of emergency departments
by category and facility). Category A emergency departments have a minimum of
one physician dedicated to providing emergency services and on-site 24-hours a day
and are in hospitals that, by definition, have acute care beds and specialty services.
Category B emergency departments are primarily in the more rural areas of the
province, have lower patient volumes and while a physician is always available, they
may not be on-site.
| Page 1
Within the first 120 days in office,
we will produce a provincial
strategy on reducing wait times
in emergency rooms. This
strategy will identify means
of improving the timeliness of
services, utilization of existing
emergency room capacity,
physical infrastructure and
policies to enhance “patient flow”
and communication with patients
regarding the anticipated wait
time. (2011 Blue Book)
WAIT TIME IssuEs
The anatomy of an emergency department wait time
A patient’s wait time starts as soon as they walk through the doors of
an emergency department and doesn’t end until the patient is either
discharged home or admitted to hospital. The causes of long wait
times are complex and often unique to each emergency department.
A patient’s visit is made up of a series of smaller events or services
and is referred to as the patient flow. These services can include
such things as triage (the first nursing assessment of how urgent the
patient’s presenting condition is), registration, nursing assessment,
physician (or nurse practitioner) assessment, consultations,
investigations and treatments. A delay in any one of these events or
services will increase a patient’s wait time and can create bottlenecks
in the emergency department.
Research has shown that emergency department wait times are
also affected by what’s happening outside of the emergency
department, in both the hospital and the community. This includes
such things as how quickly in-patient beds are vacated and cleaned
to be able to transfer a patient who is waiting for admission from the
emergency department to the number of family doctors working in
the community and providing evenings and weekend clinics.
The order in which patients are seen and the maximum time that
a patient should have to wait to be seen initially by a physician (or
nurse practitioner) will vary and should be based on the severity or
urgency of the patient’s condition. In Canada, the most commonly
used scale to assign patient urgency in the emergency department
is the Canadian Triage and Acuity Scale (CTAS). More detailed
information on CTAS is available on page 12 of this document.
Unlike other health care services, such as radiation treatment for
cancer, there are no nationally agreed upon benchmarks for wait
times in Canadian emergency departments. In this province, there
is a lack of emergency department wait times data and the data
available is not consistently gathered, which limits the ability to
compare and appropriately plan. Based on a sample of patient
visits reviewed in preparation for this Strategy, we know that the
more urgent patients are being seen quickly, while moderate and
less urgent patients may be waiting longer than recommended,
particularly in the higher volume emergency departments.
Page 2 |
10 of 13 Category A emergency
departments are trained in and
recording CTAs levels.
What we have learned
Understanding the factors that contribute to wait times is the first
step in addressing the issue. As part of the development of this
Strategy, Eastern Health, in collaboration with the Department of
Health and Community Services, contracted with an internationally
recognized group of experts in emergency department wait times to
complete reviews of its two busiest adult emergency departments
at the Health Sciences Centre and St. Clare’s Mercy Hospital. The
reviews included two weeks of on-site shadowing and patient
sampling to help understand how the two emergency departments
were operating and staff were providing services. Staffing schedules,
patient volumes, CTAS ratings and physical structures were reviewed
and recommendations made to improve patient flows and shorten
wait times.
Each emergency department is unique and serves its own patient
population. The recommendations that were made by the external
consultants to reduce emergency department wait times at the
Health Sciences Centre and St. Clare’s Mercy Hospital provided both
specific requirements for each of the two emergency departments
as well as lessons learned that can be generalized to all of the
emergency departments in the province.
Some of these lessons include:
• Emergency department wait times can be reduced through
better use of existing resources. The number and type of staff
and how they are scheduled must line up with the numbers and
timing of when patients present to the emergency department.
The physical layout of an emergency department may limit the
number of patients that can be seen, including where they are
seen. Additionally, if equipment and supplies are not stored
properly and conveniently, the time that staff can spend with
patients will be reduced.
• Hospitals that focus only on what happens in the emergency
department to reduce wait times will not be completely
successful. Other hospital policies, such as how the X-ray and
lab departments prioritize patients, must be reviewed and
wherever possible, aligned to meet the needs of the emergency
department.
| Page 3
Combined, the Health
sciences Centre and st. Clare’s
Mercy Hospital emergency
departments have more than
85,000 patient visits a year.
• In some cases, emergency departments are replacing the
services that would normally be provided in the community
and in particular by family doctors. Finding community-based
alternatives to emergency department care, such as the addition
of urgent care clinics and after-hours primary care services can
significantly reduce the number of patient visits to an emergency
department3 and wait times.
• Patients may think that they can get faster access to specialists
and investigations of their medical condition(s) by going to the
emergency department, rather than being referred by their
family doctor.
• Through real time observation and the recording of the time
periods that make up a patient visit, issues that are causing
longer wait times can be identified and actions quickly taken
to reduce them. Currently, no emergency department in the
province is publicly reporting on their emergency department
wait time statistics.
• Listening to patients and communicating with them and the
public about wait times in the emergency department is essential
for successful outcomes.
What we have done
In advance of the Strategy, the Department of Health and Community
Services has already implemented initiatives that complement
the actions of this Strategy, including: increased the number of
medical school seats from 64 to 84 (planned for September 2013);
increased the number of family practice residency positions;
funded an additional year in the Family Practice residency program
for physicians planning to work in an emergency department;
and, increased the number of bursaries offered to family practice
residents. The Provincial Government has also increased the number
of nursing seats from 255 to 291 and continues to provide BN and
Nurse Practitioner bursary programs.
The Access and Clinical Efficiency Division in the Department of
Health and Community Services was established in 2011 to take the
provincial lead on the issue of wait times in the province’s health care
system.
3 Jones D.C., Carrol L.J, and Frank L., 2011 After Hours Care in Suburban Canada:
Influencing Emergency Department Utilization; Journal of Primary Care and Community
Health, May 25, 2011. Page 4 |
In 2011-12, 50 bursaries were
offered to 47 Family Practice
residents, at a cost of $1.25
million. Each bursary has a one
year return in service commit-
ment to an area of need in the
province.
Work, in collaboration with the four regional health authorities, is
currently being done to reduce wait times for selected services, such
as endoscopy.
The Department of Health and Community Services has also
recently developed other strategies for implementation, related to
wellness and chronic disease management. Actions arising from
these strategies will impact on emergency department utilization
and help reduce wait times.
THE sTrATEGY
This is a five-year Strategy, designed to reduce wait times in the
province’s higher volume emergency departments, while promoting
patient safety, quality of care and treatment standards.
To reduce wait times, the Strategy has five goals:
1. To improve the efficiency of higher volume (Category A)
emergency departments;
2. To improve access to community-based health services that
will support effective utilization of emergency departments;
3. To implement a province-wide standard for patient triage
and wait times to receive initial medical attention;
4. To improve the collection, reporting and use of emergency
department wait time data; and,
5. To improve communication with patients and the public
regarding emergency department wait times.
These goals are consistent with the 2011-2014 Strategic Plan of the
Department of Health and Community Services under the issues of
improved access and increased efficiency. By meeting these goals,
the provincial health care system will be able to provide high quality
emergency department care in as short a time as possible for the
people of the province.
To develop the Strategy, the Department of Health and Community
Services worked closely with the support of senior leadership in the
four regional health authorities, various emergency physicians, the
Canadian Association of Emergency Physicians and other health care
professionals involved in providing emergency department services.
| Page 5
The Department’s Access and Clinical Efficiency Division has
responsibility to work with the four regional health authorities to
implement the Strategy’s actions.
Goal #1 To improve the efficiency of higher volume
(Category A) emergency departments
Improving how an emergency department functions does not always
require more money or new resources. Rather, the focus should be on
removing the barriers that impede or slow down patient flow. Each
emergency department is unique and remedies have to be tailored
to recognize this; for example, each emergency department makes
staffing decisions based on its own patient volumes and levels of
patient acuity or urgency.
Objective: Ensure optimal staff scheduling, skill mix,
supportive policies, physical layout and patient
flow in emergency departments.
In order to improve efficiency in high volume emergency
departments, the way staff is scheduled and what duties health
professionals are required to do, must be addressed. Staffing
schedules need to match patient volumes, acuity and time of
presentation. Skill mix also has to be optimized to ensure that the
right staff are there to meet the needs of the patients. This includes
reviewing the potential role of nurse practitioners to help address
high volumes of less urgent patients.
Efficiency also relies on factors other than staffing levels. Some
hospital policies can negatively impact emergency department wait
times, such as their Discharge Policy, including how early in the day
discharge orders must be written by a physician. These policies need
to be identified, reviewed and changed wherever possible so that
they align with emergency department needs. The physical layout
of the emergency department can also negatively impact efficiency;
proper set up can reduce or eliminate inefficiencies.
Ensuring that high volumes of less urgent patients are seen efficiently
can reduce emergency department overcrowding. As these patients
often do not need a bed to be seen and treated, emergency
departments and nearby spaces should be set up to meet the needs
of this group of patients.
Page 6 |
The use of standardized protocols should be considered, in
consultation with emergency physicians. This will allow nursing staff
to begin a patient’s investigations and possible treatments based
on the patient’s presenting problem while waiting for the physician,
for example, administrating medication to a child presenting with a
fever or completing blood work and an EKG on a patient with chest
pain.
Actions:
• External reviews of all 13 Category A facilities will be completed
to determine current and baseline wait times, identify the
causes of delays in patient flow and implement quick wins and
solutions to reduce wait times.
o It takes three to four months to complete an external
utilization and staffing review of an emergency
department;
o Completion of all 13 Category A emergency departments
reviews is planned within three years; and,
o The Provincial Government will allocate funding for
six new nursing staff positions to be placed in St.
John’s, Gander and Grand Falls-Windsor emergency
departments, as well as one ward clerk position in
Stephenville.
• Front-line emergency department staff will be educated and
trained in process improvements to reduce wait times in an
emergency department.
o A three-day workshop is planned for Spring 2012 and
providers from all 13 Category A emergency departments
will be invited to participate.
o Other training needs will be identified and addressed as
each review is completed.
| Page 7
Goal #2 To improve access to community-based health
services that will support effective utilization of
emergency departments
Many patients visit an emergency department as they either do not
have a family doctor or they are not able to see one quickly. Some
patients use the emergency department to try and access specialists
and diagnostic tests (X-ray and other services) more quickly.
High volumes of low-urgency patients can create overcrowding in an
emergency department and lead to longer wait times. In 2010-11, 56
to 86 per cent of patients who presented in one of the 10 Category A
emergency departments that are using CTAS, were triaged as either
CTAS 4 or 5, indicating non-urgent, routine conditions.
Historically, the thinking has been that reducing or diverting the
number of low-urgency patients would not significantly reduce
demands on and wait times in an emergency department.4 Recent
research however, demonstrates that community-based alternatives
to the emergency department reduce the number of patients who
would otherwise present there.5
To achieve this goal, the Strategy has three objectives to: 1) increase
access to family doctors, 2) increase awareness and usage of the
provincial HealthLine and 3) provide community-based alternatives
to hospital admission by seniors, where appropriate.
Objective: Increase access to family doctors
Some patients present to the emergency department as their family
doctors may not have appointments available to see them quickly
or they do not offer services after hours or on the weekends. The
Canadian College of Family Physicians and the Institute for Health
Care Improvement have endorsed the model of Open Access
Scheduling. This is a type of scheduling that can be used in a family
doctor’s office, where a number of appointment times are left open
each day so they can provide same-day appointments to patients
who call with acute illnesses. This approach also enhances the
coordination of care as patients are seen by their own physician,
instead of visiting the emergency department.
4 Auditor General of Ontario report, Chapter 3, Section 3.05, Hospital Emergency
Departments, 2011
5 Alberta Medical Association, Primary Care Network Backgrounder, January 21, 2011. Page 8 |
Some family physicians are in solo or group practices that provide
clinics only on weekdays and during regular working hours. As a
result, patients often feel that they have no other choice but to seek
medical attention in an emergency department when they require
care after hours.
Action:
• The Department of Health and Community services will
collaborate with the Newfoundland and Labrador Medical
Association to increase the availability of community-based
services by:
o Promoting the use of Open Access Scheduling;
o Providing incentives to family doctors to increase the
number of evening and weekend clinics they provide;
and,
o Exploring alternate models of care, including family
doctors working with other groups of physicians to
provide after-hours coverage or in teams with other
health care providers.
Objective: Increase awareness and use of the provincial
HealthLine
Today’s public is often confused about who to call and where they
should go to receive advice on their medical problem or condition.
Since September 2006, the Department of Health and Community
Services has been funding HealthLine, a provincial phone line, which
is staffed by experienced nurses, to provide both medical advice and
direction to patients who have minor, non-urgent health complaints.
Currently, capacity exists to increase the number of phone calls that
HealthLine receives.
The HealthLine receives approximately 2,600 calls a month, with
50 per cent repeat callers. Approximately 75 per cent of the phone
calls are made by either patients or care-givers regarding medical
symptoms. Of these, approximately 20 per cent are referred to an
emergency department, 60 per cent are referred to the family doctor
or health care provider for follow up if their symptoms don’t resolve
and 20 per cent are recommended self-treatment.
| Page 9
Each month the HealthLine does a follow-up survey of clients who
called in the prior month. On average, 80-85 per cent of the clients
surveyed reported that they followed the nurse’s recommendations.
The Department of Health and Community Services is collaborating
with the Newfoundland and Labrador Centre for Health Information
to complete an external review of the impact of HealthLine on the
provincial health care system. To date, Phase One of the review has
been completed, which included an extensive literature review and
audit of the HealthLine’s statistical reports. Phase Two of the review
will focus on patient satisfaction and the impact that the information
provided by the HealthLine has on a patient’s subsequent behavior
and in particular, whether it deters them from presenting to an
emergency department for those who were advised otherwise.
Actions:
• The Department of Health and Community services will
continue to promote awareness and use of the provincial
HealthLine.
• The Department of Health and Community services, in
collaboration with the Newfoundland and Labrador Centre for
Health Information, will complete Phase Two of its utilization
review of the HealthLine.
• Eastern Health will commission the HealthLine to do follow-
up, within 24 hours of the visit, of patients who left their
emergency departments without being seen to determine
their status.
Objective: Provide community-based alternatives for seniors
to prevent hospital admissions
One of the most common reasons for long wait times in an emergency
department is patients staying in an emergency department for
long periods of time after the decision to admit them has been made
but no hospital in-patient bed is available. As a result, these patients
experience longer wait times in the emergency department and both
the emergency department and acute care system are impacted.
Policies and actions that increase the number of available hospital
beds will lead to decreased wait times in an emergency department.
Page 10 |
In our province, 94 per cent of seniors live at home; 25 per cent live
alone. Often, seniors present to the emergency department with a
worsening of a chronic medical condition, such as chronic obstructive
lung disease and because they need some level of nursing or
supportive care that prevents them from returning home, they are
admitted to hospital. Once admitted, a senior’s length of stay is 50 per
cent longer than a non-senior being treated for the same condition.
We also know that 71 per cent of patients that are designated
as requiring alternate levels of care (patients who are medically
discharged but need rehabilitation or are unable to return home) are
admitted through an emergency department.
Other jurisdictions have found that by delivering rehabilitation and
other services to seniors with medical needs in their own homes,
admissions through emergency departments have been reduced.
Following the implementation of such a program at the Red Deer
Regional Hospital Centre in Alberta, a 50 per cent reduction in
admissions to hospital through their emergency department was
reported.
Action:
• The Department of Health and Community services will work
with the regional health authorities to provide access to
enhanced community-based health services for seniors, who
present at an emergency department and could otherwise be
supported at home and avoid hospital admission, by piloting
two Community-based rapid response Teams.
o A community-based rapid response team is comprised
of medical professions including nursing, physiotherapy,
occupational therapy and physicians who provide short-
term intervention and support to seniors in their own
homes;
o Seniors, who are identified by the emergency department
physician as being able to return home with additional
supports, will be referred to the team for follow-up care
and monitoring in the patient’s home. As their condition
improves, patients will be referred back to regular
community supports; and,
o 24-hour home support for up to seven days will also be
available.
| Page 11
In 2010-11, 35 per cent of
all hospital admissions were
for patients aged 65+; 70
per cent of these admissions
were through an emergency
department.
Goal #3 To implement a province-wide standard for patient
triage and wait times to receive initial medical
attention
How long a patient waits to be seen and assessed in an emergency
department will vary. Some of the variation is medically acceptable
and based on the urgency of the patient’s condition at the time of
arrival in the emergency department.
The most common classification system used in Canadian
emergency departments to determine the urgency or severity of a
patient’s condition on arrival to the emergency department is the
Canadian Triage and Acuity Scale (CTAS), developed by the Canadian
Association of Emergency Physicians in 1998. CTAS is being used in
approximately 80 per cent of Canadian emergency departments for
quality assurance and standardization purposes. CTAS is currently
being used by 10 of the 13 Category A emergency departments in
the province. Implementation of a province-wide system, like CTAS,
will allow the capture of consistent data and help reduce wait times
in emergency departments.
CTAS is a five point scale that an emergency department can use to
evaluate a patient’s presenting condition and identify their need for
care. CTAS also establishes the maximum recommended time that a
patient should wait until their initial medical assessment, by either a
physician or appropriate health care provider.
When used, each patient is assigned a CTAS level of 1-5 during the
initial nursing assessment (triage). The following summarizes the
CTAS:
• Level I – Resuscitation (e.g. cardiac arrest) requiring an immediate
response;
• Level 2 – Emergent (e.g. chest pain) requiring a response within
15 minutes;
• Level 3 – Urgent (e.g. mild to moderate asthma) requiring a
response within 30 minutes;
• Level 4 – Less Urgent (e.g., minor trauma, urinary symptoms)
requiring a response within 60 minutes; and,
• Level 5 – Non-Urgent (e.g. common cold, sore throat) requiring a
response within 120 minutes.
Page 12 |
The training for, implementation and use of the CTAS scale (or
equivalent) is the first step in measuring emergency department
wait times and establishing wait time targets in the province.
Action:
• The Department of Health and Community services will
adopt and implement CTAs as the provincial standard
for both patient triage and recommended maximum
wait times to initially be seen by either a physician or
appropriate health care provider in all 13 Category A
emergency departments.
Goal #4 To improve the collection, reporting and use of
emergency department wait time data
Prior to the completion of the two emergency department reviews
in Eastern Health, no Category A emergency department was
recording a comprehensive list of patient wait times. The two adult
emergency departments in St. John’s have now started. Collection
of this information is essential to understand the magnitude of wait
time delays in an emergency department, be able to set reasonable
and realistic targets to reduce excessive wait times and report to the
patients and the public.
There are four nationally recognized wait time metrics or
measurements that document how well an emergency department
is meeting the needs of the population it serves. Collection of
information on these four measures has been recommended by the
consultants who completed the two external reviews of the adult
emergency departments in St. John’s and includes:
| Page 13
The two adult emergency
departments in st. John’s see
25 per cent of the total patients
that visit Category A emergency
departments.
Currently, 50 per cent of
Category A emergency
departments are electronically
recording at least one of the
four key metrics.
1. “Door to Doc” – This time period is based on the CTAS and
includes the time from when the patient presents to an
emergency department and is registered or triaged until
they are initially seen by a physician or the most appropriate
health care provider. This time period sets the standard for a
commitment to safety and is often the one that determines a
patient’s overall satisfaction with their visit.
2. Length of stay – This is the total time that a patient spends in
the emergency department, from when they first arrive until
they are either discharged home or admitted to hospital. This
time period indicates how well an emergency department is
working and performing.
3. Left without being seen – This is the percentage of patients
who registered in the emergency department but left
before their visit was completed. It is an indirect measure of
wait times and indicates patient dissatisfaction. It may also
indicate that the visit to the emergency department was not
required.
4. Patient satisfaction – All regional health authorities have
Complaint/Compliment procedures. However, none of the
regional health authorities have an emergency department
satisfaction survey.
An electronic wait time system allows for the ongoing gathering
of information and recognition of bottlenecks in patient flow so
that quick actions can be taken to resolve the problem. These
systems, which support the monitoring and communication of
actual and current wait times, are best utilized in larger, high
volume emergency departments.
Page 14 |
The recommended target for
left without being seen is two to
three per cent or less.
Actions:
• The Department of Health and Community services,
working with Eastern Health, will implement an electronic
Emergency Department Information system in the emergency
departments at the Health sciences Centre and st. Clare’s
Mercy Hospital.
o Business cases will be completed during each external
review of the higher volume emergency departments
to determine the return on investment of implementing
an Emergency Department Information System in other
Category A emergency departments.
• The Department of Health and Community services will
standardize the measurement of provincial emergency
department wait times based on the collection and recording
of, at a minimum: Door to Doc and length of stay wait times,
the percentage of patients who left without being seen and
patient satisfaction.
Goal #5 To improve communication with patients and the
public regarding emergency department wait
times
Knowledge is power. An emergency department that is patient-
focused should communicate to the patients who are waiting, as
best they can, what their expected wait time should be. Patients
need to be educated that wait times are based on urgency and not
the order in which they register. Patients also need to understand
that unplanned and urgent events, such as a motor vehicle accident
or a cardiac arrest, will impact their wait time. Priority will always be
given to the most urgent patients, making less urgent patients wait
longer. Improving a patient’s knowledge, their experience and the
service they receive all contributes to patient satisfaction.
One way to improve a patient’s knowledge of expected emergency
department wait times is through the use of historical, averaged wait
time data. In those emergency departments where an emergency
department information system has been implemented, wait time
information can be available in real time.
| Page 15
To date, the Provincial Government is reporting quarterly on
provincial and regional wait times in the five priority areas identified
in the 2004 Canadian Health Accord; emergency department wait
times were not included. No regional health authority is providing
information on emergency department wait times to the public.
Actions:
• The Department of Health and Community services will work
with each regional health authority to ensure that information
on CTAs is posted in the waiting rooms of all Category A
emergency departments.
• Emergency departments will provide wait time information to
patients in either real time or on a historical basis.
• In consultation with the Department of Health and Community
services, each regional health authority will develop a
communication strategy to determine patient satisfaction
with their emergency department visit.
• The Provincial Government will report annually to the public
on emergency department performance, including wait times,
on the Department of Health and Community services’ website
as emergency department-specific information becomes
available.
Page 16 |
CoNCLusIoN
Improving overall access to the health care system is a priority for the
Government of Newfoundland and Labrador. In 2011, the Provincial
Government committed to reduce wait times in emergency
departments. This Strategy is evidence of this commitment and
provides the means for the promise to be met.
Actions that make an emergency department more efficient,
reduce the number of low urgency patients that use the emergency
department and reduce the number of hospital admissions by
seniors, where appropriate, will reduce emergency department
wait times. These actions will ensure that patients receive timely
access to the health care system in the most appropriate setting. By
replicating the external reviews that have already been completed
and have begun to reduce wait times in the province’s two largest
emergency departments, we will reduce emergency department
wait times throughout the province on a site by site basis. The plan is
that within three years, all Category A emergency departments will
be reviewed, recording wait times information and will have begun
to implement changes that will reduce wait times. While Category B
emergency departments are not the focus of this Strategy, the lessons
learned and changes that are made in larger volume emergency
departments can be considered at all sites.
We care about what we measure. By adopting CTAS standards and
ensuring that emergency departments are recording, monitoring
and reporting on wait time information, we know that this, in itself,
will reduce wait times. Improving communication with patients and
the public on wait times will increase transparency, performance
and satisfaction.
The information that we collect through the implementation of this
Strategy will help to ensure that the Provincial Government is able
to establish evidence-based wait time targets for our 13 Category A
emergency departments that meet the needs of the public and can
be achieved.
| Page 17
APPENDIX A
Category A Emergency Departments
Eastern Health
• Burin Peninsula Health Care Centre, Burin
• Carbonear General Hospital, Carbonear
• Dr. G.B. Cross Memorial Hospital, Clarenville
• Health Sciences Centre, St. John’s
• Janeway Children’s Health and Rehabilitation Centre, St. John’s
• St. Clare’s Mercy Hospital, St. John’s
Central Health
• Central Newfoundland Regional Health Centre, Grand Falls-
Windsor
• James Paton Memorial Regional Health Centre, Gander
Western Health
• Sir Thomas Roddick Hospital, Stephenville
• Western Memorial Regional Hospital, Corner Brook
Labrador-Grenfell Health
• Captain William Jackman Memorial Hospital, Labrador City
• Charles S. Curtis Memorial Hospital, St. Anthony
• Labrador Health Centre, Happy Valley-Goose Bay
Category B Emergency Departments
Eastern Health
• Bonavista Community Health Centre, Bonavista
• Dr. A.A. Wilkinson Memorial Health Centre, Old Perlican
• Dr. Walter Templeman Community Health Centre, Bell Island
• Dr. William Newhook Community Health Centre, Whitbourne
• Grand Bank Community Health Centre, Grand Bank
• Placentia Health Centre, Placentia
• U.S. Memorial Health Centre, St. Lawrence
Central Health
• A.M. Guy Memorial Health Centre, Buchans
• Baie Verte Peninsula Health Centre, Baie Verte
• Brookfield/Bonnews Health Care Centre, Brookfield
• Connaigre Peninsula Health Care Centre, Harbour Breton
• Dr. Hugh Twomey Health Care Centre, Botwood
• Fogo Island Hospital, Fogo
• Green Bay Community Health Centre, Springdale
• North Haven Emergency Centre, Lewisporte
• Notre Dame Bay Memorial Health Centre, Twillingate
Western Health
• Bonne Bay Health Centre, Bonne Bay
• Calder Health Care Centre, Burgeo
• Dr. C.L. Legrow Health Centre, Port aux Basques
• Rufus Guinchard Health Care Centre, Port Saunders
Page 18 |
Department of Health and Community services
1st Floor, West Block, Confederation Building
P.O. Box 8700, St. John’s, NL A1B 4J6
www.health.gov.nl.ca
2012
Improving waiting time
in vaccination room
using Lean Six Sigma
methodology
Dr/ Mohamed Adel El Faiomy
Dr/ Ayatullah Amr Muhamad Shabana
S A U D I M I N I S T R Y O F H E A L T H
S E N A Y A P R I M A R Y H E A L T H C A R E C E N T E R
background information
Background information
ELsenayea primary healthcare centre is one of the
largest primary healthcare centers in Khamis region in
KSA it provides preventive, curative and health
promotion services to more than 29000 population,
due its large catchment area it serves more than 300
customer per day so the waiting time is very important
to calculate and to improve
1-Define phase
▲▲▲ A) Identify the project
To select the most appropriate project we review the data on
potential project against specific criteria & after evaluation of
these projects we decided to work on the problem of
prolonged waiting time in vaccination room because it meet
the criteria of selecting a project as follow:
Chronicity of the problem as it is a persistent problem
Significant because it has a favorable outcome
It is of manageable size as it can be completed in less
than six months
Improve the level of competition
It has potential impact on
☻Retaining customer
☻Attracting new customer
☻Reducing the cost of poor quality
☻Enhancing employee & customer satisfaction.
▲▲▲ B) Prepare problem statment & goals
►The problem
Waiting time before entering vaccination room is too long
(average 25.4 minute) between 2
1
st
of
March to 21
st
of
April 2012 which lead to external customer dissatisfaction
and internal customer pressure.
►The goal is to reduce average waiting time in the
vaccination room to meet customer expectations which is
10 minutes.
PROJECT TEAM CHARTER
1- Problem statement
Waiting time before entering the vaccination room is too
long (average 25.4 minute) between 21
st
of March to 21
st
of April 2012 which lead to external customer
dissatisfaction and internal customer pressure.
2-bussiness case
About 30 children are vaccinated daily. The delay in
vaccination negatively affects the customers satisfaction,
organizational reputation in the catchment area of the
PHCC, disciplinary actions from higher authorities in
response to customer complaints and puts more pressure
on internal customers .
3-Goal statement
to reduce average waiting time in the vaccination room
to
meet customer expectations which is 10 minutes.
4-Project scope
The process starts by the parent ordering his child’s family
health record & end by the child entering the vaccination
room.
5- Select team
Sponsor (PHCC director)
Green belt [Quality professional Dr Mohamed Adel Elfaiomy]
Green belt [Quality professional dr Ayatullah Amr Shabana]
Team member [medical supervisor]
” ” [general practitioner]
” ” [head of nurse]
” ” [vaccination nurse]
” ” [medical record clerk]
“ “ [well baby clinic nurse]
6-Project plan
Define phase 10/3/2012 to 10/4/2012
Measure phase 11/4/2012 to 30/4/2012
Analyze phase 01/5/2012 to 9/5/2012
Improve phase 10/5/2012 to 23/6/2012
Control phase 23/6/2012 to 30/6/2012
Voice of customers:
4 focus groups were done with 57 parents from the
60 surveyed cases to estimate the upper specification
limit for the process, and the mean of customer`s
requirements was 10 minutes.
An AD HOC team was formed from all the
process
owners to estimate the minimal time for the process
using the above mentioned flow chart, and it was 5
minutes, which we the team considered as the lower
specification limit.
CTQs
Customer needs Drivers CTQs Internal metrics
Least waiting time Least cycle
time in vital
signs room
Standard
procedures
for pre
vaccination
process
Time for pre
vaccination
process
Least cycle
time in
examinatio
n room
Least cycle
time in
vaccination
process
.
2-Meassure phase
The measure step identifies the symptom of the problem &
establishes base line measurement of current and recent
performance.
It also maps the process that is producing the problem in
order to understand how the current process actually
operates.
High level flow chart of the current process
Data collection plan:
variable operational defenition
data
source
data collection method who will
collect data
when data
will be
collected
waiting
time in
file room
it starts since the parent ask
for his child’s medical
record till the file reaches
the well baby room
waiting
time data
collection
sheet
the medical record clerck
register the time when the
parent ask for the file and
record it in the collection
sheet the
vaccination nurse record the
time when the child enters
the room and before he
takes the vaccination
the nurse supervisor collect
the data from data collection
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
well baby
room
it starts since the file reach
the room till the child name
is called in well baby room
waiting
time data
collection
sheet
the medical record clerck
register the time when the
parent ask for the file and
record it in the collection
sheet the
vaccination nurse record the
time when the child enters
the room and before he
takes the vaccination
the nurse supervisor collect
the data from data collection
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
pediatric
clinic
it starts since the file reach
the room till the child name
is called in pediatric clinic
waiting
time data
collection
sheet
the medical record clerck
register the time when the
parent ask for the file and
record it in the collection
sheet the
vaccination nurse record the
time when the child enters
the room and before he
takes the vaccination
the nurse supervisor collect
the data from data collection
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
vacination
room
it starts since the file reach
the room till the child name
is called in vaccination room
waiting
time data
collection
sheet
the medical record clerck
register the time when the
parent ask for the file and
record it in the collection
sheet the
vaccination nurse record the
time when the child enters
the room and before he
takes the vaccination
the nurse supervisor collect
the data from data collection
sheet
nurse
supervisor
between 21
march and 28
march
number
of staff
working
in each
room
staff actually working in
every room involved in the
process
staff
checksheet
number of staff actually
working in each room is
collected by the nurse
supervisor
nurse
supervisor
between 21
march and 28
march
Step 3 Analyze phase
*Analyze phase seeks to discover root causes of the major
contributes to the problem. Theories are generated by mean of
brainstorming; the list of theories is organized by mean of cause-
effect diagram so the team can discern the specific theories of root
causes. Finally, theories of root causes are tested and causes are
identified.
Test theory :
After gathering data about phases of waiting time the team used Scatter
diagram to find the cause of prolonged waiting time through correlation
So we have four theories to test using scatter diagram:-
1. The delay because of waiting at file room
2. The delay because of waiting at well baby room
3. The delay because of waiting at pediatrician room
4. The delay because of waiting at vaccination room
Correlations: file waiting time; total waiting time by minutes
Pearson correlation of file waiting time and total waiting time by minutes =
0.712
10987654321
7
0
60
50
40
30
20
10
0
f ile w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i n u t e s v s f i l e w a i t i n g t i m e
Correlations: well baby waiting time; total waiting time by minutes
Pearson correlation of well baby waiting time and total waiting time by minutes
= 0.891
403020100
80
70
60
50
40
30
20
10
0
w e ll b a b y w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i n u t e s v s w e l l b a b y w a i t i n g t i m e
Correlations: pediatrician waiting time; total waiting time by minutes
Pearson correlation of pediatrician waiting time and total waiting time by
minutes = 0.668
35302520151050
80
70
60
50
40
30
20
10
0
p e d ia t r ic ia n w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i v s p e d i a t r i c i a n w a i t i n g t i m
Correlations: vaccination room waiting time; total waiting time by minutes
Pearson correlation of vaccination room waiting time and total waiting time by
minutes = 0.725
121086420
70
60
50
40
30
20
10
0
v a c c in a t io n r o o m w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i v s v a c c i n a t i o n r o o m w a i t i n g
And from the above graphs we found positive correlation
between increased total waiting time and waiting time in
well baby room
At the end of analysis phase:
We found that the highest correlation was at the phase of waiting at well baby room
Step 4 Improvement phase
1- choose remedy.
the team sit together after analyze phase and by brainstorming
the team agreed upon a remedy which is :
redesigning the process of pre vaccination to be in one room
only to avoid waiting time between steps
2- Design remedy.
After the team reviewed the goals and determined the
required resources from people-money-time-material,
the team decided the following remedy:-
“Using lean technique to make the whole process done in
one room.”
So we will calculate and sum the area of the three rooms and transfer
the whole process to the vaccination room after arranging it using
lean technique, so that the parent and child will only wait one time
before getting the service.
The team defines a tree diagram to identify the role of each member
in the new project.
The tree diagram
3- Prove effectiveness:-
Before an improvement is finally adopted, it must be proven effective
under operating condition.
pilot test is designed to start working in the new room for 1 week
from 9
th
of may 2012 to 16
th
of may 2012 and calculating waiting time
in this period.
464136312621161161
40
30
20
10
0
O b s e r v a t io n
W
a
it
in
g
t
im
e
_
X=11.04
UCL=28.73
LCL=-6.65
1
1
I C h a r t o f w e l l b a b y w a i t i n g t i m e
This control chart showing waiting time before well
baby room (the red X) before applying the remedy
This is the control chart showing waiting times before
applying the remedy showing:-
1. 53 out of 60 observations are above the upper
specification limit which is 10 minutes according
to VOC, with percentage = 88.3%.
2. The mean is 25.42
This is the control chart showing waiting times after
applying the remedy showing:-
1. All observations are within the specification limits.
2. The mean is 7.55
5- Implementation
After the one week pilot and calculating waiting time
and according to the improvement proven by the
control chart we decided to implement this remedy
using the attached tree diagram
The new flow chart
Step 5 Control
Implementation 3 activities for control:
1- Design effective quality controls.
2- Foolproof the improvement.
3- Audit the controls.
A) Design control
To ensure that the breakthrough is maintained, the quality
improvement team needs to develop effective quality control by
feedback loop.
ok
Not ok
Measure
actual
performance
Compare
to
specificatio
ns
Regulate
process
Customer
specifications
(upper and
lower control
limits)
To build a feedback loop, the team will need to
1- Measure the end results or the outcome of the improved process
must be measured to be between upper and lower specification limits
(5 min and 10 min) by random samples taken every week using the
following data collection plan.
variable operational defenition
sample
size
data
source
data collection method who will
collect data
when data
will be
collected
waiting
time
before
vaccination
it starts since the parent ask
for his child’s medical
record till the child name is
called in vaccination room
5% of
cases in
the
week
waiting
time data
collection
sheet
the medical record clerk
register the time when the
parent ask for the file and
record it in the collection
sheet
the vaccination nurse record
the time when the child
enters the room and before
he takes the vaccination
the nurse supervisor collect
the data from data
collection sheet
nurse
supervisor
Starting from
23 June 2012
Waiting
time in
vaccination
room
It starts from entry of child
till he is out
5% of
cases in
the
week
Vaccination
room
register
The room nurse register the
time when child enters the
room and when he leaves
the room and record it in
collection sheet
Room nurse
Starting from
23 June 2012
The act of comparing actual performance to specifications will be the
role of quality professional:-
plotting the actual performance on control chart
monitor the chart for trends and pattern and special causes
decide with the team what is the corrective action that will be
taken to control the process according to control plan:
B) Audit the control
Routine reporting of result is maintained
Clear documentation of control is done
What done Who
acts
Who
analyze
Upper
and
lower
control
limits
Where
measured
How
measured
Control
variable
5 why
technique to
know the
reason for
variation
Team meeting
to suggest
error proof
solution
Team
leader
Quality
professional
Between
5 min
and 10
min
Files room
Vaccination
room
since the
parent ask
for his
child’s
medical
record till
the child
name is
called in
vaccination
room
Waiting
time for
pre
vaccination
process
5 why
technique to
know the
reason for
variation
Team meeting
to suggest
error proof
solution
Team
leader
Quality
professional
Less
than 10
min.
Vaccination
room
Since the
child
enters the
room till he
leaves
Waiting
time in
vaccination
room