Bringing sustainable change and results to the Emergency Department


‘Trimming the fat’ and ‘Lean’ are not your typical health-care terminology, however the principles behind the words have been instrumental in changing ‘end to end’ patient flow at Toronto East General Hospital (TEGH).

Known as the Process Improvement Program (PIP), the flow project aims to simplify the patient’s journey – from arrival in Emergency (ER) through the inpatient stay and right up to discharge – by removing wasted steps. For TEGH, identifying the unnecessary steps has enabled the Hospital to decrease delays for patients from triage to seeing a physician as well as from admission in the ER to an inpatient floor; two gaps staff had tirelessly attempted to narrow in the past.

“The PIP process is very simple,” reveals Michelle Samm, PIP team lead for the Emergency Department. “We began exploring the current processes step by step and asked ‘is this necessary? Is this beneficial to the patient? By decreasing the steps, we have increased the value for our patients.”

PIP was comprised of two teams – ER and inpatient – that met twice weekly beginning in September 2009. The teams explored current processes in order to identify areas of delay and opportunities for improvement. Through an extensive collection of both quantitative and qualitative data as well as staff input, the teams identified the root causes of delays for patients.

“We did a lot of myth busting initially,” reveals Brenda Page, ER Supervisor and PIP team member. “When we asked staff what they thought caused delays, in reality the data did not support it.” The evidence surprised many staff and physicians, however talking to them and gathering their opinions helped get them on board with the project.

PIP is a five phase process consisting of preparation, diagnostic, solution design, pilot and roll-out. Preparation and diagnostic involved the establishment of the teams and data collection. The design phase introduced the PDSA: Plan-Do-Study-Act cycle, which teams ran every two weeks to test process changes. What they discovered is that small changes made a big impact. Some simple changes included visual cues, such as colour coding signage and placing coloured tape on the floor for patients to easily identify areas. For every process made, there was a communication board to ensure staff had the opportunity to provide their feedback.

“Once you heard from staff that there was an issue, they saw the results. They saw their ideas being listened to and something being done about it,” reveals Samm.

Less than a year later, the results speak for themselves. PIP has reduced ER wait-times, increased capacity in the system and patients are being discharged in a safe and timely manner.

As well, the latest ER patient satisfaction results have increased by as much as 10 per cent in some areas including quality of care, comfort and respect, surpassing the Toronto community hospital average.

“You don’t need a lot of money or technology to be successful. All you need is the willingness to change, staff engagement, leadership and collaboration,” states Samm.

Another big difference is that numbers in the ER have actually increased by approximately 6 per cent. On average, 180 patients are seen every day compared to 170 before PIP. “We’re able to see so many more patients, but staff don’t feel overwhelmed,” states Page.

“Results for admitted patients are outstanding,” says Samm. Before PIP there was an average of 14 admitted patients waiting in the ER and now there will be 2-3 patients. Patients coming into the ER now see a physician within a reasonable time; usually within an hour.

TEGH is one of sixteen hospitals participating in PIP whose shared outcomes will lead the way to improved patient flow across the Ontario health system.

“PIP allowed staff to see the bigger picture in terms of the impact their processes can have on the organization,” says Samm. “This understanding really set the tone for the notion of teamwork and support and set them on a clear path, which allowed them to become engaged in process improvement work.”

“PIP has brought sustainable change to TEGH,” says Page. “When I went into this project, I didn’t believe in sustainable change because in my 12 years here, I would see initiatives fall short as people would revert back to what they are comfortable with. However, with PIP, I watch the staff and see that this is sustainable change. They have embraced it and are willing to make whatever changes are needed in the future to maintain it.”

The best part of the project for the team was the energy that was created early on. “The excitement and the willingness to change is what PIP has left behind. That yes, we can make a difference. You can do something very simple and make a change at a very little cost. You’ve improved both patient and staff satisfaction.”

The success from the PIP project was enough to encourage the executive team to invest in it further. Beginning in July, a core team will implement PIP throughout the organization, transforming the culture to embrace lean methodology and helping programs become more efficient.