Players Guide

Lakeview

Contents
Within this Player's Guide you'll find: the Lakeview case study; a section for taking interview notes; and a detailed list of all the tactics available to you in the simulation.

CASE STUDY The Situation The Hospital The Stakeholders The Meeting Exhibit 1 Emergency Department: Flow Diagram Exhibit 2 Newspaper Article 1 2 4 5 6 7

INTERVIEW LIST

TACTICS LIST

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Canadian version last revised: December 13, 2010

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CASE STUDY

The Situation
You have just returned from a meeting with the senior management committee of Lakeview Regional Hospital. You have been put in charge of a key project. The projects mandate is to use lean methods to improve the performance (e.g. safety, efficiency and patient satisfaction) of the Emergency Department. 1 You have been asked to pay particular attention to the change management aspects of this project (i.e. getting buy-in from key stakeholders on the adoption of lean). As the Vice President, Patient Services at Lakeview Regional Hospital, you have been in your role for only three months. You were recruited from the West Coast where you worked in a large urban community hospital. During your career you were part of a lean initiative in the surgical area of the hospital so youre familiar with lean tools, terminology and processes. The CEO of Lakeview Regional Hospital, Charlotte Ekins, has recently become interested in lean methodology and is convinced of its merit. The Ministry of Health and Long-Term Care (MOHLTC) had asked your Local Health Integration Network (LHIN) to organize a series of meetings with healthcare providers in your area about lean approaches to improving flow and wait times in Emergency Services. In addition to your CEO, these meetings involved other hospitals, your LHINs Community Care Access Centre, and providers from the Long Term Care sector. Solving the Emergency Services problem is a top priority for the MOHLTC and the LHIN. Youre an active participant at these meetings and have begun to build a good relationship with your local CCAC. From your experience on the West Coast you know how important community resources can be in improving flow, but initially youll focus your project within the hospital to keep the scope manageable. The CCAC will be much more interested in working with Lakeview once youve shown youve done all you can in-house. Your CEO has asked you to use your lean experience to deal with the issues in the Emergency Department (ED). Youve been dedicated to this project until completion, with a mandate to form whatever ad-hoc team(s) are required. Youve been given a budget of $150,000 and 40 weeks to accomplish your task. There is a lengthy list of stakeholders that you have access to for interviews, or to support your project and youre beginning to think about what first steps you might take. The CEO has advised you that the concepts of lean are totally foreign to Lakeview staff, so you may need deal with this, especially in the early stages. Youve also been told that staff has been worn down by one performance improvement initiative after another. At the senior management committee meeting, your CEO had announced that youd be spearheading the project because of your lean experience. Her expectation is that you will bring a fresh perspective by virtue of your experience in your previous hospital: Im going to turn this issue over to our VP Patient Services for handling. I want each and every one of you to help out wherever needed to come up with a solution to this problem. Although it has worked well in manufacturing, some of my CEO colleagues have had trouble implementing lean at their hospitals. They didnt pay enough attention to the change management side of things. Remember folks, you need buy-in from a lot of stakeholders if any change is going to work and be sustainable. For this project, you will be reporting back directly to the CEO.
1

Please see Lean FAQ for details about lean methodology.

The Hospital
Lakeview Regional Hospital is a 350-bed community hospital. Situated lakeside on a two-acre site, it is the main hospital for the surrounding Dunedin County suburban community. Dunedin County lies west of Capital City, a major urban centre. Lakeview has an over-extended 30-bed Emergency Department, where patients are frequently held on stretchers in the hallways. Long wait times are common. All patients arriving at the Emergency Department via ambulance or on their own are first assessed by a Triage nurse who determines whether they are Canadian Triage Assessment Scale (CTAS) Levels 1, 2, 3, 4 or 5. The triage nurse also gathers basic information about the presenting complaint and documents current vital signs such as blood pressure, heart rate, etc. The CTAS level determines the order in which patients need to be seen by a physician, with Level 1 the most urgent.

Triage Level

Triage (CTAS) Description 2

Inbound Volume

% Who Are Admitted

1 Resuscitation 2 Emergent 3 Urgent 4 Less Urgent

Conditions that are threats to life and limb requiring aggressive interventions, e.g. cardiac/respiratory arrest, major trauma, actively seizuring, unconscious. Conditions that are potential threats to life, limb or function, e.g. head injury, severe trauma, high risk overdose, depression/attempted suicide. Conditions that could potentially progress to a serious problem requiring medical intervention, e.g. moderate trauma, asthma, acute abdominal pain, active labour. Conditions that are related to patient age and /or distress, and have potential for deterioration or complication that would benefit from intervention or re-assurance within one to two hours, e.g. headache, chronic back pain, laceration with bleeding controlled Conditions that may be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration, e.g. suture removal, prescription renewal, sore throat, mild abdominal pain with normal vital signs.

2%

71%

17%

34%

52%

13%

27%

4%

5 Non-urgent

2%

2%

Definitions taken from Implementation Guidelines for the Canadian Emergency Department Triage and Acuity Scale (CTAS), Version 16, November 30,1998 and Bullard, Michael J; Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) adult guidelines; Canadian Journal of Emergency Medicine; March 2008; 10(2): 132-42.

The Emergency and General Medicine volume statistics at Lakeview Hospital are as follows:
Most Recent Year: Emergency Department Last Year This Year General Medicine Last Year This Year

# of patients handled % Ambulance Patients Average Total LOS (Length of Stay) CTAS 1-3 (% that meet LHIN target LOS of 8 hours) CTAS 4, 5 (% that meet LHIN target LOS of 4 hours) Bed Capacity Utilization (%) Patient Satisfaction Full Time RN (Registered Nurse) Turnover Rate

70,000 16.5%

73,000 14.1%

6,500 n/a 7 days

7,100 n/a 8 days

55% 65% n/a 79% 19%

52% 60% n/a 69% 25% 90% 82% 12% 94% 77% 15%

In addition to the Emergency Department, Lakeview also provides a variety of inpatient and outpatient services to the LHIN and these services compete for beds with admissions from Emergency: 1. At any given time, Lakeview Hospital has scheduled visits for patients to provide certain surgeries/procedures, and each of those patients needs a bed post-op for a certain amount of time. For example, hip replacement surgeries and maternity deliveries. However, any attempt to cut back on beds for this purpose would compromise the hospitals ability to meet volume commitments agreed to with the LHIN. 2. Lakeview Hospital also runs several outpatient clinics, and some of the patients attending the clinics need beds after their procedure or if complications arise. For example, patients receiving chemotherapy may require a bed. While the majority of inpatient admissions go to General Medicine, 8% of ED admissions go to Surgery for treatment, 8% go to Mental Health and 4% go to Paediatrics, but these patient flows are beyond the scope of your project. Lakeview also attempts to manage patient discharges from General Medicine, Surgery and Emergency on a timely basis. However, at any given time, due to a shortage of home care resources and long-term care beds, there are approximately 45-50 ALC 3 patients at Lakeview.

ALC refers to Alternate Level of Care patients. These are patients who are waiting to be transferred out of the hospital but cant leave because they are waiting for the services they need in the community (e.g. nursing home, rehabilitation centre, hospice, home care) to become available.

Based on the statistics of the Emergency Department, you estimate that the average total length of stay (time of arrival until time of disposition) is approximately ten hours, while the average time to see a physician is roughly three hours, although Triage Level 1 patients are seen within 9 minutes on average. At any given time, the Emergency Department holds a number of admitted patients being cared for by an overburdened staff (see Exhibit 1 Emergency Flow diagram). As the Vice President, Patient Services, youre aware that there is a shortage of nurses in the Emergency Department, and that overtime hours already average 50%. You have been actively recruiting additional staff ever since you assumed your position, but the department is still experiencing shortages (five fulltime RN vacancies, and two part-time RN vacancies) and has no back-up resources. Lakeview is organized on a program management basis. Overall, the hospital has acceptable employee satisfaction levels, but these scores are markedly lower within the Emergency Department.

The Stakeholders
Although you have only been at Lakeview Regional for three months, youve gotten the lay of the land. You have a pretty good idea of the resources that are available, the key members who could contribute to or undermine your project, and the various individuals and groups in the hospital and community. Youve mapped out in your mind all the key stakeholders.

In trying to manage this project, you will have to decide which of the key stakeholders are critical to its success, and to determine who are Champions, Helpers, Bystanders and Resisters. 4

See your Change Primer for definitions of these terms.

The Meeting of the Senior Management Committee

At the same senior management committee meeting where she announced your appointment as Project Lead, Charlotte Ekins also raised the issue of the newspaper article. (see Exhibit 2) Have you seen the paper today? Its not good. This is the last straw, coming as it does on top of the reports of the Annual Hospital Ranking where Lakeviews rankings have fallen substantially. Part of the reason is our poor performance on ER wait times. Weve always had a respectable record, and I am not about to let Lakeview slip any further. Lakeview is a hospital with a longstanding reputation for excellence in patient care and staff loyalty. I realize that our staff have been struggling to work under increased pressure in recent years. We are understaffed and there are higher patient caseloads, with less resources and funding. We are also experiencing an increase in complaints from patients who have had to wait hours before being seen in the ED. The problem is bigger than ED wait times. That is a symptom of a larger problem. It is a problem with the flow of patients from the ED to the rest of the hospital. We also need to get staff to realize that it doesnt have to be this way. Too many people just take for granted that long waits are inevitable. Some of our staff and physicians are resisting any suggestion that we can improve our operational efficiency. I want to let you all know that the hospitals Board of Directors is very concerned about the challenges were facing, and they are pressuring me to find a solution. And I dont even want to speculate on what our friends at the LHIN and Ministry are thinking as they read this mornings newspaper. This is the sort of story that feeds the gristmill of politicians seeking headlines. Charlotte Ekins waited for a response from the group, and one by one, each person offered up what they felt were reasonable explanations for the unusual waits experienced by patients in Emergency and the poor results in the patient satisfaction survey. Each one attempted to subtly shift the blame from their respective areas or divisions. Frustrated by the circular and unproductive direction of the conversation, Charlotte Ekins slammed the boardroom table with her fist and got everybodys attention: As CEO of this hospital, Im on the line here. I have the Board asking questions, and the Ministry wants to see an action plan from us too. I am not going to stand by and watch as the reputation we have strived to build crumbles beneath us. And I sure as hell dont want these problems to be ignored. We need fresh eyes to assess Lakeviews Emergency Department, figure out the issues that are causing the problems, and then fix them. Why is our Emergency Department always so backlogged? We need strategies to overcome these problems, because simply throwing money at them wont solve anything. Over the last few months Ive heard more and more about lean practices in health care, and Im convinced its the approach we need to consider. Our new VP Patient Services did some work with it out west, and there are reports that some hospitals have had great success with it so youre likely to see it around here very soon. The key now is to develop a good change management plan to get buy in for the adoption of our lean approach.

Exhibit 1 Emergency Department: Flow Diagram

Exhibit 2 Newspaper Article

Eleven Hour Nightmare in ER for Local Resident By Jenny Kenyon, Healthbeat Reporter

(Dunedin County) - A Dunedin resident is furious after being forced to wait for eleven hours before being seen by a doctor in the emergency department of a local hospital. Following a minor car accident Thursday evening, Mary Martindale was taken by ambulance to the Lakeview Regional Hospital Emergency Department with a badly sprained ankle and a deep gash on her forehead. It was disgraceful, Martindale stated. My ankle was swollen up like a balloon and my forehead was bleeding. Eleven hours later I was finally seen by a doctor. Unfortunately, Martindales experience is played out in emergency departments across the province as emergency department wait times continue to grow and a patient backlog is forcing hospitals to close their doors to ambulances more often, unable to handle the growing volume. This is having a negative impact on the various hospitals in Dunedin County area. Several of these hospitals have dropped in the Annual Hospital Ranking, following an increase in emergency department wait times, and numerous patient complaints. Only one hospital, number one ranked City Centre Hospital, improved year-over-year in ER wait time scores. Earlier this year, the Minister of Health made a public commitment to improve Emergency Department wait times, and the Ministry put in place targeted funding for improvement. When asked to provide examples of Emergency Room improvements that have been achieved, they mentioned an initiative to encourage the use of lean methods to address problems in ER wait times.

INTERVIEW LIST
Please use the space below to take notes during the stakeholder interviews.

Dr. John Barclay | Chief of Staff

Resister
Notes:

Bystander

Helper

Champion

Project Team

Elizabeth Briarwood | Nurse Manager, General Medicine

Resister
Notes:

Bystander

Helper

Champion

Project Team

Charlotte Ekins | CEO

Resister
Notes:

Bystander

Helper

Champion

Project Team

Hannah Green | Social Worker

Resister
Notes:

Bystander

Helper

Champion

Project Team

Jenny Kenyon | Journalist

Resister
Notes:

Bystander

Helper

Champion

Project Team

Dr. Linda Leung | Medical Director, GM

Resister
Notes:

Bystander

Helper

Champion

Project Team

Dr. Yanni Makris | Medical Director, Emergency Department

Resister
Notes:

Bystander

Helper

Champion

Project Team

Dr. Craig Markson | Head of General Surgery

Resister
Notes:

Bystander

Helper

Champion

Project Team

Mary Martindale | Patient

Resister
Notes:

Bystander

Helper

Champion

Project Team

Robbie McTavish | Shop Steward

Resister
Notes:

Bystander

Helper

Champion

Project Team

Sveta Michaud | Senior Manager, Laboratories

Resister
Notes:

Bystander

Helper

Champion

Project Team

Dennis Ping-Tao | Professional Practice Lead

Resister
Notes:

Bystander

Helper

Champion

Project Team

Jake Ringham | Nurse Manager, Emergency Department

Resister
Notes:

Bystander

Helper

Champion

Project Team

Wyatt Simpson | Ambulance Services

Resister
Notes:

Bystander

Helper

Champion

Project Team

Pamela Small | Chief Nursing Officer

Resister
Notes:

Bystander

Helper

Champion

Project Team

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LIST OF TACTICS
Build and execute a change plan at Lakeview by selecting from the following tactics. denotes How tactic (additional options provided that specify how to implement)

Adopt 5 S's | Clinicians | 2 weeks | $ 3,000

The 5 S's are Sort, Set, Sweep, Standardize, Sustain. Start by sorting instruments into colour-coded bins so that nurses and allied health workers do not waste time looking for them.

Announce Project | Entire Organization | 0.5 weeks | $ 1,500

Announce the establishment of the project and identify the VP, Patient Services as the project lead.

* Appoint Change Team | Change Team | 1 week | $ 1,000

Appoint an inter-professional change team that includes representatives from clinicians and administrative functions to guide the change management aspects of the project.

Briefing on Vision | Entire Organization | 0.5 weeks | $ 3,000

Have senior leaders present their vision for the project to directors and managers through a series of presentations, each of which includes an interactive discussion to promote understanding.

* Choose Appropriate Metrics | Senior Management | 1 week | $ 2,500

Choose appropriate metrics for hospital reporting and tracking progress.

Conduct External Scan | Clinicians | 3 weeks | $ 10,000

Hire consultants to assess external healthcare organizations for best practices, nationally as well as locally (City Centre Hospital), to see what has been done successfully in other hospitals.

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Conduct Further Targeted Interviews | ED and General Medicine | 2 weeks | $ 3,000

Conduct interviews with targeted individuals in ED/General Medicine beyond the stakeholders you have interviewed to understand their concerns, ideas for flow improvements, and what they would recommend.

Conduct Online Employee Survey | Entire Organization | 1 week | $ 2,000

Conduct an anonymous online survey to solicit the concerns of healthcare professionals and staff to gauge their readiness for change.

Continuous Communication | Entire Organization | 2 weeks | $ 6,000

Create two-way channels for continuous communication between administration and front line workers around the changes.

Create a Rapid Assessment Zone (RAZ) | Clinicians | 4 weeks | $ 20,000

Create a Rapid Assessment Zone (RAZ) with chairs for lower acuity patients to free beds for higher acuity patients. RAZ could be run by a physician who sees the patients on a bed and then moves them back to a chair in ED (not waiting room) to wait for next assessment.

Create Visual Controls | Change Team | 1.5 weeks | $ 3,000 Install an encased whiteboard (with sliding doors that can cover it to protect confidentiality). The whiteboard could indicate pending labwork, reassessment flags and room numbers of patients to provide real-time information.

Debrief Change Process and Monitor | Entire Organization | 1 week | $ 3,000 Debrief on the change project and consolidate learnings into a toolkit. Revisit the initial targets and plan for incremental improvements in the future.

Define ED Data Requirements | Senior Management | 2 weeks | $ 5,000

Consult with top internal team of clinicians and performance measurement staff to identify what quality data can be gathered, presented and analyzed utilizing the hospitals existing and newly acquired information technology.

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* Develop Project Vision | Senior Management | 1 week | $ 2,000

Develop a vision of what the hospital will look like after the lean transformation.

Engage Patient Advocate | Change Team | 1 week | $ 1,000

Contact Mary Martindale and apologize on behalf of the hospital for what happened to her. Invite her to be part of a change process to prevent her experience from happening again. If she agrees, make her a Guest Member on the Change Team.

* Frame Issue for Change Team | Change Team | 1 week | $ 2,000

Identify the root cause of the wait-time problem.

Hire PR Consultant to Improve Image | Entire Organization | 1 week | $ 2,000

Given the negative media story, Lakeview needs to engage a PR Consultant to help them get out the good stories about Lakeview and help shift public perceptions towards being more favourable. This will also help drive up patient satisfaction scores.

Implement Patient-Pull | Clinicians | 2 weeks | $ 10,000

Work with General Medicine staff to identify and overcome barriers. For example, implement a system whereby General Medicine nurses call the Emergency Department when a bed is ready for the next patient.

Include Project in Strategic Goals | Senior Management | 2 weeks | $ 3,000 Demonstrate that administration is accountable to the Board of Directors by putting the projects goals and deliverables on the five-year strategic plan and scorecard.

Initiate Quality Certification | Certification Organization | 1 week | $ 1,000

Begin the process of acquiring a Quality Certification for the hospital.

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Introduce Medical Directives | ED, GM | 1 week | $ 1,000

Medical Directives are pre-approved physician orders that allow a nurse or nurse practitioner to order diagnostic tests and/or begin specific treatments prior to being assessed by a physician. Allows the process to get started earlier to reduce the waits later in the system.

Invite Media | Senior Management | 1 week | $ 1,000

Invite the media to report on issues in the hospital and help create a sense of urgency.

Involve Ambulance Services | Change Team | 1 week | $ 1,000

Involve Ambulance Services by inviting their feedback on process flow changes that impact their role.

Make Comforting Speech | Entire Organization | 1 week | $ 1,000

Have the CEO reassure hospital staff that changes will not significantly affect the day-to-day activities of the average employee.

* Map Out Where People Stand | Entire Organization | 0.5 weeks | $ 3,000
Map out where the key people stand to identify the support and resistance across key stakeholder groups in the hospital and to understand their initial perceptions of change.

Ongoing Measurement | Entire Org & Other Hospitals | 2 weeks | $ 6,000 Ensure ongoing measurement is undertaken with a goal to be vigilant against reverting to former behaviours. Share evidence of Emergency Department improvements with other departments and hospitals and, selectively, with the media.

Present Clinical Case | Physicians and Senior Management | 2 weeks | $ 3,000 Have clinical leaders present an incident to administration showing the mismanagement of a patient led to a 'Near Miss' that was fortunately averted by quick action by an alert nurse.

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Present Initial Findings | Entire Organization | 1 week | $ 3,000

Present initial findings of the external scan.

Presentations on Change | Entire Organization | 1 week | $ 3,000

Have the change team make presentations at the department level on what the strategy is and what changes are going to take place.

Provide Incentives to Involve Physicians | Physicians | 1 week | $ 6,000

Involve doctors in sharply-defined, results-oriented change activities to engage them in the transformation.

Provide Patient Comment Cards | Patients | 2 weeks | $ 3,000

Provide ongoing feedback channel for all incoming patients and admissions around their patient experience. Comment card instructions should be written in all community languages.

Provide Replacements to Enable Training | Nurses | 1.5 weeks | $ 40,000

Provide temporary replacements for nurses and health professionals so that they can attend lean training and improvement sessions.

Public Thank Yous | Senior Management | 1 week | $ 1,000 Thank five top managers who have been effective leaders on the project during a well-attended town hall meeting.

Publicize and Celebrate Successes | Entire Organization | 2 weeks | $ 3,000

Plan a hospital-wide celebration to showcase the positive changes that have occurred. Present changes as positive examples for others to follow.

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Re-assign a Persistent Resister | Entire Organization | 1 week | $ 1,000

Transfer a persistent resister to another role in the hospital.

Repeat Vision Constantly | Entire Organization | 2 weeks | $ 5,000

Repeat the vision constantly and consistently to ensure hospital staff understand the need for change.

Report Quality-of-Care Indicators | Entire Organization | 2 weeks | $ 3,000

Report quality-of-care indicators for Lakeview Regional Hospital to provide quantitative evidence that change is needed.

Run a Rapid Improvement Event | Entire Organization | 1 week | $ 5,000

Complete a week long quality improvement event focused on standardizing the triage processes and make modifications to decrease triage times to under 5 minutes for 80% of patients.

Send Chief of Staff to Open Up GM Beds | ED | 1 week | $ 3,000

When a backlog of patients is stacked up in the Emergency Department, send the Chief of Staff into General Medicine to review patients for discharge in order to free up needed beds.

Shadow Patients | Change Team and Patients | 2 weeks | $ 5,000

Observe the experiences of a sample of individual patients within the ED.

Speech to Work Harder | Entire Organization | 1 week | $ 1,000 Have the CEO make an encouraging speech that change is possible if everyone pulls together and works a little harder.

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Transfer to Ongoing Management | Entire Organization | 2.5 weeks | $ 5,000

Transfer the responsibilities of the change team to managers and clinical leaders to allow continual improvement throughout the hospital.

* Value Stream Mapping | Change Team | 1 week | $ 2,000

Bring together all staff involved in a patient's journey to: 1) define patient and staff activities; 2) map current and ideal picture of activities; and 3) find ways to make the ideal map a reality.

Weekly Performance 'Huddle' | Clinicians | 1 week | $ 2,000

Every week, bring doctors, nurses, porters, and lab technicians together in one room to recognize efforts and create ideas of how to improve the Emergency Department for patients.

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