Amazing service. Great professionalism. Compassionate staff.
These are just a few of the compliments The Scarborough Hospital (TSH) has heard in the last year from patients who have received care in the Emergency Departments (ED) at both the hospital’s General and Birchmount campuses.
One such patient was Bradley Campbell who visited the ED following a significant bicycle accident.
“Knowing that your hospital has some of the best ED wait times in the GTA, I deliberately went to the Birchmount campus to see about my situation – I am so glad that I did,” says Bradley in a letter to TSH. “The entire process – from triage to registration through to the examination, x-ray and discharge – was positive. I did not experience any delays in care, and everyone I interacted with was professional and caring. I cannot identify any aspect of the care process that could have been improved.”
Six years ago, the Ministry of Health and Long-Term Care (MOHLTC) provided funding to TSH to support changes in the ED, and they have continued the Pay for Results (P4R) funding program that provides one time recurring annual incentive funding to EDs in provincial hospitals based on their successful reduction of ED wait times. The Central East Local Health Integration Network has supported TSH through this allocation, and their support has been instrumental in our success in reducing wait times, improving quality of care and strengthening employee and physician engagement.
Hospital staff immediately embraced the opportunity to bring their innovative ideas to life and enhance care for the Scarborough community. The hard work and commitment to excellence paid off, and recently TSH was recognized by the province for providing the lowest wait times in the province in the ED while maintaining high quality care in the Very High Volume Community-Hospital Group.
“The funding gave us what was needed to work collaboratively with our staff, physicians, Emergency Medical Services (EMS) and Toronto Police Services (TPS) to implement some truly remarkable and innovative ideas,” says Susan Engels, Director, Emergency Services and Mental Health, TSH. “Everyone came together, and with effort and enthusiasm, the ED team consistently improved the emergency care provided at TSH.”
Emergency staff and physicians participated in a series of Rapid Improvement Events (RIE), which are short, intense problem-solving sessions that challenge the status quo and identify gaps in routine practices. They are one approach within the LEAN methodology that TSH is using to transform its culture, affect positive change and develop processes that add value to the patient experience.
“The RIEs allowed the team to identify barriers and develop solutions for more efficient care,” says Dr. Norman Chu, Medical Director and Chief of Emergency, TSH. “The front-line providers are the ones who know the system best, and together they designed and customized their own unique plans and tools to support each other and ultimately improve patient care.”
Throughout the RIEs, the team generated many strategies that have been implemented with outstanding success.
One major focus for improvement was to streamline the offloading process, which would reduce the time it took to transfer the care of a patient from EMS to the ED clinicians. Staff from both sides participated in an improvement event that allowed them to examine their daily work processes and create solutions to improve patient flow throughout the entire system.
The collaborative effort also provided an opportunity for EMS and hospital staff to gain a better perspective of the full scope of work behind each role, which led to enhanced understanding, appreciation and respect for each other’s challenges.
“Events like these help us to establish better relationships,” says Chris Olynyk, Commander of System Performance, Toronto EMS. “Having our paramedics see all that’s involved in moving a patient from the ED to create room, and in turn, having hospital staff see how longer offloading times affect care for the rest of the community, really brought the team together and helped create a much more fluid system.”
The trend in reduced offloading times continues at TSH, and both campuses are in the top 10 among GTA hospitals.
Often in the ED, it can be overwhelming, particularly in the Rapid Assessment Zone. Previously, if staff and physicians required assistance, they would have had to ask for support. In order to alleviate the pressure from these areas, the team put their heads together and developed a customized tracking application that acts like the dashboard of a car. It provides an instant status update on the ED – how many patients are waiting, how long they have been waiting, and the reason why they are there. If an area becomes overwhelmed, the tracker provides an alert and physicians will automatically adjust their priorities and go to the area in greatest need.
“A key part of our success was our partnership with our Information Services (IS) team,” says Dr. Larry Nijmeh, a physician in the hospital ED who led the project. “Our clinical team took time to better understand the capabilities of our clinical information system and our IS team sought to better understand our workflow practices in the ED.”
Dr. Nijmeh adds that it was this collaborative approach that enabled the team to achieve improvements in efficiency, safety and quality of care.
Other IS initiatives have included the use of an electronic forms database and the revision on the ED record to improve communication and decrease physician documentation time.
“The bottom line is that our front-line staff want to spend, and should be spending, less time in front of computers and filling out paperwork, and more time in direct patient care.”
COMMUNICATION AND TEAM-BUILDING
Communication is the cornerstone of any strategy, and a large part of the ED’s success is due to the outstanding teamwork shown by staff and physicians.
“When we’re able to come together as a team it boosts morale and we naturally provide better customer service,” says Harj Purewall, a Unit Clerk who was involved in the RIEs. “We learned how to better help one another; and with less pressure on everyone, we saw improvements in turnaround time and an increase in patient satisfaction.”
Physicians have also begun providing additional support by arriving for a shift early or staying late if the ED is over capacity.
“It’s straight up physician engagement,” says Susan. “They want to support their colleagues and the department. It’s not one player or group, but a tightly connected team that wants to provide the best possible care to the residents of Scarborough.”
In the pursuit of shorter wait times, offloading times, and more efficient care in the ED, TSH wanted to ensure there were provisions in place to maintain quality of care. Therefore, an initiative to capture patient satisfaction in “real time” is underway for the hospital’s ED.
“We’re going to use iPads to measure the satisfaction or dissatisfaction and capture the ‘in-the-moment’ impact,” says Dr. Chu. “This way, feedback can be immediately provided to the team members who provided care to that specific patient on that specific shift.”
Hospital translators are actively involved to ensure that patient satisfaction information can be captured in a variety of different languages.
SHARING THE WEALTH
Building on the success realized in the ED, in 2013, TSH began sharing a portion of its performance funding with other departments in the hospital. The goal was to enable other programs to develop their own strategies for more efficient care, which would ultimately allow patients to be transferred from the ED more quickly once they are admitted.
“Providing incentive funding to our colleagues creates a more efficient patient flow throughout the continuum of care,” says Susan. “We had great success with our first collaboration involving our Medicine and Geriatrics program, and we have begun working collaboratively with our Nephrology and Cardiac programs.”
The emergency staff and physicians at TSH are motivated and enthusiastic about building on their success and with many exciting initiatives underway including an ED renovation at the Birchmount campus to improve patient flow through triage, the future for emergency health care in Scarborough certainly looks bright.