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Quality Improvement Initiatives on Clinical Teaching Units: Part 2

The Problem

Our hospital has been plagued by high occupancy rates, long lengths of stay and difficulty discharging complex patients. These have resulted in high occupancy rates in the Emergency Department (ED) and long wait times. In the next paper we will demonstrate the multidisciplinary approach we used that integrates aspects of Lean Six Sigma, project management and the theory of constraints methodology. Our approach was not ideological but directed towards problem solving and used aspects of each set of tools depending on the problem. This approach, supported by the organization not only in principle but also with necessary resources, produced effective teams consisting of physician and non-physician providers along with quality and project management experts. The primary goal of the institution was to reduce the average occupancy rates on medical units from 108 per cent to 95 per cent by reducing readmissions, unnecessary admissions and lengths of stay (see Figure 1).

It was expected that achieving such a goal would reduce waiting for mission times for emergency department patients.

Figure 2

                                                                                              Figure 1

Part 2


It was apparent to the organization that our Emergency Department was experiencing overcrowding and long wait times for medical patients who had been approved for admission despite their own lean projects. The Emergency Department itself embarked on several quality improvement initiatives that had some improvement, but not sufficient to cure the overcrowding.  A major part of the problem was the inability to discharge medical patients in a timely fashion. As shown in Figure 2 below, several projects were undertaken to relieve the bed pressures. These projects or initiatives used aspects of Lean Six Sigma and Project Management (PM).

The first moment of clarity occurred when we realized long waits in the ED could not be solved without breaking bottlenecks in the system elsewhere. The creation of a value stream map for medical consultation on emergency patients revealed a ‘Time to Assessment’ bottleneck for senior medical residents especially during peak hours. Our first project added an additional senior medical resident to the ED Internal Medicine Rotation during peak hours. This is a classic Lean technique of leveling the load.

The second project was to initiate a pilot Rapid Access Clinic. This clinic was an additional clinical teaching unit (CTU) but it was for ambulatory patients (not inpatients). The Rapid Access Clinics used aspects of Lean Six Sigma to measure and assess our demand, resource utilization and potential benefits of this intervention as we sought to relieve congestion in the ED. These clinics required additional resources, again funded by the Province of Ontario's payment for performance, but allowed rapid access to ED patients who might otherwise have been admitted into hospital. We identified the available attending physicians as well as senior residents to staff this clinic along with sufficient nursing staff and services (radiology, physiotherapy, social work, and pharmacy). This initiative provided an alternative channel for urgency route emergency-room physicians and internal medicine services to provide care without admission.

A quality improvement event or Kaizen was held, specifically to optimize discharge. The Kaizen group, consisting of physicians, nurses, administrators and allied health workers, created a value stream.
The discharge value stream identified in the Discharge Kaizen revealed over 200 steps of which 47 per cent were judged to be non-value added.


                                                                                                                                   Figure 2

A Pareto diagram (Figure 3) shows the top reasons for delay in discharge on inpatient medical units. The most common reason for delay in discharge was completing necessary paperwork, followed by waiting for a test, or consultation from another service and arranging transportation.  These reasons accounted for nearly 80 per cent  of our delay.

Figure 3

                                                                                                        Figure 3

A work product arising from the Discharge Kaizen was the creation of a 2X2 table of priorities (Figure 4) comparing effort to impact for potential projects that might help us achieve our goals.                                                                             

Seven projects were identified to be of the highest value:


                                                                                       Figure 4