Marian J Vermeulen1, Therese A Stukel2, Astrid Guttmann3, Brian H Rowe4, Merrick Zwarenstein5, Brian Golden6, Amit Nigam7, Geoff Anderson8, Robert S Bell9, Michael J Schull10. 1. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Electronic address: marian.vermeulen@ices.on.ca. 2. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dartmouth Institute for Health Policy and Clinical Practice, Giesel School of Medicine at Dartmouth, Hanover, NH. 3. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Paediatric and Emergency Medicine, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada. 4. Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada. 5. Centre for Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. 6. Rotman School of Management, University of Toronto, Toronto, Ontario, Canada. 7. Cass Business School, City University, London, UK. 8. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. 9. University Health Network, Toronto, Ontario, Canada. 10. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Abstract
STUDY OBJECTIVE: In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. METHODS: We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. RESULTS: In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (-14 minutes [95% confidence interval {CI} -47 to 20]) but decreased after wave 2 (-87 [95% CI -108 to -66]) and wave 3 (-33 [95% CI -50 to -17]); median ED length of stay decreased after wave 1 (-18 [95% CI -24 to -12]), wave 2 (-23 [95% CI -27 to -19]), and wave 3 (-15 [95% CI -18 to -12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI -0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. CONCLUSION: Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.
STUDY OBJECTIVE: In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. METHODS: We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. RESULTS: In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (-14 minutes [95% confidence interval {CI} -47 to 20]) but decreased after wave 2 (-87 [95% CI -108 to -66]) and wave 3 (-33 [95% CI -50 to -17]); median ED length of stay decreased after wave 1 (-18 [95% CI -24 to -12]), wave 2 (-23 [95% CI -27 to -19]), and wave 3 (-15 [95% CI -18 to -12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI -0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. CONCLUSION: Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.
Authors: Leahora Rotteau; Fiona Webster; Erin Salkeld; Chelsea Hellings; Astrid Guttmann; Marian J Vermeulen; Robert S Bell; Merrick Zwarenstein; Brian H Rowe; Amit Nigam; Michael J Schull Journal: Acad Emerg Med Date: 2015-05-20 Impact factor: 3.451
Authors: Katherine E Harding; Sandra G Leggat; Jennifer J Watts; Bridie Kent; Luke Prendergast; Michelle Kotis; Mary O'Reilly; Leila Karimi; Annie K Lewis; David A Snowdon; Nicholas F Taylor Journal: BMC Med Date: 2018-10-19 Impact factor: 8.775