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Back rehabLetter from the region
ED wait times

Change in organizational culture
leads to a focus on results
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Réal Cloutier
Interim President and CEO
Winnipeg Regional Health Authority
Nov/Dec 2017

It has long been argued that the only way to improve health care is to spend more money. That is particularly true, some say, if the goal is to improve care by reducing wait times.

However, a new report suggests that you don't need a massive increase in spending to improve care.

The insight comes from statistics compiled by the Canadian Institute for Health Information (CIHI), which regularly publishes data on health-care performance indicators.

As many readers will know, the Winnipeg Regional Health Authority has consistently lagged behind other jurisdictions in CIHI's annual survey of emergency department performance indicators. But the most recent survey suggests that things are starting to change. In fact, the latest CIHI report indicates our wait time numbers are the most improved in Canada.

According to the recenty released report, 90 per cent of emergency department patients in Winnipeg waited 5.1 hours or less to see a doctor during the year ending in March, 2017, down from 5.5 hours the previous year. That represents an improvement of 27 minutes, or about eight per cent.

The trend established through the early part of 2017 carried on into the summer and fall, according to statistics compiled by the Region. They show 90 per cent of patients waited 4.3 hours or less to see a doctor between April and October of this year, an improvement of 14.5 per cent over the same period a year earlier.

The numbers were also impressive during the month of October, following the conversion of the Victoria Hospital Emergency Department into an urgent-care centre. According to our data, 90 per cent of patients in Winnipeg emergency departments waited 3.9 hours during October, compared with five hours for the same period a year earlier - an improvement of 22 per cent.

Even the total time patients spend in an emergency department before being admitted to a bed on a hospital ward (known as length of stay) is trending in the right direction. According to CIHI, the maximum time 90 per cent of patients spent in Winnipeg emergency departments before being moved to an inpatient bed was 43.5 hours or less for the year ending March 2016. While this was a slight increase over the previous year, the number has improved significantly since, dropping to a maximum of 30.7 hours as of October, compared with a national average of 32.6 hours, according to Region statistics.

The most interesting thing about these improvements is that they are being achieved even though our overall number of visits has remained relatively constant over the past few years. It is also worth noting that all of this is being done without a massive increase in our $2.7 billion budget. In fact, we are focused on delivering a balanced budget by the end of March 31, 2018.

So what accounts for this turn of events?

Generally speaking, I would say the answer comes down to having an increased focus and a clear idea of what we expect from our health-care system. This, in turn, has led to changes in our organizational culture, particularly when it comes to tackling specific problems.

Whenever an organization of our size and scope is faced with a pressing issue, such as emergency department wait times, it is often tempted to reach for the easiest solution. Usually, that means spending more money. But while that may result in temporary relief, it rarely provides a long-term, sustainable solution. That's because if you don't have good processes in place to analyze a problem and come up with solutions, you are just going to end up throwing good money after bad.

So when it came to addressing wait times, we opted for a different approach, one anchored in a shared vision for improving patient flow and ensuring sustainability of our health-care system.

Using this approach, we were able to identify some of the major impediments to improving our emergency department wait times. Dozens, if not hundre ds, of health-care providers and administrators were involved in the process, coming up with different ways to tackle various aspects of the problem in facilities across the Region. We also took the pulse of our patient advisory councils, which confirmed wait times were an issue that we needed to address.

One by one, solutions were identified and implemented. The initial list included the creation of mid/low acuity assessment units in emergency departments to help ensure people could be cared for sooner, and the introduction of new technology to monitor patient flow. These initiatives were followed by other comprehensive measures, including the major realignment of services outlined in the Healing Our Health System plan.

The first phase of that plan, launched in October, involved converting the emergency department at Victoria Hospital into an urgent-care centre. Phase two, which will begin next year, includes plans to expand emergency services at three hospitals - St. Boniface, Grace and Health Sciences Centre Winnipeg - while converting the emergency departments at three other hospitals - Victoria, Concordia and Seven Oaks - into urgent-care centres.

The consolidation of emergency services in three hospitals means we can free up acute-care beds at Concordia, Victoria and Seven Oaks for other patients, including those who are convalescing or needing other types of specialized services, thereby enhancing patient flow and ensuring patients get the right care, at the right time, in the right place.

In addition, we have also launched a new initiative called Priority Home and added additional transitional care home beds in the community. Both of these efforts will make it easier to discharge seniors from hospitals to their own homes or a temporary bed at another facility, where they can be more appropriately supported. These moves will also help expedite the discharge of patients from hospital and free up beds for admissions from the emergency department.

To support all of these changes, we have redeployed resources where needed to ensure we are getting the best value for our patients while living within our overall budget.

Our commitment to improving patient flow as a means to reducing wait times was acknowledged by Kira Leeb, CIHI's Director of Health System Performance.

"There has been a focus on trying to improve patient flow through the hospital, with many facilities having initiatives to reduce emergency department wait times," Leeb said in her comments in the report. "We have seen some change with these efforts, such as in Manitoba. By shinning the light on some of the specific problem areas where increases are more evident - seniors and visits late in the day - these initiatives can be even more targeted to improve inpatient flow."

Now, none of this is to say that everything is perfect or that we are satisfied with what we have been able to achieve so far. Our short-term goal is to ensure our wait time to see an emergency doctor is in line with the national average of 3.1 hours for 90 per cent of patients. And, eventually, we would like to have the shortest wait times in the country.

But I do believe the approach we have used to tackle emergency department wait times also provides us with a template for improving care in other areas. Enhancing access to elective surgery, diagnostic imaging, home care and long-term care will be priorities for us in the months and years to come.

Ultimately, our goal is to become a high-performance health-care system, one that is focused on improving the patient journey and supporting innovation and fiscal sustainability. That means we will need to continue engaging our staff and ensuring everyone understands that we all have a responsibility to drive better value for patients. That doesn't mean cutting corners. It means reducing wasteful practices so that money can be re-invested to meet other needs. In addition, we will also step up efforts to engage patients in this process. Patients make us accountable. They know what good care is and they too see waste in our system.

Of course, building a high-performance health-care system is not an easy thing to do, and it will take some time. But if the experience of the last year has taught us anything, it is this: When we work as a team to create a vision for change, focus on the task at hand and align our efforts, we can find innovative solutions to any problem. And we can do so without a massive increase in spending.