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Lakeview Players Guide

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Players GuideLakeview

ContentsWithin 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





Canadian version last revised: December 13, 2010

ExperiencePoint Inc. All rights, [email protected]


The SituationYou 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 HospitalLakeview 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.









5 Non-urgent



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 level

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