Healthcare Quarterly

Healthcare Quarterly 16(2) April 2013 : 31-35.doi:10.12927/hcq.2013.23410
Quality Improvement

Building Sector-Wide Bridges to Improve Patient Flow and Care

Thelma Horwitz and Josie Walsh


Healthcare system transformation relies upon innovative solutions that build sector-wide bridges and challenge conventional thinking to benefit patients and families. Providence Healthcare – a Toronto leader in rehabilitation – is doing this by partnering with the Toronto Central Local Health Integration Network (LHIN), community care access centres and four acute care hospitals to improve system-wide patient flow. This article explains how Providence's Transformation by Design demonstration project was launched and sustained through engaging key stakeholders, and is now demonstrating positive, measurable results on key metrics in patient flow in Toronto.

Providence Healthcare's Transformation by Design project began with a series of "what if?" scenarios during a "blue-sky" brainstorming session: What if we reach out to patients in acute care to plan their recovery before their arrival to our rehabilitation program? What if we redesign the care experience during their stay at Providence, so that it better reflects the needs of patients and their families when they return home and continue their recovery? What if we manage the transitions and hand-offs in care for our patients so that they have a small and connected clinical team? And what if we promise patients rehabilitation everywhere, always, one patient at a time?

The questions were exciting ones and were prompted after administrative and clinical leaders from acute care hospitals were interviewed as part of a strategic planning process for Providence Healthcare. Providence heard a unanimous recommendation: "Improve patient flow by admitting more of our patients – particularly those with complex conditions – at an earlier stage in their recovery." Acute care executives believed this would be an important step in reducing pressures to move patients faster through the hospital, impacting wait times from emergency room admissions to surgeries while also reducing costly and non-productive alternative level of care (ALC) beds.

Providence Healthcare's leadership and board members realized an unprecedented opportunity to continue a rich history of responding to the needs of the times. The organization's legacy of responsive innovation goes back 156 years to 1857, when the Sisters of St. Joseph established the original House of Providence in downtown Toronto, Ontario, to care for the needs of the sick and the poor, the homeless and the vulnerable. Providence became an innovative solution to a challenging time in society.

The original House of Providence was demolished, and the organization moved in 1962 to its current Toronto East location. Here, Providence further evolved to include rehabilitation, long-term care and a wide range of community programs and services. Today, Providence Healthcare includes a rehabilitation hospital with in-patient and outpatient programs, as well as a renowned palliative care program, a long-term care home (the Cardinal Ambrozic Houses of Providence) and a variety of community programs including the Adult Day Program for clients with progressive dementia. Providence Hospital offers rehabilitation programs for stroke and neurological conditions, hip fractures and lower limb amputations, and the complex geriatric conditions associated with aging.

Transformation by Design is the next milestone in a long legacy of innovations in care. The project supports the first direction in the organization's strategic plan: "Good patient flow processes support good patient care." Essentially, Transformation by Design uses "breakthrough thinking" to design new processes associated with the patient care experience before, during and after rehabilitation. The design of the new processes is based on system-wide needs, insights from key partners and feedback about changing needs from hundreds of patients, families, staff, volunteers and physicians. The initial demonstration project was given the support of the Toronto Central (LHIN), and the planning, designing and implementation subsequently got under way from September 2010 to August 2011 on one of the units within Providence Hospital.

The project's initial aims were developed to address changes in the healthcare system – increased patient complexity, a growing and aging demographic and an increased focus on efficiency and effectiveness. The goals were to accomplish the following:

  • Achieve tighter hand-offs of care between acute care and rehabilitation
  • Reduce the number of staff caring for a patient during his or her hospital stay for consistency of care
  • Create forced functions related to clinical team communication
  • Improve patient flow by admitting patients sooner from acute care, reducing ALC numbers at Providence and within our four acute care partner hospitals
  • Deliver on our performance targets: to improve the number of patients admitted annually, increase the percentage of patients discharged home and reduce the incidents of patient harm

To do this, the project emphasized three core concepts throughout development and implementation:

  1. Partnerships with healthcare providers and funders
  2. Engagement with patients, families, staff, physicians, volunteers, donors and other stakeholders, particularly through soliciting and listening to the experiences associated with giving and receiving care
  3. A relentless focus on quality and safety to improve the patient care experience; a cornerstone of this focus is increased collaboration, coordination and communication among members of inter-professional teams

Early metrics from the demonstration project showed a significant decrease in Providence Hospital ALC cases from upwards of 100 in 2009–2010 to 40 current ALC cases. The number of admissions to Providence Hospital has increased from 1,905 to 2,074, and the percentage of admissions discharged to home has increased to 78%. Based on the current success of our demonstration project, the transformation of all six hospital rehabilitation units will be complete by 2015 (Figure 1).

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A Micro Solution to a Macro Issue

Transformation by Design provides a micro solution to an issue of ongoing and intense public interest and debate: with an aging population, how can we best provide continuity of care to maximize both patient care outcomes and healthcare resources? Providence Healthcare answers this question by building a "bridge" between acute care and home. The 40 processes that were developed in creating this bridge are grouped into three stages that describe the various steps patients encounter along the way to recovery. Providence works with its partners at every step of the journey to minimize the risks associated with transitions and hand-offs from one level of care to another:

  • My Journey to Providence improves patient flow through coordinating and preparing for patient access to rehabilitation while the patient is still in an acute care hospital. A clinician from Providence is positioned in each of our partnering acute care hospitals to create a "pull" strategy that brings patients to Providence. While they are placed in the acute care hospitals, Providence staff build strong relationships with their acute care colleagues and are able to collectively problem solve and find solutions to support patient flow.
  • My Journey While at Providence focuses on increased patient admissions and improved efficiency in achieving outcomes as measured by the Functional Independence Measure (FIM) and the lengths of stay.
  • My Journey Home ensures a high level of support for patients after discharge to ensure a safe and ongoing recovery, continued access to outpatient programs and support services and reduced admissions to the emergency departments of acute care hospitals. Providence staff follow up with patients and families 48 hours after discharge. A strong partnership with the Toronto Central Community Care Access Centre ensures that the necessary home support services and mobility devices are available for patients so that they can continue their recovery at home without interruption. Access to Providence Healthcare's outpatient programs is also facilitated in a timely fashion. The in-patient record follows the patient to outpatient care.

By focusing on a seamless patient journey, Transformation by Design is already demonstrating improved patient flow and access across the four Greater Toronto Area acute care hospitals now partnering with Providence (St. Michael's Hospital, Sunnybrook Health Sciences Centre, the Scarborough Hospital and Toronto East General Hospital). Toronto East General Hospital, for example, is tracking a 50% improvement in the time it takes a patient to access rehabilitation from acute care, as well as a substantial reduction in ALC days. Ongoing support from the Toronto Central LHIN has ensured project success to improve patient flow, access and outcomes.

Staff Engagement Drives Breakthrough Thinking

To encourage the breakthrough thinking needed for Transformation by Design, Providence Healthcare builds upon an internal environment recognized for transparency and openness in communication. Clinicians are actively engaged in redesigning the patient care experience before, during and after rehabilitation through a number of ongoing, focused change events where process design, prototypying and testing occur. During the original design of the project, hospital space was made available as a "living laboratory" so that process changes to patient flow and patient care could be tested and evaluated in a controlled and risk-free environment. As each unit is redesigned, slight variations and changes in processes accommodate the particular needs and challenges of the patient population served.

Quality improvement tools and methodologies – 3P (production, preparation, process), rapid prototyping, simulations, 6S (a process used for improving the organization of the workplace. The name comes from the six steps required to implement the process: Sort, Straighten, Scrub, Safety, Standardize and Sustain), Process-at-a-Glance, 5 Whys etc. – are used to facilitate breakthrough thinking instead of incremental changes, and patients and their families are regularly engaged in providing ongoing insights and feedback through the Plan-Do-Study-Act (PDSA) cycle.

Communication throughout all phases of transformation is ongoing, consistent and transparent. Performance boards on each transformed unit track biweekly progress against key performance indicators. There are regular scheduled "walk-arounds" to discuss results with staff and to engage them in ongoing problem solving. Weekly "checkpoint" meetings solicit ongoing feedback from staff and reinforce engagement in the project, and a QI Kudos Program recognizes employees who have made significant contributions to key project deliverables. A scorecard with 17 performance indicators is shared with front-line staff, management, the Quality Committee of the board of directors and the board as a good measure of progress.

Inter-professional teamwork is a key cornerstone of Transformation by Design, and the project's underlying goal is to provide "rehabilitation everywhere, always, one patient at a time." Successful rehabilitation depends upon inter-professional communication, collaboration and coordination. Strategies are developed to ensure that inter-professional teamwork is encouraged and sustained in order to benefit patient care and communication. Staff engagement levels are high, and enthusiasm and momentum for the project are maintained through a rigorous management and clinical leadership model that focuses on coaching clinicians to extend their reach and own the changes in patient flow and in their practice.

Staff are surveyed at four intervals: pre-implementation, during implementation, post-implementation and after post-implementation. Over these time periods, the surveys showed improvement in understanding and engagement. For example, over a nine-month period, staff improved their understanding of the definition and rationale of Transformation by Design by 48%. During that same time period, staff understanding of why Providence Healthcare is dedicated to improvements in patient flow bettered by 30%.

In spite of a robust communications strategy, there were times during implementation when staff raised issues that slowed project momentum. The key lesson learned during this project was this: build staff engagement by involving many front-line staff – both union and non-union – as early as possible in the development process. Increase the feedback loop by informally asking and tracking feedback at regular intervals during implementation to ensure understanding and ownership. Ensure that all levels of management are equipped with clear, simple messaging to explain the benefits of change, both at the "big picture" level and at the local level where staff experience the impact of change firsthand. At regular intervals, keep all stakeholders informed and apprised of changes both big and small.

Remodelled Physical Space Supports New Processes

When the first Transformation by Design unit was launched in May 2010, the physical transformation was as dramatic as the process transformation. Providence Healthcare Foundation mobilized the support of individual and corporate donors to fund the remodelling of 12 innovative new spaces that support the project's philosophy of rehabilitation everywhere, always, one patient at a time. New rehabilitation spaces for the practice of home safety and community activities ensure that essential tasks such as grocery shopping, meal preparation and cleanup, laundry and maintenance of personal hygiene can be practised in a safe environment that has the look and feel of home.

Rehabilitation all of the time is further enhanced by access to computers and Internet service and by quiet spaces that are provided for socialization and interaction with family and friends. Ninety percent of the patients surveyed agree that the environment helps to achieve their rehabilitation goals.

As new processes improve patient flow and enhance the patient care experience, there has also been a reduction in internal patient bed transfers, with services coming to the patient instead. In addition, patients interact with fewer clinical staff regularly during their stay – a decrease from 35 to 14 clinicians. A small and tighter team ensures consistency of care.

Through Transformation by Design, new processes have been developed to do the following:

  • Standardize patient outings and home passes to ensure the patient is ready for a safe discharge home
  • Link patients to a family physician if they do not have one, before discharge
  • Ensure consistency of care through a smaller inter- professional team working with each patient
  • Improve inter-professional communication with patients and families – through regularly planned and predictable communication meetings ("huddles") with the team at the bedside
  • Facilitate timely in-patient-to-outpatient referrals
  • Ensure ongoing patient and family engagement through feedback and surveys
  • Sustain process improvements through accountability, ongoing measurement, celebrations, recognition programs and problem-solving through challenges
  • Extend our connection with patients to the time before their admission and after their discharge

At first glance, the idea to place a patient flow coordinator from a rehabilitation hospital into an acute care setting to improve patient flow and access seemed simple. In reality, a number of implementation issues emerged, from simple to complex:

  • Space and equipment needs
  • Computer approvals and access for retrieving patient files and information
  • Ensuring appropriate strategies to safeguard patient privacy
  • Training and education to better understand different patient populations

Issues are resolved through communication, transparency and processes. At the beginning of each partnership, Providence Healthcare developed a memorandum of understanding for each acute care partner to outline working expectations such as office space and telephone and computer access; to identify processes for resolving risk or other issues of employment in a shared workplace; and to confirm an anticipated number of admissions. Partner-to-partner meetings were held frequently during project start-up and are now held annually to maintain face-to-face contact among leadership staff. For transparency, an automated weekly report is distributed to all four partners to track the number of admissions for all partners for the week. Processes are in place to handle escalating issues that, for one reason or another, are difficult to resolve at the local level.

Ongoing communication and education have strengthened an understanding of the roles each organization plays in a patient's recovery and have demonstrated evidence of how Providence's new model of care benefits flow and access. Providence held open houses for referring professionals such as social workers and discharge planners, and often visited partners to highlight program and process changes and to identify issues and concerns. Partners came on-site to offer in-service education on caring for specific patient populations such as the homeless and marginalized. Over time, a high level of trust has enabled all partners to make informed and thoughtful decisions together on what best serves the patients.

Metrics and Key Insights

The key metrics tracked throughout Transformation by Design show that the demonstration project has been successful and that process changes are being sustained for ongoing results:

  • Hospital ALC cases have been reduced both at Providence and in acute care partner hospitals.
  • Admissions to the first unit transformed increased in the past fiscal year from 141 to 204.
  • For the fiscal year 2011–2012, 74.5% of patients from the transformed unit were discharged to home, against a target of 75%.
  • One hundred percent of patients surveyed after their discharge from the transformed unit rated their experience as either excellent or good, and 100% said they would recommend Providence to their family and friends.
  • The average length of stay on the first transformed unit decreased from 74 to 56 days.
  • There has been an improvement in FIM efficiency scores overall for the patients on the first transformed unit.
  • Staff members from the first unit to undergo the transformation have since recorded the highest level of employee satisfaction on Providence's annual Employee Satisfaction Survey.
  • When patients discharged from the demonstration project unit were called 48 hours after discharge, we learned the following: (1) 95% said they found the call helpful and (2) 76% said they felt prepared to go home when discharged.
  • There were no visits to acute care emergency departments four months after discharge.

Transformation by Design provides powerful lessons for the future of healthcare. The voices of our patients and families, staff, physicians, partners and donors who support the project gave us the most insightful and compelling reasons for change (Figure 2). Today, they provide testimonials to the project's success and support our ongoing progress. Continued engagement of staff, patients and families and our healthcare partners will remain a key focus in shaping and sustaining our work into the future.

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About the Author(s)

Thelma Horwitz, RN, BScN, MN, is the director of quality and process improvement at Providence Healthcare, in Toronto, Ontario. She has over eight years' experience at Providence, working in a variety of areas such as infection prevention and control, nursing practice and Lean. She is currently the project lead of the Transformation by Design project and is a Health Care Black Belt candidate.

Josie Walsh, RN, MHSc, has been the president and chief executive officer of Providence Healthcare since June 2011. Walsh joined Providence in 2001 as vice-president and chief nurse executive. She has a master's degree in health sciences (health administration) and is also a certified health executive with the Canadian College of Health Leaders. Walsh's expertise was honed first on the front lines and later in a number of progressively senior positions.


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About the Authors

Thelma Horwitz, RN, BScN, MN, is the director of quality and process improvement at Providence Healthcare, in Toronto, Ontario. She has over eight years' experience at Providence, working in a variety of areas such as infection prevention and control, nursing practice and Lean. She is currently the project lead of the Transformation by Design project and is a Health Care Black Belt candidate.

Josie Walsh, RN, MHSc, has been the president and chief executive officer of Providence Healthcare since June 2011. Walsh joined Providence in 2001 as vice-president and chief nurse executive. She has a master's degree in health sciences (health administration) and is also a certified health executive with the Canadian College of Health Leaders. Walsh's expertise was honed first on the front lines and later in a number of progressively senior positions.


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