Stakeholders in GGH Process Improvement Initiative Discussion.

Please first answer this question separate from the case study… As Williams contemplates her decision, who are the key stakeholders, and to whom should she pay the most attention? Then You must apply concepts from a chapter in the
textbook to the corresponding case, and submit a 1-2 page write-up that applies the concepts from the chapter to the content of the case. This is based on chapter 8 from the textbook Healthcare and business strategy by George Mosele, the second edition.

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For the exclusive use of A. Williams, 2022. W16166 GUELPH GENERAL HOSPITAL Justin Cottrell, Abhinay Sathya, Austin Allison, Daniel Korsunsky, Scott Anders McGillis and Moneca Nicols wrote this case under the supervision of Professor Michael J. Rouse solely to provide material for class discussion. The authors do not intend to illustrate either effective or ineffective handling of a managerial situation. The authors may have disguised certain names and other identifying information to protect confidentiality. This publication may not be transmitted, photocopied, digitized or otherwise reproduced in any form or by any means without the permission of the copyright holder. Reproduction of this material is not covered under authorization by any reproduction rights organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Ivey Business School, Western University, London, Ontario, Canada, N6G 0N1; (t) 519.661.3208; (e) cases@ivey.ca; www.iveycases.com.

Copyright © 2016, Richard Ivey School of Business Foundation Version: 2016-03-29 In November 2010, Jennifer Williams, senior director of Inpatient Services, Guelph General Hospital (GGH), returned to her office and reflected on the results to date of the GGH Process Improvement Program (GGHPIP). She wondered how to resolve a series of issues — if they could be resolved at all — that could, potentially, undermine the initiative. Williams had been chosen by the Local Health Integration Network and GGH’s chief executive officer to implement the GGHPIP. Williams had begun the implementation of the program in October 2009, as part of a province-wide pilot project supported by the Ontario Ministry of Health and Long Term Care. As mandated by the chief executive officer, the program was being tested at GGH in the wake of a deteriorating organizational culture and poor performance reviews. The government-led implementation had just finished and initial success had been promising, but the strategy was based on “lean” methodology, a manufacturing operations philosophy that had not been thoroughly tested in a Canadian healthcare setting. DEMOGRAPHICS Considered to be one of Canada’s best places to live, Guelph boasted consistently low crime rates, a clean environment, and a generally high standard of living. Located in Southwestern Ontario, the city was home to more than 121,000 individuals, with a median age of 37.7 and population growth rate of 2 per cent annually. 1 As the only hospital for Guelph and its surrounding 90,000 residents, GGH’s resources were already significantly constrained. The city had no walk-in clinics, and its population growth and aging population had increased the number of patients seen by GGH’s Emergency Department (ED) by 10 per cent annually, implicating future resource constraints. 1 “Focus on Geography Series, 2011 Census,” accessed January 26, 2015, recensement/2011/as-sa/fogs-spg/Facts-csd-eng.cfm?Lang=Eng&GK=CSD&GC=3523008. www12.statcan.gc.ca/census- This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022.

For the exclusive use of A. Williams, 2022. Page 2 9B16M038 PROBLEMS AT GGH In October 2009, the GGH ED was struggling. The increasing number of patients coupled with inefficiencies within the department had led to patients leaving dissatisfied, resulting in overall low staff morale. Hospital performance metrics were extremely poor (see Exhibit 1). The average length of stay for the 90th percentile of admitted patients peaked at almost 28 hours. Furthermore, because wait times were so long, 10.56 per cent of the patients “left without being seen.” Stories of patients with broken bones and fractures becoming tired of waiting and returning home were commonplace. Unfortunately, a simple solution was elusive. A defensive working culture made it difficult to get to the root of the problem. In many circumstances, the ED would blame the inpatient staff, and vice-versa. Inpatient and outpatient care services were often seen as two distinct processes, hampering collaboration and process improvements. In the past, many efforts to try to implement changes to improve patient care and efficiency had been undertaken; however, many of the solutions were ad hoc and therefore proved to be ineffective in the long term. A lack of communication between working staff and managers only compounded the problem. Resentment and frustration on both fronts had ultimately impeded further progress and led to a standstill. Further clouding the issue was the attitude of the staff towards operations at the hospital before GGHPIP was implemented. Over half of the staff felt dissatisfied with their workload, interdepartmental cooperation, recognition and award systems, and the amount of control they felt in their jobs. This contributed to an overall low level of morale and high levels of stress. Staff members felt that they could not properly care for their patients, given their current environment. This frustration led to a number of nurses quitting. “One year ago, we were really in a dark place,” said Becky Jackson, a registered nurse working in the ED. “We were at our wits end.” THE EMERGENCY DEPARTMENT PROCESS IMPROVEMENT PROGRAM 2 In Canada, more than 12 million emergency department visits were made each year. Since 2005, rising patient demand contributed to lengthy wait times and inefficient processes, calling into question the legitimacy of emergency departments. When patients had to wait, they were at greater risk of experiencing adverse events and poor outcomes.

In April 2008, the Ontario Ministry of Health and Long Term Care introduced the Emergency Department Process Improvement Program (EDPIP) in four Ontario emergency departments as part of a strategy to reduce demand, improve processes, and accelerate processes for Alternative Level of Care patients (ALC). As part of the mandate, EDPIP would address the aforementioned concerns by applying process improvement processes used in the lean methodology (a strategy most commonly found in the manufacturing sector). At GGH, the EDPIP implementation was named the Guelph General Hospital Process Improvement Program (GGHPIP). 2 “Transforming the Patient Experience Emergency Department Process Improvement Program Case Book,” accessed January 26, 2015, www.ipac.ca/showabstract.lasso?id=490. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 3 9B16M038 LEAN METHODOLOGY Lean methodology was a practice that considered the expenditure of resources for any goal other than the creation of value for the end consumer to be wasteful. It essentially aimed to preserve value with less work. Originating in Japanese industrial organizations, lean methodology offered an approach to making production processes more efficient. Its goal was to maximize the value added by each activity by paring unnecessary operations and delays. Some of the tools used included: • • • • • Just-in-time (JIT) inventory systems: Ordering and stocking items only as needed. Muda: Waste reduction. The “5S” principles: Sort, straighten, sweep, standardize and sustain. Kanban inventory management system: A scheduling system paired with JIT to ensure an even flow of inventory. Continuous improvement: Strive to constantly monitor the system and improve it as needed. While lean methodology was originally developed in the automotive sector, it had spread to many manufacturing and service industries. Before coming to the Canadian healthcare system, its principles had proven to be beneficial in hospitals throughout the United States, the United Kingdom, and Australia.3 In fact, lean methodologies were believed to be potentially more lucrative in the service sector than in manufacturing, since an estimated 50 per cent of costs for service businesses were non-value-added. 4 Overproduction, waste of time on hand, waste in transportation, waste of processing, waste of stock on hand, waste of movement, and waste from making defective products were all common issues.

Evidently, significant waste was occurring, especially in healthcare settings.5 Despite lean methodology’s success in other hospitals, Williams was concerned that the cultural differences between automobile manufacturers and the healthcare sector were too great to overcome. She knew that implementing lean methods would change the workplace dynamics, although they could produce significant benefits. Reviewing her learning materials, Williams identified five main processes often involved in identifying and reducing waste in hospitals: 6 • • • • • Identify customer value: What do patients want and need from a visit to GGH? Manage the value stream: Develop a value stream map to help the ED team depict where waste exists. Develop a flow of production: Does the patient flow through the system? Use pull techniques: Does the process allow patients to pull value? Continuously seek improvements: Continuous improvement persists until the future state is achieved. PRELIMINARY LEAN IMPLEMENTATION The 5S Principles Throughout the implementation, several lean methodologies were employed, especially the 5S principles. This approach focused specifically on inventory management and efficiency, and allowed departments to 3 Ben Fine, Brian Golden, Rosemary Hannam, and Dante J. Morra, “Leading Lean: A Canadian Healthcare Leader’s Guide,” Healthcare Quarterly 12, no. 3 (2009): 26–45, accessed January 26, 2015, www.rotman.utoronto.ca/-/media/Files/Programsand-Areas/HealthSector/Research_HQ_vol12_no3_Fine.pdf. 4 David Wood, “A Prescription for Lean Healthcare,” Healthcare Quarterly 17, no. 2, (April 2014): 24–28. 5 Larry P. Ritzman, Lee J. Krajewski, Manoj K. Malhotra, and Robert D. Klassen, Foundations of Operations Management, 3rd ed. (Toronto: Pearson, 2013). 6 Fine et al., op. cit. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 4 9B16M038 identify a variety of inefficiencies. The ED found about $250,000 7 worth of out-of-date supplies (effectively waste) that had been thrown in cupboards or removed from staff kits. To combat this waste from reoccurring, GGH began to track medical tools and supplies by placing red tags on all equipment in the spring. Once an employee had used a piece of equipment marked with a tag, the tag would be removed. After two weeks, equipment not used was identified and a new inventory strategy designed. New standardization protocols were also introduced. For example, the contents of all crash carts were made uniform. In addition, signs were created on the walls to indicate where equipment must be placed after use. This made it easier for the staff to visualize what was missing, making tracking and restocking supplies more efficient. It also substantially decreased the time it took for nurses to locate supplies, saving money and ensuring patients were cared for promptly in an emergency. Patient Processing In trying to make the patient experience more efficient, GGH focused primarily on decreasing patient throughput times by addressing inefficient uses of staff time. Colour-coded lines on the walls and floors enabled patients to find where they needed to go without a nurse so nurses could spend more time managing and seeing patients rather than escorting able-bodied patients through the hospital. Another example of an effort to cut non-value-added activities was the implementation of an electronic screen that colour coded X-rays to show whether the X-ray had been requested, performed, or read. This saved staff time from constantly having to check if the test had been completed and/or results reported. Now, ED staff could easily see when X-ray results were ready with minimal effort. Use of Beds in the Emergency Department GGH implemented a new triage system to assign patients to different locations within the ED. In the old system, patients with minor illnesses (e.g., a cough) would still be assigned to a bed within the department. This process often resulted in the space not being available for more acutely ill patients and led to prolonged waiting times. A “see and treat” model of care was implemented for lower acuity patients that focused on rapid assessment, diagnostics, and discharge; it virtually eliminated the time that patients waited in a bed. By freeing up these scarce resources, patients who actually needed beds were granted greater access to them. Thus, GGH was able to add capacity and increase efficiency without resorting to the “band-aid approach” of having to add beds. Private Rooms GGH also decided to add more private rooms. This was a difficult decision, as private rooms were conventionally considered to be an extremely inefficient use of space. However, staff recognized that they were having difficulty accessing private rooms for patients who required isolation. In this case, GGH felt that the efficiency gained from such initiatives was greater than the efficiency lost from adding more private rooms. Initiatives like this further demonstrated GGH’s dedication to thoughtful resource allocation in order to increase the overall efficiency of the hospital. 7 All funds in Canadian dollars unless specified otherwise. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 5 9B16M038 Team Champions As part of the process, GGH was required to pick two “champions” in the ED, each supplemented by a four- to six-person team.

These champions were to be trained by external consultants. The teams consisted of physicians, nurses, and administration staff, thus creating more collaboration within the culture. Furthermore, by having multiple disciplines within the team, more insight was gained when making decisions that would satisfy all stakeholders. The champions were integral for providing motivation within the ED to identify further waste and prevent staff from reverting to old habits. Rewards Metrics were updated daily, allowing individuals to see the improvements occurring in real time. This created a sense of accountability and transparency within the program. The Local Health Integration Network had set out benchmarks to be achieved within two years; however, Williams decided to set lower benchmarks and then raise them once they had been met. This provided the departments with the ability to celebrate multiple short-term wins, which led to long-term buy-in. To celebrate these short-term gains, social events were often held to congratulate departments for high performance.

OBSTACLES IN GGHPIP IMPLEMENTATION Many gains were realized with the first year of GGHPIP’s implementation, although a few of the metrics showed a slight decline (see Exhibit 1). The most recent quarter showed increases in admitted patients and the length of stay of ED patients, as well as an increase in the percentage of patients who left without being seen. Fewer admitted and low-acuity patients were being seen within the target time. More importantly, patient satisfaction dropped. Though staff satisfaction had gone up in some categories, many felt that they had a larger workload, less access to resources/supplies, and less recognition. Williams believed that this indicated a reversion to old habits, and that the changes associated with GGHPIP would not be sustained. Williams knew that many other companies and institutions had often experienced the same kind of results when implementing changes. The literature suggested that the initial implementation of the program would likely be a big shock to operations and would take some adjustment. Unfortunately, many began to question the efficacy rate of an operations-based system within a healthcare culture.

Williams, however, was undeterred by the performance reviews, citing the recent H1N1 pandemic as an irregular disruption of normal operations, which had contributed to the sub-par results post implementation. By having nurses championing the process and multidisciplinary teams, a significant shift in the old power dynamic had occurred. Some staff strongly resisted this. “We absolutely had people in the ‘this is never going to work’ group, and even after we could show them that it is working, they still wouldn’t play ball,” said Williams. A small number decided to leave the hospital as a result of GGHPIP. Some felt uncomfortable with the level of accountability — a staple of lean principles — that was being integrated into GGH. They felt that people were looking over their shoulders, trying to catch their every mistake. Others were also concerned about the trial-and-error nature of GGHPIP and felt that it was inappropriate in a healthcare setting, which was typically very risk-averse. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 6 9B16M038 DECISION Williams was wary about what these issues meant and how to move forward. She had heard of other hospitals in the program failing after initial successes, even when a physician was the champion. Stakeholders in GGH Process Improvement Initiative Discussion.

Did this mean that lean methodology could not work in health care and should be reserved for manufacturing? Was GGH different, since initial buy-in from all levels had been strong, and was the deteriorating performance just a short-term issue? The outbreak of H1N1 flu had placed considerable strain on all emergency departments throughout the province. Was the flu the issue? Or was GGHPIP being poorly implemented? Ultimately, patient care was of utmost importance. If the decline continued, patient safety could be at risk. How should Williams move forward?

How should she address those who were not supportive of GGHPIP and how should she deal with potential turnover? Should she voice an opinion to eliminate the program? Should she rearrange the teams? Or should she just wait and see if the program improved? This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 7 9B16M038 EXHIBIT 1: HOSPITAL PERFORMANCE METRICS PRE-GGHPIP (PATIENT METRICS) This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 8 9B16M038 EXHIBIT 1 (CONTINUED) Source: Company files. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. Stakeholders in GGH Process Improvement Initiative Discussion.

Stakeholders in GGH Process Improvement Initiative Discussion.