Using Lean to reduce wait times for COVID-19 tests

In response to the global pandemic, Hôpital Montfort, a 289-bed francophone teaching hospital in Ottawa, was mandated by the Champlain Health Region Incident Command to set up a COVID-19 care clinic to service the east end of the city.

At the time the request came through, the clinic had to be ready for operation within the following week, as a surge of ill patients was anticipated. Different in its mandate, as compared to a testing-only centre, this care clinic allowed medical care on site. (i.e. X-rays, bloodwork, ECGs).

The initial workflow was inspired by the same one used in the main-site’s emergency room, with slight adjustments. Electronic registration and documentation were possible through an extension of our hospital IT network and HIS.

Within five days of determining the location of our “walk-in type” COVID-19 Care Clinic, a nearby decommissioned school that was now used for storage, we were ready to accept our first patients, on a first-come first-serve basis.

Within the initial workflow, the patient’s journey started by undergoing a triage process, paired with clinical data collection tools, built in the MEDITECH Expanse EHR.

After going through the registration process, patients were directed to a waiting room until they could meet with one of our clinical teams to undergo a medical evaluation and/or COVID-19 testing. These teams were composed of a physician and a registered practical nurse (RPN).

At this point, although we aimed to see as many patients as possible, some processes involved duplication of the documentation. Examples included data collection from the patient, as well as laboratory requisitions that were documented both on paper and electronically to meet Ontario Public Health’s as well as regional laboratories requirements.

The use of workstations on wheels allowing electronic clinical documentation outside the patient room; this contributed to reducing the use of personal protective equipment to better protect very limited stocks. By working with this model, our clinic was still able to see up to 470 patients per day with good population satisfaction.

It was only towards the end of summer 2020, as the clinic became well established, that we experienced a surge in patient demand, which resulted in very long waiting lines.

Full capacity was sometimes reached within only a few hours after opening time. We were then starting to refuse patients up to five hours before the clinic’s scheduled closing time, as we would not be able to meet the demand.

Daily wait times easily went up to nearly 5-6 hours during this period. This situation of course led to population dissatisfaction and an overworked staff.

At this point, we found ourselves in a position where we had to rethink the clinic’s processes to become more efficient and increase patient satisfaction back to its original level.

Since our hospital has been using the Lean methodology for continuous improvement since 2008, the team referred to their Lean knowledge to address the situation. A few Lean principles were used to create our new flow: “decrease variation”, which is one of the key principles, “better use of talent” and “simplify the process”.

This new model aimed to minimize the time spent by our patients on-site, increasing efficiency and consequently output, as well as improving patient satisfaction.

Reflections led us towards a totally different workflow, composed of a two-tiered appointment system, which also met the new requirements of the government of Ontario, of eliminating the “walk-in type” model.

By using appointments, we were able to decrease variation in demand, allowing a steadier flow throughout the day.

Consequently, to optimize human, technical, and financial resources, we partnered with another Ottawa hospital to implement an online booking system where patients were able to reserve an appointment up to 48 hours in advance.

Through customization of the SAVIENCE solution, patients would self-triage by choosing between either a COVID-19 “test-only” appointment or receiving a medical evaluation, combined with a COVID-19 screening test, if their symptoms required so.

Within this new model, our registration and electronic clinical documentation processes and tools were also revamped. Improvements focused on streamlining data collection and data entry into only one instance of documentation.

Improved workflow: The improved workflow permitted an adjustment to the skill mix of healthcare workers required to operate the clinic.

Where our first model was physician-driven, our second model allowed our physicians to attend to the sicker patients. A new type of healthcare worker, called a test administrator, was introduced in the skill mix for the patients choosing a “test-only” appointment.

Patients who came in for a “test-only” could always change care paths if they were identified to be sicker than originally expected. These changes allowed patients to receive the right type of service, in a timely manner, by the right healthcare provider.

In addition, our efforts decreased duplication and associated potential errors. A notable example was to allow the printing of a report that identically mimicked the paper-format COVID-19 laboratory requisition required by Ontario Public Health laboratories, by using the administrative and clinical data documented through our HIS.

The report was printed once the order was completed in the HIS by our frontline worker. This meant we were no longer required to fill out a paper version of the laboratory requisition.

By introducing two different types of visits in our second model, we became more efficient and reduced direct human resources cost by 33%.

By using technology to our advantage, we were able to decrease the time to complete a visit for a “test-only” appointment by approximately 50%. As an example, patients spent on average 24.7 minutes initially for a “test-only” visit. Our new model decreased this time to roughly 12 minutes. Consequently, patient satisfaction improved.

Although the staff was reluctant at first, they are now very happy with the changes and would not go back to our original model.