Process Improvement

Lean training group

Process improvement (Lean Healthcare case study)

Jane Bishop, Director of Healthcare Services, Leading Edge Group, looks at how to strengthen healthcare processes using simulation techniques.

Process improvement in healthcare, while not new, is still in its infancy when compared to the improvement work done in manufacturing globally for the past 50 years. We are only now beginning to understand the importance of removing non-value-added activities from our processes in order to have the capacity to meet the demands on our services and the increasing need to meet regulatory requirements.

While we are charged with doing more with less in order to contain the rising costs of healthcare, we do not always have the ability to focus on what is truly adding value to our patients’ care or our healthcare system generally. Therefore, we are not always able to make informed decisions as to what can be cut and in order to still meet the demand for service and ensure quality outcomes. 

Many process improvement efforts involve the use of Plan, Do, Check, Act (PDCA) cycles to trial new processes in a clinical setting. A continuous review of these trials allows the improvement team to constantly try new ideas until a process improvement occurs.

Simulation has the potential to improve healthcare practices and to enable potential improvements to be tested before being implemented in a clinical setting. Simulation is a technique — not a technology — to replace or amplify real experiences with guided experiences. It is these guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.*

Many simulation techniques have historically been used to teach medical and clinical techniques. More recently, simulations have been used to test designs for new medical facilities or to test process improvements in existing environments.

Software simulations allow participants to change the test parameters. This enables closer examination and isolation of the impact of process changes on specific areas of interest, such as patient flow, patient outcomes and throughput, staffing ratios and budgetary impacts. Some types of simulations also use props to allow participants to experience a hands-on approach to process improvement.

By using simulation techniques, staff who are interested in quality management and process improvements can test improvements ideas in a safe and supported environment. They can also quickly redesign process improvements and trial these new ideas far more easily than they could if testing changes in the real world. Furthermore, measuring the process improvement and outcome metrics through simulations allow staff to prioritise which ideas are best used for PDCA cycles in the clinical settings. This creates some degree of confidence that any implemented improvement strategies will likely result in positive outcomes.

Staff at Halton Health Services in Oakville, Ontario, recently used simulations to test new process improvement ideas for their Emergency Department (ED), which is often under pressure. As the existing ED is set to move to a newly built hospital in the vicinity, the staff felt it was important to streamline processes as much as possible, prior to the move.

A total of 25 participants embarked on a six month process improvement course which included four instructor-led days. Here, participants had the opportunity to move ‘patients’ though the system from registration and triage to discharge or admission, all in a classroom environment.

The simulation mimicked real life events in the ED, including the arrival of code patients and long bottle necks in process steps, such as diagnostic imaging and admission to hospital. Metric collection allowed the team to audit patient outcomes, patients in progress through the system, lead times and queue times, as well as cost to the hospital budget.

After the students had learnt some basic principles and tools involved in process improvement, they redesigned processes and the physical design of their ED. 

They again ran a simulation exercise under the same conditions with the same variables, such as number of staff and code patients. The metrics for round two showed a significant improvement in patient flow, reduction of bottlenecks, increased rate of discharge, reduced lead and queue time, as well as a decrease in the costs involved in treating each patient.

The students are now trialling new processes in their existing ED in hope of reducing the pressure prior to moving to their new facility.



*  Gaba, D.M. (2004). The future vision of simulation in health care. Quality & Safety in Health Care, 13(Supp 1): i2–i10.

Image: Process improvement students at Halton Health Services using simulation techniques, courtesy of Jane Bishop.