Photo caption: Members of Royal Victoria Regional Health Centre’s Cross Functional Team.
By: Rachel Kean, RVH Vice President, Quality, Risk and Performance Improvement
With the goal of improving flow between the ED and Inpatient Units, improving safe quality care and patient experience, Royal Victoria Regional Health Centre's (RVH) President & CEO invited members from across the organization to apply to join a cross functional team to conduct an analysis and provide recommendations.
After an overwhelming response from members across the organization in a variety of roles, a multidisciplinary cross functional team was formed including representatives from nursing, pharmacy, physiotherapy, credentialed staff, quality improvement, and decision support.
Over six months, they conducted a detailed analysis and identified numerous opportunities to drive meaningful change. Through leader engagement sessions, staff Waste Day (open forum for feedback with frontline staff through rounding), provider discussions, site visits, provincial benchmarking, comprehensive review of national and international literature, and patient experience surveys, the team discovered opportunities to improve patient flow.
The findings revealed a significant burden, with patients admitted to medicine and surgery programs experiencing average Time to Inpatient Bed (TTIB) of 13.5 and 3.5 hours respectively. Patients with specific needs, such as telemetry or private rooms, waited longer (16.2 and 19.9 hours respectively). On average, over 11 beds were permanently occupied by admitted patients, limiting accessibility for new ED patients in a 40-bed department. RVH's discouraging 90th percentile TTIB of 24.7 hours ranked 29th among hospitals in the 2023/34 Pay-for-Results metrics.
Based on the evidence, the team developed 13 recommendations, within eight areas of focus:
FOCUS AREA
| RECOMMENDATIONS
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Build a Data Driven Culture
| 1. Eliminate gaps in data collection, including bed clean requests, rationale for a private room and delays in discharge.
2. Define, endorse, and provide accessible patient flow data—retrospectively and in real time—required for decision making, with a shared understanding of thresholds for action. 3. Improve the culture of data reliance, with a clear accountability structure for responding to data and a commitment to data-driven decisions.
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Medicine program closed units, repurposed bullet rounds | 4. Close medicine units and repurpose Bullet Rounds with the objective of accurate and timely data for the Daily Bed Meeting. Specifically, the CFT recommends membership include the Most Responsible Physician, Unit Physiotherapist/Occupational Therapist, Unit Resource Nurse, and Unit Transitional Planner.
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Centralize Bed Management | 5. Centralize coordination of all bed assignments and bed moves to members of the Patient Flow Team only.
6. Conduct in-person Daily Bed Meeting with a focus on patient flow utilizing a revised Surge Plan.
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Implement Electronic Transfer of Accountability (TOA) | 7. Support electronic TOA through the ERM with a centralized patient information framework and remove the requirement of in-person TOA within an expected timeframe.
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Accelerate Patient Portering | 8. Leverage logistics staff when appropriate to porter admitted patients from the ED and between inpatient (IP) units.
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Prioritize Early Transition Planning | 9. Implement an Estimated Discharge Date (EDD) within 48 hours of admission and use it as a focus for discharge planning.
10. Develop an early transition strategy.
11. Prioritize and clarify accountability for patient mobility.
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Appropriate Telemetry Reassessment | 12. Affirm early morning reassessment of telemetry patients by Most Responsible Physician.
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This initiative reflects RVH's commitment to evidence-based decision-making, cross-functional collaboration, and continuous improvement. The 13 recommendations developed by the team represent practical, data-informed strategies aimed at improving patient flow, enhancing safety and quality of care, and optimizing the experience for both patients and staff. With a dedicated project team now leading the implementation, this work remains a priority. Progress will be closely monitored, and a post-project analysis will assess the impact of these efforts, ensuring that meaningful and sustainable improvements are realized across the organization.
For questions about this work, please contact Rachel Kean, Vice President, Quality, Risk and Performance Improvement at keanr@rvh.on.ca