Emergency department team, Nyaho Medical Centre, Accra, Ghana. Left to Right: Emmanuel Tsormey (Nurse), Stephen Salu (Nurse), Dr. Eric Smart Yeboah (Emergency Specialist), Dr. Faiqa Bashir (Medical Officer), and Dr. Jessica Efa (Medical Officer).

Nyaho Medical Centre is located in Accra, Ghana. It is one of the few private hospitals in the country offering inpatient acute care, specialist care, and a 24-hour Emergency Department (ED).

Prior to the COVID-19 pandemic, the ED used a metric called “door-to-needle time” to measure its delivery of timely care. Before COVID-19, the ED patient beds were often filled and sometimes there was overcrowding, however the inpatient wards typically reported a bed occupancy rate of only 20–50% capacity. While not all patients in the ED required admission for inpatient care, patients seemed to be staying in the ED longer than needed or were not transferred to the inpatient wards. It was clear that the ‘door-to-needle time” metric was not providing the ED team with enough information to improve patient flow and determine where the processes may be insufficient.

Patient safety metrics are a primary concern in emergency care

To run safely and efficiently, an ED requires coordination between emergency physicians and nurses, on-call specialists, other health professionals, laboratory, diagnostic imaging services, and inpatient units. Overcrowding in the ED can have a negative impact on patient safety, potentially increasing mortality, delaying care, and creating longer waiting times.

Overcrowding is an indication of system inefficiencies and broader organizational issues, such as staff shortages and leadership oversight. A patient safety metric that measures patient length of stay can help identify the root causes of overcrowding and develop solutions to improve the patient care process from door-to-discharge. Internationally, the acceptable length of stay in an ED is 6 hours or less.

Planning improvements: Developing the length of stay metric

With patient safety in mind, the Quality Team at Nyaho Medical Centre developed a new metric to determine patients’ length of stay in the ED. To develop their length of stay metric, weekly findings were collated in a Word document, while record-keeping and analysis, including the run chart, were recorded in an Excel sheet.

One of the first challenges the Quality Team encountered was identifying patient arrival and departure times. Initially, there was a documentation challenge due to limitations in the Electronic Medical Record (EMR), and incomplete clinician documentation. When a patient’s departure time was incomplete, or absent, the date and time of the patient’s final ED bill was used to determine the total length of stay.

Via planning meetings and reviews of weekly results, the Quality Team involved non-clinical staff, physicians, nurses, and staff who held non-management, senior, and executive leadership positions. This interdisciplinary focus ensured that all ED staff understood the changes that would take place as the metric was defined and tracked.

Bridging the cultural gap with Lean practices

As many staff working at Nyaho are Ghanian national, meaning they live, work and attended school in Ghana for most or all of their lives, the Nyaho work culture resembled the traditional Ghanian culture in many ways. Differences existed between the traditional culture of Nyaho Medical Centre and Lean practices creating what felt like barriers to improving patient safety. The Lean Cultural Compass, a tool to support quality improvement initiatives, helps to bridge the differences. The compass highlights the potential cultural pitfalls that may exist between Lean principles and other cultures. The compass also shows the similarities between cultures and these similarities can be utilized to act as levers to support the quality improvement initiatives.

Potential pitfalls

• In traditional Ghanian culture, collaboration (consensus decision-making) in a mixed hierarchical group does not occur easily as power is concentrated in the hands of the management team where decisions are made by one person. Conversely, Lean practices encourages consensus decision making prior to finalizing a decision.
• Ghana’s culture places an emphasis on the short-term impact of a decision with a limited respect for schedules and deadlines, whereas Lean practices’ value a long-term orientation.
• In Ghanian culture, rule flexibility is valued as it allows for adaptation to an unpredictable environment, while Lean practices, in contrast, adheres to strict compliance with specific standards and rules.

Supporting lever

• Both the Ghanaian culture, including the Nyaho work culture, and Lean practices support the use of empiric reasoning and identifying methods to employ risk mitigation.

The traditional Ghanian cultural elements that did not align with Lean practices had the potential to hinder planning and make implementing new processes difficult. Unsurprisingly, the contrast between Lean practices and the Nyaho work culture became apparent as the Quality Team began initial discussions with the ED team about the new patient safety metric. To bridge the cultural differences, the Quality Department utilized a Lean management tool, a visual management dashboard, to establish the length of stay metric’s relevance and importance in the ED.

Reporting the Emergency Discharge Metric

Graph 1 shows the results of tracking patients’ length of stay for one year in the ED. Through training implemented by the Quality Team, nearly 95% of patients had a documented discharge date and time from a doctor or nurse before the end of the second month of metric reporting, eliminating the need to rely on the final date of payment.

Graph 1. Patients’ monthly average length of stay at Nyaho Medical Centre’s Emergency Department

As the Quality Team developed the patient length of stay metric, it was important to identify a method for displaying the results so that all the staff could see the real-time impact of the process changes the ED was making. One way to share results is through a visual management board located in the private work areas where staff gather. Unfortunately, Nyaho’s hospital space is limited. The ED is spread across two buildings, and it can be difficult to find space for staff to meet away from patients and their families.

Additionally, measuring the average length of stay was a new concept for the hospital. The Quality Team knew that to draw attention to the quality improvement initiative and to help all staff, including managers and directors, learn about the length of stay metric, they needed to broadcast weekly results in a format that was accessible and easily shared.

Nyaho Medical Centre uses Microsoft Teams for all staff communication. All Nyaho staff have access to a General Staff Teams (GST) channel. The Quality Team used the GST channel as a virtual visual dashboard to share the ED’s weekly average length of stay metric, and to communicate the improvements that the ED team was introducing. As the metric was reported electronically, ED clinical managers were able to recirculate GST postings easily via the WhatsApp app to their ED teams.

In one year since establishing the length of stay metric, the ED demonstrated improvement in patients’ length of stay. The initial average length of stay of 40 hours dropped to 9 hours within four months (see Graph 2). In addition, whilst the ED continues to strive to reach a 6-hour target, since February 2021, the health care team has successfully ensured that the length of stay remains at 14 hours and less.

Graph 2. Patients’ weekly average length of stay in Nyaho Medical Centre’s Emergency Department during first four months of implementing the new metric

Sustaining improvements

Reducing the ED’s length of stay for patients at Nyaho Medical Centre required system improvements and continuous staff support as they learned new methods for patient management. In quality improvement initiatives, establishing new processes is often referred to as a “change idea”. As shown in Graph 2, the change ideas initiated by the ED team accelerate improvement, but sustaining the changes required long-term focus. To aid the ED staff in the cultural shift toward Lean principles, several actions reinforced the change ideas:

• Ownership of the metric’s measurement and reporting was moved to the Emergency Department (ED) team. Accordingly, accountability, and adherence to the new processes were transferred to the ED’s staff.
• Until the EMR could be enhanced, staffs’ skill in documenting patients’ arrival and departure times in clinical notes was developed.
• Later, the EMR was enhanced to support data elements that clinicians needed to document patients’ admission and discharge times.
• Staff were educated on the importance of patients’ length of stay in the ED during onboarding and via the procedures written to support the new processes.
• A separate turnaround time was established for ED patients’ lab results.
• Better utilization of space on the inpatient wards improved transfers for admitted patients.

Left to Right: Godfred Hanson (Quality Officer), Augustine Kumah (Quality Manager)

In summary

Lean principle’s culture and Nyaho Medical Centre’s work culture at first appeared to be opposed. Teaching the ED staff to lead in the change ideas that emerged from the creation of the length of stay metric supported this continuous improvement initiative and lean journey. Leveraging the similarities between these two cultures helped drive the success of the new metric’s implementation. Developing a metric tied to a quantitative measure bolstered the similarity between the cultures’ alignment with empiric reasoning. Finally, reporting the measurement widely within the organization appealed to both cultures’ interests in risk mitigation. By promoting the metric through a virtual visual dashboard, and sharing improvements across the hospital, the Quality Department supported the ED team in its quality improvement journey, and closed the cultural gap between traditional Ghanaian culture and Lean principles.