title: Ontario's emergency department process improvement program: the experience of implementation.
abstract: OBJECTIVE
  In recent years, Lean manufacturing principles have been applied to health care quality improvement efforts to improve wait times. In Ontario, an emergency department (ED) process improvement program based on Lean principles was introduced by the Ministry of Health and Long-Term Care as part of a strategy to reduce ED length of stay (LOS) and to improve patient flow. This article aims to describe the hospital-based teams' experiences during the ED process improvement program implementation and the teams' perceptions of the key factors that influenced the program's success or failure.
  
  
  METHODS
  A qualitative evaluation was conducted based on semistructured interviews with hospital implementation team members, such as team leads, medical leads, and executive sponsors, at 10 purposively selected hospitals in Ontario, Canada. Sites were selected based, in part, on their changes in median ED LOS following the implementation period. A thematic framework approach as used for interviews, and a standard thematic coding framework was developed.
  
  
  RESULTS
  Twenty-four interviews were coded and analyzed. The results are organized according to participants' experience and are grouped into four themes that were identified as significantly affecting the implementation experience: local contextual factors, relationship between improvement team and support players, staff engagement, and success and sustainability. The results demonstrate the importance of the context of implementation, establishing strong relationships and communication strategies, and preparing for implementation and sustainability prior to the start of the project.
  
  
  CONCLUSIONS
  Several key factors were identified as important to the success of the program, such as preparing for implementation, ensuring strong executive support, creation of implementation teams based on the tasks and outcomes of the initiative, and using multiple communication strategies throughout the implementation process. Explicit incorporation of these factors into the development and implementation of future similar interventions in health care settings could be useful.
authors.affiliation: The Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Leahora
authors.initials: L
authors.lastname: Rotteau
authors.affiliation: The Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Fiona
authors.initials: F
authors.lastname: Webster
authors.affiliation: The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Erin
authors.initials: E
authors.lastname: Salkeld
authors.affiliation: The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Chelsea
authors.initials: C
authors.lastname: Hellings
authors.affiliation: The Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|The Department of Paediatrics, Division of Paediatric and Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.|The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Astrid
authors.initials: A
authors.lastname: Guttmann
authors.affiliation: The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Marian J
authors.initials: MJ
authors.lastname: Vermeulen
authors.affiliation: The Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Bell
authors.affiliation: The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|The Centre for Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
authors.affiliation: The Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Brian H
authors.initials: BH
authors.lastname: Rowe
authors.affiliation: Cass Business School, City University, London, UK.
authors.forename: Amit
authors.initials: A
authors.lastname: Nigam
authors.affiliation: The Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|The Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.|The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|The Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Schull
mesh_terms: D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D007902:Length of Stay; D009864:Ontario; D010564:Personnel, Hospital; D036301:Qualitative Research; D058996:Quality Improvement; D011787:Quality of Health Care / Q000458:organization & administration*; D014850:Waiting Lists