Performance Improvement (Lean)

Our Lean Journey

In 2013, following the ThedaCare model (from a US healthcare facility based in Appleton, Wisconsin), Pembroke Regional Hospital embarked on a journey to implement a Lean Management System that supports a culture of continuous improvement. Our goal “ to develop our people to solve problems and improve performance”.


Our Lean Management System is now used hospital-wide. From April, 2013 until March, 2019, our employees and physicians have brought forward just over 3,000 ideas for improvement and we have implemented 2,653 of those as reported in our daily improvement huddles (part of the Lean system). In the past year alone (April 2018 until March 2019) 761 new ideas were brought forward, of which 540 were implemented.  

What is Lean? 

More than an improvement project, Lean healthcare is a system of process management which helps improve the flow of information from the front lines to senior leaders and back, fosters the engagement of all employees in process improvement, and allows for daily coaching and teaching. This approach is now being used in many fields including healthcare where Lean is improving patient flow and adding value to each patient’s care experience.

Lean healthcare is about maximizing value for our patients.


Lean healthcare is about continuous quality improvements while eliminating unnecessary steps. In the Lean way of thinking, the organization relies on the expertise of its frontline workers to identify improvement opportunities, to lead changes and to solve problems.


Lean healthcare is about providing the right service, when it is needed, the right way, the first time.


Quality Improvement Work at Pembroke Regional Hospital

Using the Lean Management System, 23 of our departments have daily stand-up meetings to discuss, initiate and implement quality improvements at PRH. Strategic goals for the hospital are identified annually and shared with the health care team. In 2018-2019 those goals were: Embracing patients and their families as partners in their care (Patient and Family Centre Care); Providing a safe environment for our patients and my co-workers (Culture of Safety); Using resources wisely (Improving the value per day, per visit); and Taking pride in the work that I do (Staff engagement). Our teams and departments have worked to support these goals.


Current Improvement Work 2019/2020


Our Strategic Plan  

Development of the goals
key features of a strategic plan



























Our Annual Quality Improvement Plan

four identified priorities

quality improvement plan































PRH Staff Showcase How Lean Management Transforms Care For Patients






Quality Improvement Work at PRH 2018/2019   

Here's a sample of some of the goal-oriented initiatives from the past year:


Goal: Patient and Family Centred Care 

Acute Mental Health / Emergency Department / Mental Health Services

  •  Created a standard assessment tool for patients with mental health conditions and/or addictions for use at all Renfrew County hospitals. Work is also being done to develop a standard discharge tool for the same patient group.


Food Services

  • Introduced a revised patient menu based on patient feedback and will continue to adjust to work towards an improved patient experience.


Surgical Program / Health Records

  • All surgical patients now register upon arrival in the Emergency Department at PRH. This reduces errors in the process and makes it more efficient for patients and staff.


Surgical Program

  • Updated patient information materials and standardized education for those requiring breast surgery.
  • Improved the Operating Room scheduling process. Patients now receive their surgery time by phone the day before their procedure to ensure accurate arrival times. This phone call is also a time for the patient to ask questions and ensure clear understanding of any instructions. Patients complete a health questionnaire when they call to determine if there is any reason why the procedure can't take place.


Intensive Care Unit

  • Introduced an electronic patient satisfaction survey for patients and families at discharge.


Emergency Department

  • A six-month trial of Patient Service Attendants in the waiting room is taking place to assist with communications and provide comfort to those coming to the ED.


Goal: Culture of Safety  

Ambulatory Clinics / Diagnostic Imaging / Emergency Department

  • Patients identified at registration now receive a fall risk self screening tool. This helps patients identify if they are at risk of fall and prompts staff to discuss this risk with them and recommend appropriate follow up.


Ambulatory Clinics

  • All registered outpatients now wear an identification band to ensure the right tests and treatments are given to the right patient.

 Man in chair with nurse












Medical Program

  • In partnership with families, developed and implemented a supportive behavioural care plan to better meet the needs of admitted patients who are diagnosed with dementia or delirium.   


Hospital wide

  • A new process has been put in place to identify patients at risk of violence as a safety measure for both patients and staff.


Goal: Improving the value per day, per visit  

Diagnostic Imaging

  • Improved the financial performance of the Ultrasound program by identifying efficiencies, improving patient flow and reducing wait times.


Operating Room

  • Decreased the overall number of same-day surgery cancellations by 30% and improved the process to fill those spots where cancellations have occurred.


Surgical Program

  • Using best practice guidelines, the number of patients who need to be seen in the Pre-Op Assessment Clinic prior to surgery was reduced by over 25%, resulting in less inconvenience for patients (time off work, parking fee, etc.), improved patient flow, and greater efficiency.


Finance Department

  • Improved the collection method for ambulance fees and updated the language on billing forms based on patient feedback to improve the payment process.


Materials Management

  • Standardized the inventory of frequently used office supplies and streamlined the order process.


Goal: Staff Engagement 

Rehabilitation (inpatient)

  • Adjusted Unit Clerk hours so that coverage is provided during peak times for admissions to assist with admission process.


Food Services

  • Staff worked with the hospital's dietitian to gain a better understanding of therapeutic diets and how food choices impact patient care.



Here are some of the department-based "quick fix" improvements that directly impact patient care which were implemented.


Acute Mental Health

  • Created a better process for labelling patient cell phone chargers and a designated charging station for all patient-owned electronic devices.
  • Updated the admission and discharge checklists to ensure patients receive their education and information at the right time.
  • Developed a sign-out process for Quiet Room resources.
  • Developed a recovery booklet with input from patients to identify goals during their hospital stay and goals to continue to work on at discharge.


Ambulatory Clinics

  • Improved patient signage.
  • Improved the patient seating layout to ensure confidentiality.
  • Started monthly tests of bathroom call bells to ensure patient safety.
  • Worked with Food Services to ensure that systemic therapy patients who require a lunch receive a meal that meets any dietary restrictions they may have.
  • Worked with Pharmacy to improve the patient identification process and communication to ensure the right medications reach the right person.
  • Installed emergency lighting in the patient bathroom.
  • Ensured consistent coverage for the registration desk to reduce wait times for patients.


Emergency Department

  • Worked with Diagnostic Imaging to improve the follow up process for non-admitted patients who require an x-ray following assessment in the ED.
  • Ordered a personal amplifier to communicate with patients who have decreased hearing and do not have hearing aids.
  • Started bringing completed comment cards to daily improvement huddles so that they can be discussed and improvements can be identified.

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  • Updated patient information to include an overview of the role of the Geriatric Emergency Medicine Nurse so that they understand why they may receive a telephone assessment after visiting the Emergency Department.



  • Improved the process for timely communication with patients regarding bills and payment options.


Food Services

  • Worked with nurses to ensure that inpatient meal trays are brought into the rooms in a timely fashion for patients on isolation precautions.
  • Transitioned from the use of styrofoam containers to more environmentally friendly options.
  • Installed a regular toaster in the kitchen for staff use for patients who would like toast at night.


Maternal Child Care

  • Ensured we have enough scrubs for support person to wear in the operating room during C-sections.
  • Created a standard process for completing the lactation consultant form to ensure those who want this public health service receive it.



  • Worked with our Spiritual Care Coordinator to set up a weekly activity with our medical patients, currently this consists of weekly music sessions.

 man playing a guitar in door way











  • Improved the care needs documentation process for our palliative care patients so the whole care team has access to the same information.



  • Worked with the nurse educator to ensure there is an effective process for administration of the flu shot to patients who require it.
  • Improved a number of processes throughout the hospital that involve identification and labelling of medications for enhanced patient safety.


Rehabilitation (outpatient)

  • Established a process that identifies high-priority patients (orthopaedics, stroke) for the weekend physiotherapist.
  • Made improvements to patient education materials.


Rehabilitation (inpatient)

  • Therapy staff developed new processes to ensure patients receive optimal therapy time. Therapy staff and the discharge planner now meet daily to discuss patients and ensure there are no barriers to therapy.
  • Patients receiving stroke rehabilitation therapy are identified on their chart and on the nursing whiteboard to indicate which patients need to be ready for their therapy first.

Surgical Program

  •  Improved tracking system for equipment to ensure all equipment is returned to the unit and is ready for patients. 
  • Installed new chairs in the link corridor between Tower A and Tower B for patients/family members who want to have a quiet space outside of the busy surgical unit. 
  • Worked with the Emergency Department to create an Orthopaedics Fracture Checklist for patients who come to the Emergency Department and need to be transferred to the Surgical Program. This ensures they are properly prepared prior to the transfer (x-ray completed, street clothes removed, pain medication administered prior to transfer etc.). This has resulted in improved patient comfort and a more efficient treatment process.  

Vascular Health - Diabetes Education Clinic 

  •  Improved access to the insulin fridge and the stocking process for our clients that require this. 
  • Reorganized the space to accommodate patient appointments and minimize interruptions. 
  • Updated patient education materials.  



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