Background: On June 6, 2011 the Emergency Department (ED) at Southlake Regional Health Center, a very high-volume ED, initiated a comprehensive redesign project to improve patient waiting times. The primary initial goal of the project was to reduce Time to Physician Initial Assessment (TPIA) - one of the Key Performance Indicators (KPIs) tracked by the Ontario Ministry of Health and Long-Term Care. The objective was to achieve a significant improvement in TPIA without sacrificing performance on any other important KPIs such as Length of Stay (LOS), Left Without Being Seen (LWBS), or time to admission (T2A). The effect on TPIA was immediate and dramatic: the 90th percentile TPIA declining from 4 hrs to under 2.5 hrs, with further improvements seen over time. The patient in-flows also increased; anecdotally this increase was directly related to shorter wait time. However, like any other large-scale and ongoing system redesign project, the impacts are not limited to the listed KPIs, but are multi-dimensional, affecting patient inflows, flows within the ED, workloads, staffing levels, etc. Thus, teasing out the impact of system redesign requires from other concurrent factors (population changes, staffing changes, etc.) requires a comprehensive system assessment. The available data exhibits auto-correlations, heteroscedasticity, and interdependence among variables, rendering simple statistical analysis of individual KPIs inapplicable. We develop a novel methodology and conduct counterfactual analysis demonstrating that the decrease in TPIA, as well as new patient in-flows can indeed be attributed to the ED redesign. This suggests that a similar system redesign should be considered by other EDs looking to improve wait times. Objectives: To (1) statistically estimate the impacts of the redesign project on various performance measures over time, (2) examine whether the initial goal of improvement in TPIA without compromising other service performance measures was achieved, and (3) study whether the project impacted patient inflows. Methods: We (1) estimate simultaneous equations models to quantify interdependent and time-varying relations among variables, (2) conduct an iterative counterfactual analysis to estimate the mean-level impacts of the project, and (3) construct 95% confidence intervals for the estimated impacts using the Bootstrap method. Results: We study project impacts over 720 days after it was initiated. During this time, the 90th percentile of TPIA has been reduced by nearly 2.5 hours on average (translating into an over 50% improvement), with continuous improvement over the study period. This effect is statistically and operationally significant. The project also improved LOS for non-admitted patients (both acute and non-acute), and did not have statistically significant impact on LOS for admitted patients. There was also a decrease in LWBS, though it was not statistically significant. Thus the project achieved its stated primary goals. We also observed an increase in inflows of both acute and nonacute patients; our analysis confirms that this increase can be attributed to the project, indicating that improvements in TPIA attracted new patients to the ED. All of these effects have persisted over the 720-day post-project period. Conclusions: The redesign project has significantly reduced TPIA over time while also improving some LOS measures; none of the waiting time KPIs were compromised. The reduction in TPIA also attracted significant volumes of new patients. However, the redesigned process was able to deal with this volume without compromising performance. The redesign project involved a number of major changes in ED operations. We provide an overview of these changes, and while our analysis cannot attribute specific project impacts to specific changes, we believe that implementing similar changes should receive strong consideration by other EDs.

The authors have declared no competing interest.

This study was funded by NSERC and MITACS.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The Research Ethics Board of The Southlake Regional Health Centre gave ethical approval for this work.

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All data produced in the present study are available upon reasonable request to the authors.