ORIGINAL ARTICLE
A protocol to reduce police wait times in the emergency department Barb Pizzingrilli, RN, BN, MN, CPMHN (C), MBA1; Ron Hoffman, PhD2; and Daniel Pearson Hirdes, BA3
Healthcare Management Forum 2015, Vol. 28(4) 134-138 ª 2015 The Canadian College of Health Leaders. All rights reserved. Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0840470415581257 hmf.sagepub.com
Abstract Healthcare organizations are increasingly tasked with implementing change initiatives that improve the patient experience and target priorities such as Emergency Department (ED) volumes. This article describes the development, implementation, and outcomes of a collaborative protocol between the Niagara Health System and the Niagara Regional Police Service that resulted in a 57% reduction in police wait times in the ED. Six critical success factors contributed to the outcomes that were achieved and are detailed for those organizations interested in engaging in a similar change initiative.
Introduction Healthcare organizations continually explore opportunities for improvement that contribute to a safer, more effective, efficient, and quality-focused experience for patients. However, the successful execution of change within the complex landscape of today’s healthcare environment is challenging. In order to increase the potential for success, designing and implementing any change initiative needs to ensure that focus is placed on six critical success factors: leadership,1,2 stakeholder collaboration,3 metrics,4 staff engagement,2,4-6 innovation,2 and sustainability.7 This article will outline the planning, implementation, and outcomes of a protocol between the Niagara Health System (NHS) and the Niagara Regional Police Service (NRPS), which led to a reduction in police wait times in the Emergency Department (ED). The six critical factors that contributed to the success of the change initiative will be highlighted and may be useful to other healthcare institutions interested in developing a similar protocol.
Background and impetus for change The impetus for change came with the planning for a new NHS hospital in St. Catharines that includes a four-bed Psychiatric Emergency Service (PES). The NRPS was identified as a key stakeholder in the planning process for the new PES unit, given that individuals apprehended by police under the Mental Health Act8 are accompanied to the ED for assessment. Once in the ED, officers are often subjected to extended wait times before care is transferred to the receiving facility, and this is primarily due to a lack of hospital security resources and dedicated space to safely manage the care of high-risk patients.9 Patients with mental illness wait longer in EDs compared to those presenting with medical issues,10-13 and this has significant implications because prolonged wait times can reduce police presence in the community,9,14 contribute to stigmatization of the apprehended individual,15 and impact the individual’s willingness to share pertinent health information in the presence of the officers.15 Additionally, the chaotic, fast-paced, and overstimulating
emergency environment may exacerbate the presenting psychiatric issue and extend the length of stay.13 Mental health issues are represented in approximately 3% to 5% of emergency presentations16-18 and, of these, 17% to 20% are accompanied by police.17,19 This represents a significant volume of patients depending on the size of the ED. The issue of police wait times has therefore been identified as a healthcare topic of considerable interest, as hospitals are increasingly pressured to develop strategies to manage increasing volumes and overcrowding in emergency settings,20 to improve the patient experience, and to engage with stakeholders in effecting system change.
Protocol planning and development In preparation for the opening of the new PES, an existing NHS and NRPS partnership committee was revitalized with new participants who were leaders within their respective agencies with the decision-making ability to effect change. As a key stakeholder in the PES planning, the NRPS leaders were engaged in the development of a protocol for the safe and quality-informed care of individuals with mental health and addiction issues brought to the ED by police. The development process was dynamic and reflected cooperation by both parties to achieve the committee’s mandate of having the protocol completed and ready for implementation with the opening of the PES unit in March 2013. One of the committee’s priorities was to obtain baseline data (Figure 1) of the number of Mental Health Act apprehensions (770) and the associated average police wait time (242 minutes). The committee negotiated a target wait time of 90 minutes that was included as an outcome measure in the 1 2
3
Niagara Health System, St. Catharines, Ontario, Canada. Ontario Police College, Ministry of Community Safety and Correctional Services and Nipissing University, North Bay, Ontario, Canada. University of Waterloo, Waterloo, Ontario, Canada.
Corresponding author: Barb Pizzingrilli, Niagara Health System, St. Catharines, Ontario, Canada. E-mail: [email protected]
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Figure 1. Niagara Regional Police Service Mental Health Act apprehensions and associated wait times in Niagara Health System emergency departments, January to December 2011
protocol. Setting a clear, measurable goal at the onset of the protocol development was important in moving planning in the right direction, ensuring that resources were used appropriately and being able to determine whether the change accomplished what was intended.4 An initial draft protocol, titled Mental Health Act Apprehension and Care of Persons in Custody Protocol,21 was written and introduced to the partnership committee in 2012 by the NHS manager lead. The protocol content reflects strategies identified by the Provincial Human Services and Justice Coordinating Committee9 for reducing police wait times in the ED. Protocol revisions were made with input from all members throughout the year, and a finalized draft was completed by the date of the PES opening. The protocol objectives are the following: to ensure a standardized approach for individuals apprehended under the Mental Health Act who are accompanied to hospital by police, to ensure that the transition of care from NRPS to the NHS occurs within 90 minutes, to outline clear roles and accountabilities for NHS and NRPS staff, and to outline mechanisms for ongoing communication and collaboration around issues that may arise related to the above protocol items.21
Protocol process flow The protocol articulates a clear process flow (Figure 2) for apprehended individuals in the ED. When the decision is made to transport the apprehended individual to hospital, a telephone call is initiated by the police to the ED charge nurse at the NHS St. Catharines Site. The intent of the call is to inform staff of the impending arrival and to highlight any risk-related issues that might require a secure bedded space. The individual is brought in through the emergency services entrance to avoid
Expedited move to Psychiatric Emergency Service if high risk situaon
Individual moved to Psychiatric Emergency Service immediately aer triage
Niagara Regional Police complete Brief Mental Health Screener tool
Psychiatric Emergency Service staff priorize transfer of care with Niagara Regional Police
Niagara Regional Police released prior to physician assessment
Figure 2. Process flow for Niagara Regional Police Service Mental Health Act apprehensions
stigmatizing exposure to the larger patient population in the waiting room. When the triage process is complete, the individual is moved to the PES and the police then complete the Brief Mental Health Screener (BMHS).22 The BMHS is an evidencebased tool designed specifically to assist officers in articulating their grounds for apprehension and sharing observations with hospital staff. The form is based on health data and written in health language, which helps in bridging the gap between the criminal justice and the mental health systems.22 Police use of the BMHS enables PES staff to access valuable, risk-focused information that is fully consistent with their own interRAI Emergency Screener for Psychiatry (ESP).23 The BMHS and the ESP instruments are part of the interRAI Mental Health Assessment System, which is currently mandated for all psychiatric admissions in the province of Ontario.24
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Once the officers have completed the BMHS, the PES staff prioritize completion of the transfer of accountability process. They review the BMHS with the officers and discuss any documented risk indicators that will inform the immediate plan of care for the individual. Once the transfer of accountability is complete, the officers are released from the ED without waiting for a physician assessment.
Targeted education and staff engagement The majority of process changes made in relation to the NHS and NRPS protocol involved the PES staff. Therefore, it was essential to generate enthusiasm about the process changes and inspire the staff to achieve success.25 In order to create change, leaders must possess various skills and characteristics including emotional intelligence, integrity, drive, motivation, selfconfidence, intelligence, and knowledge.26 The NHS manager lead met regularly with all PES staff to assist them in understanding the reason for the change, the protocol details, and how individual and collective actions would assist in meeting the desired goal of reducing police wait times. The face-to-face communications gave staff the opportunity to ask questions relevant to their needs and to receive timely answers so that they understood all aspects of the protocol and their related responsibilities. Taking time to nurture relationships with the PES staff was integral to the success of the changes that were implemented to reduce the police wait times. The manager lead connected regularly with staff to ensure they felt valued and involved with the goal of increasing their commitment to the change. One of the key approaches in engaging the PES staff was to solicit their input from the onset of all protocol planning. Engaging staff in meaningful discussions was particularly important related to the development of the process flow for patients once they are in the ED. The frontline staff were able to identify practical issues with some of the process components, and this led to refinement of the protocol details. This approach creates a sense of co-ownership in the change initiative and minimizes the potential for resistance, which can derail planning and attainment of goals.4 The manager lead also communicated regularly with the ED staff prior to the protocol implementation to ensure understanding of the process flow and key accountabilities. A monthly PES and ED staff meeting was initiated as a collaborative forum in which issues related to the protocol could be brought forward for review and resolution with a focus on identifying opportunities for ongoing process improvement.
Outcomes In reviewing the wait time data (Figure 3) following implementation of the protocol in March 2013, the number of apprehensions was increased slightly to 820 from the 2011 baseline of 770. The wait times begin a downward trend starting in April within one month of implementing the protocol with the lowest time noted in November, two months after the PES unit opened fully. The average wait time between
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Figure 3. Niagara Regional Police Service Mental Health Act apprehensions and associated wait times in Niagara Health System emergency departments, January to December 2013
April and December was 103 minutes compared to the baseline average of 242 minutes in 2011, which represents a 57% reduction in police wait times. The process flow is now standardized so there is no variability in the manner in which individuals accompanied to hospital by police are streamed once they arrive in the ED. There is an escalation process included in the protocol to ensure that issues arising in the frontline are addressed and resolved in a timely manner. While patient-specific satisfaction with the new process was not included as a metric, it is expected that the patient experience is improved with a reduction in potentially stigmatizing exposure to the waiting room through consistent entry via the emergency services entrance. Furthermore, patients may feel more at ease sharing confidential health information required for the provision of safe and timely care once the officers are released. Once the protocol was implemented, it was important to support and sustain the change to minimize the potential for regression to former practices.7 An ongoing quality group, consisting of leaders from the partnership committee, initially met every two weeks for the first six months after implementation and then monthly thereafter. The purpose of the quality committee is to: identify and review inter-organizational systemic issues that are pertinent to the care of individuals apprehended and brought to the ED by NRPS; highlight strengths that exemplify inter-organizational collaboration; review data to inform improvement initiatives and protocol revisions as needed; provide a forum for systemic challenges around confidentiality, ethics, legislation, or other issues; and enhance communication among service providers, fostering an environment of dialogue, transparency, and continuous improvement.21
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The quality group ensures that wait time data are provided to the PES staff to demonstrate the impact of their work and to generate discussion about further process improvement. It is imperative that data are shared with the staff most intimately involved in the change work to generate ongoing enthusiasm and commitment to meeting established goals. As part of ongoing process improvement to achieve the 90minute target wait time, a pilot project was initiated in October 2014 using an iPad application27 at triage for NRPS to complete their BMHS documentation prior to transfer to the PES. An evaluation will be undertaken to determine the impact of this technology for the wait time at the end of six months. This use of technology has the potential to not only improve the police wait times but also raise the profile of the NHS as it is the only hospital system currently using the newly developed iPad application. This creates the opportunity to be leaders within the healthcare industry related to this innovative practice.
Conclusion The development and implementation of a collaborative protocol between the Niagara Health System and the Niagara Regional Police Service contributed to a significant reduction in police wait times in the emergency department. This article contributes to the quality improvement literature and has applicability to healthcare organizations interested in applying the following six critical success factors: leadership, stakeholder collaboration, metrics, staff engagement, sustainability, and innovation in similar change initiatives. References 1. Lundy V, Morin PP. Project leadership influences resistance to change: The case of the Canadian public service. Proj Manag J. 2013;44(4):45-64. doi:http://dx.doi.org/10.1002/pmj.21355. 2. Ransdell GA. Personal reflections on leadership for change: An invited article. Int J Leadership Change. 2014;2(1):1-8. Available at: http://digitalcommons.wku.edu/ijlc/vol2/iss1/1. Accessed November 6, 2014. 3. Conteh C. Strategic inter-organizational cooperation in complex environments. Publ Manag Rev. 2013;15(4):501-521. doi:http:// dx.doi.org/10.1080/14719037.2012.674424. 4. Merrell P. Effective change management: The simple truth. Manag Serv. 2012;56(2):20. 5. Groysberg B, Slind M. Leadership is a conversation. Harvard Bus Rev. 2012;90(6):76-84. 6. MacPhee M, Chang L, Lee D, Spiri W. Global healthcare leadership development: Trends to consider. J Healthc Leader. 2013;5: 22-29. doi:http://dx.doi.org/10.2147/JHL.S23010. 7. Bra¨nnmark M, Benn S. A proposed model for evaluating the sustainability of continuous change programmes. J Change Manag. 2012;12(2):231-245. doi:http://dx.doi.org/10.1080/14697017. 2012.672449. 8. Mental Health Act (1990). The Service Ontario Web site. Available at: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_ statutes_90m07_e.htm. Accessed November 12, 2014.
9. Provincial Human Services and Justice Coordinating Committee (2011). Police and mental health: A critical review of joint police/mental health collaborations in Ontario. Available at: http://www.hsjcc.on.ca/Provincial/Police%20and%20Mental% 20Health%20Project/Police%20and%20Mental%20Health%20%20A%20Critical%20Review%20of%20Joint%20Police-Mental% 20Health%20Collaborations%20in%20Ontario.pdf. Accessed November 2, 2014. 10. Altzema CL, Schull MJ, Kurdyak P, et al. Wait times in the emergency department for patients with mental illness. CMAJ. 2012;184(18):E969-E976. doi:http://dx.doi.org/10.1503/cmaj. 111043. 11. Llewellin P, Arendts G, Weeden J, Pethebridge A. Involuntary psychiatric attendances at an Australasian emergency department: A comparison of police and healthcare worker initiated presentations. Emerg Med Aust. 2011;23(5):593-599. doi:http://dx.doi. org/10.1111/j.1742-6723.2011.01448.x. 12. Slade EP, Dixon LB, Semmel S. Trends in the duration of emergency department visits, 2001-2006. Psychiatr Serv. 2010;61(9): 878-884. doi:http://dx.doi.org/10.1176/appi.ps.61.9.878. 13. Clarke DE, Dusome D, Hughes L. Emergency department from the mental health client’s perspective. Int J Ment Health Nurs. 2007;16(2):126-131. 14. Lamb HR, Weinberger LE, DeCuir WJ. The police and mental health. Am Psychiatr Assoc. 2002;53(10):1266-1271. 15. Human Services and Justice Coordinating Committee Ontario (2013). Ontario police-emergency department protocols. Available at: http://www.hsjcc.on.ca/Resource%20Library/Policing/ Ontario%20Police%20Emergency%20Department%20Protocols% 20-%202013.pdf. Accessed November 2, 2014. 16. Gerdtz MF, Weiland T, Jelinek GA, Mackinlay C, Hill N. Perspectives of emergency department staff on the triage of mental health-related presentations: Implications for education, policy and practice. Emerg Med Aust. 2012;24(5):492-500. doi:http:// dx.doi.org/10.1111/j.1742-6723.2012.01592.x. 17. Lee S, Brunero S, Fairbrother G, Cowan D. Profiling police presentations of mental health consumers to an emergency department. Int J Ment Health Nurs. 2008;17:311-316. doi:http://dx. doi.org/10.1111/j.1447-0349.2008.00553.x. 18. Wooden M, Air TM, Schrader GD, Wieland B, Goldney RD. Frequent attenders with mental disorders at a general hospital emergency department. Emerg Med Aust. 2009;21(3):191-195. doi:http://dx.doi.org/10.1111/j.1742-6723.2009.01181.x. 19. Knott JC, Pleban A, Taylor D, Castle D. Management of mental health patients attending Victorian emergency departments. Aust N Z J Psychiatry. 2007;41(9):759-767. 20. Ministry of Health and Long Term Care (2014). Ontario’s emergency room wait time strategy. Available at: http://www. health.gov.on.ca/en/pro/programs/waittimes/edrs/strategy.aspx#2. Accessed November 8, 2014. 21. Niagara Health System and Niagara Regional Police Service. Mental Health Act Apprehension and Care of Persons in Custody Protocol. St Catharines, Ontario, Canada: Author; 2014. 22. Hoffman RE. Development of the interRAI brief mental health screener to enhance the ability of police officers to identify persons with serious mental disorder. The University of Waterloo
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Library Database. Available at: http://hdl.handle.net/10012/7497. 2013. Accessed November 6, 2014. 23. InterRAI (2014). Emergency Screener for Psychiatry (ESP). Available at: http://www.interrai.org/emergency-screener-psychiatry.html. Accessed November 22, 2014. 24. InterRAI (2014). Mental Health for Inpatient Psychiatry (MH). Available at: http://www.interrai.org/mental-health.html. Accessed December 11, 2014.
25. Gomez-Mejia LR, Balkin DB. Management (8th ed). New York: McGraw-Hill; 2002. 26. McShane SL, Von Glinow M. Organizational behavior: Emerging realities for the workplace. New York: The McGraw-Hill Companies; 2005. 27. Hirdes DP, MacKenzie D. Brief Mental Health Screener [Application]. Available at: http://healthinformaticsmobile.com/index.html. Accessed November 22, 2014.
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A protocol to reduce police wait times in the emergency department Barb Pizzingrilli, RN, BN, MN, CPMHN (C), MBA1; Ron Hoffman, PhD2; and Daniel Pearson Hirdes, BA3
Healthcare Management Forum 2015, Vol. 28(4) 134-138 ª 2015 The Canadian College of Health Leaders. All rights reserved. Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0840470415581257 hmf.sagepub.com
Abstract Healthcare organizations are increasingly tasked with implementing change initiatives that improve the patient experience and target priorities such as Emergency Department (ED) volumes. This article describes the development, implementation, and outcomes of a collaborative protocol between the Niagara Health System and the Niagara Regional Police Service that resulted in a 57% reduction in police wait times in the ED. Six critical success factors contributed to the outcomes that were achieved and are detailed for those organizations interested in engaging in a similar change initiative.
Introduction Healthcare organizations continually explore opportunities for improvement that contribute to a safer, more effective, efficient, and quality-focused experience for patients. However, the successful execution of change within the complex landscape of today’s healthcare environment is challenging. In order to increase the potential for success, designing and implementing any change initiative needs to ensure that focus is placed on six critical success factors: leadership,1,2 stakeholder collaboration,3 metrics,4 staff engagement,2,4-6 innovation,2 and sustainability.7 This article will outline the planning, implementation, and outcomes of a protocol between the Niagara Health System (NHS) and the Niagara Regional Police Service (NRPS), which led to a reduction in police wait times in the Emergency Department (ED). The six critical factors that contributed to the success of the change initiative will be highlighted and may be useful to other healthcare institutions interested in developing a similar protocol.
Background and impetus for change The impetus for change came with the planning for a new NHS hospital in St. Catharines that includes a four-bed Psychiatric Emergency Service (PES). The NRPS was identified as a key stakeholder in the planning process for the new PES unit, given that individuals apprehended by police under the Mental Health Act8 are accompanied to the ED for assessment. Once in the ED, officers are often subjected to extended wait times before care is transferred to the receiving facility, and this is primarily due to a lack of hospital security resources and dedicated space to safely manage the care of high-risk patients.9 Patients with mental illness wait longer in EDs compared to those presenting with medical issues,10-13 and this has significant implications because prolonged wait times can reduce police presence in the community,9,14 contribute to stigmatization of the apprehended individual,15 and impact the individual’s willingness to share pertinent health information in the presence of the officers.15 Additionally, the chaotic, fast-paced, and overstimulating
emergency environment may exacerbate the presenting psychiatric issue and extend the length of stay.13 Mental health issues are represented in approximately 3% to 5% of emergency presentations16-18 and, of these, 17% to 20% are accompanied by police.17,19 This represents a significant volume of patients depending on the size of the ED. The issue of police wait times has therefore been identified as a healthcare topic of considerable interest, as hospitals are increasingly pressured to develop strategies to manage increasing volumes and overcrowding in emergency settings,20 to improve the patient experience, and to engage with stakeholders in effecting system change.
Protocol planning and development In preparation for the opening of the new PES, an existing NHS and NRPS partnership committee was revitalized with new participants who were leaders within their respective agencies with the decision-making ability to effect change. As a key stakeholder in the PES planning, the NRPS leaders were engaged in the development of a protocol for the safe and quality-informed care of individuals with mental health and addiction issues brought to the ED by police. The development process was dynamic and reflected cooperation by both parties to achieve the committee’s mandate of having the protocol completed and ready for implementation with the opening of the PES unit in March 2013. One of the committee’s priorities was to obtain baseline data (Figure 1) of the number of Mental Health Act apprehensions (770) and the associated average police wait time (242 minutes). The committee negotiated a target wait time of 90 minutes that was included as an outcome measure in the 1 2
3
Niagara Health System, St. Catharines, Ontario, Canada. Ontario Police College, Ministry of Community Safety and Correctional Services and Nipissing University, North Bay, Ontario, Canada. University of Waterloo, Waterloo, Ontario, Canada.
Corresponding author: Barb Pizzingrilli, Niagara Health System, St. Catharines, Ontario, Canada. E-mail: [email protected]
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Figure 1. Niagara Regional Police Service Mental Health Act apprehensions and associated wait times in Niagara Health System emergency departments, January to December 2011
protocol. Setting a clear, measurable goal at the onset of the protocol development was important in moving planning in the right direction, ensuring that resources were used appropriately and being able to determine whether the change accomplished what was intended.4 An initial draft protocol, titled Mental Health Act Apprehension and Care of Persons in Custody Protocol,21 was written and introduced to the partnership committee in 2012 by the NHS manager lead. The protocol content reflects strategies identified by the Provincial Human Services and Justice Coordinating Committee9 for reducing police wait times in the ED. Protocol revisions were made with input from all members throughout the year, and a finalized draft was completed by the date of the PES opening. The protocol objectives are the following: to ensure a standardized approach for individuals apprehended under the Mental Health Act who are accompanied to hospital by police, to ensure that the transition of care from NRPS to the NHS occurs within 90 minutes, to outline clear roles and accountabilities for NHS and NRPS staff, and to outline mechanisms for ongoing communication and collaboration around issues that may arise related to the above protocol items.21
Protocol process flow The protocol articulates a clear process flow (Figure 2) for apprehended individuals in the ED. When the decision is made to transport the apprehended individual to hospital, a telephone call is initiated by the police to the ED charge nurse at the NHS St. Catharines Site. The intent of the call is to inform staff of the impending arrival and to highlight any risk-related issues that might require a secure bedded space. The individual is brought in through the emergency services entrance to avoid
Expedited move to Psychiatric Emergency Service if high risk situaon
Individual moved to Psychiatric Emergency Service immediately aer triage
Niagara Regional Police complete Brief Mental Health Screener tool
Psychiatric Emergency Service staff priorize transfer of care with Niagara Regional Police
Niagara Regional Police released prior to physician assessment
Figure 2. Process flow for Niagara Regional Police Service Mental Health Act apprehensions
stigmatizing exposure to the larger patient population in the waiting room. When the triage process is complete, the individual is moved to the PES and the police then complete the Brief Mental Health Screener (BMHS).22 The BMHS is an evidencebased tool designed specifically to assist officers in articulating their grounds for apprehension and sharing observations with hospital staff. The form is based on health data and written in health language, which helps in bridging the gap between the criminal justice and the mental health systems.22 Police use of the BMHS enables PES staff to access valuable, risk-focused information that is fully consistent with their own interRAI Emergency Screener for Psychiatry (ESP).23 The BMHS and the ESP instruments are part of the interRAI Mental Health Assessment System, which is currently mandated for all psychiatric admissions in the province of Ontario.24
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Once the officers have completed the BMHS, the PES staff prioritize completion of the transfer of accountability process. They review the BMHS with the officers and discuss any documented risk indicators that will inform the immediate plan of care for the individual. Once the transfer of accountability is complete, the officers are released from the ED without waiting for a physician assessment.
Targeted education and staff engagement The majority of process changes made in relation to the NHS and NRPS protocol involved the PES staff. Therefore, it was essential to generate enthusiasm about the process changes and inspire the staff to achieve success.25 In order to create change, leaders must possess various skills and characteristics including emotional intelligence, integrity, drive, motivation, selfconfidence, intelligence, and knowledge.26 The NHS manager lead met regularly with all PES staff to assist them in understanding the reason for the change, the protocol details, and how individual and collective actions would assist in meeting the desired goal of reducing police wait times. The face-to-face communications gave staff the opportunity to ask questions relevant to their needs and to receive timely answers so that they understood all aspects of the protocol and their related responsibilities. Taking time to nurture relationships with the PES staff was integral to the success of the changes that were implemented to reduce the police wait times. The manager lead connected regularly with staff to ensure they felt valued and involved with the goal of increasing their commitment to the change. One of the key approaches in engaging the PES staff was to solicit their input from the onset of all protocol planning. Engaging staff in meaningful discussions was particularly important related to the development of the process flow for patients once they are in the ED. The frontline staff were able to identify practical issues with some of the process components, and this led to refinement of the protocol details. This approach creates a sense of co-ownership in the change initiative and minimizes the potential for resistance, which can derail planning and attainment of goals.4 The manager lead also communicated regularly with the ED staff prior to the protocol implementation to ensure understanding of the process flow and key accountabilities. A monthly PES and ED staff meeting was initiated as a collaborative forum in which issues related to the protocol could be brought forward for review and resolution with a focus on identifying opportunities for ongoing process improvement.
Outcomes In reviewing the wait time data (Figure 3) following implementation of the protocol in March 2013, the number of apprehensions was increased slightly to 820 from the 2011 baseline of 770. The wait times begin a downward trend starting in April within one month of implementing the protocol with the lowest time noted in November, two months after the PES unit opened fully. The average wait time between
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Figure 3. Niagara Regional Police Service Mental Health Act apprehensions and associated wait times in Niagara Health System emergency departments, January to December 2013
April and December was 103 minutes compared to the baseline average of 242 minutes in 2011, which represents a 57% reduction in police wait times. The process flow is now standardized so there is no variability in the manner in which individuals accompanied to hospital by police are streamed once they arrive in the ED. There is an escalation process included in the protocol to ensure that issues arising in the frontline are addressed and resolved in a timely manner. While patient-specific satisfaction with the new process was not included as a metric, it is expected that the patient experience is improved with a reduction in potentially stigmatizing exposure to the waiting room through consistent entry via the emergency services entrance. Furthermore, patients may feel more at ease sharing confidential health information required for the provision of safe and timely care once the officers are released. Once the protocol was implemented, it was important to support and sustain the change to minimize the potential for regression to former practices.7 An ongoing quality group, consisting of leaders from the partnership committee, initially met every two weeks for the first six months after implementation and then monthly thereafter. The purpose of the quality committee is to: identify and review inter-organizational systemic issues that are pertinent to the care of individuals apprehended and brought to the ED by NRPS; highlight strengths that exemplify inter-organizational collaboration; review data to inform improvement initiatives and protocol revisions as needed; provide a forum for systemic challenges around confidentiality, ethics, legislation, or other issues; and enhance communication among service providers, fostering an environment of dialogue, transparency, and continuous improvement.21
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The quality group ensures that wait time data are provided to the PES staff to demonstrate the impact of their work and to generate discussion about further process improvement. It is imperative that data are shared with the staff most intimately involved in the change work to generate ongoing enthusiasm and commitment to meeting established goals. As part of ongoing process improvement to achieve the 90minute target wait time, a pilot project was initiated in October 2014 using an iPad application27 at triage for NRPS to complete their BMHS documentation prior to transfer to the PES. An evaluation will be undertaken to determine the impact of this technology for the wait time at the end of six months. This use of technology has the potential to not only improve the police wait times but also raise the profile of the NHS as it is the only hospital system currently using the newly developed iPad application. This creates the opportunity to be leaders within the healthcare industry related to this innovative practice.
Conclusion The development and implementation of a collaborative protocol between the Niagara Health System and the Niagara Regional Police Service contributed to a significant reduction in police wait times in the emergency department. This article contributes to the quality improvement literature and has applicability to healthcare organizations interested in applying the following six critical success factors: leadership, stakeholder collaboration, metrics, staff engagement, sustainability, and innovation in similar change initiatives. References 1. Lundy V, Morin PP. Project leadership influences resistance to change: The case of the Canadian public service. Proj Manag J. 2013;44(4):45-64. doi:http://dx.doi.org/10.1002/pmj.21355. 2. Ransdell GA. Personal reflections on leadership for change: An invited article. Int J Leadership Change. 2014;2(1):1-8. Available at: http://digitalcommons.wku.edu/ijlc/vol2/iss1/1. Accessed November 6, 2014. 3. Conteh C. Strategic inter-organizational cooperation in complex environments. Publ Manag Rev. 2013;15(4):501-521. doi:http:// dx.doi.org/10.1080/14719037.2012.674424. 4. Merrell P. Effective change management: The simple truth. Manag Serv. 2012;56(2):20. 5. Groysberg B, Slind M. Leadership is a conversation. Harvard Bus Rev. 2012;90(6):76-84. 6. MacPhee M, Chang L, Lee D, Spiri W. Global healthcare leadership development: Trends to consider. J Healthc Leader. 2013;5: 22-29. doi:http://dx.doi.org/10.2147/JHL.S23010. 7. Bra¨nnmark M, Benn S. A proposed model for evaluating the sustainability of continuous change programmes. J Change Manag. 2012;12(2):231-245. doi:http://dx.doi.org/10.1080/14697017. 2012.672449. 8. Mental Health Act (1990). The Service Ontario Web site. Available at: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_ statutes_90m07_e.htm. Accessed November 12, 2014.
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