A Qualitative Study of the Theory Behind the Chairs: Balancing Lean-Accelerated Patient Flow With the Need for Privacy and Confidentiality in an Emergency Medicine Setting

Abstract

Background Many emergency departments (EDs) have used the Lean methodology to guide the restructuring of their practice environments and patient care processes. Despite research cautioning that the layout and design of treatment areas can increase patients’ vulnerability to privacy breaches, evaluations of Lean interventions have ignored the potential impact of these on patients’ informational and physical privacy. If professional regulatory organizations are going to require that nurses and physicians interact with their patients privately and confidentially, we need to examine the degrees to which their practice environment supports them to do so. Objective This study explored how a Lean intervention impacted the ability of emergency medicine physicians and nurses to optimize conditions of privacy and confidentiality for patients under their care. Methods From July to December 2017, semistructured interviews were iteratively conducted with health care professionals practicing emergency medicine at a single teaching hospital in Ontario, Canada. The hospital has 1000 beds, and approximately 128,000 patients visit its 2 EDs annually. In response to poor wait times, in 2013, the hospital’s 2 EDs underwent a Lean redesign. As the interviews proceeded, information from their transcripts was first coded into topics and then organized into themes. Data collection continued to theoretical sufficiency. Results Overall, 15 nurses and 5 physicians were interviewed. A major component of the Lean intervention was the construction of a three-zone front cell at both sites. Each zone was outfitted with a set of chairs in an open concept configuration. Although, in theory, professionals perceived value in having the chairs, in practice, these served multiple, and often, competing uses by patients, family members, and visitors. In an attempt to work around limitations they encountered and keep patients flowing, professionals often needed to move a patient out from a front chair and actively search for another location that better protected individuals’ informational and physical privacy. Conclusions To our knowledge, this is the first qualitative study of the impact of a Lean intervention on patient privacy and confidentiality. The physical configuration of the front cell often intensified the clinical work of professionals because they needed to actively search for spaces better affording privacy and confidentiality for patient encounters. These searches likely increased clinical time and added to these patients’ length of stay. We advocate that the physical structure and configuration of the front cell should be re-examined under the lens of Lean’s principle of value-added activities. Future exploration of the perspectives of patients, family members, and visitors regarding the relative importance of privacy and confidentiality during emergency care is warranted.

Qualitative exploration of patient flow in a Caribbean emergency department

“… 1 This finding is also supported by another qualitative study which promoted the use of chairs for ambulatory patients. 32 However, it was noted that while the strategy aimed to improve waiting times, staff were often concerned about the lack of privacy and confidentiality associated with this open chair concept. 32 Although not an area explored in the current study, it is possible that staff and patients in the study ED may express similar concerns.…”

“… 32 However, it was noted that while the strategy aimed to improve waiting times, staff were often concerned about the lack of privacy and confidentiality associated with this open chair concept. 32 Although not an area explored in the current study, it is possible that staff and patients in the study ED may express similar concerns. Additionally, in the current study, there were no formally documented departmental policies for any of the identified organisational work processes.…”

A Case Study of a Whole System Approach to Improvement in an Acute Hospital Setting

“…Considerable time and effort need to be spent on implementation for LSS to be associated with gains in hospital performance. The degree to which this investment is made depends on the system maturity, leadership commitment, daily management system use, and training [16,17]. There is also increasing recognition of the importance of improving both patient and staff experience of healthcare [18,19] and moving to person-centred approaches in healthcare [20].…”

Evaluation of an Access-Risk-Knowledge (ARK) Platform for Governance of Risk and Change in Complex Socio-Technical Systems

“…The healthcare sector has widely adopted Lean, Six Sigma and Lean Six Sigma as process improvement methodologies, which aim to empower staff to reduce waste by standardising practice [ 10 , 11 , 12 , 13 ]. While there are some positive associations between Lean adoption and performance indicators in individual case studies, overall evidence on the success of Lean is mixed [ 14 , 15 , 16 ]. Considerable time and effort on implementation across the organisation are needed for Lean to be associated with gains in hospital performance, which are in turn mediated by the degree of system maturity, leadership commitment, daily management system use and training [ 14 , 16 ].…”