Table 1.

Selected quality improvement and patient safety projects published

Year	Name [Reference]	Team composition	Funding	Brief description	Lessons learned
2014	Improving emergency department flow through a Rapid Medical Unit [3]	Co-Leads: nursing and medical leadership Core members: front-line providers, clerical staff	Cost neutral to operational budget; in-kind by contributors	Patients presenting with very-low acuity concerns had disproportionately long wait times in our tertiary care centre, so we reassigned staff, modified schedules and repurposed resources to streamline their care in a dedicated area. Both physician initial assessment time (98–70 min) and total length of stay (165–130 min) decreased despite increased patient volumes, without affecting wait times for higher acuity patients	For projects that affect workflow of front-line providers, deeply embedding them in the improvement team and carefully incorporating their feedback led to ongoing iteration and sustained improvement
2015	Improved emergency department flow through optimized bed utilization [4]	Lead: nurse (patient care coordinator) Core members: medical leadership, front-line providers (especially nurses)	Operational budget; protected time for physician improver	Due to flow-interrupting challenges including operational bottlenecks and cultural issues, high-acuity patients were experiencing undue delays in their time waiting between triage and bed placement. We underwent seven PDSA cycles, mostly focused on optimizing communication strategies, leading to a 90th percentile time-to-bed decrease from 120 to 66 min	The most conspicuous root causes may not be the ones contributing the most to the problem, and utilizing QI process tools (e.g., Ishikawa diagram, process mapping, Pareto chart) can be extremely revealing
2016	A Quality Improvement Initiative to Decrease the Rate of Solitary Blood Cultures in the Emergency Department [16]	Lead: physician Core members: physician assistants, physicians, nursing leadership	Cost neutral to operational budget; admin time for physician assistant; in-kind by physicians	Sending a solitary blood culture to the laboratory (as opposed to two, as per best practice) can lead to safety gaps and resource utilization issues. We compared an educational approach to one where a forcing function was added, and this combined method led to a 71.8% relative reduction (29.5% absolute reduction) in the number of solitary samples sent	Education is necessary but not sufficient to change behaviours, and forcing functions are powerful tools that can be added
2017	Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilization for head injuries in the emergency department [13]	Lead: resident Core members: physician leader, clerical staff, nursing leadership, nurse practitioners, physician assistants	Operational budget and academic practicum project for resident lead; small hospital QI grant for subsequent phase	Most patients with head injury are diagnosed with minor ones, yet a large proportion undergo computed tomography (CT) scans. Through provider education, a checklist developed iteratively by the team from evidence-based materials, improved patient communication and practice feedback on local group practices, we reduced the proportion of CT scans by 13.9% over 3 months (sustained to 8% at 16 months) without causing adverse events	Engrained practice patterns are difficult to change, but improvements can be achieved through multi-modal approaches that involve front-line providers in their development
2018	Improving timely analgesia administration for musculoskeletal pain in the emergency department [15]	Lead: nurse practitioner Core members: physician leader, nursing leadership and front-line nurses (especially those who do triage)	Operational budget and academic protected time for nurse practitioner lead	Musculoskeletal injuries are common presentations to EDs and patients are often in pain, but our time-to-analgesia (from patent triage) was felt to be suboptimal for patient-centred care. Through triage-initiated analgesia protocols and process improvements, a documentation aid, reference materials and targeted provider feedback, the time-to-analgesia decreased from 129 to 100 min	Interventions need to be co-designed and championed by those who will be utilizing them; otherwise, time is wasted on solutions that cannot be operationalized or will encounter unnecessary resistance
2019	Quality improvement initiative for improved patient communication in an ED rapid assessment zone [14]	Lead: resident Core members: medical, clerical and nursing leadership	Operational budget and academic project for resident lead; in-kind for contributors	Patient-clinician communication in the ED is challenged with time pressures and interruptions, leading to decreased patient satisfaction. We engaged patients (i.e., focus group, surveys) and providers to develop a novel tool (AEI: Acknowledge, Empathize, Inform), patient information pamphlets and a multimedia solution aimed at improving communication. It resulted in improved patient satisfaction and decreased patient anxiety	Meaningfully engaging patients in QI initiatives leads to new and improved insights that can then inform interventions that are more robust and effective
2020	Sharing and Teaching Electrocardiograms to Minimize Infarction: reducing diagnostic time for acute coronary occlusion in the emergency department [12]	Lead: physician Core members: medical leadership, front-line physicians	Cost neutral to operational budget; in-kind for physician lead	ECGs that do not meet classic STEMI criteria can nonetheless represent occlusion myocardial infarction, and prompt recognition of select pattern can lead to improved patient care. Through broad then recurrent and targeted multi-modal educational approaches combined with group audit and feedback, the median ECG-to-cath lab activation time decreased from 28.0 to 8.0 min, without any increase in the balancing measure of percentage of Code STEMI without culprit lesion	Educational approaches are more effective when varied (e.g., multi-modal) and repeated or recurrent, and they can be bolstered with targeted audit and feedback

N.B. PDSA Plan-Do-Study-Act, QI quality improvement, ED emergency department, ECG electrocardiogram, STEMI ST-Elevation Myocardial Infarction