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1. Role of cloud ERP and big data on firm performance: a
dynamic capability view theory perspective
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Role of cloud ERP and big data on firm performance: a dynamic
capability
view theory perspective
Management Decision
September 12, 2019
Copyright 2019 Emerald Publishing Limited All Rights
Reserved
Section: Pg. 1857-1882; Vol. 57; No. 8; ISSN: 0025-1747
Length: 9734 words
Byline: Shivam Gupta, Xiaoyan Qian, Bharat Bhushan, Zongwei
Luo.
Body
ABSTRACT
Purpose
Technological developments have made it possible for
organizations to use enterprise resource planning (ERP)
services without indulging in heavy investments like IT
infrastructure, trained manpower for implementation and
maintenance and updating the systems regularly to maintain
business competitiveness. Plug and play model
offered by cloud ERP has led to a constant creation of large

data sets which are structured, semi-structured and
unstructured by nature. Thus, there has been a need to analyze
such complex data sets and the purpose of this
paper is to focus on how cloud ERP and big data predictive
analytics (BDPA) will impact the performance of a firm.
Design/methodology/approach
A dynamic capability view (DCV) theory-based model was
developed and the authors have collected data by using
an online questionnaire from India. Thereafter, the authors have
analyzed it by employing structural equation
modeling.
Findings
SEM analysis of 231 respondents showcases that the use of
DCV theory to define the relationships of cloud ERP
and BDPA has been the right move. Out of the 13 hypotheses
empirically tested, only 7 hypotheses were supported
by the data.
Research limitations/implications
The study showcases cross-sectional data from India. It would
be interesting for this study to see if the country-level
differences would influence these relationships between cloud
ERP and financial performance, BDPA and financial
performance and cloud ERP and BDPA.
Originality/value
This study empirically tests the relationship of cloud ERP and
BDPA through a model based on DCV theory.
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Page 2 of 14
capability view theory perspective
1.Introduction
Enterprise resource planning (ERP) systems provide firms
extensive facilities and capabilities to share and transfer
data and processes of organizations inside and outside the
enterprise into a single system and single database
(Peng and Nunes, 2013). Sharing data between firm’s
departments or firms across the supply chain helps in many
aspects (inter alia in the form of decision support) and aims to
achieve the objectives of better firm performance
(FP). Elmonem et al. (2016) commented ERP as a category of
business management software system that aims to
integrate all functional units, typically a suite of integrated
applications in a cooperative way. It facilitates
organizations to collect, record, manage and interpret data from
these business activities. The fact is that, ERP has
so far been widely implemented by different organizations with
different sizes in many sectors and in many
countries to seek competitive advantages in the market.
With time going by, ERP has revolutionized, and continuous up
gradation has taken place to strengthen its
functionality of resources sharing and integration capabilities of
functional units. Scholars increasingly tout internet-
enabled ERP systems as an important perspective for the

performance of a firm or even firms across the supply
chain. With the advent of cloud computing technologies in the
late 2000s, Peng and Gala (2014) highlight that there
exists an increasing trend for firms to move their ERP-based
applications and database into the cloud. According to
Salleh et al. (2012), cloud ERP as a concept has been a boon to
the FP, inter alia for small and medium enterprises
over large companies since they could conform to the
infrastructure requirements of the on-premise ERP solution
as well as the high cost. Cloud computing brings firms the very
model that enables ubiquitous access to share data
and resources to achieve coherence, get the application up and
run faster, often over the internet.
Exploring the cloud enterprise resource planning (CERP)
system enabled with predictivity ability may help to
resolve high uncertainties and gain more competitive
advantages than other competitors in the dynamically
changing market. According to Duan et al. (2013), CERP
systems give the enterprise a chance to access the
advanced computing resources that are available over the cloud,
and even support the firms to manage their
business functions to achieve higher productivity. Beheshti
(2006) also argued that CERP systems are capable to
manage and handle the large volume of operations and
information that is created daily within the firm. Besides the
potential benefits for operational performance (OP), one of the
main drivers from a CERP would be the technical
and operational integrations of functional processes to
harmonize the data and information stream based on
product lifecycle (PLC) (material flow of goods or services)
(Qian et al., 2016). In view of Beatty and Williams
(2006), this would happen through integrating the values across
PLC within a seamless business process
streamlining, which could potentially precede the firm’s market
competitiveness and responsiveness in the rapidly

changing environment. Therefore, implementing ERP systems
on the cloud platform is showcased for resolving the
limitations of ERP systems and provides better scalability,
reliability, availability and cost efficiency that are all the
very components for a higher FP.
On the other hand, big data predictive analytics (BDPA) would
be the next big frontier of innovation, efficiency,
productivity and competitiveness of an organization (Srivastava,
2014; Waller and Fawcett, 2013). Reaping the
benefits of big data, CERP systems enhanced with e-commerce
capabilities and its ability of integration and sharing
resources and capabilities, collaboration with corporate alliance
(suppliers, partners and even customer portals),
and tracking of incoming resources and outgoing final products
extends the visibility and control from inside and
outside with big data analytics (McAfee et al., 2012). In doing
so, upstream and downstream firms in the supply
chain could provide reporting capabilities to management via
sharing information (i.e. data) needed to support
strategic decision-making that is of huge importance for long-
term benefits of firms in the supply chain.
Organizations in various sizes from various areas are jumping
on the bandwagon of big data and predictive
analytics (BDPA) due to the data sharing and interactive nature
of CERP systems for firm competitive advantages.
By definition, BDPA is a decision-making field which consists
of big data; use various statistical tools and
techniques and machine learning, deep learning artificial
intelligence and even data mining to derive potential
insights from huge data sets, improving the market performance
(MP) and OP of a firm (Gupta et al., 2018a).
Analyzing big data using predictive techniques would be a
necessity for decision support, although big data alone is
ubiquitous (Prescott, 2014; Duan and Xiong, 2015). Extracting

potential insights from large data sets via analytics
techniques are an all-encompassing term among the senior
executives to make decisions for their enterprises.
Page 3 of 14
McAfee et al. (2012) highlight that firms of various sizes need
to take the data-driven decision-making into strategy
practices via which the top management decision-makers
execute any plans based on data instead of gut feeling.
Apart from data, Waller and Fawcett (2013) argue that the
appropriate managerial skills (MS) and technical skills
(TS) play a non-substitutable role in the success of predictive
analytics initiatives. Matthias et al. (2017) include that
the application and exploitation of BDPA would create first-
mover competitive benefits for sustainable improvement
for a firm. Consistent with the rich research around
(surrounding) the extraction of valuable data and potential
insights from a large database, we argue that BDPA may be a
well-accepted technology for decision-making on the
performance of a firm. For instance, organizations may react
differently to the same CERP systems on the FP due
to the differences in the ability of BDPA capability.
The existing research and studies on CERP and BDPA,
respectively are very rich, but the vast majority of them
focus merely on its own capabilities and effects. In contrast,
knowledge on the joint role of CERP and BDPA
capabilities for the performance of a firm is scant. Very few
scholars investigated on the specific relationships of

CERP and BDPA, CERP and FP, BDPA and FP. Such a void
leaves a significant gap between firm’s resources and
capabilities and its performance. To address this gap, we
propose a theory-driven and empirically proven model
that aligns CERP and BDPA and could explain the impacts of
CERP and BDPA on FP drawing on dynamic
capability view (DCV) model (Teece et al., 1997). More
specifically, our current research objectives of this paper are
to address two main issues as follows: develop a theoretical
framework based on DCV theory to understand the
role of cloud-based ERP services and BDPA on the performance
of a firm; andempirically validate this theoretical
framework by employing structural equation modeling (SEM).
This paper is organized as follows. In Section 2, we begin with
a brief review of the relevant literature pertaining to
CERP and BDPA. In Section 3, we describe our theoretical
model based on DCV and hypotheses development. In
Section 4, we would outline the research methodology and data
analytics for the empirical validation of this
theoretical framework by employing SEM. Section 5 consists of
our discussion related to our analysis results,
including theoretical contribution, managerial implications and
limitations and further directions. In Section 6, we
conclude with our discussion results.
2.Theoretical background
2.1Dynamic capability view
In the strategic management area, the distinct mechanism of
capability-building resource-based view (RBV) is for
understanding how we could create our economic
competitiveness for a firm. According to Teece et al. (1997), in
order to locate a firm’s position in the market via its resources,
the RBV theory was the first concept among the

management strategy literature. Wernerfelt (1984) supplemented
the conception that resources could be studied
and examined as the source of a firm with competitive
advantages. RBV tends to support firms to create more
economic advantages than their competitors by being more
effective at defining internal and outside resources and
deploying strategic resources, and subsequently building
capabilities (Makadok, 2001; Kim et al., 2015). However,
Kraaijenbrink et al. (2010) asserted that RBV was not able to
address how firms utilize resources and capabilities in
a dynamic market as RBV is primarily a static theory that helps
the firms to maintain a competitive advantage by
employing resources at their disposal. Therefore, the DCV as an
extension of RBV (Wang et al., 2016) was
proposed which promotes innovation (Lawson and Samson,
2001).
Going back to the origins of capabilities, it began with the
request that static nature of RBV could not fully showcase
how the resources of a firm developed and integrated in a
rapidly changing market (Teece et al., 1997; Winter et al.,
2003; Smith et al., 2014). Teece et al. (1997) defined the
dynamic capabilities as the abilities to deploy, integrate,
build and reconfigure the competencies inside and outside a
firm to resolve the dynamically changing market.
Lawson and Samson (2001) highlighted dynamic capabilities
support enterprises to improve the profits by
managing firm’s capabilities (efficiency, quality, velocity,
flexibility, etc.) in a dynamic and uncertain environment.
Given the need of rapid responsiveness of a firm’s resources
stock to increasingly dynamically changing
environments, Vogel and Güttel (2013) indicated that dynamic
capabilities would be of inherent strategic relevance
to a firm, to keep pace with competitive dynamics. As such,
DCV theory would be regarded as the distinct process
that allows resources and focuses on learning and change

capabilities to relate them to FP.
Page 4 of 14
Given that one of the main objectives of this study is to identify
various resources that will enable firms to create
CERP and BPDA capabilities, which in turn may lead to
superior MP and OP, the choice of DCV as a theoretical
framework for this study seems appropriate.
In this paper, DCV is used to conceptualize BDPA and CERP as
capabilities that have an impact on FP. Resources
like data (D), MS) and TS support BDPA (capability), which
impacts on MP and OP. In a similar manner, dynamic
capabilities grouped into organizational factors (OF), people
factors (PF) and technological factors (TF) constitute
CERP (capability) that has an impact on MP and OP of an
organization (Figure 1).
2.2Cloud-based ERP (CERP)
Most recently, one of the most popular trends is cloud
computing that has a huge potential to reshape the way ERP
systems operate. Armbrust et al. (2010) defined cloud
computing as both the applications and systems software in
the information centers. Cloud computing would be a key
computing paradigm for the next ten years, anticipated by
Smith et al. (2014). Literature has highlighted the role of ERP
in the cloud computing enables many applications of
web services via the internet (Chen et al., 2015).

It is not surprising that toward developing a fully functional
CERP system has been a center of focus by both firms
and researchers, given that CERP is built to provide firms with
huge benefits of flexibility, improved accessibility,
scalability, lower upfront and operating costs, rapid
implementation, cost transparency, sales automation, higher
security standards and free trials (Gupta and Misra, 2016). The
power of CERP usually refers to the performance of
an organization, including MP and OP. These benefits derived
from CERP system not only saves the cost of
operation when improving the effective productivity but also
supports the changed business size into the
dynamically changing market when satisfying the firm’s needs
of new markets shares more quickly than
competitors.
2.3Toward the conceptualization of CERP capability
The key competitive edge for a firm now is its capability to
define, standardize and adapt its processes and
information with supplier, partner, customers based on PLC in a
dynamically changing environment (Chen et al.,
2015). Cloud computing allows firms convenient and on-
demand access to share a pool of configurable resources.
Therefore, cloud computing supports to improve the operational
efficiency and help firms to achieve dynamic
capabilities (Battleson et al., 2016).
In this paper, we argue that CERP could be conceptualized as a
capability with the aid of cloud computing. This
paper would identify the dynamic capabilities that explain how
firms could effectively respond to market dynamism
by developing CERP capability. CERP capability is created by
the intrinsic factors combination of OF, PF and TF
(Gupta and Misra, 2016) for they are under the control of cloud

user. In terms of the determinants of CERP
capability, OF, PF and TF are briefly discussed below.
2.3.1Organizational factors (OF)
The research proposed that the success of CERP capability
building was affected by OF (Law and Ngai, 2007) and
suggests that OF act as the major determinants of FP (Hansen
and Wernerfelt, 1989). Determining the appropriate
organizational factor or the construct of performance involves
communicating the top management strategy to front-
line subordinates and organizational structures and systems to
people simultaneously. The OF are considered here
to capture the multi-dimensional phenomena – strategic goals
and objective, implementation strategy, business
process re-engineering, organizational resistance, project
management and budget and even communication.
The important organizational factor in CERP is the alignment
between CERP and organizational objectives. The fit
between strategic goals and objectives and CERP systems is
brutal critical to achieving FP (Law and Ngai, 2007).
In terms of the implementation strategy, it would be set before
the implementation of CERP for it guides the future
function and capability for our CERP capability. The project
budget has a positive impact on better outcome for the
enterprise as it is in sync with the implementation strategy
(Hasibuan and Dantes, 2012; Somers and Nelson,
2004). Business process re-engineering is the extent to which
organizations have to change and re-engineer the
Page 5 of 14

existing business process to fit the coming new system in line
with the requirements of customization or new
markets development (Saleh et al., 2013). What is asserted by
prior research is that more the abilities an
organization holds for business process re-engineering to
change, more powerful could be its ERP systems (Grover
et al., 1995). Consequent with re-engineering business process
in CERP solutions, organizational resistance may
be also be a hindrance factor to operate smoothly (Utzig et al.,
2013). Project management is indispensable role for
the CERP capability, which refers to set the vision and
directions for business process and harness the cooperation
and potentials of employees to exploit the technological
capabilities of CERP (Al-Mashari et al., 2003; Esteves and
Pastor-Collado, 2001), as well as efficient execution of
implementation strategy (Gupta and Misra, 2016).
Communication has to be in sync with the project management
for better understanding the roles between
superior–subordinate and among employees with good working
relationships across the project. Most projects
failed due to its communication, either a lack of thereof or
miscommunication. The need for effective communication
is permanent and would affect all the factors listed above. All
these measurement constructs would be in the
collaboration as OF in executing CERP system.
2.3.2People factors
People are the biggest potential power of a firm. According to
Lalsing et al. (2012), PF have been proven to be the
most critical success factors for development systems. From the
employee’s perspective, there would be many
measure constructs identified to cover the PF. The key

components which are being created as PF are user
involvement, vendor selection, project team, top management
support, training of user and trust on vendor (Gupta
and Misra, 2016).
During building CERP capability, there would be a non-
substitutable consideration that actively involves user
(Françoise et al., 2009; Hasibuan and Dantes, 2012). User
involvement and participation could help to ensure
user’s requirements with our better quality and user-friendly
CERP systems since user involvement in the decision-
making process result in greater attachment to the CERP
capability and functionality (Lalsing et al., 2012; Françoise
et al., 2009). In addition, training of user is also perceived.
Needless to say, our CERP system would not create any
values and profits if the employees do not know how to operate
it. The need for user training and support is crucial
in building CERP capability.
Vendor selection is an important decision regarding building
CERP capability since most organizations purchase
ERP packages from vendors. Based on the end-users
requirements and owners’ consultants, organizations could
take guidance to map the needs of the organizations with the
respective vendor (Saleh et al., 2013; Françoise et al.,
2009). In addition, trust on the vendor is a necessity to keep the
good working relationship between firms and cloud
vendor. Vendor support provides extended technical assistance
for emergency aid and maintenance, updates,
service responsiveness and user training (Somers and Nelson,
2001) during the period of CERP existence.
Project teamwork refers to the amount of knowledge and skills
that are responsible for CERP capability building and
business operation process. Umble and Umble (2002) suggested
ERP teams should be composed of cross-

functional members who possess skills, good reputations on past
accomplishments and decision-making
responsibility. In addition, the team would be supported by the
leadership of the company.
Literature underlines the role of top management in
orchestrating resources and creating capabilities and
subsequently helping to achieve the competitive advantages of a
firm (Hitt et al., 2016; Chadwick et al., 2015). Top
management not only defines new objectives that could provide
employees a clear vision of the orientation the
organization is taking with careful consideration to the
objectives but also supports all the decisions that need to be
made to handle any conflicts that may happen. Thus, top
management is required to commit and support for CERP
system with enthusiasm, full consideration and even
continuously monitoring among all the process (Prajogo and
Olhager, 2012).
2.3.3Technological factors (TF)
Factors related to technologies that shall be affecting building
CERP capability would be considered for the
selection of ERP packages, IT infrastructure, data integrity and
system testing, and its functionality of cloud ERP
Page 6 of 14
modules. Selecting ERP packages based on different cloud
layers from a vendor should be strategic in nature in

such a way that it matches the required business process (Gupta
and Misra, 2016) and enhances the organization’s
competitiveness and efficiency. IT infrastructure refers to the
important components required for the CERP’s
existence, operation and management in the form of hardware
and software (Alaskari et al., 2012; Somers and
Nelson, 2001), which is more significant to CERP vendor rather
than the user. Data integrity is a critical aspect to
the design, implementation and usage of CERP systems that are
required to store, process and even retrieve data,
as well as for the maintenance and the assurance of the accuracy
and consistency of data over its entire lifecycle
(Boritz, 2005). To make sure that CERP system would operate
quickly and smoothly after the go-live, it is often
tenable that system testing would continue as long as errors
remain. Functionality is supposed to be in the sync
with the selection of ERP vendor since it makes sure the
consistency between ERP modules and organization
business requirements. The decision for all these TF needs to be
done before building the implementation of CERP
(Gupta and Misra, 2016).
2.4Big data and predictive analytics
Given business processes with CERP capability and data sharing
with the up and down partners are moving online,
large-scale data would be created from these applications. As
what most researchers asserted, BDPA would be the
next big thing for firms to gain competitiveness in the
dynamically changing market (Akter et al., 2016; Wamba et
al., 2015). BDPA is actually an interdisciplinary field due to
leveraging not only the statistical technologies such as
regression, time-series analysis, etc., but also the computer and
data science tools including data mining, machine
learning, etc. (Dubey and Gunasekaran, 2015). It would be
defined as a systematic process of descriptive analytics

for explaining the data rules, predictive analytics for picture
future insights and the final prescriptive analytics for
optimizing or simulating the outcomes of organizational
decisions.
In addition, recent scholars have acknowledged that BDPA is an
organizational capability that they would process
and exploit to know how organizations could achieve and
sustain competitiveness regarding MP and OP of a firm
(Gupta and George, 2016; Wamba et al., 2017). So how
organizations could exploit resources and capabilities to
build a BDPA capability would be examined next, which is
defined as a firm’s edge to assemble, integrate and
deploy its big data-specific resources to gain market share or
improve profitability. Drawing upon DCV logic, we
suggest that firms need a unique combination of data, MS and
TS as the resources of building a firm-specific BDPA
capability for making operational decisions or predictions.
2.5Toward the conceptualization of BDPA capability
2.5.1Data (D)
The world is witnessing an unprecedented huge interest in big
data that is heralded as the next big hit for firms to
gain the competitive edge (Frisk and Bannister, 2017; Rajput
and Singh, 2018). The term “big data” is often used to
describe a resource that features big in volume, big in forms
(structured data, unstructured data and often semi-
structured data) and big in velocity (fast-changing and real-time
streaming), which most firms could approach
(Lamba et al., 2018). Gupta and George (2016) highlighted that
data are also the premise of deriving usable
information for improved decision-making, action and positive
change, besides labor and capital. Nevertheless, data
by itself do little value to organizations. In other words, big

data on its own are unlikely to be a source of competitive
edge, since most firms have likely collected hordes of
structured, unstructured or semi-structured data from various
sources (Lamba and Singh, 2018a). It is imperative to have
sophisticated data administration, data analytics and
processing techniques to extract inherited insights (Beyer and
Laney, 2012). Data are one of such immense
resources, which are necessary but not sufficient to create a
BPDA capability. It is imperative for firms to be aware
of the various resources that are required to build BPDA
capability (Lamba and Singh, 2018b).
2.5.2Managerial skills
MS are developed as a result of long years working experiences,
which play a non-substitutable role for analytics
projects as managers. The success of BDPA projects greatly
depends on how well managers could infuse
employees the common goals and assemble a team with right
skills (Lamba and Singh, 2017; Dubey et al., 2018).
Page 7 of 14
The essential quality to predict market behavior and the
interpersonal skills to develop swift have been regarded as
the critical parts to the successful use of BDPA for FP. Big data
analytics managers should be enabled to work with
functional managers, suppliers and customers, to coordinate big
data-related activities, to anticipate the future
business needs with the good sense of where to apply big data

and to understand and evaluate the output
extracted from big data (Gupta and George, 2016).
2.5.3Technical skills
TS commonly refers to the know-how to possess specific skills
and ability to extract intelligence from big data with
the knowledge in statistics, computer and data science, as well
as problem-solving skills and strong people skills
(Lamba and Singh, 2016; Jeble et al., 2018). In terms of
developing TS, firms could hire new talented employees
with BDPA capability or conduct some big data analytics
training for current employees. Big data analysts need are
supposed to have the rights skills to accomplish their jobs
smoothly with the suitable education and work
experience (Schoenherr and Speier-Pero, 2015). More
specifically, these right skills involve competencies and
proficiency in statistics analytics, data cleaning, extraction
analytics, data mining, machine learning and master of
programming paradigms (Davenport, 2014).
2.6Organizational culture
Previous researchers have acknowledged the intangible resource
of organizational culture is a source of sustained
FP since it would be built over a long period and varies from
organization to organization, which could not be
duplicated by other competitors or coordinators (Teece, 2015;
Jeble et al., 2018). Along similar lines, recent work
regarding big data has identified organizational culture as a
critical success factor to inhibit an organization’s ability
to benefit from big data for analytics and …

2012
Improving waiting time
in vaccination room
using Lean Six Sigma
methodology
Dr/ Mohamed Adel El Faiomy
Dr/ Ayatullah Amr Muhamad Shabana
S A U D I M I N I S T R Y O F H E A L T H
S E N A Y A P R I M A R Y H E A L T H C A R E C E N T E
R
background information
Background information
ELsenayea primary healthcare centre is one of the
largest primary healthcare centers in Khamis region in
KSA it provides preventive, curative and health
promotion services to more than 29000 population,
due its large catchment area it serves more than 300
customer per day so the waiting time is very important
to calculate and to improve

1-Define phase
▲▲▲ A) Identify the project
To select the most appropriate project we review the data on
potential project against specific criteria & after evaluation of
these projects we decided to work on the problem of
prolonged waiting time in vaccination room because it meet
the criteria of selecting a project as follow:
leted in less
than six months
☻Retaining customer
☻Attracting new customer
☻Reducing the cost of poor quality
☻Enhancing employee & customer satisfaction.
▲▲▲ B) Prepare problem statment & goals

►The problem
Waiting time before entering vaccination room is too long
(average 25.4 minute) between 21
st
of March to 21
st
of
April 2012 which lead to external customer dissatisfaction
and internal customer pressure.
►The goal is to reduce average waiting time in the
vaccination room to meet customer expectations which is
10 minutes.
PROJECT TEAM CHARTER
1- Problem statement
Waiting time before entering the vaccination room is too
long (average 25.4 minute) between 21
st
of March to 21
st
of April 2012 which lead to external customer
dissatisfaction and internal customer pressure.

2-bussiness case
About 30 children are vaccinated daily. The delay in
vaccination negatively affects the customers satisfaction,
organizational reputation in the catchment area of the
PHCC, disciplinary actions from higher authorities in
response to customer complaints and puts more pressure
on internal customers .
3-Goal statement
to reduce average waiting time in the vaccination room to
meet customer expectations which is 10 minutes.
4-Project scope
The process starts by the parent ordering his child’s family
health record & end by the child entering the vaccination
room.
5- Select team

Sponsor (PHCC director)
Green belt [Quality professional Dr Mohamed Adel Elfaiomy]
Green belt [Quality professional dr Ayatullah Amr Shabana]
Team member [medical supervisor]
" " [general practitioner]
" " [head of nurse]
" " [vaccination nurse]
" " [medical record clerk]
“ “ [well baby clinic nurse]
6-Project plan
Define phase 10/3/2012 to 10/4/2012
Measure phase 11/4/2012 to 30/4/2012
Analyze phase 01/5/2012 to 9/5/2012
Improve phase 10/5/2012 to 23/6/2012
Control phase 23/6/2012 to 30/6/2012
Voice of customers:
60 surveyed cases to estimate the upper specification
limit for the process, and the mean of customer`s

requirements was 10 minutes.
from all the process
owners to estimate the minimal time for the process
using the above mentioned flow chart, and it was 5
minutes, which we the team considered as the lower
specification limit.
CTQs
Customer needs Drivers CTQs Internal metrics
Least waiting time Least cycle
time in vital
signs room
Standard
procedures
for pre
vaccination
process
Time for pre
vaccination
process
Least cycle
time in
examinatio
n room
Least cycle
time in

vaccination
process
.
2-Meassure phase
The measure step identifies the symptom of the problem &
establishes base line measurement of current and recent
performance.
It also maps the process that is producing the problem in
order to understand how the current process actually
operates.

High level flow chart of the current process
Data collection plan:
variable operational defenition
data
source
data collection method who will
collect data
when data
will be
collected
waiting
time in
file room
it starts since the parent ask
for his child's medical
record till the file reaches
the well baby room
waiting
time data
collection
sheet

the medical record clerck
register the time when the
parent ask for the file and
record it in the collection
sheet the
vaccination nurse record the
time when the child enters
the room and before he
takes the vaccination
the nurse supervisor collect
the data from data collection
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
well baby
room
it starts since the file reach
the room till the child name
is called in well baby room
waiting
time data
collection
sheet

sheet the
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
pediatric
clinic
is called in pediatric clinic
waiting
time data
collection
sheet

sheet the
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
vacination
room
is called in vaccination room
waiting
time data
collection
sheet

sheet the
sheet
nurse
supervisor
between 21
march and 28
march
number
of staff
working
in each
room
staff actually working in
every room involved in the
process
staff
checksheet
number of staff actually
working in each room is
collected by the nurse
supervisor
nurse
supervisor

between 21
march and 28
march
Step 3 Analyze phase

*Analyze phase seeks to discover root causes of the major
contributes to the problem. Theories are generated by mean of
brainstorming; the list of theories is organized by mean of
cause-
effect diagram so the team can discern the specific theories of
root
causes. Finally, theories of root causes are tested and causes are
identified.
Test theory :
After gathering data about phases of waiting time the team used
Scatter
diagram to find the cause of prolonged waiting time through
correlation
So we have four theories to test using scatter diagram:-
1. The delay because of waiting at file room
2. The delay because of waiting at well baby room
3. The delay because of waiting at pediatrician room
4. The delay because of waiting at vaccination room

Correlations: file waiting time; total waiting time by minutes
Pearson correlation of file waiting time and total waiting time
by minutes =
0.712
10987654321
70
60
50
40
30
20
10
0
f ile w a it in g t im e
t
o
t
a

l
w
a
it
in
g
t
im
e
b
y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i n u
t e s v s f i l e w a i t i n g t i m e

Correlations: well baby waiting time; total waiting time by
minutes
Pearson correlation of well baby waiting time and total waiting
time by minutes
= 0.891
403020100
80
70
60
50
40

30
20
10
0
w e ll b a b y w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u

t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i n u
t e s v s w e l l b a b y w a i t i n g t i m e
Correlations: pediatrician waiting time; total waiting time by
minutes
Pearson correlation of pediatrician waiting time and total
waiting time by
minutes = 0.668
35302520151050
80
70
60
50
40

30
20
10
0
p e d ia t r ic ia n w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u

t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i v s
p e d i a t r i c i a n w a i t i n g t i m
Correlations: vaccination room waiting time; total waiting time
by minutes
Pearson correlation of vaccination room waiting time and total
waiting time by
minutes = 0.725
121086420
70
60
50
40
30
20

10
0
v a c c in a t io n r o o m w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u
t
e

s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i v s
v a c c i n a t i o n r o o m w a i t i n g
And from the above graphs we found positive correlation
between increased total waiting time and waiting time in
well baby room
At the end of analysis phase:
We found that the highest correlation was at the phase of
waiting at well baby room
Step 4 Improvement phase
1- choose remedy.

the team sit together after analyze phase and by brainstorming
the team agreed upon a remedy which is :
redesigning the process of pre vaccination to be in one room
only to avoid waiting time between steps
2- Design remedy.
After the team reviewed the goals and determined the
required resources from people-money-time-material,
the team decided the following remedy:-
"Using lean technique to make the whole process
done in
one room."
So we will calculate and sum the area of the three rooms and
transfer
the whole process to the vaccination room after arranging it
using
lean technique, so that the parent and child will only wait one
time
before getting the service.
The team defines a tree diagram to identify the role of each
member
in the new project.

The tree diagram
3- Prove effectiveness:-
Before an improvement is finally adopted, it must be proven
effective
under operating condition.
pilot test is designed to start working in the new room for 1
week
from 9
th
of may 2012 to 16
th
of may 2012 and calculating waiting time
in this period.

464136312621161161
40
30
20
10
0
O b s e r v a t io n
W
a
it
in
g
t
im
e
_
X=11.04
UCL=28.73
LCL=-6.65
1

1
I C h a r t o f w e l l b a b y w a i t i n g t i m e
This control chart showing waiting time before well
baby room (the red X) before applying the remedy
This is the control chart showing waiting times before
applying the remedy showing:-
1. 53 out of 60 observations are above the upper
specification limit which is 10 minutes according
to VOC, with percentage = 88.3%.
2. The mean is 25.42
This is the control chart showing waiting times after
applying the remedy showing:-
1. All observations are within the specification limits.
2. The mean is 7.55

5- Implementation
After the one week pilot and calculating waiting time
and according to the improvement proven by the
control chart we decided to implement this remedy
using the attached tree diagram
The new flow chart
Step 5 Control
Implementation 3 activities for control:
1- Design effective quality controls.
2- Foolproof the improvement.
3- Audit the controls.
A) Design control

To ensure that the breakthrough is maintained, the
quality
improvement team needs to develop effective quality control by
feedback loop.
ok
Not ok
Measure
actual
performance
Compare
to
specificatio

ns
Regulate
process
Customer
specifications
(upper and
lower control
limits)
To build a feedback loop, the team will need to
1- Measure the end results or the outcome of the improved
process
must be measured to be between upper and lower specification
limits
(5 min and 10 min) by random samples taken every week using
the
following data collection plan.
variable operational defenition
sample
size
data
source

data collection method who will
collect data
when data
will be
collected
waiting
time
before
vaccination
it starts since the parent ask
for his child's medical
record till the child name is
called in vaccination room
5% of
cases in
the
week
waiting
time data
collection
sheet
the medical record clerk
sheet
the vaccination nurse record
the time when the child
enters the room and before
he takes the vaccination

the data from data
collection sheet
nurse
supervisor
Starting from
23 June 2012
Waiting
time in
vaccination
room
It starts from entry of child
till he is out
5% of
cases in
the
week
Vaccination
room
register
The room nurse register the
time when child enters the
room and when he leaves
the room and record it in

collection sheet
Room nurse
Starting from
23 June 2012
The act of comparing actual performance to specifications will
be the
role of quality professional:-
the corrective action that will be
taken to control the process according to control plan:
B) Audit the control
Clear documentation of control is done
What done Who
acts
Who
analyze
Upper

and
lower
control
limits
Where
measured
How
measured
Control
variable
5 why
technique to
know the
reason for
variation
Team meeting
to suggest
error proof
solution
Team
leader
Quality
professional
Between
5 min
and 10
min

Files room
Vaccination
room
since the
parent ask
for his
child's
medical
record till
the child
name is
called in
vaccination
room
Waiting
time for
pre
vaccination
process
5 why
technique to
know the
reason for
variation
Team meeting
to suggest
error proof
solution
Team

leader
Quality
professional
Less
than 10
min.
Vaccination
room
Since the
child
enters the
room till he
leaves
Waiting
time in
vaccination
room
A Strategy to Reduce Emergency Department Wait Times
in Newfoundland and Labrador
2012
Minister’s Message

The Government of Newfoundland and Labrador is committed
to
investing in the health and well-being of all of our residents and
ensuring that health care programs and services are available to
everyone. A key piece of that commitment is enhancing access
and reducing wait times for patients in emergency departments
throughout the province. As Minister of Health and Community
Services, I am pleased to present the Provincial Government’s
Strategy to Reduce Emergency Department Wait Times.
Our vision through this Strategy is that all our residents will
receive appropriate and timely access to services provided in
emergency departments. This will help individuals, families and
communities to achieve optimal
health and well-being.
Enhancing the way emergency departments function for both
health care professionals and
patients is a main goal of the Strategy. The health care
providers who work in the emergency
departments in our province are well-trained, highly-skilled
professionals. They come to work
each day committed to providing the best possible care to their
patients. By taking actions to
reduce patient wait times, both the patients and health care
providers will be better served.
Implementation of the goals and objectives of the strategy will
be a long-term process and require
a coordinated approach, with departmental, regional health
authorities’ and health professionals’
cooperation and input. We are committed to this process, which
will be led by the new Access
and Clinical Efficiency Division within the Department of

Health and Community Services.
We recognize that health care affects each and every individual
in our province and we will ensure
that our investments result in improvements to the health care
system for everyone. I look forward
to reporting to the public on our Strategy to Reduce Emergency
Department Wait Times.
Sincerely,
Honourable Susan Sullivan
MHA, Grand Falls-Windsor-Buchans
Minister of Health and Community Services
A Strategy to Reduce Emergency Department Wait Times
in Newfoundland and Labrador
Map of Newfoundland and Labrador
showing the location of the 13 Category
A emergency departments
INTroDuCTIoN
For many individuals the emergency room or department
represents
the “front door” to the province’s health care system. In
Canada, almost
60 per cent of admissions to hospital are through an emergency
department.1 With a population of approximately 512,000, in
2010-11,
520,000 patient visits were made to the 33 emergency
departments
in Newfoundland and Labrador. Of the 33 emergency
departments,

13 are larger, have the highest number of patient visits each
year and
are most often the sites where patients may experience long
wait
times.2 In 2010-11, a total of 180 physicians and 344 staff,
including
nurses, nurse practitioners, licensed practical nurses, and clerks,
provided coverage in the larger emergency departments.
The Provincial Government knows that the public expects more
timely access, shorter wait times and better communication and
information regarding emergency department wait times. In
2011,
the Provincial Government made a commitment to address wait
times in emergency departments.
Recognizing the need for health care system enhancements, the
Provincial Government has invested over $140 million over the
past
eight years to improve wait times throughout the province, but
more needs to be done. This Strategy builds on that recognition
and furthers the commitment to ensure Newfoundlanders and
Labradorians receive appropriate and timely access to services
provided in emergency departments.
1 Canadian Institute for Health Information report, 2008
2 This province has 13 emergency departments that are
designated as Category A and
20 designated as Category B (refer to Appendix A for a list of
emergency departments
by category and facility). Category A emergency departments
have a minimum of
one physician dedicated to providing emergency services and
on-site 24-hours a day
and are in hospitals that, by definition, have acute care beds and

specialty services.
Category B emergency departments are primarily in the more
rural areas of the
province, have lower patient volumes and while a physician is
always available, they
may not be on-site.
| Page 1
Within the first 120 days in office,
we will produce a provincial
strategy on reducing wait times
in emergency rooms. This
strategy will identify means
of improving the timeliness of
services, utilization of existing
emergency room capacity,
physical infrastructure and
policies to enhance “patient flow”
and communication with patients
regarding the anticipated wait
time. (2011 Blue Book)
WAIT TIME IssuEs
The anatomy of an emergency department wait time
A patient’s wait time starts as soon as they walk through the
doors of
an emergency department and doesn’t end until the patient is
either
discharged home or admitted to hospital. The causes of long
wait
times are complex and often unique to each emergency
department.

A patient’s visit is made up of a series of smaller events or
services
and is referred to as the patient flow. These services can include
such things as triage (the first nursing assessment of how urgent
the
patient’s presenting condition is), registration, nursing
assessment,
physician (or nurse practitioner) assessment, consultations,
investigations and treatments. A delay in any one of these
events or
services will increase a patient’s wait time and can create
bottlenecks
in the emergency department.
Research has shown that emergency department wait times are
also affected by what’s happening outside of the emergency
department, in both the hospital and the community. This
includes
such things as how quickly in-patient beds are vacated and
cleaned
to be able to transfer a patient who is waiting for admission
from the
emergency department to the number of family doctors working
in
the community and providing evenings and weekend clinics.
The order in which patients are seen and the maximum time that
a patient should have to wait to be seen initially by a physician
(or
nurse practitioner) will vary and should be based on the severity
or
urgency of the patient’s condition. In Canada, the most
commonly
used scale to assign patient urgency in the emergency
department
is the Canadian Triage and Acuity Scale (CTAS). More detailed

information on CTAS is available on page 12 of this document.
Unlike other health care services, such as radiation treatment
for
cancer, there are no nationally agreed upon benchmarks for wait
times in Canadian emergency departments. In this province,
there
is a lack of emergency department wait times data and the data
available is not consistently gathered, which limits the ability to
compare and appropriately plan. Based on a sample of patient
visits reviewed in preparation for this Strategy, we know that
the
more urgent patients are being seen quickly, while moderate and
less urgent patients may be waiting longer than recommended,
particularly in the higher volume emergency departments.
Page 2 |
10 of 13 Category A emergency
departments are trained in and
recording CTAs levels.
What we have learned
Understanding the factors that contribute to wait times is the
first
step in addressing the issue. As part of the development of this
Strategy, Eastern Health, in collaboration with the Department
of
Health and Community Services, contracted with an
internationally
recognized group of experts in emergency department wait
times to
complete reviews of its two busiest adult emergency
departments

at the Health Sciences Centre and St. Clare’s Mercy Hospital.
The
reviews included two weeks of on-site shadowing and patient
sampling to help understand how the two emergency
departments
were operating and staff were providing services. Staffing
schedules,
patient volumes, CTAS ratings and physical structures were
reviewed
and recommendations made to improve patient flows and
shorten
wait times.
Each emergency department is unique and serves its own patient
population. The recommendations that were made by the
external
consultants to reduce emergency department wait times at the
Health Sciences Centre and St. Clare’s Mercy Hospital provided
both
specific requirements for each of the two emergency
departments
as well as lessons learned that can be generalized to all of the
emergency departments in the province.
Some of these lessons include:
• Emergency department wait times can be reduced through
better use of existing resources. The number and type of staff
and how they are scheduled must line up with the numbers and
timing of when patients present to the emergency department.
The physical layout of an emergency department may limit the
number of patients that can be seen, including where they are
seen. Additionally, if equipment and supplies are not stored
properly and conveniently, the time that staff can spend with
patients will be reduced.

• Hospitals that focus only on what happens in the emergency
department to reduce wait times will not be completely
successful. Other hospital policies, such as how the X-ray and
lab departments prioritize patients, must be reviewed and
wherever possible, aligned to meet the needs of the emergency
department.
| Page 3
Combined, the Health
sciences Centre and st. Clare’s
Mercy Hospital emergency
departments have more than
85,000 patient visits a year.
• In some cases, emergency departments are replacing the
services that would normally be provided in the community
and in particular by family doctors. Finding community-based
alternatives to emergency department care, such as the addition
of urgent care clinics and after-hours primary care services can
significantly reduce the number of patient visits to an
emergency
department3 and wait times.
• Patients may think that they can get faster access to specialists
and investigations of their medical condition(s) by going to the
emergency department, rather than being referred by their
family doctor.
• Through real time observation and the recording of the time
periods that make up a patient visit, issues that are causing
longer wait times can be identified and actions quickly taken
to reduce them. Currently, no emergency department in the
province is publicly reporting on their emergency department

wait time statistics.
• Listening to patients and communicating with them and the
public about wait times in the emergency department is
essential
for successful outcomes.
What we have done
In advance of the Strategy, the Department of Health and
Community
Services has already implemented initiatives that complement
the actions of this Strategy, including: increased the number of
medical school seats from 64 to 84 (planned for September
2013);
increased the number of family practice residency positions;
funded an additional year in the Family Practice residency
program
for physicians planning to work in an emergency department;
and, increased the number of bursaries offered to family
practice
residents. The Provincial Government has also increased the
number
of nursing seats from 255 to 291 and continues to provide BN
and
Nurse Practitioner bursary programs.
The Access and Clinical Efficiency Division in the Department
of
Health and Community Services was established in 2011 to take
the
provincial lead on the issue of wait times in the province’s
health care
system.
3 Jones D.C., Carrol L.J, and Frank L., 2011 After Hours Care
in Suburban Canada:

Influencing Emergency Department Utilization; Journal of
Primary Care and Community
Health, May 25, 2011. Page 4 |
In 2011-12, 50 bursaries were
offered to 47 Family Practice
residents, at a cost of $1.25
million. Each bursary has a one
year return in service commit-
ment to an area of need in the
province.
Work, in collaboration with the four regional health authorities,
is
currently being done to reduce wait times for selected services,
such
as endoscopy.
The Department of Health and Community Services has also
recently developed other strategies for implementation, related
to
wellness and chronic disease management. Actions arising from
these strategies will impact on emergency department utilization
and help reduce wait times.
THE sTrATEGY
This is a five-year Strategy, designed to reduce wait times in
the
province’s higher volume emergency departments, while
promoting
patient safety, quality of care and treatment standards.
To reduce wait times, the Strategy has five goals:

1. To improve the efficiency of higher volume (Category A)
emergency departments;
2. To improve access to community-based health services that
will support effective utilization of emergency departments;
3. To implement a province-wide standard for patient triage
and wait times to receive initial medical attention;
4. To improve the collection, reporting and use of emergency
department wait time data; and,
5. To improve communication with patients and the public
regarding emergency department wait times.
These goals are consistent with the 2011-2014 Strategic Plan of
the
Department of Health and Community Services under the issues
of
improved access and increased efficiency. By meeting these
goals,
the provincial health care system will be able to provide high
quality
emergency department care in as short a time as possible for the
people of the province.
To develop the Strategy, the Department of Health and
Community
Services worked closely with the support of senior leadership in
the
four regional health authorities, various emergency physicians,
the
Canadian Association of Emergency Physicians and other health
care
professionals involved in providing emergency department
services.

| Page 5
The Department’s Access and Clinical Efficiency Division has
responsibility to work with the four regional health authorities
to
implement the Strategy’s actions.
Goal #1 To improve the efficiency of higher volume
(Category A) emergency departments
Improving how an emergency department functions does not
always
require more money or new resources. Rather, the focus should
be on
removing the barriers that impede or slow down patient flow.
Each
emergency department is unique and remedies have to be
tailored
to recognize this; for example, each emergency department
makes
staffing decisions based on its own patient volumes and levels
of
patient acuity or urgency.
Objective: Ensure optimal staff scheduling, skill mix,
supportive policies, physical layout and patient
flow in emergency departments.
In order to improve efficiency in high volume emergency
departments, the way staff is scheduled and what duties health
professionals are required to do, must be addressed. Staffing
schedules need to match patient volumes, acuity and time of
presentation. Skill mix also has to be optimized to ensure that

the
right staff are there to meet the needs of the patients. This
includes
reviewing the potential role of nurse practitioners to help
address
high volumes of less urgent patients.
Efficiency also relies on factors other than staffing levels.
Some
hospital policies can negatively impact emergency department
wait
times, such as their Discharge Policy, including how early in
the day
discharge orders must be written by a physician. These policies
need
to be identified, reviewed and changed wherever possible so
that
they align with emergency department needs. The physical
layout
of the emergency department can also negatively impact
efficiency;
proper set up can reduce or eliminate inefficiencies.
Ensuring that high volumes of less urgent patients are seen
efficiently
can reduce emergency department overcrowding. As these
patients
often do not need a bed to be seen and treated, emergency
departments and nearby spaces should be set up to meet the
needs
of this group of patients.
Page 6 |

The use of standardized protocols should be considered, in
consultation with emergency physicians. This will allow nursing
staff
to begin a patient’s investigations and possible treatments based
on the patient’s presenting problem while waiting for the
physician,
for example, administrating medication to a child presenting
with a
fever or completing blood work and an EKG on a patient with
chest
pain.
Actions:
• External reviews of all 13 Category A facilities will be
completed
to determine current and baseline wait times, identify the
causes of delays in patient flow and implement quick wins and
solutions to reduce wait times.
o It takes three to four months to complete an external
utilization and staffing review of an emergency
department;
o Completion of all 13 Category A emergency departments
reviews is planned within three years; and,
o The Provincial Government will allocate funding for
six new nursing staff positions to be placed in St.
John’s, Gander and Grand Falls-Windsor emergency
departments, as well as one ward clerk position in
Stephenville.
• Front-line emergency department staff will be educated and
trained in process improvements to reduce wait times in an
emergency department.

o A three-day workshop is planned for Spring 2012 and
providers from all 13 Category A emergency departments
will be invited to participate.
o Other training needs will be identified and addressed as
each review is completed.
| Page 7
Goal #2 To improve access to community-based health
services that will support effective utilization of
emergency departments
Many patients visit an emergency department as they either do
not
have a family doctor or they are not able to see one quickly.
Some
patients use the emergency department to try and access
specialists
and diagnostic tests (X-ray and other services) more quickly.
High volumes of low-urgency patients can create overcrowding
in an
emergency department and lead to longer wait times. In 2010-
11, 56
to 86 per cent of patients who presented in one of the 10
Category A
emergency departments that are using CTAS, were triaged as
either
CTAS 4 or 5, indicating non-urgent, routine conditions.
Historically, the thinking has been that reducing or diverting the
number of low-urgency patients would not significantly reduce

demands on and wait times in an emergency department.4
Recent
research however, demonstrates that community-based
alternatives
to the emergency department reduce the number of patients who
would otherwise present there.5
To achieve this goal, the Strategy has three objectives to: 1)
increase
access to family doctors, 2) increase awareness and usage of the
provincial HealthLine and 3) provide community-based
alternatives
to hospital admission by seniors, where appropriate.
Objective: Increase access to family doctors
Some patients present to the emergency department as their
family
doctors may not have appointments available to see them
quickly
or they do not offer services after hours or on the weekends.
The
Canadian College of Family Physicians and the Institute for
Health
Care Improvement have endorsed the model of Open Access
Scheduling. This is a type of scheduling that can be used in a
family
doctor’s office, where a number of appointment times are left
open
each day so they can provide same-day appointments to patients
who call with acute illnesses. This approach also enhances the
coordination of care as patients are seen by their own physician,
instead of visiting the emergency department.
4 Auditor General of Ontario report, Chapter 3, Section 3.05,
Hospital Emergency

Departments, 2011
5 Alberta Medical Association, Primary Care Network
Backgrounder, January 21, 2011. Page 8 |
Some family physicians are in solo or group practices that
provide
clinics only on weekdays and during regular working hours. As
a
result, patients often feel that they have no other choice but to
seek
medical attention in an emergency department when they
require
care after hours.
Action:
• The Department of Health and Community services will
collaborate with the Newfoundland and Labrador Medical
Association to increase the availability of community-based
services by:
o Promoting the use of Open Access Scheduling;
o Providing incentives to family doctors to increase the
number of evening and weekend clinics they provide;
and,
o Exploring alternate models of care, including family
doctors working with other groups of physicians to
provide after-hours coverage or in teams with other
health care providers.
Objective: Increase awareness and use of the provincial
HealthLine

Today’s public is often confused about who to call and where
they
should go to receive advice on their medical problem or
condition.
Since September 2006, the Department of Health and
Community
Services has been funding HealthLine, a provincial phone line,
which
is staffed by experienced nurses, to provide both medical advice
and
direction to patients who have minor, non-urgent health
complaints.
Currently, capacity exists to increase the number of phone calls
that
HealthLine receives.
The HealthLine receives approximately 2,600 calls a month,
with
50 per cent repeat callers. Approximately 75 per cent of the
phone
calls are made by either patients or care-givers regarding
medical
symptoms. Of these, approximately 20 per cent are referred to
an
emergency department, 60 per cent are referred to the family
doctor
or health care provider for follow up if their symptoms don’t
resolve
and 20 per cent are recommended self-treatment.
| Page 9
Each month the HealthLine does a follow-up survey of clients

who
called in the prior month. On average, 80-85 per cent of the
clients
surveyed reported that they followed the nurse’s
recommendations.
The Department of Health and Community Services is
collaborating
with the Newfoundland and Labrador Centre for Health
Information
to complete an external review of the impact of HealthLine on
the
provincial health care system. To date, Phase One of the review
has
been completed, which included an extensive literature review
and
audit of the HealthLine’s statistical reports. Phase Two of the
review
will focus on patient satisfaction and the impact that the
information
provided by the HealthLine has on a patient’s subsequent
behavior
and in particular, whether it deters them from presenting to an
emergency department for those who were advised otherwise.
Actions:
continue to promote awareness and use of the provincial
HealthLine.
• The Department of Health and Community services, in
collaboration with the Newfoundland and Labrador Centre for
Health Information, will complete Phase Two of its utilization
review of the HealthLine.

• Eastern Health will commission the HealthLine to do follow-
up, within 24 hours of the visit, of patients who left their
emergency departments without being seen to determine
their status.
Objective: Provide community-based alternatives for seniors
to prevent hospital admissions
One of the most common reasons for long wait times in an
emergency
department is patients staying in an emergency department for
long periods of time after the decision to admit them has been
made
but no hospital in-patient bed is available. As a result, these
patients
experience longer wait times in the emergency department and
both
the emergency department and acute care system are impacted.
Policies and actions that increase the number of available
hospital
beds will lead to decreased wait times in an emergency
department.
Page 10 |
In our province, 94 per cent of seniors live at home; 25 per cent
live
alone. Often, seniors present to the emergency department with
a
worsening of a chronic medical condition, such as chronic
obstructive
lung disease and because they need some level of nursing or
supportive care that prevents them from returning home, they
are

admitted to hospital. Once admitted, a senior’s length of stay is
50 per
cent longer than a non-senior being treated for the same
condition.
We also know that 71 per cent of patients that are designated
as requiring alternate levels of care (patients who are medically
discharged but need rehabilitation or are unable to return home)
are
admitted through an emergency department.
Other jurisdictions have found that by delivering rehabilitation
and
other services to seniors with medical needs in their own homes,
admissions through emergency departments have been reduced.
Following the implementation of such a program at the Red
Deer
Regional Hospital Centre in Alberta, a 50 per cent reduction in
admissions to hospital through their emergency department was
reported.
Action:
• The Department of Health and Community services will work
with the regional health authorities to provide access to
enhanced community-based health services for seniors, who
present at an emergency department and could otherwise be
supported at home and avoid hospital admission, by piloting
two Community-based rapid response Teams.
o A community-based rapid response team is comprised
of medical professions including nursing, physiotherapy,
occupational therapy and physicians who provide short-
term intervention and support to seniors in their own
homes;

o Seniors, who are identified by the emergency department
physician as being able to return home with additional
supports, will be referred to the team for follow-up care
and monitoring in the patient’s home. As their condition
improves, patients will be referred back to regular
community supports; and,
o 24-hour home support for up to seven days will also be
available.
| Page 11
In 2010-11, 35 per cent of
all hospital admissions were
for patients aged 65+; 70
per cent of these admissions
were through an emergency
department.
Goal #3 To implement a province-wide standard for patient
triage and wait times to receive initial medical
attention
How long a patient waits to be seen and assessed in an
emergency
department will vary. Some of the variation is medically
acceptable
and based on the urgency of the patient’s condition at the time
of
arrival in the emergency department.
The most common classification system used in Canadian
emergency departments to determine the urgency or severity of
a

patient’s condition on arrival to the emergency department is
the
Canadian Triage and Acuity Scale (CTAS), developed by the
Canadian
Association of Emergency Physicians in 1998. CTAS is being
used in
approximately 80 per cent of Canadian emergency departments
for
quality assurance and standardization purposes. CTAS is
currently
being used by 10 of the 13 Category A emergency departments
in
the province. Implementation of a province-wide system, like
CTAS,
will allow the capture of consistent data and help reduce wait
times
in emergency departments.
CTAS is a five point scale that an emergency department can
use to
evaluate a patient’s presenting condition and identify their need
for
care. CTAS also establishes the maximum recommended time
that a
patient should wait until their initial medical assessment, by
either a
physician or appropriate health care provider.
When used, each patient is assigned a CTAS level of 1-5 during
the
initial nursing assessment (triage). The following summarizes
the
CTAS:
• Level I - Resuscitation (e.g. cardiac arrest) requiring an
immediate

response;
• Level 2 - Emergent (e.g. chest pain) requiring a response
within
15 minutes;
• Level 3 - Urgent (e.g. mild to moderate asthma) requiring a
response within 30 minutes;
• Level 4 - Less Urgent (e.g., minor trauma, urinary symptoms)
requiring a response within 60 minutes; and,
• Level 5 - Non-Urgent (e.g. common cold, sore throat)
requiring a
response within 120 minutes.
Page 12 |
The training for, implementation and use of the CTAS scale (or
equivalent) is the first step in measuring emergency department
wait times and establishing wait time targets in the province.
Action:
adopt and implement CTAs as the provincial standard
for both patient triage and recommended maximum
wait times to initially be seen by either a physician or
appropriate health care provider in all 13 Category A
emergency departments.
Goal #4 To improve the collection, reporting and use of
emergency department wait time data

Prior to the completion of the two emergency department
reviews
in Eastern Health, no Category A emergency department was
recording a comprehensive list of patient wait times. The two
adult
emergency departments in St. John’s have now started.
Collection
of this information is essential to understand the magnitude of
wait
time delays in an emergency department, be able to set
reasonable
and realistic targets to reduce excessive wait times and report to
the
patients and the public.
There are four nationally recognized wait time metrics or
measurements that document how well an emergency
department
is meeting the needs of the population it serves. Collection of
information on these four measures has been recommended by
the
consultants who completed the two …
Example of A3 (lean management ) model
Example:
Toyota is known for its continued commitment to improving
operational performance. How does a company with close to
350,000 employees consistently, rapidly improve? With a Lean
thinking tool called the A3 process. See how the A3 process and
problem solving approach helps organizations practice
continuous improvement.
The A3 process and problem solving approach helps
organizations practice continuous improvement.
What is the A3 Process?
The A3 process is a problem solving tool Toyota developed to

foster learning, collaboration, and personal growth in
employees. The term “A3” is derived from the particular size of
paper used to outline ideas, plans, and goals throughout the A3
process (A3 paper is also known as 11” x 17” or B-sized paper).
Toyota uses A3 reports for several common types of work:
· Solving problems
· Reporting project status
· Proposing policy changes (policy meaning rules agreed upon
and enforced by the group)
Why Use an A3 Process?
In most organizations, on most teams, we aren’t collaborating as
strategically as we could be. We leave meetings with ideas half-
baked. We often move hastily to begin working on
implementing a solution, without aligning around important
details. Projects move slowly due to rework and duplicate
effort, two symptoms of a lack of alignment.
The A3 process allows groups of people to actively collaborate
on the purpose, goals, and strategy of a project. It encourages
in-depth problem solving throughout the process and adjusting
as needed to ensure that the project most accurately meets its
intended goal.
The A3 process prescribes to the famed quote by Abraham
Lincoln: “Give me six hours to chop down a tree and I will
spend the first four sharpening the axe.” The A3 process helps
an organization sharpen its proverbial axes by fostering
effective collaboration, bringing out the best problem solving in
teams.
Collaboration between talented people is critical for innovation
and speed. Using the A3 process to foster collaboration can help
organizations and teams invest their time, money, and
momentum most effectively.
Steps of the A3 Process?
There are nine (well, ten) steps in the A3 process.
0: Identify the problem
Since the purpose of the A3 process is to solve problems or
address needs, the first, somewhat unwritten, step is that you

need to identify a problem or need.
1: Capture the current state of the situation
Once you align around the problem or need you’d like to
address, then it’s time to capture and analyze the current state
of the situation. Toyota suggests that problem solvers:
· Observe the work processes firsthand and document your
observations.
· Gather around a whiteboard and walk through each step in
your process. You can use fancy process charting tools to do
this, but stick figures and arrows will do the job just as well.
· If possible, quantify the size of the problem (e.g., % of tickets
with long cycle times, # of customer deliveries that are late, #
of errors reported per quarter). Graph your data if possible;
visualizations are really helpful.
2: Conduct a root cause analysis
Now that you see your process, try to figure out the root cause
of the efficiencies. You can ask questions like:
· Where do we suffer from communication breakdowns?
· Where do we see long delays without activity?
· What information are we needing to collaborate more
effectively/smoothly?
Document these pain points, then dig deeper. The 5 whys is a
helpful tool for conducting a thorough root cause analysis. The
basic idea is that you begin with a problem statement, and then
you ask “Why?” until you discover the real reason for the
problem. You may or may not have to ask why exactly five
times – this is simply an estimate.
3: Conduct a root cause analysis
Countermeasures are your ideas for tackling the situation; the
changes to be made to your processes that will move the
organization closer to ideal by addressing root causes.
Countermeasures should aim to:
· Specify the intended outcome and the plan for achieving it.
· Create clear, direct connections between people responsible
for steps in the process.
· Reduce or eliminate loops, workarounds, and delays.

4: Define your target state
Once you’ve selected your countermeasures, you are able to
clearly define your target state. In the A3 process, you
communicate our target state through a process map. Be sure to
note where the changes in the process are occurring so they can
be observed.
5: Develop a plan for implementation
Now that you’ve defined your target state, you can develop a
plan for how to achieve it. Implementation plans should
include:
· A task list to get the countermeasures in place
· Who is responsible for what
· Due dates for any time-sensitive work items
Most teams choose to document their implementation plan in
their A3.
6: Develop a follow-up plan with predicted outcomes
A follow-up plan allows Lean teams to check their work; it
allows them to verify whether they actually understood the
current condition well enough to improve it. A follow-up plan is
a critical step in process improvement because it can help teams
make sure the:
· implementation plan was executed
· target condition was realized
· expected results were achieved
These first six steps are captured in the A3 report. Most teams
use a template for their A3.
7: Get everyone on board
The goal for any systemic improvement is that it improves every
part of the system. This is why it’s vital to include everyone
who might be affected by the implementation or the target state
in the conversation before changes are made.
Building consensus throughout the process is usually the most
effective approach, which is why many teams choose to include
this at each critical turning point in the A3 process. Depending
on the scope of the work, it might also be important to inform
executives and other stakeholders who might be impacted by the

work.
8: Implement!
Now it’s time for implementation. Follow the implementation as
discussed, observing opportunities for improvement along the
way.
9: Evaluate results
In far too many situations, the A3 process ends with
implementation. It’s critical to measure the actual results and
compare them to your predictions in order to learn.
If your actual results vary greatly from what was expected, do
research to figure out why. Alter the process as necessary, and
repeat implementation and follow-up until the goal is met.
1. Personal Mastery :Tell us your experience when leading a
group of people to coordinate work. How did you approach the
task, what specifically did you do, what was the response to my
efforts, describe in detail the outcome and if you would do
anything differently?
Success story: Challenge-Context- Action-Result (CCAR)
Model
Position: Patient Advocate- Dental ranked #1 in customer
service complaints
Challenge: How to best reward and recognize employees in
order to improve quality of care for our Veterans and improve
their outcome.
· The goal is to increase morale, improve patient experience,
and business outcomes.
I caught you caring initiative – to reinforce extraordinary
customer service behavior through peer or Veteran recognition.
This contains two folds
· Increased attention to the contribution of co-workers.
· Enhance collaboration and teamwork.
Focus Area/ Piolet Clinic: Dental

I shared my vison with the top administrators in the Dental
Clinic-Operative Care Line team. I met weekly with these
officials and presented key components to increase customer
satisfaction and build morale in the Dental section. I created a
PowerPoint presentation from data produced by the VEO
showing dental ranking #1 in customer service complaints. I
successfully argued that launching the Caught you caring
initiative/campaign that will boost the morale, improve patient
satisfaction, and the veteran experience. My Vision for ICYC
initiative includes recognizing individuals who demonstrates
our hospital values, the values expressed by our
patients/community, and our vision to deliver excellent
customer service. I proposed, lobbied for, and succeeded in
including the ICYC initiative as part Dentals award/recognition
segment in quarterly meetings.
My ability to communicate my expectations of the ICYC
initiative allowed me to garner the support of upper
management administrators. The Dental clinic employees rallied
and provided positive feedback on how this initiative made
them feel recognized and this award drives the dental team to
provide the best customer service to our Veterans. Management
backing was key in obtaining support from executive leadership
and the award ceremony was a success and vital to increasing
customer satisfaction.
Within the next 6 months I would like to establish the ICYC as
an important program that give us the opportunity to recognize
an individual who demonstrates compassion, care and
contributes to delivering an excellent care experience. The goal
is to recognize the employee with the most compliments every
quarter. That employee will get to select a gift or compensatory
time, get to take a professional headshot photo, be recognized in
employee newsletter.

A3 Problem Solving
Seeking to Understand Problems, Big and Small
Lisa Segerstrom
10/02/2018
What does A3 Mean?
De-Mystifying a simple tool
The A3 Method
• A3 simply refers to a paper size (11x17 aka A3).
• Mainstay of the Toyota Production System for:
• Proposals
• Status Reports
• Problem Solving
A3 is an approach to problem solving that grew out of Lean
Manufacturing at
Toyota. The A3 report condenses project information onto a
single page in an
easy-to-read, graphical format. This A3 template provides
sections for describing
background information, current conditions, root cause analysis,
target
conditions, implementation plan, and follow-up.
Why Use A3?
• Basic methodology to:

• Identify problem, gap, or need
• Understand current state
• Develop simple target
• Understand root cause
• Brainstorm or identify countermeasures
• Create action plan
• Check results of corrective actions or improvements
• Sustain results
Same Idea, Different Templates
No standard template – your organization or department
may have preferred template.
A3 Report: Project name
Project mission statement
What is the team trying to accomplish?
Background
• Problem background
• Why the problem needed to be fixed
• Importance of identifying solution
Original state/problem statement
• Use a diagram if possible
• Show where the problems exist with Kaizen bursts, i.e.
graphic
indicators of opportunities for improvement
• Extent of the problem (e.g., metrics or measures of success
that
are below target)

Problem analysis
• Why does the problem exist?
• Does asking “why?” five times help identify the root cause?
• What influences caused the problem?
Team
Executive sponsor:
Champion:
Team lead(s):
Project team: List names and departments
Solution
• Describe recommendations of team
• Show diagram or map of new process
• Measurable targets to achieve within determined timeframes
Implementation plan
• Use a diagram if possible
• Who is responsible for which tasks?
• What resources are required?
• What targets have been identified? Timeline for achieving?
• How regularly will the improvement team connect while the

change is underway?
Graph results
Show improvement over time
Sustain
Implementing a project doesn’t guarantee long-term success.
How
does the team plan to continue to make the improvement part of
daily
practice, long after the “project” as ended? Determine metrics
to
track, feedback loops for staff, and maintain regular A3 updates
to
share with the team and supporting leadership.
0
10
Source: AMA. Practice transformation series: starting lean
healthcare. 2015.

6) Check: (Summary of the solutions’ results, overall goal
success, and any supporting metrics)
1) Problem Statement: (description of the problem and its
effect)
Project Lead:
Project Champion(s):
Date Updated:
Project Team:
2) Current State: (depiction of the current state, its processes,
and problem(s)
Best Practices/Literature Search:
3) Goal: (how will we know the project is successful;
standard/basis for
comparison)
4) Root Cause Analysis: (investigation depicting the problems’
root causes)
A3 Project Title

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