https://www.infirmiere-canadienne.com/blogs/ic-contenu/2025/04/14/modele-de-soins-hopital-montfort
Lessons learned
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The pod model made it possible to standardize patient care and practices to better plan emergency department activities. There are now fewer fluctuations in the course of a day despite an increased number of patient visits and/or a lack of nurses. Indeed, the emergency department was able to function while providing high-quality care despite the shortage of RNs.
Takeaway messages:
- Ensure good interprofessional collaboration and that each employee can work to the maximum of their abilities.
- Foster and support good communication among everyone.
- Develop common goals for the organization to help implement changes despite non-ideal situations.
The shortage of health-care workers, particularly registered nurses (RNs), is being felt in many health-care facilities in Canada. Located in Ottawa, Hôpital Montfort is no exception; we have faced, and continue to face, major challenges in recruiting and retaining RNs. This shortage has become even more pronounced in the context of the pandemic, where health workers have had to take time off or have left the health sector. The turnover rate of RNs at Hôpital Montfort increased from around 6% in 2020 to more than 16% in 2022. It therefore proved urgent to find a different way of delivering care in order to meet the needs of patients.
Before the pandemic, it had been observed that health professionals at Monfort were not all practising to their full scope of practice (Déry, D’Amour, & Roy, 2017). Furthermore, some RNs performed tasks that could be accomplished by other workers. These observations were considered in light of scientific literature that shows interprofessional practice offers an opportunity to overcome human resource deficits by amalgamating varied skills and expertise (Nancarrow et al., 2013).
Using this premise, a care model based on an amalgamation approach was implemented (following a quality improvement process) in the emergency department of Hôpital Montfort. This article aims to share the efforts that have been made to implement this new interprofessional and collaborative model of care that has made it possible to optimize the work of nursing staff and improve patient care.
How innovation has influenced nursing practice
From concept to implementation
The change to an amalgamation approach began in June 2022. Consideration first focused on the causes of the staffing problem and then shifted to strategies to engage other types of regulated professionals and unregulated support staff to support RNs in their clinical activities. One of the first steps was to carry out a review of the literature to identify precedents in terms of best interprofessional practices. In addition to the review, a survey was conducted to find out how other hospitals across the country were managing to relieve the clinical activities of RNs by enhancing the practice of respiratory therapists. In light of our research, it appeared that respiratory therapists were not practising to their full scope in the emergency department and that the care teams would benefit from additional support from them.
We began by communicating the intended intervention to staff. The primary objective was to raise employee awareness of this new way of enacting this practice change in a safe manner. To do this, we emphasized the importance of communication between the physician, nursing staff, respiratory therapist and paramedic; the participation of all care staff (registered nurses and licensed practical nurses, newly graduated nurses, respiratory therapist, nursing aide, paramedic, clerk, personal support worker) would be required. We organized several weekly meetings with all department staff to generate ideas for improving care. Finally, we drew up an action plan based on the proposed solutions.
Using Lean methodology, we developed a new pod model of care. Pods are small groups of health professionals and support staff (doctors, registered nurses, licensed practical nurses, respiratory therapists, nursing assistants, paramedics, clerks, attendants, etc.) within the emergency department. Each pod helps members within its group provide patient care. Care therefore becomes a team effort in which activities are shared, and each pod is assigned a determined number of patients. Each pod is autonomous.
To understand the impacts of the pod structure on communication, a theoretical model was developed. Considering 21 stretchers, three doctors and four nurses, as well as a random assignment of stretchers, we estimate that there could be more than 177,000 possible interactions (see Figure 1).
Figure 1
Communication network: 177,243 possible combinations
On the other hand, with a pod-type grouping, the number of interactions can drop to 144 (see Figure 2). This result coincides with some facts described in the literature (Gavin & Peterson, 2017; HealthManagement, 2015).
Figure 2
Communication network: 144 possible combinations
To evaluate the communication and movement models that are demonstrated in the figures, we chose a scenario and used a combinatorial analysis to demonstrate the possibilities. In Figure 1, the first doctor can go to seven stretchers among 21 available stretchers, the second doctor can go to seven stretchers among 14 stretchers and the last doctor can go to the remaining seven stretchers. For nurses, the number of possible combinations is also increased. The combinations of doctors’ movements in addition to those of nurses make a total of more than 177,000 possibilities for different interactions between doctors, nurses and patients.
However, in an improved model such as the pod in Figure 2, these interaction numbers drop to 144 because each doctor and nurse can only go to one of three pods. This is important because each trip represents a waste of time. This makes the model in Figure 2 more efficient.
The thinking behind the use of this methodology was to reduce sources of waste such as excess movement of staff across the sector or underutilization of talent (i.e., not using a team member’s skills to their full potential). The patient proximity element assigned to a pod made it possible to modify the workload of the RNs; for example, unnecessary travel from one section to another in the emergency department was eliminated.
Another example of the model’s effectiveness was in enhancing the activities of respiratory therapists, who were involved in patient assessment, were able to take care of oximetry, and participated in teaching fall prevention techniques to patients. In addition, the role of paramedics in the emergency department has changed to integrate them into the team, enabling them to take care of patients before they were admitted. This allowed RNs to be assigned to other care activities.
The role of support staff (e.g., porters and clerks) has also been reviewed to allow them to work to their maximum scope of practice, which helps compensate for the lack of RNs. For example, patient transport and transfers to care units can be handled by unregulated health-care staff. The responsibilities of the unregulated care providers are documented in the electronic medical record, and enhanced training is provided as necessary.
Frequent meetings were held throughout the process to review issues, listen to feedback and identify areas for improvement. Training sessions were also carried out to strengthen the clinical capacities of staff. This concept facilitated the integration of these employees into the emergency department and thus lightened the workload of the RNs.
Summary of results
Impact and success
It is imperative to mention that all the success goes to Montfort employees at all levels (from directors to clerks) who were open to change. The commitment of employees, particularly respiratory therapists, was essential to support nursing staff and to avoid service disruptions in the emergency sector. In addition, the involvement of managers and other leaders to convey coherent messages on the implementation of the model and its added value was essential in change management. The gradual establishment of effective communication not only between employees but also with patients has been relevant for the continuum of care.
The impact of the model can be seen from two perspectives. First, for employees, team spirit and a culture of collaboration were strengthened at a time when the dynamic in the emergency department was particularly fragile. The complementarity of expertise proved tangible, and a climate of communication was fostered between employees. In addition, the commitment of the nursing staff — who saw a redistribution of their tasks with the sole aim of meeting the needs of patients — has definitely had a positive impact on their work climate, with a reduced work burden. Nursing staff can better manage triage and appreciate the increased role of the paramedic in the emergency department and the respiratory therapist in the care of certain patients. The workload is now shared.
This teamwork created a sharing of experiences, which meant that caregivers developed new knowledge and integrated new expertise. They were better recognized for their abilities and skills, which increased the recognition of their expertise.
The second impact was at the system level, where the pod model made it possible to standardize patient care and practices to better plan emergency department activities. There are now fewer fluctuations in the course of a day despite an increased number of patient visits and/or a lack of nurses. Indeed, the emergency department was able to function while providing high-quality care despite the shortage of RNs.
Employee motivation has also increased, which boosts staff retention. The number of departures and corporate hiring has stabilized. Before the start of the project, the emergency department had 42% vacant nursing positions. In September 2022, there were 15 nursing staff departures; by early 2023, that number had fallen to one to five.
Challenges
The pod model has led to a change in mentality and culture. We had to work on communication to ensure that everyone understood their roles and how tasks would be delegated. Also, new staff members (including respiratory therapists, ambulance attendants, orderlies and nurses) had to undergo additional training to familiarize themselves with the new approach, as most of them had not previously worked in the emergency department. It took staff some time to adapt.
We would like to point out that under normal circumstances, implementing the pod model would likely have taken a few years; Hôpital Montfort, however, implemented it in the space of two months during the pandemic. Despite a very tight deadline, expectations were clear to ensure that nursing staff and administrative staff could achieve this feat.
Prospects and sustainability
This collaborative interprofessional model is now well in place and will remain the new model of emergency care. The next steps are to continue training staff to strengthen skills and optimize this model by continuing to integrate other members from different disciplines, such as a physiotherapist and a pharmacist or pharmacy technician. Ultimately, the guiding principles will be used to disseminate this model in other departments by adapting according to each sector within the Lean principles. An evaluation is under way. Hôpital Montfort, as a university hospital, remains on the lookout for innovative solutions to provide quality care to patients and attract health professionals.
Acknowledgements
It is important to mention that the success of this change in the care model is attributed to key players in the organization. Thanks are in order to Sara Leblond, Alberto Ramirez, Nicholas Comeau, Dominic Séguin, Valérie Dubois-Desroches, Julie Boulianne, Dr. Francis Dubé and the entire large team of emergency department employees: clerks, registered nurses, licensed practical nurses, respiratory therapists, doctors, nursing assistants, attendants and all other health professionals and support staff, as well as the project management team and the professional practice team. Thank you for your efforts and support. You can be very proud of your work.
Thank you also to the Institut du Savoir Montfort for its support, particularly to Marie-Junelle Jean-François Michel and Miryam Duquet, without whom the development of this article would not have been possible.
References
Déry, J., D’Amour, D., & Roy C. (2017). L’étendue optimale de la pratique infirmière. Perspective Infirmière, 14(1), 51–55.
Gavin, N., & Peterson, K. (2017). Team-based pod system reduces lengths of stay for treat-and-release patients. ED Management, 29(6), 67–69.
HealthManagement. (2015, November 23). Pod-and-huddle ED model speeds processes. Retrieved from https://healthmanagement.org/c/hospital/news/pod-and-huddle-ed-model-speeds-processes
Nancarrow, S. A., Booth, A., Ariss, S., Smith, T., Enderby, P., & Roots, A. (2013). Ten principles of good interdisciplinary team work. Human Resources for Health, 11, 19. doi:10.1186/1478-4491-11-19
The authors are all employed by Hôpital Montfort in Ottawa.
Josette Roussel, RN, M.Ed., M.Sc., FCAN, is associate vice president, patient care, and chief nursing executive.
Patrice Lampron, RN, BScN, is a clinical manager in the emergency department.
Natalie Ladouceur, RN, BScN, MScN, is the director of professional practice.
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