Engaging Frontline Staff Research Articles

Implementation of delirium screening in the emergency department: A qualitative study with early adopters.

Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one-third of cases. Evidence-based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation. We conducted semi-structured interviews with clinician-administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives. Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff. Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion.

How do healthcare providers use national audit data for improvement?

BackgroundSubstantial resources are invested by Health Departments worldwide in introducing National Clinical Audits (NCAs). Yet, there is variable evidence on the NCAs’ effectiveness and little is known on factors underlying the successful use of NCAs to improve local practice. This study will focus on a single NCA (the National Audit of Inpatient Falls -NAIF 2017) to explore: (i) participants’ perspectives on the NCA reports, local feedback characteristics and actions undertaken following the feedback underpinning the effective use of the NCA feedback to improve local practice; (ii) reported changes in local practice following the NCA feedback in England and Wales.MethodsFront-line staff perspectives were gathered through interviews. An inductive qualitative approach was used. Eighteen participants were purposefully sampled from 7 of the 85 participating hospitals in England and Wales. Analysis was guided by constant comparative techniques.ResultsRegarding the NAIF annual report, interviewees valued performance benchmarking with other hospitals, the use of visual representations and the inclusion of case studies and recommendations. Participants stated that feedback should target front-line healthcare professionals, be straightforward and focused, and be delivered through an encouraging and honest discussion. Interviewees highlighted the value of using other relevant data sources alongside NAIF feedback and the importance of continuous data monitoring. Participants reported that engagement of front-line staff in the NAIF and following improvement activities was critical. Leadership, ownership, management support and communication at different organisational levels were perceived as enablers, while staffing level and turnover, and poor quality improvement (QI) skills, were perceived as barriers to improvement. Reported changes in practice included increased awareness and attention to patient safety issues and greater involvement of patients and staff in falls prevention activities.ConclusionsThere is scope to improve the use of NCAs by front-line staff. NCAs should not be seen as isolated interventions but should be fully embedded and integrated into the QI strategic and operational plans of NHS trusts. The use of NCAs could be optimised, but knowledge of them is poor and distributed unevenly across different disciplines. More research is needed to provide guidance on key elements to consider throughout the whole improvement process at different organisational levels.

Respectful maternity care in health centers of Addis Ababa city: a mixed method study

ObjectiveThe study aims to assess quality of obstetric and newborn care including respectfulness of the maternity care.DesignThe study used explanatory sequential mixed methods design .SettingThis study was conducted in 50 health centres in Addis Ababa city administration January 25 to April 31, 2021.MethodsDuring the quantitative phase 500 women in postpartum period were interviewed using structured questionnaire. In the second phase in-depth interview was conducted with 20 midwives and 13 health centre managers. The quantitative data was analysed using Statistical Package for Social Sciences (SPSS). The qualitative data was analysed using Colaizzi’s seven step process.ResultsOnly 24.6% of women had respectful maternity care (RMC). Only 46% of women had effective communication during child birth. Only 9.6% of women had emotional support during child birth. Majority of women were encouraged to mobilize, take food and be on labor position of their choice. However, only 22.4 and 18.8% of women respectively had a companion of choice and any pharmacologic pain relief during child birth. One in seven women (15%) had one form of disrespect and abuse during child birth.ConclusionEnsuring respectful maternity care needs strong policy direction to health facilities, public education on their right to respectful maternity care, training of care givers and monitoring care through engagement of frontline staff and clients.

Reduction of CAUTI Events in an ICU During the COVID-19 Pandemic Through Shared Governance and Using Process Improvement Strategies

BackgroundCatheter Associated Urinary Tract Infections (CAUTIs) are associated with an increase in mortality, morbidity, length of stay, and hospital costs. Intensive Care Units (ICUs) have higher rates of CAUTIs than other hospital units. During the Coronavirus (COVID-19) pandemic, Hospital Associated Infections (HAIs) have increased, including a 30% increase in CAUTI events within ICUs nationwide. The aim of this project was to engage the frontline staff in reducing CAUTI rates in the ICU.MethodsThis project occurred on a 40 bed Intensive Care Unit (ICU) in a 350+ bed community hospital. The patient population included patients positive for COVID-19. The Shared Leadership Council (SLC), which comprised of both unit leadership and frontline staff, utilized Plan-Do-Check-Act (PDCA) framework to reduce the incidence of CAUTIs on the unit. Peri-care and catheter care was identified as a gap in recent CAUTI events. The SLC developed a 4-pronged approach to include: hand hygiene cues, peri-care and catheter care training, CAUTI prevention bundle and external device review, and Patient Care Assistants (PtCA) to champion and standardize catheter and peri-care in daily unit workflow.ResultsThe result was a reduction in the number of CAUTI events in the ICU during 2021 from 3 in Quarter 1, to 2 in Quarter 2, to 0 in Quarter 3.ConclusionsThese results support success in engaging front line staff in Process Improvement Projects aimed at reducing HAIs. The SLC identified opportunities to close CAUTI prevention bundle element gaps, developed a set of interventions, and executed the interventions in the ICU.

When TikTok Is Not Enough: Engaging Nurses at All Levels in the Advocacy Process

Nurses took to social media at the height of the pandemic. They leveraged the popular app TikTok to share their experiences with the pandemic, educate the public, combat misinformation, and used it as a tool to advocate for the nursing profession. Although many nurses leveraged this platform to educate, others used it as a platform to challenge the system and highlighted the great divide within the nursing profession. With 4.2 million nurses in the United States, it is estimated less than 10% are members of professional organizations. These professional organizations are the primary groups advocating on behalf of the profession. How are we developing legislative agenda’s that meet the need of the profession if less than 10% of nurses are engaging and speaking up? There are multiple ways nurse leaders can engage frontline staff in the advocacy process. Levels of engagement can range from within the organization to local, state, national, and global efforts. The opportunities to engage are endless. We are 4 million strong, yet we struggle to have an aligned collective voice. Our divide begins with unions versus non-unions, mandated staffing ratios versus other staffing models, associate degree versus bachelor’s degree, and so on. How do we ever expect to be heard if we are not aligning our voices and coming to consensus on what is best for the profession as a whole? Social media is not getting us in front of the right people. As leaders, we must role model what advocacy looks like and provide avenues for our nurses to engage in this process.

Implementation of initiatives designed to improve healthcare worker health and wellbeing during the COVID-19 pandemic: comparative case studies from 13 healthcare provider organisations globally

BackgroundHealthcare workers are at a disproportionate risk of contracting COVID-19. The physical and mental repercussions of such risk have an impact on the wellbeing of healthcare workers around the world. Healthcare workers are the foundation of all well-functioning health systems capable of responding to the ongoing pandemic; initiatives to address and reduce such risk are critical. Since the onset of the pandemic healthcare organizations have embarked on the implementation of a range of initiatives designed to improve healthcare worker health and wellbeing.MethodsThrough a qualitative collective case study approach where participants responded to a longform survey, the facilitators, and barriers to implementing such initiatives were explored, offering global insights into the challenges faced at the organizational level. 13 healthcare organizations were surveyed across 13 countries. Of these 13 participants, 5 subsequently provided missing information through longform interviews or written clarifications.Results13 case studies were received from healthcare provider organizations. Mental health initiatives were the most commonly described health and wellbeing initiatives among respondents. Physical health and health and safety focused initiatives, such as the adaption of workspaces, were also described. Strong institutional level direction, including engaged leadership, and the input, feedback, and engagement of frontline staff were the two main facilitators in implementing initiatives. The most common barrier was HCWs’ fear of contracting COVID-19 / fear of passing COVID-19 to family members. In organizations who discussed infection prevention and control initiatives, inadequate personal protective equipment and supply chain disruption were highlighted by respondents.ConclusionsCommon themes emerge globally in exploring the enablers and barriers to implementing initiatives to improve healthcare workers health and wellbeing through the COVID-19 pandemic. Consideration of the themes outlined in the paper by healthcare organizations could help influence the design and deployment of future initiatives ahead of implementation.

A Comprehensive Unit-based Safety Program to Improve Perioperative Efficiency in Adolescent Idiopathic Scoliosis.

Addressing operational inefficiencies in operating rooms (ORs) enhances patient access to care, reduces delays, and improves employee and patient satisfaction. The Comprehensive Unit-based Safety Program (CUSP) promotes patient safety through increased teamwork, empowerment of frontline staff, and utilization of science of safety principles. CUSP has demonstrated success in outpatient and inpatient settings to decrease complication rates and establish a culture of safety but has been used minimally in the perioperative setting. In this study, the CUSP methodology was utilized to improve perioperative efficiency in pediatric spine surgery, and preimplementation and postimplementation efficiency were compared, using the rate of first case on-time starts (FCOTS) as the primary metric. A CUSP quality improvement workgroup including nurses, technicians, surgeons, anesthesiologists, and administrators sought feedback on opportunities for improvement and tracked key performance metrics in the OR from 2015 to 2020. Key interventions developed in response to feedback included standardizing and streamlining room setup and adjusting staffing models for greater efficiency. Univariate analysis was conducted to compare time periods pre-CUSP and post-CUSP implementation. First case on-time starts increased from 38% to a high of 81% after implementation. For more complex cases, the average patient in the room to anesthesia ready time improved by 31% with decreased variance over time, and average closure to patient out of room time improved by 45%. Improvements were sustained through Year 3, while CUSP remained a primary focus for the team. CUSP is effective in enhancing perioperative efficiency, demonstrating strong improvement in on-time starts over 5 years. The results indicate that process improvement in ORs requires consistent attention to sustain gains over time. Engaging frontline staff in quality improvement fosters collaboration and provides employee buy-in to promoting a culture of safety and improving value in patient care. Level III-retrospective comparative study.

Development of a clinical practice guideline for weaning and discontinuing parenteral nutrition in hospitalized children as part of a central line-associated bloodstream infection-focused quality improvement initiative.

Overprescribing of parenteral nutrition (PN) increases costs and risks to patients, including from central line-associated bloodstream infection (CLABSI). With CLABSI reduction in mind, our children's hospital began an iterative quality improvement effort to decrease PN utilization by first ensuring appropriate initiation and then defining and ensuring appropriate discontinuation. Education was launched along with audits to evaluate for appropriate PN indications. Next, a literature review was conducted to guide the development of an algorithm to appropriately wean and discontinue PN. Lastly, all PN discontinuations were audited for agreement with the new guideline. Retrospectively, monthly PN utilization index (orders per patient-day) was plotted on a statistical process control chart to assess change over time. The presence of PN as a risk factor for CLABSI events and the overall hospital CLABSI rate were trended. Mean PN utilization index fell from 0.156 (July 2018 to January 2019) to 0.12 (February 2019 to August 2020) (P < .01). For 18 months, no PN utilization index reached the baseline lower control limit of 0.144, demonstrating special-cause variation and sustained change. PN as a risk factor for hospital CLABSI cases decreased from most prevalent (49% of cases) to fifth most prevalent (29%) as the CLABSI rate trended down. Engaging frontline staff in the development of a clinical practice guideline and increased accountability to reduce potential patient harm led to a significant and sustained reduction in PN utilization, as well as decreased prevalence of PN as a risk factor in hospital CLABSI cases.

Application of a four-dimensional framework to evaluate the quality of the HIV/AIDS data collection process in China

ObjectiveTo qualitatively evaluate the quality of the data collection process used by the Chinese national HIV/AIDS data repository (CRIMS), using a four-dimensional (4D) framework. The process is vital for the acquisition of high-quality data for ending the HIV/AIDS epidemic in China. MethodsThe study was carried out in China from September 2014 to April 2015. Stratified convenient sampling was conducted to recruit 28 study participants including health administrators, public health professionals and clinicians. Data were collected through semi-structured interviews with the participants and from field observations in six hospitals. Content analysis was conducted following the 4D Framework. Results61 percent of the facilitators and 74 percent of the barriers of the 4D Framework were confirmed in the CRIMS data collection process. The CRIMS achieved better-quality data collection management. The perceived gaps primarily included: impractical data collection protocol and invalid quality assessment mechanism for data collection management; weak leadership and unsupportive organizational policy for data collection environment; poor communication and job fatigue for data collection personnel; and inflexibility and inaccessibility of data collection system. Areas for improvement included: engaging frontline staff in the design of data collection protocol, standardizing quality assurance procedures, strengthening leadership, recognizing data collector’s contributions, and meeting end-users’ needs for the CRIMS. ConclusionThe findings generated knowledge about the quality of the CRIMS data collection process. The 4D Framework has potential as an evaluation tool for decision-makers on the improvement of the public health data collection process.

Real-Time Bedside Root Cause Analysis (RCA) as a Catalyst for Clostridioides difficile Reduction

Background:C. difficile infection has been a significant cause of morbidity and mortality over the past decade. Our hospital had rates of hospital-onset, laboratory-identified, C. difficile infection (HO-CDI) that were significantly higher than our state and national benchmarks. HO-CDI is defined as a test positive for C. difficile occurring on or after day 4 of hospitalization, regardless of the presence of symptoms. New leadership at the hospital sought a creative way to engage staff in finding solutions to our high rates of HO-CDI. Objective: The purpose of this intervention was to engage frontline staff in reporting and solving patient care situations that may increase infection risk to decrease HO-CDI rates. Methods: Starting in July 2015, real-time bedside RCAs were performed weekly for any HO-CDI on the unit to which the infection was attributed and on any unit from which the patient had been recently transferred. Top clinical leadership of the hospital, and all services and departments, physicians, nurses, and others involved with the patient’s care were expected to attend and identify factors that may have contributed to the infection. The findings were documented, and changes to care were made based on the findings. The rate of incident hospital onset HO-CDI per 10,000 patient days was used to measure outcome because standardized infection ratios for the period before 2016 were not available. Results: Staff members suggested 6 specific actions that were undertaken to decrease HO-CDI risk (Table 1). The HO-CDI rate during the preintervention period (2012–2014) was 6.85 per 10,000 patient days (275 cases). In the postintervention period (2016–2018) the HO-CDI rate was 3.13 per 10,000 patient days (101 cases). There was a 54% reduction in the HO-CDI rate in the postintervention period (P &lt; .001). Conclusions: The multidisciplinary bedside RCA process resulted in staff providing recommendations for actions to reduce HO-CDI risk. Implementation of staff suggestions resulted in a sustained, significant decrease in HO-CDI.Funding: NoneDisclosures: None

Using the Model for Improvement and Plan-Do-Study-Act to effect SMART change and advance quality.

Using the Model for Improvement and Plan-Do-Study-Act to effect SMART change and advance quality.

Let’s talk about adaptation! How individuals discuss adaptation during evidence-based practice implementation

Purpose Researchers suggest that adaptation should be a planned process, with practitioners actively consulting with program developers or academic partners, but few studies have examined how adaptation unfolds during evidence-based practice (EBP) implementation. The purpose of this paper is to describe real-world adaptation discussions and the conditions under which they occurred during the implementation of a new practice across multiple county child welfare systems. Design/methodology/approach This study qualitatively examines 127 meeting notes to understand how implementers and researchers talk about adaptation during the implementation of SafeCare, an EBP aimed at reducing child maltreatment and neglect. Findings Several types of adaptation discussions emerged. First, because it appeared difficult to get staff to talk about adaptation in group settings, meeting participants discussed factors that hindered adaptation conversations. Next, they discussed types of adaptations that they made or would like to make. Finally, they discussed adaptation as a normal part of SafeCare implementation. Research limitations/implications Limitations include data collection by a single research team member and focus on a particular EBP. However, this study provides new insight into how stakeholders naturally discuss adaptation needs, ideas and concerns. Practical implications Understanding adaptation discussions can help managers engage frontline staff who are using newly implemented EBPs, identify adaptation needs and solutions, and proactively support individuals who are balancing adaptation and fidelity during implementation. Originality/value This study’s unique data captured in vivo interactions that occurred at various time points during the implementation of an EBP rather than drawing upon data collected from more scripted and cross-sectional formats. Multiple child welfare and implementation stakeholders and types of interactions were examined.

1154. Impact of Educational Feedback on Reducing Hospital-Onset Catheter-Associated Urinary tract Infections at an Academic Medical Center

BackgroundHigh regulatory burden on hospital-onset (HO) infections has increased performance pressure on infection prevention programs. Despite the availability of comprehensive prevention guidelines, a major challenge has been communication with frontline staff to integrate appropriate prevention measures into practice. The objective of our study was to evaluate the impact of educational intervention on HO CAUTI rates and urinary catheter days.MethodsAt the University of Mississippi Medical Center, Infection prevention (IP) reports unit-based monthly HO infections via email to respective unit managers and ordering physician providers. Starting May 2018, IP assessed compliance to CAUTI prevention strategies per SHEA/IDSA practice recommendations (2014). HO CAUTI cases with noncompliance were labeled as “preventable” infections and educational justification was provided in the email report. No other interventions were introduced during the study period. CAUTI data were collected using ongoing surveillance per NHSN and used to calculate rates per 1,000 catheter days. One-way analysis of variance (ANOVA) was used to compare pre- and post-intervention data.ResultsPrior to intervention (July 2017–March 2018), HO CAUTI rate was 1.43 per 1,000 catheter days. In the post-intervention period (July 2018–March 2019), HO CAUTI rate decreased to 0.62 per 1,000 catheter days. Comparison of pre- and post-intervention rates showed a statistically significant reduction in HO CAUTIs (P = 0.04). The total number of catheter days reduced, but the difference was not statistically significant (8,604 vs. 7,583; P = 0.06). Of the 14 HO CAUTIs in post-intervention period, 64% (8/14) were reported preventable. The preventable causes included inappropriate urine culturing practice in asymptomatic patients (5) or as part of pan-culture without urinalysis (2), and lack of daily catheter assessment for necessity (1).ConclusionAt our institute, regular educational feedback by IP to frontline staff resulted in a reduction of HO CAUTIs. Feedback measure improved accountability, awareness and engagement of frontline staff in practicing appropriate CAUTI prevention strategies. Disclosures All authors: No reported disclosures.

Changing the Culture of Pediatric Palliative Care at the Bedside

Background: Pediatric palliative care programs typically have limited resources yet must meet the needs of an increasing patient population. In order to continue to provide quality care at the bedside, it is necessary to engage frontline staff in the delivery of palliative care. However, nurses report a lack of knowledge and confidence in providing the essential components of palliative care. A Palliative Care Champions Program was designed to identify and train palliative care …

Managing the Mayo Clinic brand: a case study in staff-developed service performance standards

One goal of healthcare reform in the USA is to increase the availability of quality and patient satisfaction data to help consumers choose their hospitals and doctors. This increased transparency is meant to encourage consumers to shop for health care by researching reputation, quality, price, and patient satisfaction. A strong healthcare brand, combined with a superior patient experience provided by skilled frontline service performers, can influence consumers’ healthcare choices in this highly competitive market. Through qualitative inquiry, this case study explores the reasons for service quality variation on the front line. Facilitated roundtable discussions were used to help staff define their own role-specific service performance standards and positively influence brand perception and value through improved frontline staff service performance. These methods for engaging frontline staff improved their understanding of service performance expectations, their awareness of important internal customer groups, and their self-reported willingness to serve. This case study approach to improve the patient experience may be useful to other healthcare organizations navigating an increasingly value- and consumer-driven healthcare market.

Data accuracy and completeness of monthly midwifery returns indicators of Ejisu Juaben Health Directorate of Ghana

&lt;span lang="EN-US"&gt;The broad range of activities contained in the provision of Primary Health Care (PHC) places a burden on providers to make optimal use of limited resources to achieve maximal health benefit to the population served. All too often, ad hoc decisions and personal preferences guide PHC resource allocations, making accountability for results impossible. Problems constraining Routine Health Information System (RHIS) performance in low-income countries include: poor data quality; limited use of available information; weaknesses in how data are analyzed and poor RHIS management practices. This study sought to investigate these constraints.&lt;/span&gt;&lt;span&gt; A non-experimental before and after study involving bassline assessment of data accuracy and completeness, application of innovative strategies such as mentoring and coaching of Health Information Officers in data quality improvement process. Coincidentally, the intervention &lt;/span&gt;&lt;span lang="EN-US"&gt;improved both data accuracy and completeness performance significantly among the participating facilities. The outstanding performance may be attributed to management’s new orientation and growing interest towards quality data. Engaging frontline staff in data quality improvement work and provision of regular feedback leads to improvement in data accuracy and completeness. This has implications for decision-making and resource allocation, especially in low-income countries, where the routine health information management system relies heavily on paper work&lt;/span&gt;&lt;span lang="EN-US"&gt;.&lt;/span&gt;

Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway

To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services. Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital-community interface. The initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative. The initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working. CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.

Education and engagement of front line staff to lower incidence of Clostridium difficile

Education and engagement of front line staff to lower incidence of Clostridium difficile

Engaging Learners in Health System Quality Improvement Efforts.

In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education.The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.

Using Lean to Rapidly and Sustainably Transform a Behavioral Health Crisis Program: Impact on Throughput and Safety

Lean has been increasingly applied in health care to reduce waste and improve quality, particularly in fast-paced and high-acuity clinical settings such as emergency departments. In addition, Lean's focus on engagement of frontline staff in problem solving can be a catalyst for organizational change. In this study, ConnectionsAZ demonstrates how they applied Lean principles to rapidly and sustainably transform clinical operations in a behavioral health crisis facility. A multidisciplinary team of management and frontline staff defined values-based outcome measures, mapped the current and ideal processes, and developed new processes to achieve the ideal. Phase I was implemented within three months of assuming management of the facility and involved a redesign of flow, space utilization, and clinical protocols. Phase II was implemented three months later and improved the provider staffing model. Organizational changes such as the development of shift leads and daily huddles were implemented to sustain change and create an environment supportive of future improvements. Post-Phase I, there were significant decreases (pre vs. post and one-year post) in median door-to-door dwell time (343 min vs. 118 and 99), calls to security for behavioral emergencies (13.5 per month vs. 4.3 and 4.8), and staff injuries (3.3 per month vs. 1.2 and 1.2). Post-Phase II, there were decreases in median door-to-doctor time (8.2 hours vs. 1.6 and 1.4) and hours on diversion (90% vs. 17% and 34%). Lean methods can positively affect safety and throughput and are complementary to patient-centered clinical goals in a behavioral health setting.