Quality Improvement (Lean)

Our Lean Journey

In 2013, following the ThedaCare model (from a US healthcare facility based in Appleton, Wisconsin), Pembroke Regional Hospital embarked on a journey to implement a Lean Management System that supports a culture of continuous improvement. Our goal “ to develop our people to solve problems and improve performance which results in enhanced patient care and increased staff satisfaction”.


Our Lean Management System is now used hospital-wide. Since April 2013, our employees and physicians have identified and implemented over 3,000 improvements through improvement huddles. 


What is Lean? 

More than an improvement project, Lean healthcare is a system of process management which helps improve the flow of information from the front lines to senior leaders and back, fosters the engagement of all employees in process improvement, and allows for daily coaching and teaching. This approach is now being used in many fields including healthcare where Lean is improving patient flow and adding value to each patient’s care experience.

Lean healthcare is about maximizing value for our patients.


Lean healthcare is about continuous quality improvements while eliminating unnecessary steps. In the Lean way of thinking, the organization relies on the expertise of its frontline workers to identify improvement opportunities, to lead changes and to solve problems.


Lean healthcare is about providing the right service, when it is needed, the right way, the first time.


Quality Improvement Work at Pembroke Regional Hospital 

  • Using the Lean Management System, 26 of our departments have regular stand-up meetings to discuss, initiate and implement quality improvements at PRH.


  • Priorities for the hospital are identified annually through the Quality Improvement Plan (QIP), and shared with the health care team. In 2022-2023, those goals were: 


Patient and Family Experience: Ensuring patients and families feel informed about the care they are receiving and are involved in care decisions

Provider Experience: Stabilizing hospital workforce through innovative staffing models 

Provider Experience: Create a workforce that has a strong leadership and can respond to the current needs of the population seeking care (Provider Experience) 

Best Possible Health Outcomes: Ensure Pembroke Regional Hospital maintains Accreditation from Accreditation Canada


  • Our teams work to support these priorities by implementing improvements within their departments that are directly linked to the Quality Improvement Plan.   


Quality Improvement 2022-2023

Our Strategic Plan  

Graphic outling aspects of strategic plan  


 Our Quality Improvement Plan 2022-2023  Quality improvement plan graphic

Quality Improvement Work at PRH 2022-2023   

Patient and Family Experience


  • Redesigned whiteboards in patients' rooms to include more information to keep patients and families better informed about their condition and treatment. 
  • Created a French version of the Bereavement Resource Package to give to French speaking families.  


Acute Mental Health

  • Created an information sharing board on the unit to educate patients and families about resources available in the community. 
  • Provided education to staff regarding involvement of families in care planning and redesigned discharge sheet to track the percentage of families who are involved. 


  • Created a virtual tour video of the labour and delivery floor and uploaded this to the PRH website for expectant mothers to be able to view ahead of time.  


Vascular Health 

  • Standard work created for paediatric consultation referrals for more timely and standardized follow-up.  


Human Resources

  • Implemented a digital process for the identification of French-speaking staff currently working to better serve French speaking patients.  


Provider Experience

Inpatient Rehabilitation

  •  A standard sheet was created to help Health Care Aides make notes throughout the day to better manager their workflow.   

Emergency Department 

  • Camera was installed in Zone B in order to improve visibility for patient and staff safety.  


Human Resources 

  •  Reorganized department structure to assign staffing clerks to department-specific portfolios.  



  • Created a list of daily duties to share with staff from other departments who are helping out on unit.  


Systemic Therapy  

  • Updated telemedicine system for an improved provider and patient experience.  


Value and Efficiency


Acute Mental Health

  • Created a transfer envelope with pre-populated checklist for patients being transferred to other facilities.  


Medical Device Reprocessing

  • Created a process to identify stilette blade for ICU to reduce accidental disposal.  



  • Created an "on-call" form to more easily identify which surgeon is currently on call and the process to follow. 
  • Began stocking a new medication on the unit for easier accessibility.  


Environmental Services

  • Relocated supplies that are needed every day to a more easily accessible storage area. 



  • Added a digital whiteboard to track and display outpatient procedures happening on the unit.  


Clinical Administration

  • Created standard work for internal memos in hospital as well as an archiving system.  



  • Reorganized and alphabetized the medication shelves in the pharmacy.  


Intensive Care Unit

  • Combined two different storage locations into one space to improve accessibility and time wasted searching for items.  


Materials Management

  •  Implemented new dual monitors for purchasing clerks to improve efficiency when working.  



  • Created new accounts and reports to reduce errors. 
  • Worked with Mental Health Services department to set up automatic payment options for clients paying rent.  


Information Technology 

  • Implemented a new voicemail message to indicate to staff that they are aware of hospital-wide IT issues to reduce the number of voicemails they receive about the same issue.  


Ambulatory Clinics 

  • Created and online calendar for daily doctors so that it is accessible to everyone in the department.  


Best Possible Health Outcomes 

Operating Room 

  • Created an emergency scope bucket for faster response to Code Omegas and is available in the Operating Room at all times. 

Outpatient Rehabilitation

  • Added distance markers in the ICU to be able to assess patient's stability and mobility.  



  • Worked with pharmacy to improve identification of two medications with very similar packaging to prevent errors. 


Vascular Health 

  • Reimplemented fall prevention surveys and identification bracelets to meet fall prevention guidelines.  

























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