A Qualitative Study of the Theory Behind the Chairs: Balancing Lean-Accelerated Patient Flow With the Need for Privacy and Confidentiality in an Emergency Medicine Setting

Elaine Zibrowski; Lisa Shepherd; Richard Booth; Kamran Sedig; Candace Gibson

doi:10.2196/11714

A Qualitative Study of the Theory Behind the Chairs: Balancing Lean-Accelerated Patient Flow With the Need for Privacy and Confidentiality in an Emergency Medicine Setting

JMIR Hum Factors. 2019 Feb 6;6(1):e11714. doi: 10.2196/11714.

Authors

Elaine Zibrowski¹, Lisa Shepherd², Richard Booth³, Kamran Sedig^{1

4}, Candace Gibson⁵

Affiliations

¹ Health Information Science, Faculty of Information & Media Studies, University of Western Ontario, London, ON, Canada.
² Department of Medicine, Division of Emergency Medicine, University of Western Ontario, London, ON, Canada.
³ Arthur Labatt Family School of Nursing, University of Western Ontario, London, ON, Canada.
⁴ Department of Computer Science, University of Western Ontario, London, ON, Canada.
⁵ Department of Pathology, University of Western Ontario, London, ON, Canada.

PMID: 30724743
PMCID: PMC6381406
DOI: 10.2196/11714

Abstract

Background: Many emergency departments (EDs) have used the Lean methodology to guide the restructuring of their practice environments and patient care processes. Despite research cautioning that the layout and design of treatment areas can increase patients' vulnerability to privacy breaches, evaluations of Lean interventions have ignored the potential impact of these on patients' informational and physical privacy. If professional regulatory organizations are going to require that nurses and physicians interact with their patients privately and confidentially, we need to examine the degrees to which their practice environment supports them to do so.

Objective: This study explored how a Lean intervention impacted the ability of emergency medicine physicians and nurses to optimize conditions of privacy and confidentiality for patients under their care.

Methods: From July to December 2017, semistructured interviews were iteratively conducted with health care professionals practicing emergency medicine at a single teaching hospital in Ontario, Canada. The hospital has 1000 beds, and approximately 128,000 patients visit its 2 EDs annually. In response to poor wait times, in 2013, the hospital's 2 EDs underwent a Lean redesign. As the interviews proceeded, information from their transcripts was first coded into topics and then organized into themes. Data collection continued to theoretical sufficiency.

Results: Overall, 15 nurses and 5 physicians were interviewed. A major component of the Lean intervention was the construction of a three-zone front cell at both sites. Each zone was outfitted with a set of chairs in an open concept configuration. Although, in theory, professionals perceived value in having the chairs, in practice, these served multiple, and often, competing uses by patients, family members, and visitors. In an attempt to work around limitations they encountered and keep patients flowing, professionals often needed to move a patient out from a front chair and actively search for another location that better protected individuals' informational and physical privacy.

Conclusions: To our knowledge, this is the first qualitative study of the impact of a Lean intervention on patient privacy and confidentiality. The physical configuration of the front cell often intensified the clinical work of professionals because they needed to actively search for spaces better affording privacy and confidentiality for patient encounters. These searches likely increased clinical time and added to these patients' length of stay. We advocate that the physical structure and configuration of the front cell should be re-examined under the lens of Lean's principle of value-added activities. Future exploration of the perspectives of patients, family members, and visitors regarding the relative importance of privacy and confidentiality during emergency care is warranted.

Keywords: Lean health care; emergency medicine; privacy and confidentiality; qualitative research; work intensification.

©Elaine Zibrowski, Lisa Shepherd, Richard Booth, Kamran Sedig, Candace Gibson. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 06.02.2019.