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The General now sits in the middle of the pack among large teaching hospitals, with infection numbers similar to several comparable hospitals in Toronto, Hamilton and London. The Civic is at the low end among comparable hospitals, with C. difficile infection numbers almost identical to those of three Toronto hospitals: St. Michael's, Princess Margaret and Toronto Western. Moreover, the General campus beat the hospital's target of 0.45 infections per 1,000 patient days seven out of 12 months last year.

In 2013, it did that only twice. The Civic was below target 10 out of 12 months in 2014 after doing so only four times the previous year. "We're very pleased to see the rates come down," said Dr. Kathy Suh, the hospital's medical director of infection prevention and control. "It's been a long time coming for us.

"We've had our challenges, which have been quite prolonged, with C. difficile, so we're pleased to see the rates drop like this." C. difficile, which is found in stool, is typically spread in hospitals after patients or stafftouch soiled surfaces such as toilets, handles and bedpans. Patients taking antibiotics are especially vulnerable because the medication kills good bacteria as well as bad, allowing C. difficile bacteria to multiply more easily.

Suh attributed the reduction to several initiatives, including an emphasis on hand hygiene, the use of bleach to clean patients' rooms and a program to improve the use of antibiotics, a key driver for C. difficile. A team of physicians and pharmacists reviews individual cases to ensure that antibiotics are only used when necessary, that they're stopped when no longer needed and that the most appropriate antibiotics are prescribed, Suh said. The hospital also continues to use anti-infection "SWAT teams," first introduced two years ago, whenever cases of C. difficile are diagnosed. The multi-disciplinary teams review processes in the affected unit and ensure that patients are promptly isolated and tested.

It all seems to be working. The General reported just three new C. difficile cases in December, a month when infections often spike. In December 2013, for example, it reported 11 new cases. In December 2012, there were 15. At the Civic, there were seven new C. difficile infections in December, the most since February 2014. But most months, the numbers have been low. In three separate months - June, August and November - the Civic reported just a single new infection.

The hospital's objective is to keep infection rates below the 0.45 threshold, Suh said.

BY THE NUMBERS C. difficile infections in Ottawa hospitals in 2014 (2013 numbers in brackets) 74 (112) Ottawa Hospital, General campus 45 (81) Ottawa Hospital, Civic campus 25 (28) Queensway-Carleton Hospital 18 (23) University of Ottawa Heart Institute 19 (34) Montfort Hospital 14 (12) Children's Hospital of Eastern Ontario

Smith’s physician belongs to one of Ontario’s 184 family health teams, the one-stop medical shops that the provincial government has trumpeted as the future of primary care.

"After my first visit with Christine, everything about losing weight finally just clicked," says Cooper. Shaddick not only discussed daily calorie needs, but also explained the role of protein, fibre, and fruit and vegetables, including why, when and how he should be incorporating them in a healthy lifestyle. It was this knowledge that helped him to adapt to every situation, control his blood sugar, and ultimately facilitate weight loss.

I loved that while Dr. House gave me the diagnosis, he referred me to other members of my care team who have the specific expertise and education to help me make improvements to my health," says Cooper. To support his challenging lifestyle changes, his care team was available in person, on the phone or by email throughout his journey. Cooper also utilized CarebookT, the Centre's convenient online health-management system, to track progress, check test results and stay motivated. This high level of personalized care and attention along with support from his wife and family helped ensure his changes were sustainable. "Christine warned me that the weight loss would be slow because I was making a lifestyle change, but I wanted it to be slow. This was not a quick fix, this was a permanent change," says Cooper, who also upped his exercise regimen to a minimum of one hour of cardio per day. "I began planning what I would eat every day and sometimes even weekly. If I knew I had a client-dinner coming up, I would check the restaurant menu in advance to pre-select a healthy option," he says.

His efforts paid off. Only four short months since his Prevention Screen, Cooper was 28 pounds lighter with significantly improved health numbers. His good cholesterol levels were up; he had dramatically lowered his triglycerides and brought his blood sugar back down to a normal, healthy level. He no longer had Metabolic Syndrome, nor was he at risk of Type 2 diabetes. "It was a total game-changer," says Cooper. "I feel 100-per-cent healthier. I have more energy, strength, and better stress management - I feel like a success story!" Cooper plans to continue along his healthy path indefinitely, and looks forward to making further improvements to his health and fitness, while inspiring others to do the same.

It was thanks to his health care team, who provided the right motivation, necessary support and knowledge, that he was able to change his game. He couldn't be more satisfied with the return on his investment in Copeman Healthcare, he says. "It's like a five-star hotel experience and it's worth it. Most people spend more on two dinners out a month or a new outfit. They just need to decide what is more important: life or a pair of pants?"

The provinces will look to expand a collective drug-purchasing plan, set new guidelines to cut the number of unnecessary medical procedures and improve home care for senior citizens. These strategies were on the table Friday as provincial health ministers hunkered down in Toronto for two meetings on overhauling the nation's universal health-care system and wrestling down its cost.

The greatest cost pressure on the system, however, may be the demographic shift and the steady rise in the number of senior citizens requiring chronic care.

The second, chaired by Ontario Health Minister Deb Matthews, focused on dealing with the nation's aging population.

The provinces are also looking at ways to cut back on pricey diagnostic tests and surgeries such as MRIs, knee replacements and cataract removals. After consulting with health-care professionals, they hope to draw up a series of voluntary guidelines, to be presented this summer, on when such procedures are necessary and when they can be skipped.

The provinces will look to expand a collective drug-purchasing plan, set new guidelines to cut the number of unnecessary medical procedures and improve home care for senior citizens. These strategies were on the table Friday as provincial health ministers hunkered down in Toronto for two meetings on overhauling the nation's universal health-care system and wrestling down its cost.

The first session was part of the Health Care Innovation Working Group

The first session was part of the Health Care Innovation Working Group

The second, chaired by Ontario Health Minister Deb Matthews, focused on dealing with the nation's aging population.

Last year, the working group produced a deal that saw the provinces and territories, with the exception of Quebec, team up to purchase six generic drugs in bulk, which resulted in savings of $100-million annually.They want to take a similar approach to buying name-brand medicines. Mr. Ghiz estimated such a plan could save $25-million to $100-million more.

Last year, the working group produced a deal that saw the provinces and territories, with the exception of Quebec, team up to purchase six generic drugs in bulk

They want to take a similar approach to buying name-brand medicines. Mr. Ghiz estimated such a plan could save $25-million to $100-million more.

The provinces are also looking at ways to cut back on pricey diagnostic tests and surgeries such as MRIs, knee replacements and cataract removals. After consulting with health-care professionals, they hope to draw up a series of voluntary guidelines, to be presented this summer, on when such procedures are necessary and when they can be skipped.

The greatest cost pressure on the system, however, may be the demographic shift and the steady rise in the number of senior citizens requiring chronic care.

finding ways to keep seniors out of hospital.

For all the provinces' innovations, however, Mr. Ghiz said they could use more help from Ottawa.

“Hopefully, some day, the federal government will be at the table with dollars and with ideas – we're open

"I think these are a real bonus to our units," said Worthington of the specialized teams made of housekeeping and infection control staff.

The risk of developing the infection in hospital is about 1%, he said.

So in their study, Report on Food Provision in Ontario Hospitals and Long-Term Care Services: The Challenges and Opportunities of Incorporating Local Food, it follows that Padanyi and her team found substantial barriers to requiring that all public health-care facilities in Ontario incorporate local food into their patient and visitor food service.

Realistically, though, not much will change on the hospital-food frontier as long as the province gives hospitals peanuts for food care. True, no one checks into the hospital for its food. But it's sure one more reason to check out.

Having looked at some institutional case studies in our area, they say local food can be offered to patients and residents very successfully, on a facility-by-facility basis.

Simply put, we're not there yet. We have a hard enough time agreeing on the definition of local food, let alone providing it en masse to sick and elderly people.

Report on Food Provision in Ontario Hospitals and Long-Term Care Services: The Challenges and Opportunities of Incorporating Local Food

Karl Rinas, 61, who was treated for a bleeding ulcer at a Leamington, Ont., hospital last February, says he ended up wiping down the bathroom himself after his complaints about the dried liquid waste he found on the floor and toilet seat failed to get a reaction, but he worried about older, less mobile patients.

Despite all her efforts, Martin says she has no doubt that the antibiotic-resistant superbug Clostridium difficile infection her mother contracted soon after surgery was related to the hospital's level of cleanliness.

"I know everybody nowadays has to work more with less, but to me, a hospital should be absolutely clean," she said.

Of the respondents who wrote into the fifth estate's survey about being harmed in hospital, most said the harm was a hospital-acquired infection such as MRSA and C. difficile.

Unlike in the food industry, there are no standardized inspections for cleanliness in hospitals.

A World Health Organization report that compared Canada's infection data with that of 12 other wealthy countries found that Canada had the second-highest prevalence (11.6 per cent) of hospital-acquired infections after New Zealand — much higher than that of Germany (3.6 per cent) or France (4.4 per cent).

Is outsourcing to blame?Those who work in hospitals have pointed to the increased outsourcing of housekeeping in recent years as one reason behind the decline in hospital cleanliness that patients and hospital workers have observed

The Canadian Nosocomial Infection Surveillance Program is the closest thing to a federal overview that Canada has, but it relies on voluntary reporting by only 54 hospitals in 10 provinces, most of them teaching facilities, which, according to infection control experts, generally have higher infection rates than other acute care hospitals because they tend to see more seriously ill patients.

But health authorities in other countries are moving away from private cleaning services. Four years ago, Scotland reversed its decision to allow outsourcing of cleaning and catering services because it felt private contractors were not doing a good enough job keeping the spread of infections in check.

Blamey says as long as housekeeping is done on a for-profit basis, employers will reduce the number of staff and cut corners on staff training and cleaning supplies.

"There's no question there's been an impact on the quality of cleaning, and you can see that throughout the years as various hospitals have struggled with very high-profile superbug outbreaks," said Margi Blamey, spokesperson for the Hospital Employees' Union (HEU), which represents 41,000 hospital cleaning and support staff in B.C.

Michael Gardam, who oversees infection prevention and control at the three hospitals that are part of Toronto's University Health Network, agrees that hospitals have fewer resources for housekeeping these days and have to concentrate cleaning on areas that are most likely to transmit bacteria — primarily the surfaces that multiple patients touch.

"I probably get more emails about dust bunnies in the stairwells than anything else in the hospital, and yet, we've done that for a reason. You're not going to catch anything from a stairwell, but you're going to catch it from your bed rails," Gardam said.

About two-thirds of hospital-acquired infections are preventable, Gardam said, but making a direct link between cleanliness and infection is not as straightforward as it might seem. Some hospital-acquired infections such as ventilator-associated pneumonia or central line-associated bloodstream infections have little to do with the hospital environment and can be controlled through proper protocols around equipment use. But a superbug like C. difficile is a lot trickier because it is hard to pinpoint its source.

Increasing cleaning staff on nights and weekends could also help. A typical medium-sized B.C. hospital that contracts out cleaning services has 24 cleaners by day but only four at night, says Blamey, and workers are often not backfilled when ill or on vacation.

"Bacteria don't care what time it is," said Gardam.

The infection expert says it doesn’t matter whether a private or public entity oversees cleaning; both have had problems with cleanliness. The bottom line is that hospitals generally undervalue the importance of cleaning staff, Gardam said.

"People don't really think of them as part of the team, but if you think about how infections are spread in hospitals, they're actually an incredibly important part of the team that goes far beyond just the cosmetic appearance of the room."

Staffing levels in nursing homes are a concern not only because they are low, but they may not be increasing fast enough to meet the rising medical complexity of patients in nursing homes.

Data from the Canadian Institute for Health Information shows that between 2008 and 2012, the proportion of residents in Canadian nursing homes with disease diagnoses increased for every category of disease.

Dementia is also increasingly common among Canadian nursing home residents, with over three quarters of residents having some level of cognitive impairment. More than one in four residents suffers from severe dementia.

As a result, the care needs of nursing home residents have grown. In Ontario, care needs are assessed using the Method for Assigning Priority Levels (MAPLe) scoring system. The system ranges from a score of 1 (low needs) to 5 (very high needs). In 2012, 85% of new admissions from the community and 78% of admissions from hospital were in the High or Very High (MAPLe 4 and 5) clinical needs categories. Less than 1% of admissions were in the low and mild (MAPLe 1 and 2) clinical needs categories. Projections from the Ontario Long Term Care Association suggest that soon virtually all patients admitted to nursing homes will be from the two highest need categories.

The increasing needs of nursing home residents in Ontario has been driven in large part by the shift from letting individual nursing homes choose their residents, to having Community Care Access Centres determine who is in greatest need of long term care, says Dr Samir Sinha, lead for Ontario’s Senior Strategy

Ontario has begun to increase both the number and skill sets of nursing home staff, while also trying to find efficiencies to free up more staff time for direct patient care.

“One of the most promising initiatives to date has been Behavioral Supports Ontario (BSO),” says Sinha. The BSO initiative is province-wide, and has funded the hiring of 604 new staff (194 nurses, 272 PSWs, and 138 other health care professionals, such as social workers) with specialized skills in caring for and supporting residents with complex and challenging behaviors, such as violence.

Researchers and policy strategists in Alberta believe another key to improving quality in nursing homes is to engage Health Care Aides (HCA in Alberta is the rough equivalent of a PSW) as full members of the care team.

Carole Estabrooks, a Professor of Nursing at the University of Alberta has been researching the engagement of HCAs in quality improvement for the last several years. She believes that too often, HCAs are not treated as members of the care team. “Care Aides typically have the least amount of formal training, and as a result doctors, nurses and others too often assume they have nothing to offer,” she says. Frequently, this means they have little input into the care plans they are expected to carry out.

"BLMTO, our ally team, Toronto's dedicated community organizers and new converts alike have been keeping #TentCity alive." These are the words of Janaya Khan, co-founder of the Black Lives Matter Toronto chapter. Khan is referring to the March 2016 occupation outside Metro Toronto Police Headquarters, where demonstrators gathered to protest police violence and anti-Black racism. The ally team consisted of Indigenous, labour and community groups, all of whom played a pivotal role in helping to occupy the space.

Canada ranked No. 8 last year on the United Nations human development index, but the same indicators would place indigenous people in Canada at about 63, added Hoskins.“These inequities can no longer be ignored,” he said. “It’s not up to First Nations to right the wrongs of colonization. Government must invest in meaningful and lasting solutions so communities can heal and have hope.”

The Ontario plan will increase physician services for 28 communities across the Sioux Lookout region in the north by up to 28 per cent, and establish up to 10 new or expanded primary care teams that will include traditional healing.There will also be cultural competency training for front-line health-care providers and administrators who work with First Nations communities, more public health nurses and a dedicated medical officer of health.The government says it will also increase access to fresh fruits and vegetables for about 47,400 indigenous children, and expand diabetes prevention and management in northern and remote communities.

ONE MILLION GOOD JOBS

A national climate strategy holds incredible potential for the labour movement. That's why the Canadian Labour Congress teamed up with a number of environmental organizations and First Nations to deliver a proposal to the prime minister in advance of the Vancouver meeting. The proposal, called "One Million Climate Jobs," presents a plan to address poverty and tackle climate change by creating jobs.

Yet most premiers are still intent on developing fossil fuel projects and Trudeau still trumpets pipelines.

EXTREME FIRES, VIABLE ALTERNATIVES In May, Canada experienced one of the worst natural disasters our country has ever seen. The devastating wild fire

A number of recent reports, including a landmark study by a global team of researchers at Stanford University, have demonstrated that Canada could switch to renewables by 2030. Indeed, renewable energy sources are already powerful and efficient enough to be a viable alternative.

Environmental groups and the Canadian Labour Congress have called for an end to fossil fuels by 2050. The extra 20 years provides a realistic timeline that also allows Canada to retrain workers as it gradually shuts down all oil, coal and natural gas projects.

The rate of unionization of all workers has been falling for decades. In 1982, it was 38 per cent. In 2014, it reached an historic low of 28 per cent. That downward trend will continue unless unions find ways to organize new sectors of workers.

Iron and Earth, a non-profit organization led by oil sands workers, plans to retrain over 1,000 oil and gas electricians in solar installation within three years.

Most Canadian hospitals have long since given up the basics, such as distilling soup stock from simmered bones, in favour of convenient powdered mixes. Some have gutted kitchens altogether, lured by the 30-per-cent labour cost savings that comes with installing what the industry terms “kitchen-less” systems. These consist mainly of “re-thermalization” units used to reheat food that is prepared offsite in massive kitchens.

Ms. Maharaj’s mission is to prove that scratch cooking is a feasible panacea in this publicly funded, cash-strapped system. She’ll try to do it by shifting the hospital’s procurement – when it’s cheaper – to produce certified by the sustainability inspection group Local Food Plus.

a $191,000 grant from the provincial government and the Greenbelt Fund

40 U.S. hospitals run by the firm Kaiser Permanente have transformed themselves into community food hubs by hosting farmers’ markets

Leslie Carson, manager of food and nutrition at St. Joseph’s Health Centre in Guelph, a 330-bed facility with acute and long-term care patients, would disagree, having recently shifted her facility back to scratch cooking.

Debbie Lennox, a cook employed by the hospital since the ’80s

Paul Sawtell, owner of the Toronto-based distributor 100km Foods Inc. “The red herrings … about local food being more expensive are slowly being proven incorrect.”

The PQ also wants to ensure every Quebecer has a family doctor, something it plans to accomplish in the next four years. To do this it will expand the current model of team-based primary care called groupes de médecine de famille (GMFs) – adding 61 to the current complement of 244 at a cost of $36 million, according to the party’s financial plan.

Furthermore, the PQ wants more emphasis on the health-care “team” by making better use of nurses (including more nurse practitioners), pharmacists and others. The financial plan earmarks another $60 million for additional manpower in GMFs.

The PQ would also move ahead with activity-based funding for hospitals

The PQ has not said categorically that it would do away with the ASSS, but during its time in opposition it said the health ministry is overly involved in day-to-day operations of health care.

One promise that will please taxpayers is the elimination of the provincial health premium – a $200 head tax – that collects about $1 billion a year

The PQ would recoup about 60 per cent of the revenue lost from the premium by adding two new income tax brackets for people earning more than $130,000 and $250,000 per year.

The immediate, in-ambulance care for patients with severe heart attacks has saved one in 100 such patients

During the first stage of the research, trained paramedics will deliver the confirmed lab results directly to the emergency doctor. That could save the 45 to 60 minutes it would normally take for a blood test to be done in the hospital, sent to a nearby lab, and results delivered.

If that initial phase proves beneficial for patients, paramedics will then begin sending the blood results to an on-call physician via a smartphone. That physician can then guide the paramedic team to give treatment right away.

The paramedics may also be counselled to drop off patients with milder heart attacks at the catheterization labs at the University or Royal Alexandra hospitals, where they would wait three to six hours to have a balloon inserted to clear the blockage. Normally, patients face a three- to four-day delay in hospital to access that lab, Welsh said.

such expedited care could save the health system money by reducing hospital stays to two days for such patients instead of the usual five to seven.

People who already have dementia or are particularly frail are at higher risk of acquiring the condition.

Once in hospital, delirium can be caused by a combination of numerous factors, including surgery, infection, isolation, dehydration, poor nutrition and medications such as painkillers, sedatives and sleeping pills.

The primary symptoms are shifting attention, poor orientation, incoherence and poor cognition. Most patients who acquire it must subsequently spend extended periods of time in expensive acute care settings. Some who suffer from the condition experience hallucinations and become aggressive and belligerent. Others, however, become sleepy and lethargic, their silence making the delirium more difficult to detect.

Treating delirium involves providing good basic care, such as ensuring patients are getting enough fluids and nutrients. It also includes reorienting them to their surroundings. Family members should ensure elderly patients have their hearing aids, dentures, glasses or whatever else they need to engage their senses. Other things that can help include daily exercise, removing medications if possible and surrounding patients with familiar objects.

delirium can cause permanent damage to cognitive ability and is associated with an increase in long-term care admissions

Alagiakrishnan is the lead author of a study that concluded health care professionals are not doing enough to identify the predisposing and precipitating factors that lead to delirium, a sentiment echoed by many in the field of geriatric medicine (Can Fam Physician 2009;55:e41-6). The study assessed 132 patients ages 65 and older who were admitted to medical teaching units at the University of Alberta Hospital over a seven-month period and found that 20 of those patients, or 15.2%, developed hospital-acquired delirium.

In Vancouver, British Columbia and Edmonton, Alberta, for example, hospitals have created “acute care for the elderly” units based on a model of elderly care which features multidisciplinary teams of specialists; elderly-friendly surroundings, including comfortable chairs and furnishings such as clocks with large faces and numbers; and policies designed to promote independence and cognitive stimulation, such as requirements that patients use bathrooms rather than bedpans and that they have their meals at central locations rather than in bed. In an effort to be elderly-friendly, other hospitals have introduced such measures as emergency room teams dedicated to detecting delirium or hired staff such as geriatric emergency nurses.

“In pockets, this is happening, but we need a more concerted movement,” says Wong.

It also leads to complications, such as pneumonia or blood clots

“We need to change how we are caring for patients in hospitals and get back to focusing on basic health care needs,” says Dr. Jayna Holroyd-Leduc, an associate professor of geriatrics at the University of Calgary in Alberta.

In a recent paper, Holroyd-Leduc and colleagues found that most interventions for hospital-induced delirium involve strategies to optimize sensory input, improve orientation, provide familiar objects and encourage family visits (www.cmaj.ca/lookup/doi/10.1503/cmaj.080519).

It will be the largest scale initiative ever undertaken in Canada. Within five years, it will involve 30 per cent of Canadians from coast to coast, testing new innovative models of care, monitoring success and engaging a national and international network of senior policy-makers to investigate the conditions that will be necessary to scale up successful models of care. We will no longer be a country of pilot projects.

Dr. Armstrong: What we propose in our assessment is to redesign the way the health professions work with each other. As opposed to solo practitioners, we believe they should be integrated, and we believe this requires a substantial cultural change because the historical divisions around scopes of practice have led to a silo mentality, and the future is clearly an integration one.

Assuming we have an accord in 2014 to succeed this one, and assuming similar funding methods are used, what are the main proposals or incentives you think should be put to the provinces?

Dr. Armstrong: I believe we need to establish national standards and make our system accountable. We need to measure those standards. We need to get return on our investment that is more meaningful than we have in the past, and we need to emphasize innovative transformative change, then publish the results on an annual basis.

one of the gaps you are referring to is the lack of a robust, country wide technology assessment system

We take it for granted that we practice evidence-based medicine, but in fact we do that only in part.

We talk about 5 million Canadians not having access to a family doctor, but they should have access to an integrated health care team where the first point of care would not necessarily be a physician.

Public health interventions aimed at improving quality of lifestyle, food security and tax reforms with respect to sales tax on foods will be a way forward.

Not all physicians should be trained the same way and, indeed, for many the training is too long.

Dr. Tamblyn: I think you need to focus on the outcomes you are wanting to achieve in accordance with basic principles that we have been known for internationally, which is equitable access, appropriate care and so on, but you need to focus on preventing disease, reducing disparities and improving outcomes, and then you need to put something in an innovation fund to actually make that happen.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness. The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

checklists, standardization and nonstop brainstorming with front-line staff

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward. Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information. “The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods

the Lean Enterprise Institute

George Labovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Joan Wellman & Associates, a process improvement consulting firm in Seattle

examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

it never ends

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.