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Author: Thomas Damiano, MD
Christiana Care Health System
Originally Published: Modern Resident February/March 2013
One of the first responses when asked what field of medicine I practice following “that must be interesting work,” undoubtedly becomes “the waits are awfully long.” The demand for emergency services has far outpaced supply over the last two decades. Administrators across the country are looking to the Lean philosophy to help deal with ED operational improvement. From a Lean perspective, resident involvement in advancing ED operations is essential.
If one were to search “Lean,” results mentioning Toyota, various courses offering black belts and attempts at definitions may quickly confuse the inquirer. Lean has nothing to do with sticking accelerator pedals (too soon?). Courses are not taught by Chuck Norris (although I would be the first to sign up). Rather, Lean is a term for a production philosophy with the central concept that the expenditure of resources for any goal other than adding value for the customer is wasteful and should be minimized. Lean involves various tools for operational improvement and seeks to foster “a community of scientists” to employ these tools.
Many of the tools and principles of the Lean philosophy applicable to ED operations and health care in general were popularized in the manufacturing industry, particularly the Toyota Production System. As such, a variety of Japanese terms becomes the vernacular when discussing Lean tools. However, the concepts rather than the terms are useful.
The central concept of Lean health care is creation of value for the patient. The patient obtains value at the emergency department by seeing the doctor, having his or her problem diagnosed, treatment initiated and appropriately dispositioned on the path to wellness. Anything outside of these is considered muda, translated as waste or non-value-added.
Efforts should be focused to decrease the often described eight forms of muda. Movement of staff, and transportation of patients and equipment should be minimized. Stocks of supplies should be both properly managed and properly positioned. Obviously, waiting should be minimized but if it cannot, patients feel better if they are either waiting for results or informed of why they are waiting. Redundancy of questioning and ordering unnecessary tests contributes to waiting. Tasks should be completed correctly the first time. Wasting staff ideas to continuously improve the system must be avoided.
All staff should feel empowered to try to improve the system with the understanding that ideas will be respected and rewarded. Residents are often a link between attendings, nursing staff, ancillary staff and admitting teams. They are fresh in the system and often full of energy. As such, residents should ideally participate in the Lean tool of value stream mapping.
Value stream mapping involves members from departments involved with a process coming together to document all the steps and find waste or ways to improve the process. The multidisciplinary team assembles in the gemba, or meeting place, near or in the work area. The team walks through the process, taking note of the multiple steps involved and where the value from the patient perspective lies. Traditionally, the team places various colored sticky notes on a large paper with each step in the process, changing colors for value-added versus non-value-added steps. The teams should then walk through the process a second time, clocking duration of tasks and waiting as well as measuring distances traveled. Once the map accurately describes the process, brainstorming sessions commence looking for ways to increase the ratio of patient added value to non-value-added.
We have all walked into an ED storage room looking for a particular supply and spent inordinate time scanning across heaps of rarely used, or even expired inventory. Organization of the workplace environment is a vital component of efficiency. A fundamental tool of Lean processes is called 5-S. The 5-S’s are Japanese terms that translate nicely to five English terms: sort, simplify, sweep, standardize and sustain. Items are rationally organized with standardized visual cues so that anyone should be able to find any item. The need for replacement can easily be signaled if organized in kanbans, or visual cues based on the industrial pull model that items need replenishment. For instance, shadow boarding can be used to easily denote an item is missing, or simply a card showing the usual time needed to obtain an item from the manufacturer, and minimum stock required so it never runs out. A kaizen, or improvement group meeting in the gemba, can chop minutes off your daily wasted time by applying the 5-S concepts to trays, supply carts and whole supply rooms.
Beyond inventory organization, Lean flow and rapid turnover are other concepts important to improving metrics such as door-to-doc time, and ultimately, patient outcomes and satisfaction. Focus should be placed on value-added steps from the patient perspective. For instance, if residents and attendings are free they can eliminate waste by entering patient rooms during nursing assessments together to avoid repetitive questioning and to “get everyone on the same page.” While it may be uncomfortable to break from “the way we have always done it,” using rapid cycle testing to show measurable improvement makes such an example catch on and become the new culture.
Small improvements effect the big picture. While residents may only be peripherally aware of metrics in the ED, the government is attentive and already attaching reimbursements to meeting metrics. Concerns about lack of resident experience secondary to decreased duty hours can be obviated if residents can see more patients in a shorter amount of time in an efficient system. While residents focus on obtaining the knowledge base and procedural competency to care for patients, an understanding of ED operational improvement and contributing to such, helps care for our patients and eventually sustain our field.
1. Crane, Jody. The Definitive Guide to Emergency Department Operational Improvement. 2011.
2. Graban, Mark. Lean Hospitals: improving quality, patient safety, and employee satisfaction. 2009.