Blog Posts


Implementing Lean Processes in Inpatient Units

Posted on Wed, Nov 23, 2016
Implementing Lean Processes in Inpatient Units

By Francisco Loya, MD, Nathan Goldfein, MD, Roxie A. Jackson, RN, MSHL, LHRM and Stacy Bruneau, RN

Lean focuses attention on expediting operational and service factors in the inpatient setting so more time can be devoted to patient care. Traditionally, inpatient services were expected to be methodical and slow to ensure appropriate patient care. Today, hospitalists are charged with efficiently coordinating all aspects of care, in essence continuously improving processes to expedite care to the patient.

With so much relying on smooth patient flow, lean can help reduce lengths of stay, improve management of resources and utilization, and improve satisfaction for patients, physicians and all stakeholders. The development of hospital medicine in and of itself is a grand example of a lean philosophy. Hospital medicine was born of the need for quality improvement and a more efficient way to manage inpatient care.

Before hospitalists came into being, inpatient care was managed by the patient’s primary care physician (PCP). The PCP would endeavor to round in the morning before office hours and again after hours. In addition to being very inconvenient and costly for the PCP, this process also placed significant limits on inpatient care management that could have potentially expedited care and helped the patient go home sooner.

As hospital payments began to be based on a standard diagnosis-related group (DRG) rate, it became obvious that the intermittent access to the PCP for admissions and discharges was not efficient. Hospitals without hospitalists found it increasingly difficult to operate within Medicaid and Medicare guidelines for length of stay, utilization and costs.

Maybe even more importantly, with increasing volumes in the emergency department, ED bed capacity became an issue that required a broad view of patient flow. When inpatient beds were filled with patients waiting for their PCPs to come by after work to discharge them, the ED was left with patients boarding in ED beds, leaving no room to see new patients who were waiting for emergency care. Hospitals needed a way to manage the discharge so that the patient was moved out of the inpatient bed at the appropriate time and on to a more suitable care setting for the next stage of care.

Visualize the value stream map from the perspective of the hospital, the ED, the PCP and the patients. The wasted time and steps (wait times, travel) brought no value to the process. The concept of hospital-based physicians who would specialize in inpatient care seemed to be a lean approach to a convoluted process.

This lean-based concept for care has had a cost saving effect from reduced lengths of stay and better management of resources and utilization. Other benefits have included improving satisfaction for patients, families, referring physicians, hospital staff, ancillary services and more.

The following results are some of the benefits of a lean strategy for inpatient services:

  • Reduced waste (reduced length of stay (LOS) for inpatients, unnecessary time in the hospital)
  • Reduced defects (reduction in readmission rates)
  • Reduced redundancy (fewer patient tests)
  • Added value (availability to a physician in the hospital 24/7)

This lean approach to managing inpatients with hospitalists improves operational efficiency and service to the patient. Managing admissions and discharges on a just-in-time basis can make a powerful impact on the patient’s length of stay and the hospital’s patient flow.

Lean helps identify redundancies, poor organization, data needs and best use of resources from beds to staffing. Some specific targets for performance improvement that may be achieved by implementing lean methodologies in the inpatient unit include:
  • Improved clinical outcomes
  • Lower mortality rates
  • Reduced average lengths of stay
  • Improved patient outcomes
  • Improved ED throughput
  • Improved bed utilization
  • Decreased cost per case
  • Reduced readmission rates
  • Improved patient experience
  • Expedited care
  • Expedited admissions
  • Better continuity of care
  • Improved interdepartmental collaboration and relationships
  • Increased physician retention

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by some of the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques. EmCare leads scores of lean projects per year with client hospitals across the country.

The impact of a lean approach to hospital medicine is one of many subjects included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about this case study and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

Francisco Loya, MD, MS, is Chief Executive Officer of EmCare Hospital Medicine. Nathan Goldfein, MD, is Vice President of Operations with EmCare Hospital Medicine and the director of the Hospital Medicine program at Gerald Champion Regional Medical Center in Alamogordo, N.M. Roxie A. Jackson, RN, MSHL, LHRM, is Director of Clinical Services with EmCare. Stacy Bruneau, RN, is a Divisional Director of Clinical Services for EmCare.


10 Rules of Engagement for Change Management

Posted on Tue, Mar 24, 2015
10 Rules of Engagement for Change Management

The process of organizational change is challenging. To be successful, organization leaders must take a disciplined approach to engaging the team. 

Rule #1: Start early (Don’t plan the change then ask for buy-in. Start when you know change is needed). 
Being reactive in the healthcare setting is usually the norm. It is imperative to be able to anticipate challenges and use prior data to your advantage (volume, surge, staffing etc.). When deciding on projects for changes within the healthcare setting, frequently clues to what needs change are right in front of you.  Anticipate changes as a team. For example, it is a certainty that E.D. volumes will increase when the flu season hits.  Do not wait until the last minute to involve people in planning for how to deal with those surges.  Use the data from the prior year to estimate what the volumes may be and discuss what staffing will be needed to take care of those patients.  Planning for change should be an ongoing process so that your team is prepared for expected changes.  For example, the staffing plan for flu season should be developed in the months when flu is not prevalent, rather than when the eventual annual epidemic is in full swing.

Rule #2: Go deep and wide (Involve people at all levels and in all departments.)
Bench strength is key. Sometimes the people on the front line will have the best ideas for how to solve issues or implement changes. In addition, make sure that you are using a multidisciplinary approach to projects. Almost never does a problem affect one department or unit.  No longer is throughput just an E.D. problem, and the most effective and efficient solutions have come from teams that are made of members from all areas of the facility.  Ancillary services, such as lab, radiology and housekeeping are key stakeholders in the overall throughput of the patients.  Most of the time, there are solutions from other departments that can have a significant impact on the project.
Rule #3: Start with a strategy (This is your plan.  Having a plan does not ensure you will reach your goal, but not having one ensures your failure.)
Make sure that you have a clear end goal in place and a well-thought plan to get there. Be able to use history, evidence, advisors and other resources around you to explore theories, options and ideas. Especially in healthcare, there are many references for past successes that can aid in reaching current goals. Having a multidisciplinary team can also help develop an operative strategy. Harness the strengths of the team to ensure a successful project. 
Rule #4: Communicate with clarity and precision (Generalities seldom make an impression.  Provide specifics and show examples of how the strategy will impact individuals. Have people consider what they need to change about their daily routine.)
Being able to effectively share the plan and goal is epic in the success of any project. Make sure that there is both written and verbal communication of the process with all stakeholders.  Ensure that communication happens early in the process to allow feedback and strong participation from the team.  Summaries of the meetings and action items should be provided and updated during the process and available for review at each of the meetings.  Meeting notes are key when utilizing sub-groups and being able to share progress with the entire team. 
Rule #5: Divide and conquer (Segment the troops. Give each team a segment of the project.)  
There is great value in defining each step of the plan to reach the end goal.  It can also helpful to break down the process into manageable pieces.  These different parts of the process can be delegated to sub-groups which are assigned by specialties or expertise of the group.  When the smaller assignments are completed, these wins can also be celebrated by the team. 
Rule #6: Choose leaders wisely (Rank does not have to be the deciding factor in change management.  Informal leaders or a person with a mission can be highly effective. Don’t be afraid to give people an opportunity to learn more about leading.)
It is imperative to identify and groom future leaders, especially in healthcare. The early investment in our successors can help guide their growth as leaders.  It can also foster free thinking if the leader of a project is not the most senior leader. The remainder of the team can frequently feel more comfortable and be more forthcoming with suggestions.  They may be more engaged in brainstorming solutions when they see that opinions are being solicited and valued and not simply mandated from administration. You may find that "diamond in the rough" when you are able to engage a young, up-and-coming staff member who may not even know he/she is up to the challenge. Frequently, we rely on "tried and true” team leaders. We need to remember that though these leaders are almost 100 percent successful, we run the risk of contributing to burnout or overload. This altruistic leader will take on "just one more project or task" for the greater good every time without regard for themselves, especially in nursing or healthcare. 

Rule #7: Award Ownership (Give project leaders ownership of the outcome including responsibility, accountability and authority.)
Too often projects are “everybody’s goal” making it too easy to point fingers at everyone else.  Give leaders the opportunity to succeed or fail.  Either way, the leader will benefit in the long run. Authority may include a budget and the ability to replace a team member.

Rule #8:  Move the line forward one step at a time (No matter how gigantic the project/change, the method of getting there is the same. Take one step at a time.)
Baby steps, especially in healthcare change, usually reap the greatest rewards. The problem that requires change didn’t happen all at once and usually is multifaceted. Being able to break down the project into manageable chunks usually leads to interesting dialogue and positive outcomes. You also have the opportunity to tap into the expertise of the team and possibly identify future leaders by soliciting feedback from all.  This is also where the team can celebrate the small wins and completions of action items throughout the process. 

Rule #9:  Evaluate and measure progress (What does success look like? What metrics are available to track success?)
Luckily in healthcare we are able to mine a wealth of metrics and data. Many of the projects are sparked by an unfavorable metric or data point such as patient satisfaction or throughput times.  At most hospitals, there is the ability to obtain data for almost every type of project.  Throughput is one of the processes that changes frequently. Not only can throughput be evaluated by looking at the prior data, but it can also be monitored for success by using the same data.  A key to success is being able to share this data with the team and the front line staff that it directly impacts in order to foster change.  For example, it has been shown that there can be improvement simply by sharing individual specific performance with providers.  Most do not want to be at the bottom and most will self-correct somewhat simply by being able to see their own scores.  There is also value in the statement “what gets measured gets results.”

Rule #10: Celebrate victories. (Praise is addictive.  People will want more.)
Celebration is paramount to the overall success of any change. Especially in healthcare when most are programmed to deal with illness and the diagnosis of problems, it is important to be able to celebrate when things go well!  Earlier I mentioned "baby steps." It is monumental to celebrate those small successes. Such celebration fuels the remainder of the project. For example, celebrating incremental increases in patient satisfaction scores. When an organization is in the bottom percentile, celebrating a shift in the right direction can frequently motivate the staff to continue their efforts and reinforce positive behaviors that lead to continued improvement. 


Ginger joined EmCare in 2013 as a Divisional Director of Clinical Services for the South Division with the strong belief that she could continue to make positive changes within healthcare by helping others focus on quality, excellence and the overall patient experience. Ginger Wirth regards her role as Director of Clinical Services as the ideal opportunity to partner with nursing, physician and facility leaders to make positive changes to the entire patient care experience. Her 20+ year nursing career has been dedicated to quality and excellence, promoting overall positive outcomes and safety for patients. 


HOW TO: Transform your organization today with Operational Integration

Posted on Tue, Jun 17, 2014

What strategies are in your arsenal to combat and conquer the thorny challenges of healthcare reform? Reducing costs? Improving quality, productivity and efficiency? Redesigning processes? Improving the patient experience? Transforming your organization from one that delivers episodic sick care to one that nurtures wellness and personal responsibility is daunting, but absolutely necessary. While consultants have prospered by touting the “solution-of-the-day,” a handful of approaches have actually gained traction. One of those is clinical integration.

Read our free whitepaper below to discover:

  1. How to build a highly integrated organization
  2. Implementation strategies
  3. Real-world examples of clinical integration