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inpatient care

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.


The Moment that Took My Breath Away: A Nurse’s Perspective on Being an Inpatient

Posted on Thu, Jul 16, 2015
The Moment that Took My Breath Away: A Nurse’s Perspective on Being an Inpatient

Sabrina Griffin, BSN, Divisional Director of Clinical Services in EmCare’s South Division, reflects on her recent experience as a cancer patient.
By Sabrina Griffin, BSN
“Life is not measured by the number of breaths we take, but by the number of moments that take our breath away.”
This last year has been quite a journey for me and my circle of friends and family. I have heard the words you never want to be mentioned with your name attached – cancer. This journey, like most of life’s challenging times, has its ups and downs
After the diagnosis, we endured the rugged uphill climb through surgery, chemotherapy and neutropenia. With every mountain, thankfully, we found peaceful valleys in between.
The next mountain to climb was reconstruction. I decided to wait several months before having this surgery to briefly reclaim a sense of normalcy, albeit temporary. However, as I looked in the mirror each day I was reminded of my loss.
My mother and daughter were apprehensive about the surgery, but I reassured them that this was the final mountain, and a small one at that; this mountain would not be nearly as difficult as the previous climbs.
The seven-hour surgery went well. My family was exhausted from the long day and felt relieved it was over. However, during the night my blood pressure dropped and my urine output was minimal, so the clinical staff increased my fluids to increase my blood pressure.
The next morning I started having difficulty breathing. The doctors decided to perform a scan to make sure I didn’t have a pulmonary embolus. When we got to nuclear medicine, I explained to them that I couldn’t lay flat because of the surgery I had the day before. In fact, I wouldn’t be able to stand upright for 14 days. My family also told them I couldn’t be laid flat and that they should contact my surgeon to discuss the best way to get the images that they needed. 
Despite our protests, they physically moved me to the scanner table, laying me flat … and I quit breathing.


  • The patient experience = Not so good
  • Patient interaction = Not so good
  • Listening to the patient = Not so good


This moment not only took my breath away, it took my family's and friends’ breaths away as well. Can you imagine hearing a code called on your spouse, mother, daughter, sister? The moments and hours that followed were a nightmare for everyone and continue to haunt us.
In healthcare today there is an increased focus on the patient. Organizations are scored and reimbursed based on the patient experience. Organizations are hiring Chief Patient Experience Officers, training physicians how to communication, and using scribes to improve patient-clinician communication.
Patient Communication 101
As a nurse, I like to collect old nursing books and found these questions in Professional Problems of Nurses from 1936:


  • What is the right thing to do?
  • What will it take to listen to the patient?
  • What does it take to truly care about the patient experience? 

There are two essentials that haven’t changed since the beginning of care:


  1. Patient Communication: Not just what you tell the patient, but also what the patient and family story is.
  2. Patient Assessment: Look at the complete picture: presentation, diagnostics, vital signs, emotional wellbeing, etc. 


Without these elements as essentials in healthcare, the patient experience, and maybe even the patient, is doomed.
I travel across the nation to help hospitals improve the patient experience. I never expected to have an “experience” of my own. Nothing gives you a new perspective on the patient experience than being one. I recently heard the mantra “nothing about the patient without the patient” at a conference, and I’m introducing that concept at all of the facilities that I visit.
Questions for Providers to Improve the Patient Experience
So, what can we do to improve each patient’s experience in our facilities? I think the beginning is always a great place to start. Ask yourself the following questions:


  • Why are we here? Is the patient the true reason we are here? To be a true patient-centric organization, the “Why” should link to the patient and the community.
  • Who is our customer? Are our systems set up to make our jobs easier or to meet the customers’ need?
  • What services do we offer? How do we add value to the patient experience and eliminate waste? Are these the right services for this community?
  • How are our customers involved in developing our care model?
  • What do we give back to the patient? 


Once you establish the “Why,” you can then focus on the “How.” How do you deliver your care to the patient? How is your care validated and continuously improved?
In closing, I am a survivor and I’m sharing the insight that I’ve received through this journey in the hope that just one patient’s experience will be improved. For me personally, we are edging down to the valley after a treacherous climb, and pray our journey will level out soon.
Sabrina Griffin, BSN
Sabrina Griffin, BSN, is the Divisional Director of Clinical Services in EmCare’s South Division.