Blog Posts

process improvement

EmCare Writes the Book on Lean

Posted on Mon, Sep 26, 2016
EmCare Writes the Book on Lean

By Kirk Jensen, MD, MBA, FACEP

We in healthcare are passionate about providing exceptional quality, safety and service to our patients.

Applying lean principles to streamline our systems and processes can free us to focus on delivering high-quality care, leading to increased satisfaction both for patients and for healthcare teams.

Quality and performance advances in the automotive industry are the foundation of what we now call lean manufacturing and lean services – standardizing processes to reinvent a business, department or even a country. Lean emphasizes processes that deliver client value, eliminate waste, promote flow and encourage the practice of continuous improvement.

In healthcare, an industry focused on quality, safety and patient care, the stakes can be high and the challenges all too real – at times literally a “matter of life or death.” We all want, and seek to build, environments where our people - talented, trained and motivated healthcare team members - can focus on their mission of delivering superior healthcare and service. The systems and processes in place must facilitate, rather than hinder, the attainment of these goals. Lean provides a philosophy, an approach, and effective tools to advance and enhance our work on all levels.

Peter Drucker said, “The only things that evolve by themselves in an organization are disorder, friction and malperformance.” Disorder, friction and malperformance exist in the complex world of healthcare, with resultant catastrophic consequences. Healthcare administrators increasingly are examining and retooling processes to improve safety, quality and efficiency while wringing out waste. For many organizations, this means implementing lean.

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

The goals for the publication are:

  • To highlight the application of lean principles in the healthcare sector, using practical real-world examples informed by the people who have actually done the work;
  • To illustrate the tools, approaches and philosophy that have enabled multiple departments and services to significantly improve their operations;
  • To put lean in its proper place or perspective as an adjunct in improving the lives of our patients and our people; and
  • To infuse a note of optimism into the current healthcare delivery conversation as we press forward in the face of healthcare delivery challenges.

The book is a compilation of lean experiences and advice from nearly 30 practicing experts. It covers a broad base of healthcare services within and beyond the walls of the hospital. It 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.

Content Highlights

The publication includes chapters on:

  • Implementing Integration Strategies
  • Lean in the ED
  • Case Study: Lean Tabletop Simulation Exercise
  • Process Improvement in Perioperative Medicine
  • Why do you need Lean in the OR?
  • Improving Value
  • Hospital Medicine Was Born of Lean Thinking
  • Culture Change versus Secret Sauce
  • Technology that Supports Lean Process Improvement
  • Strategies for Improvement: Tried and True, Bold and New
  • Creating a Lean-focused Transitional Care Team
  • Lean Beyond the Hospital Stay
  • A Lean Solution: Mobile Integrated Healthcare
  • The Value of Lean in Radiology
  • Changing Mindsets at Every Turn
  • Lean Processes for Leaders
  • Applying Lean and Creating a Culture of Excellence
  • Lean Terms and Tools
  • 10 Rules of Engagement for Change Management

Every one of our patients, every one of our client hospitals and every one of our healthcare workers deserves an environment and a department that works – people, processes and performance that reliably deliver the care, services and outcomes we want.

To learn more about “Making Healthcare Work Better™ with Lean” or to download your free copy, visit Our Website.

Kirk Jensen

Kirk Jensen, MD, MBA, FACEP, is the Chief Innovation Officer for EmCare.



Studer Spotlight: Rethinking Emergency Department Results: Are You Treating Before Diagnosing?

Posted on Wed, Jul 20, 2016
Studer Spotlight: Rethinking Emergency Department Results: Are You Treating Before Diagnosing?

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on Each month, one of Studer Group's insightful articles will be made available to blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit

By Karen Smith, MSN, RN, CEN, NE-BC

Would you ever start an antibiotic without having a diagnosed infection? How about having a cast applied before the X-ray is taken? We expect to be examined and a diagnosis made BEFORE starting any prescribed treatment. The same approach should be taken when identifying ways to improve Emergency Department (ED) results.

Have you ever wondered why your ED does not seem to have efficient processes? Do your goals for the department seem elusive and unattainable? Are you concerned that the engagement of your staff is not where you want it to be? The problem may be that you aren’t addressing the right problems, or you are trying to treat a problem before properly diagnosing.

With many ED volumes rising1, EDs and healthcare organizations must develop and implement the right tools and skills to drive results.

Our Studer Group Emergency Department experts use a diagnostic approach to determining the individual needs of an ED. This precedes the formulation of the treatment plan and consists of four key steps:

  1. Assess: The first step is to conduct a comprehensive assessment of the operational flow of the ED. This includes direct observation of patient movement, review of key operational metrics, staffing patterns to match patient volumes, overall productivity, and patient survey responses.
  2. Align goals: The next step is to determine goals for the ED and how those goals will be measured. The leaders must be in agreement of the vision for the department and setting goals that align with that vision. These are the building blocks for an objective evaluation system, such as Leader Evaluation Manager® that holds leaders accountable for achieving and exceeding their goals.
  3. Align behaviors: There are certain behaviors and tactics that drive results in the correct direction. Expecting ED staff to change patterns or habits can be hard. Careful sequencing of change implementation must be accompanied by a large dose of the ‘why’ or the evidence-based reason to change. Teams will not see the full results of these changes without ensuring each are hardwired (have become habits).
  4. Align processes: Using the observed patterns and existing ED flow metrics vs. known best practices will help teams to determine which flow models need to be implemented. Splitting the flow of patients and processing them based on their assessed acuity level will ensure that every patient receives excellent care in as timely a manner as possible.

Let’s look at an example: If an ED wants to assess and treat a higher-than-average rate of patients leaving without being seen, the four steps might look like this:
  1. Assess: Examine the reasons why the rate is elevated based on triage process flow from arrival to being seen by a provider. Key metrics may indicate prolonged door-to-provider intervals or longer-than-average lengths of stay. Analysis of staffing to match arrival patterns must be considered as well as the efficiency of key interdependent departments.
  2. Align goals: Setting goals for improvement might include reducing the overall percentage of patients leaving without being seen and also the return-on-investment resulting from captured revenue. Leaders can then formulate specific action plans to focus their attention on the goals.
  3. Align behaviors: Our approach and communication to patients as they wait to be evaluated by a provider will directly and positively affect their willingness to wait and their overall satisfaction.
  4. Aligned processes: Implementing best practices for expedited triage and direct bedding can reduce the time interval of arrival to being seen by a provider. Other process tactics to implement could include placing a provider in triage or use of a results pending model.

Remember to connect back to the ‘why’? Reducing left-without-being-seen (LWOBS) will improve patient safety and satisfaction, increase revenue, and reduce risk when patients leave without evaluation. Plus, it will save ED staff members’ valuable time.

The results of this approach are staggering. For example, in one organization coached by Studer Group, a decreased overall LWOBS resulted in an annual savings of $289,000. In another Studer Group partner organization with an ED volume of 120,000 patients, LWOBS rates decreased by more than 50 percent resulting in an ROI of $6.4M in increased annual revenue.

High-performing EDs have mastered efficient patient flow using foundational behavioral goals and behaviors. As EDs are the front door to most hospitals, our patients deserve an evidence-based approach to their clinical care that is based on a diagnostic workup. Additionally, patient flow through the ED is also positively influenced by evidence-based processes that are part of a comprehensive treatment plan based on diagnosis.

ED providers and staff make a difference every day in the lives of patients and families. By putting these steps into place, the life you save may someday be your own!

1 ER Visits Continue to Rise Since Implementation of Affordable Care Act. American College of Emergency Physicians, May 4, 2015.

Studer Group Karen Smith

Karen has over 35 years of clinical and administrative experience, primarily in emergency departments. As a Certified Emergency Nurse and a Nurse Executive – Board Certified, she maintains an expertise in emergency care and nursing administration recognized by professional organizations.

Prior to joining Studer Group, Karen served in clinical staff roles for many years in both a Level-1 trauma center and community hospital settings. Her 10 years of direct leadership experience were at a Magnet hospital within a major hospital system in Rhode Island. During these leadership years, Karen coached staff to improve the patient experience, achieving patient satisfaction scores for nurse measures consistently in the 90th percentile or better. As an emergency department consultant, she held numerous emergency department leadership positions where she implemented measures to improve the patient experience, reduce numbers of patients leaving without being seen, and reduce door-to-provider intervals among other throughput measures.



Why Lean Fails: The Challenge of Variability

Posted on Tue, Sep 22, 2015
Why Lean Fails: The Challenge of Variability

Part Two of a two-part series.
By Joseph Twanmoh MD, MBA, FACEP, FAAEM

In Part 1 of this two-part series, we discussed the history of the lean process improvement methodology, its basic tenets and how lack of leadership commitment can doom a hospital’s efforts to achieve efficiencies with lean projects. This post explores the differences between manufacturing and healthcare, and how these differences can adversely affect lean projects without mitigation.

Leadership commitment is crucial to reaping the rewards of lean. Teams need the appropriate support to plan and execute lean projects. Time is required to meet, collect data, test ideas and make any necessary changes prior to implementation. This is the classic Plan-Do-Check-Act Cycle of process improvement. When leadership doesn’t understand lean, they believe that they can just add on these additional responsibilities to managers and front line staff; dedicated time and resources for the lean improvement process isn’t viewed as a priority.

When lean is used as a tool only, piecemeal implementation can occur. Hospitals may do a rolling start, where lean is introduced in one department at a time instead of house-wide. This leads to communication failures between the departments and hampers lean implementation. An example is when the emergency department begins using lean, but the registration department does not. The ED team re-engineers their patient intake process and later informs Registration of some changes that are planned. The ED Lean team explains to Registration that the new process will revolve around the needs of the patient, add value to the patient, and reduce waste and non-value-added activities. Registration’s response is that the old process is fine because “this is the way we’ve always done it.”
Another phenomenon that occurs when lean is simply used as a tool is discontinuous improvement. Lean is all about continuous improvement. The quest for quality is never finished, with teams constantly moving from one project to the next. What happens all too often in healthcare is the “one and done” mentality. The team works on the particular project, finishes that project, and then considers their job finished. They never monitor the effectiveness or go back for a second or third round of improvement. The result is initial gain followed by backsliding, so the conclusion is that lean doesn’t work.
Choosing the Right Lean Project
Internal lean teams often work without the help of expert guidance. The result is that teams can pick the wrong project. If they pick projects that are too small, it results in meaningless outcomes.
For instance, an emergency department could have very long patient lengths of stay and one aspect of that problem could be the turnaround time for CT scans with contrast. However, if a team chooses to work at reducing CT turnaround time with a goal of reducing overall length of stay, it’s unlikely that its work will have any meaningful impact, because CT turnaround represents only a portion of the patient’s length of stay, and the number of patients receiving CT scans with contrast represents an even smaller percentage of the total number patients in an emergency department. Consequently, any time savings on CT turnaround is diluted when calculating overall length of stay. If a team chooses a project that is too large, such as reducing the length of stay for both discharged and admitted patients in the emergency department by 50 percent in the next six months, then the number of processes and workflows to be re-engineered becomes overwhelming and the team fails.

The Challenge of Variability: Manufacturing and Medicine Are Not the Same
Lean has a number of inherent shortcomings when applied to healthcare. First, lean delivers incremental change. As a result of incremental change, it can take a long time to get the desired outcome.
For instance, shortening ED length of stay is a very complex process. There are hundreds of steps in different processes that happen from the time a patient arrives until the time of discharge or admission. Taking on this project from a lean perspective requires breaking down the patient’s ED visit into small, manageable pieces. Therefore, it would take a series of lean projects to make a meaningful impact on length of stay. Particularly when leaders are not fully committed to the lean process, this incremental change is perceived to take too long, and therefore efforts often are abandoned.

Lean may be helpful to get one from Point A to Point B more efficiently. However, lean may not be helpful in telling you where Point B is. In most hospitals, the staff of nurses and physicians may have only worked in one or two other institutions. Consequently, if you’ve never worked in or been exposed to a highly efficient system, how would you know how to design one? If you take a group of people who are not experienced bakers and give them a recipe for an apple pie, what’s the likelihood that they will produce a world-class apple pie? Probably fairly low. Yet we put together teams of healthcare professionals who may never have worked in an operationally excellent facility and expect them to come up with a world-class process design using lean. Without appropriate expert guidance, their likelihood of success is fairly low.

In addition, there is variability in healthcare that lean has trouble addressing. Toyota believes that the right people following the correct processes will result in desired product. This is not the case in healthcare. Not all patients with pneumonia will respond to antibiotics, even when appropriately chosen and administered in a timely fashion. Not all patients with heart attacks survive even when life-saving cardiac catheterization is available in 90 minutes or less.
In manufacturing, one source of variability is materials. Toyota works hard to reduce the variability of materials. It works closely with suppliers to ensure that parts are free of defects. However in healthcare, our materials are our patients, and patients are rarely alike. Age alone is a major variable. Caring for a newborn is much different than caring for a 5 year old. Caring for a 20 year old is much different than taking care of an 80 year old. A morbidly obese, hypertensive, diabetic 50-year-old male with an ankle fracture is a much more challenging patient to care for than a healthy one.
The other main sources of variability in manufacturing include man, methods and machine. Man represents the workers. At Toyota, its workers are the associates on the assembly line. In healthcare, man represents physicians, nurses, technicians and the rest of the staff who directly impact the patient. Physicians and nurses have independent licenses to practice, and their licensing boards hold them to standards above and beyond that of their jobs. Consequently, changes involving patient care are much more difficult to implement than changes around the assembly line. Furthermore, not all doctors and nurses have the same background and training although they may hold the same degrees. As a result, there is variability around the healthcare worker that is more difficult to address than that of a manufacturing worker.

Then there are methods. Toyota tries to standardize methods as much as possible. And while there is certainly room to improve standardization in healthcare, there is much variability that is hard to overcome. Not all orthopedic surgeons perform joint replacement surgery using the same technique or same prosthesis. Take weight loss. What is the best diet? What type of exercise and how much should one do? Should dietary supplements be used? When should bariatric surgery be used? The evidence is not always clear.

Regarding machine, Toyota believes that all equipment should be in good working order and standardized wherever possible. However, in most hospitals, equipment is replaced over time. As an example, it’s not uncommon for hospitals to have multiple types of stretchers. Sometimes the stretchers are from different manufacturers. Sometimes they’re simply different models from the same manufacturer. Nevertheless, controls and functions may differ. For instance, some have scales built in and others don’t. The standard workflow for weighing patients may vary depending on the stretcher used.
Lastly, lean attempts to produce “single piece flow” whenever possible. Batch processing is considered bad and should be avoided. However, in the emergency department, patients rarely arrive in an orderly manner. Frequently, they show up for triage in groups of five or 10 or maybe 20. And while this flow of patients is considered natural and may be predictable, the predictability is not always precise.
For instance, Mondays always tend to be busy days, but can you predict with certainty how many patients will arrive two weeks from now at 10 a.m.? We know that volumes rise during flu season, but the severity of the flu in a given season is never known in advance. Lean doesn’t provide the tools to deal with this variability.

Joseph Twanmoh MD, MBA, FACEP, FAAEM, is the Senior Vice President of the Mid-Atlantic Division of MS2, Providence, R.I. He is a Lean-certified physician with expertise in change management. Dr. Twanmoh has more than 20 years of leadership and management experience turning around emergency departments, redesigning hospital processes, and improving patient flow. Dr. Twanmoh previously served as a Medical Director, ED Chairman and Director for Health Systems Innovation for EmCare’s North Division. He is a graduate of Robert Wood Johnson Medical School and received his MBA from the Johns Hopkins University Carey School of Business. He is past president of the Maryland chapter of the American College of Emergency Physicians, serves on the Practice Committee for the American College of Emergency Physicians, and is a fellow of the American College of Emergency Physicians and the American Academy of Emergency Medicine.