Blog Posts


Implementing Lean Processes in the ED Improves Metrics

Posted on Wed, Oct 19, 2016
Implementing Lean Processes in the ED Improves Metrics

By Christine Kelly, RN, MBA, FACHE; Amanda Maxim, RN, BSN, MBA; Jan Beck, RN, BSN; and Shayne Middleton, RN, BSN, CEN

Nowhere is a glitch in the patient experience more pronounced than in the emergency department (ED). The ED team's ability to provide fast, efficient, quality care has a signifcant impact on each patient’s perception of care and the management of life-threatening injuries.

The processes in use today to manage patient flow from arrival to treatment to disposition are widely seen as inefficient and cumbersome. These inefficiencies often lead to long wait times and a lack of attention to patient needs and, potentially, prevent needed access to care. Recent publicity surrounding patients leaving without treatment, deaths in waiting rooms and overcrowding has become a catalyst for change in the industry. As a result, we are seeing a significant increase in the use of lean at hospitals nationwide.

It’s important to understand that achieving lean in the ED may rely heavily on improving processes in other departments. Lean can be most effective for improving patient throughput, but this means looking at the ED as one part of the delicate ecosystem of hospital care. While lean implementation may start in the ED, to be most effective it needs to extend through all patient flow paths.

When lean is applied to the front-end processes, patients can be seen more quickly. Lean in radiology and ancillary services also can facilitate patient treatment and diagnoses more quickly. Extending lean into the inpatient setting helps cut unnecessary hours off of the length of stay, which opens inpatient beds for new patients to be transferred from the ED. Lean for the OR helps ensure efficient operation of surgical services, allowing accommodation of emergency cases. Lean methodology works best when it encompasses the entire path of patient care.

Implementing Lean in the ED

A lean consultant was asked to conduct an emergency department lean rapid redesign workshop with the goal of improving operational efficiency.

Patients were experiencing an increased length of stay due to delayed diagnostics. Further, without use of pre-emptive orders at triage, it was taking 35 minutes from arrival to order entry by a primary care nurse if immediate bedding took place (and longer if no beds were available).

  • Patient presents to triage = 30 minutes; to room 110 minutes, wait for provider 60 minutes, Medical Screening Exam = 10 minutes, 5 minutes to order entry = total of 215 minutes from door to order entry
  • Provider order entry was 74 minutes from arrival
  • With pre-emptive ordering at triage, 24 minutes to order entry
  • LWOTs were two times the national best practice of 2.0 percent
  • Decreased efficiency ancillary services secondary to wasted time/trips to the ED

Contributing conditions:

  • No prioritization of services ordered – X-ray may collect the patient prior to lab draw, resulting in delay in results due to collection time
  • Transport of lab specimen delayed, placed in box on counter
  • No communication between ancillary departments
  • Pre-emptive orders not consistently used by nursing
  • Inconsistent "pull ‘til full"
  • Some physicians delaying medical screening exam on low-acuity patients, some saving for advanced practice providers

The Lean Solution

The consultant worked with the hospital’s nurse leaders to reach the following goals:

  • Implement bedside triage and registration process 100% of time, with “Pull ‘til Full” concepts (Patient-Centric Care) implemented across all shifts/staff
    • Minimize redundancy
    • Standardize triage process
    • Target arrival to provider time: 40 minutes
    • Bed to provider time: 25 minutes
  • Create more organized patient flow with space for simultaneous processes to take place, eliminating wait time and redundancy
    • Adequate resources in the right place
    • Keep vertical patients vertical and give the beds to the sick
    • Use discharge sub-waiting area
  • Consider plant flow redesign with existing spaces to include reassignment of current rooms for more efficient flow
    • Use of triage preemptive protocols 70 percent of the time
    • Improved ancillary communication
    • Collection to receipt of specimen to take only 5 minutes 90 percent of the time
    • Door-to-doc time to meet 40-minute benchmark
  • Educate ED, evaluate cost and benefits, recognize waste, plan-do-study-act, gemba walks
    • Reinforce "pull ‘til full" policy with 100% use of bedside computers
    • Educate nurses/providers in use of pre-emptive protocols
    • Flag on specimen box as visual cue for specimen awaiting transport, ED to assist
    • Lab access to private tracker board to allow comments
    • Lab to notify nursing when draw complete so tracker can be updated for X-Ray
    • Educate Radiology staff on use of tracker notifications
    • Metric comparisons

After implementation, the team’s results included:

  • Streamlined patient flow
  • Decreased throughput time
  • Decreased left without being seen (LWBS) rate
  • Improved patient and employee satisfaction
  • Improved quality in delivery of care
  • Reduced financial losses

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.

This case study is one of many 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.

Christine Kelly, RN, MBA, FACHE, is Vice President of Clinical Services for EmCare. Amanda Maxim, RN, BSN, MBA, is Vice President of Clinical Quality for Valesco Physician Services, Inc. Jan Beck, RN, BSN, is a Director of Clinical Services for EmCare. Shayne Middleton, RN, BSN, CEN, is a Divisional Director of Clinical Services for EmCare.


Hardwiring Patient Flow: Making Front-End Flow Work For You

Posted on Tue, Aug 04, 2015
Hardwiring Patient Flow: Making Front-End Flow Work For You

During last month's webinar, Hardwiring Hospital-Wide Flow To Drive Competitive Performance, Drs. Jensen and Mayer shared their secrets for streamlining processes, changing behaviors, and achieving sustainable advances in hardwiring flow throughout your hospital system. Here are a few tips from their presentation.

In healthcare, “flow” is defined as adding value and decreasing waste to processes, services or behaviors as patients move through the service transitions and queues of healthcare. This can be accomplished  by increasing benefits, decreasing burdens or both.

Thom Mayer, MD, FACEP, FAAP and Kirk Jensen, MD, MBA, FACEP, authors of “Hardwiring Flow” and “The Patient Flow Advantage” explored this topic further during a recent webinar.

Finding flow, according to Drs. Mayer and Jensen, requires:

  • Engaging staff from the beginning of the process to ensure they’re with you from takeoff to landing
  • Asking “Why?” and “Why Not?” incessantly about your processes, policies  and  procedures
  • Making your staff feel hopeful by decreasing constraints and finding ways to avoid burnout
  • Taking people out of their comfort zones – just because it’s the way you’ve always done it doesn’t mean it’s the right process for your facility now

Retooling Triage

It’s important to think of triage as a process, not a place. Triage in your ED is the “front door” to your facility for the majority of your patients, and how well your staff accomplishes this will drive flow as your patients  move through the system. Goal No. 1 is to get the patient and the physician (or the advanced practice provider) together as quickly and efficiently as possible.

To optimize the triage process, you must  forecast demand and define your ability to meet it with adequate capacity, whether it be having the appropriate level of staffing to handle patient influxes, or simply having enough clean, empty beds or treatment spaces available. This requires everyone to work together, including the ability to monitor flow in real time, set realistic patient expectations regarding wait times, eliminate bottlenecks and improve patient handoffs. Piece of cake, right?

You need to know:
  • Who’s coming?
  • When are they coming?
  • What will they need when they arrive?
  • Will your service capacity match the projected patient demand?
    • And what’s your plan if it doesn’t?

Knowing this information is essential in the Emergency Department, but also necessary in med/surg units and other inpatient areas. If a patient is horizontal, they think and feel like a patient. If they are vertical, he or she feels like and thinks like a customer. Keep your vertical patients vertical and moving through the healthcare system.  Horizontal patients value real estate (a bed or treatment area) and vertical customers value speed.

Your triage process should:
  • Improve throughput
  • Increase safety
  • Improve satisfaction
  • Improve quality
  • Provide adequate, patient-friendly information
  • Increase revenue

If it doesn’t, it’s time to analyze the triage and front-end processes and retool them, which may mean eliminating triage altogether and moving to direct bedding. The more complex that your healthcare environment is, the more complex unraveling and improving the issues will be. Weigh the benefits of your current system vs. the burdens it creates. Eliminate unnecessary steps and engage your staff from the ground up. Triage should move patients into value-added segmentation streams by putting the right patient in the right area at the right time with the right resources. It should never be simply determining who can wait. There is no value in that.

EmCare has a variety of resources and tools designed to help healthcare executives make informed decisions, including calculators to assess the financial impact of improving flow and to assess ED efficiency. Our partner hospitals have the benefit of the resources of Drs. Jensen and Mayer and innovative strategies to hardwire flow