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.

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