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Dear Dr. Willing,
You have to love it when your boss says “fix the ED’s problems” yet doesn’t have first-hand knowledge of what those problems are. However, problems can often be broken down into three big categories: operational efficiency, capacity and cost. In other words, do things function well, do you have the right size and space to care for your patients, and are there ways to make more money or decrease costs and thus make your business more profitable.

Background:
To begin, “Lean” is a philosophical strategy that was born out of the manufacturing industry in the 1980s when there was intense pressure to improve both quality and speed. This “process improvement strategy” was developed to improve speed and efficiency by removing waste and non-value-added processes. Six Sigma, a process improvement strategy that often goes hand-in-hand with Lean, uses a mathematical approach to reduce variation, complexity, and errors in a given process. When employed by companies, CEOs credited Lean and Six Sigma with generating huge profits. Now these techniques are being employed in health care and your hospital may already be discussing hiring a consultant to help implement the strategies. But the basics – understanding “value” from a customer perspective and then eliminating unnecessary waste – are easy to learn, can be employed without a Zen master and are a necessary part of a medical director’s knowledge base.

The Muda
Taiichi Ohno, the former Chief Engineer at Toyota, is responsible for identifying the seven wastes in manufacturing, four of which are critical in health care. The first waste is time spent waiting. Waiting is not value added and therefore should be eliminated, or at least minimized. Waiting may be due to inappropriate staffing, but may also be due to a lack of visual cues signifying an end of one step and that the patient is ready for the next step, thus creating a pull system.

Another area of waste is in unnecessary searching. I’d hate to know how many hours I’ve lost in my career looking for a working otoscope, a tongue depressor, or the ultrasound machine. A couple years ago, we couldn’t find anything in my ED’s trauma bay. We had everything but it just wasn’t organized well. We successfully undertook a Lean “5 S” project that involved Sorting all of our supplies and determining what we needed. We then Simplified our shelves by quantifying how much we needed of which supply on a daily, weekly, or monthly level based on utilization. Next, we needed to Sweep away the clutter. The shelves had to be organized so that people wouldn’t just dump extra supplies anywhere and make it harder to find what one was looking for as well as eliminate the unused and unneeded material. The next step was to Standardize the equipment. We couldn’t store everything for everyone in this room. We realized we couldn’t keep every chest tube type and size imaginable in our trauma room (after all, that’s why we have a supply room in the ED), but we wanted to have the most commonly utilized tubes for situations when seconds count. We cleared the shelf by eliminating many boxes of chest tubes that were rarely, if ever, needed in a critical situation. The final step is to Sustain the process. Our nursing staff labeled everything, but more importantly wrote on the label the quantity of the product that should be stocked and also the exact location of the product in our ED supply area, so that even a doctor could find it if it was needed. We also perform twice daily supply rounds to sustain the process.

The third type of waste is unnecessary processing. Bedside registration and triage are used as typical examples. Lean thinking puts it in the patient’s perspective and asks you to create a value stream map. You can divide each step into value added versus non-value added versus business non-value added. There are some things that don’t benefit the patient, such as registration, that are required so that the hospital and the docs can get paid. But that doesn’t mean that it should delay patient care (the value added part of the process).

The final area of waste is unnecessary motion. Spaghetti diagrams work great for this. Spend an hour or two mapping out each step that a provider walks in your department. One colleague told me that his docs had to walk back and forth to their point of care lab result printer essentially every time they used point-of-care testing. There were no visual cues that the labs were printed so sometimes during critical cases, they’d walk to the printer several times over a 10-12 minute period. When it all added up, the docs in his ED walked 32 miles per week just to check on the point-of-care stat printer. At a 15-minute mile, which isn’t slow, that’s 8 hours a week just for walking and not providing any patient care. Fortunately, a tech suggested moving the location of the printer to between the computers where the docs work, thus eliminating the wasted motion and allowing the printout to create a visual cue.

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Find the Low Hanging Fruit
There are some wonderful things you can do to make some immediate improvements. The beauty of Lean is that it’s based on rapid evaluation and implementation. Not everything has to be a home run, but you do need to try some things first and then you can reassess. Certainly, when you’re looking for successes, pick the low hanging fruit first. My discharge process took too long so we implemented a discharge rack right in the middle of the nursing station. Any nurse could discharge the patient or the charge nurse could delegate it to someone. This seems like a no-brainer but it took a 45 minute time (dispo decision to out the door) down to 15 minutes and has been reproducible by numerous EDs. Not only does it shorten your length of stay, but in the big picture, in a typical 50K visit ED with a 20% admit rate, it frees up 10,000 hours of bed space over the course of a year, thus increasing your capacity to see an additional 2850 patients in the same space (if you assume an average LOS of 3.5 hours). That’s an easy solution that improves short term metrics and increases long term capacity.


Getting Started
Now that you have a basic understanding of Lean and Six Sigma, your first step is to go back to your VPMA and ask them to better define the “ER problems.” What your C-Suite perceives as problems may not be what your perception is so you’ll want to align your objectives with theirs. Using the techniques from Lean and Six Sigma, follow the Six Sigma Kaizen roadmap—DMAIC. Once the problem is Defined, work hard to get the right people on your team to further define the project and the outcome Measures. Then Measure your process. Analyze the data and then brainstorm performance improvement strategies with your team. Improve and test your strategies by following the “plan, do, study, act” model that has been in health care for decades and follow your metrics to make sure the targets stay in Control. Combined with the low hanging fruit, you can be a Lean master and make noticeable improvements in your operational efficiency which should translate into quality and patient satisfaction improvements as well.
 
Michael Silverman, MD, is chairman of emergency medicine at Harbor Hospital in Baltimore, MD and is on TEAMHealth’s Medical Advisory Board.
 

Comments   

# Lean is more than ToolsEd Boudreau, DO,FACEP, FAAEM 2010-02-14 02:03
Dr. Silverman is absolutely correct that Lean is a philosophical strategy. It is also much more. It is a way of thinking , a way of viewing the world and the workplace. After being CMO at hospital and being one of the leaders of a Six Sigma and Lean deployment. I have seen it work. I have seen those tools and philosophies create both operational and cultural benefits that energize an organization and the people. I now work teaching Lean and Six Sigma principles as an adjunct to my clinical practice.

My team has worked in five emergency departments in the past 12 months. Here are some bullet points to summarize what we have learned:

The work will never be successful if the CMO or CEO or anyone in the C suite does not get involved.

If you do not know the measurements of every step in the valuestream of care for ED patients, then you can not be successful.

If you have not had a consistently applied process improvement effort based on decisive measurements of current performance, and you are tempted to say, "we need more space or we need more people". You don't.

Everyone wants to fix triage. Don't! Fix the back end first.

If you understand sequential dependent processes and the impact of variation on overall performance of the value stream you have a head start.

If you have not read the book, "The Goal" by Eliyahu Goldratt and Jeff Fox , then read it soon. If when you are done you still need some convincing, then get "We all Fall Down" by Julie Wright and Russ King.

Introducing a disciplined problem solving model in your department can be one of the most energizing and exciting additions to your work.
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# The real benefit in a Lean approachMark Jaben 2010-03-23 06:29
Using Lean tools and techniques is a great way to make things run better. But the real insight is in how this teaches us to focus all the hard work individuals do, to coordinate the efforts of individuals among themselves and across departments,and to create the kind of dialogue between management and frontline staff that is actually effective and productive

By all means use these tools, and while using them, be mindful that what you are really doing is learning together how to get better at what you do.
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