Administration of emergency medicine
Application of Lean Manufacturing Techniques in the Emergency Department

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Abstract

Background: “Lean” is a set of principles and techniques that drive organizations to continually add value to the product they deliver by enhancing process steps that are necessary, relevant, and valuable while eliminating those that fail to add value. Lean has been used in manufacturing for decades and has been associated with enhanced product quality and overall corporate success. Objectives: To evaluate whether the adoption of Lean principles by an Emergency Department (ED) improves the value of emergency care delivered. Methods: Beginning in December 2005, we implemented a variety of Lean techniques in an effort to enhance patient and staff satisfaction. The implementation followed a six-step process of Lean education, ED observation, patient flow analysis, process redesign, new process testing, and full implementation. Process redesign focused on generating improvement ideas from frontline workers across all departmental units. Value-based and operational outcome measures, including patient satisfaction, expense per patient, ED length of stay (LOS), and patient volume were compared for calendar year 2005 (pre-Lean) and periodically after 2006 (post-Lean). Results: Patient visits increased by 9.23% in 2006. Despite this increase, LOS decreased slightly and patient satisfaction increased significantly without raising the inflation adjusted cost per patient. Conclusions: Lean improved the value of the care we delivered to our patients. Generating and instituting ideas from our frontline providers have been the key to the success of our Lean program. Although Lean represents a fundamental change in the way we think of delivering care, the specific process changes we employed tended to be simple, small procedure modifications specific to our unique people, process, and place. We, therefore, believe that institutions or departments aspiring to adopt Lean should focus on the core principles of Lean rather than on emulating specific process changes made at other institutions.

Introduction

In November of 1999, the Institute of Medicine's (IOM) landmark report To Err Is Human showed that 44,000–98,000 patients die in the United States each year from medical errors (1). In a follow-up report, the IOM called for a fundamental redesigning of America's health care system with focus on safety and quality (2). These reports did not escape the public's attention, and since their release there has been a palpable tension between health care systems and purchasers of their services. Patients, third party payors, and the government are now demanding health care delivery systems to be safe, efficient, and quality-driven.

Informed consumers have forced change in a variety of industries, for example, in automobile manufacturing. Information about automobile safety and quality began to spread in the mid-1960s after the publication of Ralph Nader's book Unsafe at Any Speed, which prompted consumers to demand safer, higher quality cars (3). The constant pressure from informed consumers drove the automobile industry toward improving safety, quality, and the overall value of their products, and is now driving health care in the same direction (4).

As a first step, medical centers that recognize the patient-oriented focus in health care must embrace transparent external reporting of quality and safety information to all interested parties. Next, they need to develop, implement, and sustain process management systems that welcome innovative and creative solutions to the health care delivery processes. These new systems must improve patient and worker safety while enhancing the quality of care and keeping costs down. For a number of institutions this means a re-engineering of their current process management system. According to the IOM, “innovations in industrial engineering that have swept through other sectors of the economy, from banking to air travel to manufacturing, have failed to take hold in health care delivery” (5) (p. 3).

We believe that operations improvement techniques, such as Lean Manufacturing and Six Sigma, which are used in other industries, are well suited to assist health care organizations committed to meeting the challenge (6).

Yet, why have they failed to take hold in health care delivery? First, process improvement techniques are considered core competencies in manufacturing; however, few people in the health care industry are trained and experienced in process improvement methodologies.

Second, there is a lack of goal congruence between physicians and hospitals due to the separation between hospital and physician payment (7, 8).

And finally, despite the advances made in patient-driven health care delivery, hospitals fear that shifting the focus to the patient experience will be perceived as shifting the focus away from the physicians and lead to a swing in admissions to “physician-centered” hospitals.

These factors are particularly strong in community practices of primary care and surgery. However, they tend to be less powerful in emergency medicine and academic medical centers where the physician practice plan and the hospital are often owned by the same parent company, making them particularly good candidates for the application of Lean.

Section snippets

The Lean Principles

“Lean” is a term adopted from Japanese manufacturing defining a philosophy that abhors waste in any form and relentlessly strives to eliminate defects. Waste is defined as any action that does not add value to the product; in health care this refers to the patient experience. Arguably, current health care processes are designed with a focus on the clinicians and how to make them more efficient and minimize their waste. This approach is contradictory to Lean: it is like designing a process with

Methods

Our Emergency Department (ED) is a level one trauma center that saw 37,000 patients in 2006. It is part of a teaching hospital that has about 700 staffed beds and serves as a tertiary referral center for a rural Midwest state. The ED is staffed by 16 faculty and 20 Emergency Medicine residents; it has an admission rate of approximately 30%, with 3% of them going to an intensive care unit.

The first step in instituting Lean was to educate ED managers and other participants involved in a 5-day

Results

For the purpose of monitoring our Lean program, we have chosen to monitor the following standard ED operation measures: percentage of patients ranking the overall ED care as “Very Good,” average monthly expenses (nurses, nursing assistants, and other staff working solely in the ED) per patient per month (2005 data were adjusted to 2006 hourly rates secondary to pay changes occurring during the observation period), ED LOS, including admitted patients (∼30% of ED volume), and average number of

Discussion

Institution of Lean in our ED has been associated with improvements in patient flow, patient satisfaction and, consequently, an increase in patient visits. These changes have been sustainable without increasing expense per patient or the number of ED treatment areas; thus, we believe we have added overall value to the patient experience, mainly because we have employed Lean not as expense-reducing, but as a value-driven technique.

The goal of Lean is to constantly increase the value of the

Conclusions

Lean improved the value of the care we delivered to our patients. Generating and instituting ideas from our frontline providers have been the key to the success of our Lean program. Although Lean represents a fundamental change in the way we think of delivering care, the specific process changes we employed tended to be simple, small procedure modifications specific to our unique people, process, and place. We urge institutions or departments aspiring to apply Lean to focus on the principles we

Acknowledgment

The authors thank Dr. Zlatko Anguelov for his wonderful editorial work and assistance preparing this manuscript.

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