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The Journal of Emergency Medicine, Vol. 37, No. 2, pp. 177–182, 2009Copyright © 2009 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/09 $–see front matter

doi:10.1016/j.jemermed.2007.11.108

Administration ofEmergency Medicine

APPLICATION OF LEAN MANUFACTURING TECHNIQUES IN THEEMERGENCY DEPARTMENT

Eric W. Dickson, MD, MHCM,* Sabi Singh, MS, MA,† Dickson S. Cheung, MD, MBA, MPH-C,‡Christopher C. Wyatt, MD, MBA,* and Andrew S. Nugent, MD*

*Department of Emergency Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, †Office forOperations Improvement, University of Iowa Hospitals and Clinics, Iowa City, Iowa, and ‡Department of Emergency Medicine, Johns

Hopkins Medicine, Baltimore, MarylandReprint Address: Eric W. Dickson, MD, MHCM, Department of Emergency Medicine, University of Iowa Health Care, C43-GH,

200 Hawkins Drive, Iowa City, IA 52242

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Abstract—Background: “Lean” is a set of principles andechniques that drive organizations to continually add value tohe product they deliver by enhancing process steps that areecessary, relevant, and valuable while eliminating those thatail to add value. Lean has been used in manufacturing forecades and has been associated with enhanced product qual-

ty and overall corporate success. Objectives: To evaluatehether the adoption of Lean principles by an Emergencyepartment (ED) improves the value of emergency care de-

ivered. Methods: Beginning in December 2005, we imple-ented a variety of Lean techniques in an effort to enhance

atient and staff satisfaction. The implementation followed aix-step process of Lean education, ED observation, patientow analysis, process redesign, new process testing, and full

mplementation. Process redesign focused on generating im-rovement ideas from frontline workers across all departmen-al units. Value-based and operational outcome measures,ncluding patient satisfaction, expense per patient, ED lengthf stay (LOS), and patient volume were compared for calen-ar year 2005 (pre-Lean) and periodically after 2006 (post-ean). Results: Patient visits increased by 9.23% in 2006.espite this increase, LOS decreased slightly and patient sat-

sfaction increased significantly without raising the inflationdjusted cost per patient. Conclusions: Lean improved thealue of the care we delivered to our patients. Generating andnstituting ideas from our frontline providers have been theey to the success of our Lean program. Although Leanepresents a fundamental change in the way we think ofelivering care, the specific process changes we employed

ECEIVED: 28 August 2007; FINAL SUBMISSION RECEIVED: 1

CCEPTED: 26 November 2007

177

ended to be simple, small procedure modifications specific tour unique people, process, and place. We, therefore, believehat institutions or departments aspiring to adopt Lean shouldocus on the core principles of Lean rather than on emulatingpecific process changes made at other institutions. © 2009lsevier Inc.

Keywords—Lean; health care; process change; frontlineroviders; patient satisfaction

INTRODUCTION

n November of 1999, the Institute of Medicine’s (IOM)andmark report To Err Is Human showed that 44,000–8,000 patients die in the United States each year fromedical errors (1). In a follow-up report, the IOM called

or a fundamental redesigning of America’s health careystem with focus on safety and quality (2). These re-orts did not escape the public’s attention, and since theirelease there has been a palpable tension between healthare systems and purchasers of their services. Patients,hird party payors, and the government are now demand-ng health care delivery systems to be safe, efficient, anduality-driven.

Informed consumers have forced change in a varietyf industries, for example, in automobile manufacturing.

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nformation about automobile safety and quality begano spread in the mid-1960s after the publication of Ralphader’s book Unsafe at Any Speed, which prompted

onsumers to demand safer, higher quality cars (3). Theonstant pressure from informed consumers drove theutomobile industry toward improving safety, quality,nd the overall value of their products, and is nowriving health care in the same direction (4).

As a first step, medical centers that recognize theatient-oriented focus in health care must embrace trans-arent external reporting of quality and safety informa-ion to all interested parties. Next, they need to develop,mplement, and sustain process management systemshat welcome innovative and creative solutions to theealth care delivery processes. These new systems mustmprove patient and worker safety while enhancing theuality of care and keeping costs down. For a number ofnstitutions this means a re-engineering of their currentrocess management system. According to the IOM,innovations in industrial engineering that have swepthrough other sectors of the economy, from banking toir travel to manufacturing, have failed to take hold inealth care delivery” (5) (p. 3).

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

Yet, why have they failed to take hold in health careelivery? First, process improvement techniques are con-idered core competencies in manufacturing; however,ew people in the health care industry are trained andxperienced in process improvement methodologies.

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

And finally, despite the advances made in patient-riven health care delivery, hospitals fear that shiftinghe focus to the patient experience will be perceived ashifting the focus away from the physicians and lead toswing in admissions to “physician-centered” hospitals.These factors are particularly strong in community

ractices of primary care and surgery. However, theyend to be less powerful in emergency medicine andcademic medical centers where the physician practicelan and the hospital are often owned by the same parentompany, making them particularly good candidates forhe application of Lean.

THE LEAN PRINCIPLES

Lean” is a term adopted from Japanese manufacturingefining a philosophy that abhors waste in any form and

elentlessly strives to eliminate defects. Waste is defined f

s any action that does not add value to the product; inealth care this refers to the patient experience. Argu-bly, current health care processes are designed with aocus on the clinicians and how to make them morefficient and minimize their waste. This approach isontradictory to Lean: it is like designing a process withfocus on the factory workers rather than the product

hey make.The Lean process evaluates operations step by step to

dentify waste and inefficiency and then creates newolutions to improve operations, increase efficiency, andeduce expenses. Lean Manufacturing Principles, alsoeferred to as Toyota Production System (TPS), are ubiq-itous in the manufacturing environment, especially inhe automotive industry. Two basic Lean concepts are:he relentless elimination of waste through standardiza-ion of processes and the involvement of all employees inrocess improvement (9). Empowerment of workers byroviding them with the necessary tools to effect changesn their area of work is the cornerstone of the TPS. Thewo priority duties of the employee’s job then become: a)aking the product; and b) finding ways to make the

roduct better by improving quality and flow. Trans-erred to health care, this means that all clinicians havewo jobs: to take care of the patients and to find betterays to take care of patients.An extremely useful first step in starting Lean is the

apping out of the process using a process map (Figure), then assessing the amount of waste in the systemsing a Value Stream Map (VSM, Figure 2) (10). TheSM documents the time for each process step anduantifies the amount of value-added and no value-addedwaste) time in each step. This snapshot of the processelps the improvement team to step back and determinehich steps in a process add value to the patient’s

xperience and which steps take up resources and timend incur cost without adding value. Next, the teametermines if each step in the VSM is indeed necessary.he goal is to redesign the process with a new processap that either minimizes or completely eliminates the

ncovered waste.At the center of Lean is product flow. In a Lean

ssembly line, the product continuously flows with noacklogs, even at the expense of having some downtimeor the individual worker. Although the latter may seemike waste, in reality any downtime that occurs as piecesove from station to station is made up for by the

eduction of waste in work-in-process inventory anddditional movement of partially completed cars thatould otherwise stack up. Think of all the extra work

hat is required for the patients waiting in a bed for anncillary service, test results, or movement to the floor

or admission.

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Administration of Lean Manufacturing Techniques in the ED 179

In order for Lean to work effectively, managers mustndergo a paradigm shift in considering flow and quality. Inhe non-Lean environment, managers typically work oneducing costs by constantly improving the efficiency ofingle processes. In contrast, Lean managers begin by fo-using on quality and flow. Once those have been improved

igure 1. General process map (consolidated to 8 processetailed process map (82 process steps) is used by our staffse process maps to communicate changes in work flow to

igure 2. Example of Value Stream Map (VSM): the VSM is genre measured. The VSM provides the process improvement

waste) activity in a process, which helps them focus on high yieonjunction with process maps, which are used to redesign indivi

t the current staff level, synchronization of staff becomeshe focus. Finally, without ever backtracking on quality,ow, or synchronization, Lean managers work on improv-

ng the other factors of efficiency. The end result is a muchigher-value product than the one produced using a manage-ent style focused solely on improving single-step efficiency.

used to illustrate general Emergency Department flow. Aredesigning processes to improve quality and flow. We also

after a period of observation during which cycle times (C/T)ith an overview of value added (C/T) and non-value added

steps)

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ld areas and map progress. The VSM is typically used indual processes using the suggestions of frontline staff.

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Allowing for backlogs to build up would require alant bigger than one in which a continuous flow systems in place. By focusing on flow and reducing work-in-rocess inventory, Lean plants tend to take up much lesspace. Think of all the space in emergency departmentssed for patients waiting to be seen and treatment areasccupied by patients waiting for a consult, test results, orisposition.

METHODS

ur Emergency Department (ED) is a level one traumaenter that saw 37,000 patients in 2006. It is part of aeaching hospital that has about 700 staffed beds anderves as a tertiary referral center for a rural Midwesttate. The ED is staffed by 16 faculty and 20 Emergencyedicine residents; it has an admission rate of approxi-ately 30%, with 3% of them going to an intensive care

nit.The first step in instituting Lean was to educate ED

anagers and other participants involved in a 5-dayaizen event about Lean principles and techniques. Theembers of the Kaizen team included two Emergencyhysicians, two ED nurses, an ED physician assistant,

wo physicians from other areas, two radiology techni-ians, a laboratory technician, five industrial engineers,nd five external participants from a local business coun-il. The primary role of the external participants was toefine value from a patient perspective. The Kaizenvent is one of the fundamentals of Lean; the nameenotes an approach to continuous improvement byliminating activities that don’t add value. A Kaizenvent occurs when managers in an organization gather in

workshop to set the base of Lean-driven processhanges that would be specific to the organization.

In the next step, each member of the Kaizen teambserved ED patient flow and drew a process map of ateast one portion of the total flow process, for example,riage, ordering laboratory tests, or admitting ED pa-ients. An example of a limited-detail ED process map isncluded (Figure 1). During day 1, very specific processaps were drawn and pieced together. Drawing processaps was part of the Lean educational program.Process mapping was followed by individual process

tep measurement and value analysis. Value was alsoart of the Lean educational program. The simplest wayo think of value in delivering patient care is to ask theuestion, “Would the patient be willing to pay for thatart of the process only?” As far as patients are con-erned, waiting for a laboratory test result or consultanto arrive adds no value, whereas receiving the laboratoryest result or consultation adds value. A VSM was then

onstructed (Figure 2). This map is useful in focusing the

eam on parts of the overall flow process that have theost waste and, therefore, have the greatest potential to

mpact overall flow. It was well understood by theaizen team that not all waste can be removed from anyrocess and that not all solutions are equally easy tonstitute.

Day 3 of the Kaizen event focused on generatingrocess improvement ideas from Kaizen team membersnd frontline caregivers, followed by process redesign.he ideas generated tended to be small and very specific

o our ED, for example, standardize and mark the spothere the ultrasound machine goes, put chairs in front of

he triage nurse so he/she does not have to walk as far toet patients that have not yet been triaged, and reduce theumber of questions asked as part of registration.

Days 4 and 5 focused on new process implementation,efinement, and re-measurement. Although this was thend of the Kaizen event, it was the beginning of ourong-term adoption of Lean and a management system inhich we are constantly refining and measuring ourrocesses with the goal of delivering greater value to ouratients. It should also be noted that, as part of thedoption of Lean, our ED management team had tocknowledge that frontline staff had greater insight intohe processes and were, therefore, more likely to findays of improving them. Frontline staff, in turn, had tonderstand this paradigm and be encouraged to findolutions to problems that created waste, slowed flow,nd decreased the quality of care in our ED.

The process improvements coming from Kaizen wereot particularly novel. However, because the staff de-igned them, they were more enthusiastically acceptednd fully deployed. A few examples of new processesnstituted in our ED as part of Kaizen and continuing toe part of the new standard operating procedures are:

● Utilization of all examination rooms and immediateplacement of patients in the rooms, with bedsideregistration whenever possible

● A team approach whereby a registered nurse, aresident, and the attending physician get the pa-tient’s history at the same time when possible, thusreducing duplication of history and saving stafftime

● Redefined responsibilities of registered nurse, nurs-ing assistant, and intake coordinator

● Laboratory tests/X-ray studies ordering and send-ing done earlier in the process

● Improved signage for directing patients in and outof the ED

● Identified opportunities for involvement of otherservices earlier in the process and expedition of

admissions.

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Administration of Lean Manufacturing Techniques in the ED 181

Average monthly length of stay (LOS), expense peratient, and monthly patient volume were compared bytudent’s t-test, whereas the percentage of patients rank-

ng the overall ED experience as “Very Good” wasompared by chi-squared test. For all outcomes, p � 0.05as considered significant.

RESULTS

or the purpose of monitoring our Lean program, weave chosen to monitor the following standard ED op-ration measures: percentage of patients ranking theverall ED care as “Very Good,” average monthly ex-enses (nurses, nursing assistants, and other staff work-ng solely in the ED) per patient per month (2005 dataere adjusted to 2006 hourly rates secondary to pay

hanges occurring during the observation period), EDOS, including admitted patients (�30% of ED vol-me), and average number of patient visits per month.uring calendar years 2005 (pre-Lean) and 2006 (post-ean) there was no change in the manner in whichatient volume, expense, patient satisfaction, and LOSelectronic grease board) were recorded. There were alsoo significant changes in the number of ED treatmentooms or physician coverage. There was, however, a.5% hourly rate increase for nursing personnel; hence,he data are presented normalized to the 2006 rate.

The adoption of Lean in December 2005 has beenssociated with both short-term and longer-term positiveffects on department operations. Immediately after theaizen event, we saw an improvement in patient flowith a reduction in average patient LOS, from 161 min in

he 3 months before the adoption of Lean, to 148 min inhe 3 months after the Kaizen. Despite a statisticallyignificant annual patient visit growth of 9.23% (from818 patient visits monthly to 3078; p � 0.01) and andmission growth rate of 15% in 2006, adoption of Leanllowed us to sustain our average 2006 LOS (157 min)lightly below the 2005 level (160 min).

Adoption of Lean has also been associated with sig-ificant improvement in patient satisfaction. A continu-us Press-Ganey patient satisfaction survey showed anncrease in the percentage of patients ranking the overallD experience “Very Good” from 54% in 2005 to 59%

n 2006 (p � 0.01). The significant improvement wexperienced in patient flow and patient satisfaction wasot associated with a significant increase in inflation-djusted direct expense per patient (including nurses,ursing assistants, and medical supplies only), whichas $121 in 2005 and $124 in 2006.Our greatest challenge in sustaining the early gains

roduced by adopting Lean has been to keep up with the

rowth in patient visits. Interestingly, for 3 weeks after l

he Kaizen event we never put a patient in the waitingoom. Maintaining the specific process improvementshat have been implemented since adopting Lean haseen relatively easy because they were generated byrontline staff that was performing the process. Althoughe found the week-long Kaizen event useful as a kickoff

o Lean, it has since been replaced with much shorter-day events focused on specific process areas, for ex-mple, radiology testing of ED patients. During thesevents and throughout the year, management encouragedtaff to make recommendations on how to improve flownd quality and worked to institute the suggestions thatave the greatest impact on value.

DISCUSSION

nstitution of Lean in our ED has been associated withmprovements in patient flow, patient satisfaction and,onsequently, an increase in patient visits. These changesave been sustainable without increasing expense peratient or the number of ED treatment areas; thus, weelieve we have added overall value to the patient expe-ience, mainly because we have employed Lean not asxpense-reducing, but as a value-driven technique.

The goal of Lean is to constantly increase the value ofhe product or service delivered. Value is quality of theroduct or service divided by price. Measuring value inealth care is extremely difficult for several reasons:) the patient is typically unaware of the price of theroduct; 2) the patient cannot fully quantify the qual-ty of the service; and 3) the expense that goes intoelivering the service can be extremely difficult to mea-ure. Despite the difficulties, it is critical that somebjective indicators of value be calculated when assess-ng the effect of a Lean program for both internal andxternal purposes.

A key success factor for our program was that man-gement took a subordinate role when it came to solvingow issues and let the frontline staff identify problemsnd come up with their own solutions. This led to a morempowered staff eager to institute their ideas as opposedo a reluctant staff feeling forced to institute top-downrocess improvements.

Placing flow ahead of efficiency also was critical tohe success of our program. The standard of Lean (firstow, then synchronization, then efficiency) has beeneard more and more frequently as Lean principles areecoming part of our culture.

Last but not least, it was not large breakthroughnnovations in patient flow that lead to our success butather multiple small process enhancements idiosyncratico our unique people, processes, and environment. This

ed us to believe that it is the principles and not the

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pecific process changes documented by others that thedopters of Lean should employ.

CONCLUSIONS

ean improved the value of the care we delivered to ouratients. Generating and instituting ideas from our front-ine providers have been the key to the success of ourean program. Although Lean represents a fundamen-

al change in the way we think of delivering care, thepecific process changes we employed tended to beimple, small procedure modifications specific to ournique people, process, and place. We urge institutionsr departments aspiring to apply Lean to focus on therinciples we employed and described here rather thann the specific process changes we made.

cknowledgment—The authors thank Dr. Zlatko Anguelov foris wonderful editorial work and assistance preparing this

anuscript.

1

REFERENCES

1. Institute of Medicine. To err is human. building a safer healthsystem. Washington, DC: National Academies Press; 1999.

2. Institute of Medicine. Crossing the quality chasm. a new healthsystem for the 21st century. Washington, DC: National AcademiesPress; 2004.

3. Nader R. Unsafe at any speed. The designed-in dangers of theAmerican automobile. New York: Grossman Publishers; 1965.

4. Porter ME, Teisberg EO. Redefining competition in health care.Harv Bus Rev 2004;82:64–76.

5. Institute of Medicine. Hospital-based emergency care. at the break-ing point. Washington, DC: National Academies Press; 2006.

6. Institute for Healthcare Improvement. Going Lean in health care.Cambridge, MA. White paper: IHI Innovation Series; 2005. Avail-able at: http://www.lean.org/Community/Registered/Articles.cfm?ArticleCategory�4. Accessed October 7, 2007.

7. Leverson I, Rodgers E. Hospital cost inflation and physician pay-ment. Am J Econ Sociol 1976;35:161–74.

8. Boston Scientific. Medicare finalizes new payments and policiesfor hospital outpatient, ambulatory service centers and physi-cians for CY2007. Available at: http://www.bostonscientific.com/templatedata/imports/collateral/Reimbursement/Vascular_Surgery/rmbgde_CY2007HOPPSfinalrule_01_us.pdf. AccessedOctober 7, 2007.

9. Ohno T. Toyota Production System: beyond large-scale produc-tion, 1st edn. Portland, OR: Productivity Press; 1988.

0. Rother M, Shook J. Learning to see. Brookline, MA. The LeanEnterprise Institute; Spiral Edition, Version 1.2; 1998.

ARTICLE SUMMARY1. Why is this topic important?

Emergency Departments (EDs) across the country arestruggling to improve patient flow and the quality of caredelivered. Lean on a system and ED level can helpimprove both flow and quality while empowering thefrontline caregivers in the ED.2. What does this study attempt to show?

That adoption of Lean principles improved the value ofcare delivered and allowed us to move significantly morepatients through the ED without increasing length of stay(LOS). Lean was also associated with an increase inpatient satisfaction.3. What are the key findings?

a) An improvement in ED capacity, as is evident by anability to see significantly more patients withoutincreasing LOS.

b) An improvement in patient satisfaction with the carereceived.

4. How is patient care impacted?a) Patients spend less time waiting for care and are

more satisfied with the care they receive.b) Staff feel more empowered to make changes and

improve care.