International Emergency Nursing (2010) 18, 57–58

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EDITORIAL

Is it time to ‘Lean’ in emergency care?

On first glance it would seem that emergency care hasvery little in common with industry or car manufacturing.We all recognise the importance and significance of individ-ualised and holistic care. Have you ever stopped andthought ‘why do we do this in this way?’ or ‘if only we couldjust cut out the layers of bureaucracy and make things morestraightforward for our patients?’ If so then you are readyfor the Lean management principles!

Lean management was first developed in the 1950s in carmanufacturing by Toyota. Lean thinking and managementprinciples have been widely employed in manufacturingand industrial settings subsequently with a great deal of suc-cess (King et al., 2006). While emergency nurses are pastmasters at seeing a queue and finding a solution; if we aretruthful what we are not so good at is understanding thecauses of the queue in the first place. A key element of Leanmanagement principles is NOT to start with a potential solu-tion to every problem but instead to develop a detailedunderstanding of how and what a complex process is actu-ally undertaken; such as for example a patients journeythrough the minor end of the emergency department. Whenthe processes are fully understood, it may become clearthat many additional layers have been introduced over theyears in order to ‘bypass’ problems. Lean principles inhealth care have been translated into an approach thatseeks to improve flow in the patient journey and eliminateall forms of waste for patients and staff (including waiting!).You may be familiar with the ‘Productive Ward’ programmewhich has been rolled out across many wards with very po-sitive results in terms of reducing waste and improving theexperience of patients. While the underlying concepts canbe applied to any healthcare setting the modules developedby the National Health Service (NHS) Institute for Innovationand Improvement are not really ideal for emergency caresettings.

The NHS Institute for Innovation and Improvements aimsare to ‘support the NHS to transform healthcare for patientsand the public by rapidly developing and spreading newways of working, new technology and world class leader-ship’ (www.institute.nhs.uk/). The productive ward initia-tive is a national initiative which aims to get teams to

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challenge and review the way in which they currently work,as well as to analyse the processes which are used daily. Thegoal is to remove any ‘wastes’ identified in the patient path-way and thereby release time to provide more direct patientcare. It is a self directed modular programme consisting ofeleven modules for example: medicines management;meals; shift handover. The programme provides tools andguidance for all healthcare professionals to identify blocksin the patient pathway and to make positive but simplechanges to the clinical environment and working processesthat will improve the quality of care and raise safetystandards.

The department I work in had the opportunity to takepart in a LEAN project and utilise the practical problem solv-ing (PPS) approach when the local Primary Care Trust (PCT)who commission and purchase our services for the local pop-ulation published a ‘stretch target’ (a target which is in-creased or stretched so that if achieved the target willdeliver greater outcomes) of 85% of all ‘minors’ patientbeing seen and treated and discharged within 2 h of arrivalin the department. You can imagine the looks on our facesat this news! With the support of the trust innovation teaman interdisciplinary (nurses, receptionists, performancemanagers, ED consultants, radiographers and biochemists)group embarked on a practical problem solving training pro-gramme which was built upon the underpinning principles ofLEAN. At one point the facilitators of the programme had toask us all to sit on our hands as we were all so keen to pointout solutions to problems identified in the early stages ofthe project! The beginning of the project meant that a greatdeal of data had to be collected and although we initiallyfelt this was time consuming we reaped the rewards ofthe detailed information we gained from this exercise veryquickly. Analysing the data and being taken through thepractical problem solving process meant that we understoodthe ‘points of occurrence’ or identified bits of processeswhich simply did not work.

Some of the best results came from simply having a vari-ety of professionals sitting in the same room so problemsthat were identified could be discussed and analysed. As aresult of all of the data collection and analysis we discovered

58 Editorial

a great deal of previously unidentified knowledge about ouremergency department! We found that there were 14 poten-tial different patient pathways for ‘minors’ patients; includ-ing admission to the observation unit.

We discovered the simple administrative process whichmeant that a d-dimer request could take well over 2 h toprocess (and addressed it! thus halving the length of timefor the test result to be available to the department). Oneof the most positive parts of the project was not simplyimproving the department’s performance but was actuallybeing given permission to look at a wide range of small is-sues which had needed to be looked at for some time. Issueswith triage and streaming, as well as the availability of theminor end drug keys were addressed (simply by keeping thekeys in a small safe which meant that we saved at least3 min for every patient who required medicines because itstopped us wandering around the department looking forthe person who held the keys. When this information isextrapolated it means we are releasing over 2 h of time atthe minor end every 24 h!).We even found ourselves lookingat ‘queuing theories’; a must for every emergency nurse!We looked at ‘queuing theory’ which although initially ap-peared a difficult mathematical concept showed us thatprevious ways of working when the department becameoverwhelmed; such as implemented ‘double triaging’ mean-ing that two nurses took on a triage role actually just addedto the queuing problem rather than solving it. When triagebecomes overwhelmed now, we implement ‘streaming’where a ‘see and treat’ stream is created and an experi-enced nurse practitioner or middle grade doctor will see pa-

tients before they have been triaged meaning that thepatient is pulled through the emergency care system andthe triage queue is reduced.

The changes have made the minor end of the departmenta much more pleasant area to work in and patients havecommented on how happy, friendly and helpful the staffhave been, something which did not tend to happen muchbefore. The crux of this story is to say that it is good to em-brace change especially when you and your team are in-volved and the changes implemented come from thoseworking in the area who understand and know how thedepartment works. What have we learnt as a department?Change can be for the better and queuing theory can actu-ally be quite interesting!

Reference

King, D.L., Ben-Tovim, D.I., Bassham, J., 2006. Redesigningemergency department patient flows: application of leanthinking to health care. Emergency Medicine Australasia 18,391–397.

Rebecca HoskinsConsultant Nurse, Emergency Care,

University Hospitals Bristol NHS Foundation Trust andSenior Lecturer Emergency care,

University of the West of England,Bristol