HealthOctober 13, 2015

How Lean principles revived an ailing emergency department

A bustling emergency department strains to keep up under the pressure of increasing patient volume and higher acuity cases. The scenario isn’t uncommon. What is, however, is how the emergency department staff at Stanford Health Care, Menlo Park, CA, transformed the situation.

In just two years, staff slashed door-to-physician time by a whopping 73 percent. Patient stays averaged 17 percent shorter. The percentage of patients who left the hospital without being seen dropped from 2 percent to 0.65 percent. Patient satisfaction scores rocketed in response.

What’s more, these changes occurred during a period of 7 percent growth in patient volume. The increase in unit costs? A meager 1 percent.

The emergency department change-makers describe the transformation in the September issue of The Journal of Nursing Administration. The secret, they say, is their adoption of Lean methodologies. By embracing a management philosophy derived mainly from the Toyota Production System (yes, as in the automobile manufacturer), the emergency department successfully cut waste while enhancing efficiency to truly renew the atmosphere for patients and staff.

Here’s a look at how they did it.

Sort, simplify, sweep, standardize, sustain

At its core, the Lean philosophy is about reducing waste and optimizing productivity. Putting a sort-simplify-sweep-standardize-sustain improvement concept into practice, the staff relocated scattered stores of emergency department supplies to one central area. They also arranged them by category and color coded them for quick identification. These simple moves, they reported, greatly decreased the time staff spent gathering the tools for their jobs.

New roles for existing staff

Through a series of Lean-inspired meetings called rapid process improvement workshops, a team of frontline staff and physician and nurse leaders identified the need for a couple of new roles that could be filled by reallocating existing nursing staff. One focuses on managing the overall flow in the emergency department as well as coordinating early discharge planning for patients.

“This focus was important to minimize patient delays in the emergency department,” the authors write. “For example, will a patient need guest services or social work to arrange for transport home after discharge? This simple consideration can reduce a patient’s length of stay considerably.”

Another new role was that of a greeting RN who, upon patient arrival, determines the level of patient acuity through a quick assessment. This role cuts the time patients wait to be assessed by a health care provider.

Separating fast-track patients from those with more severe conditions

Visually mapping the time-flow of patients through the various stages of the emergency department made it clear that wait times and patients leaving without being seen were issues that needed addressing. To improve flow and reduce wait times, the emergency department established a dedicated fast-track team to provide prompt attention to low-acuity patients. The aim? Get fast-track patients treated and out the door within 90 or fewer minutes.

Similarly, a physician-nurse-technician triage team was developed to provide timely care to patients with severe illnesses and injuries. The team quickly assesses patients in the triage area, and patients with urgent needs are immediately moved to a treatment room for further attention.

These processes helped slash door-to-provider time from an average 49 minutes to just 13 minutes.

Hands-on management

“Strong leadership,” the authors explain, “is needed to build a culture of Lean within an organization.”

Daily rounds by nursing and physician leaders helped ensure staff buy-in, sustain morale, and identify problem areas that needed attention. Visibility walls were also created to track the department’s improvement metrics. Huddles involving managers and staff were implemented three times a day around the visibility wall to encourage discussion about current concerns impacting patient care.

“To be successful, leadership must build a relationship with clinical staff and demonstrate an emphasis on performance improvement rather than blame or criticism,” the authors note.

Going up: patient satisfaction 

The changes brought about notable improvements in patient satisfaction.  Patients’ “likelihood to recommend” responses went from a Press Ganey score of 77.6 to 88.6; “informed about delays,” 64.1 to 78; “waiting time to see a doctor,” 69 to 83.4; and “how well pain is controlled,” 79 to 83.9. The new fast track, meanwhile, garnered a likelihood-to-recommend score of 86.3.

“In a Lean organization,” the staff explains, “the everyday goal is to attempt to provide ever-increasing value to patients through the provision of patient care that is efficient and of high quality.”

Lean principles, as the article illustrates, empowered this emergency department do just that. Has your facility looked at Lean?  Tell us your experiences in the comments below.

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