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How to improve your emergency department through Lean management

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Author: Sandra Rueda Charro

Data: 03.09.2019

 

Keywords

Lean, Lean management, Lean healthcare, Lean methodology, Emergency department, Lean six sigma. 

Have you ever wonder how would your emergency department (ED) look like if you could apply an efficient workflow and eliminate activities that don’t add any value? Lean management is here to help you.

 

About Lean

Lean healthcare is an attempt to transfer the lean management to healthcare in order to make it more efficient. Lean is a methodology that seeks continuous improvement and elimination of actions and processes that do not add any value for the patient, he/she wouldn’t pay for, that do not help him/her to heal or be more satisfied with the care. Lean healthcare will allow us to reorganize the crowded emergency departments and redirect all the resources which are wrongly used towards a more quick and safer attention to the patients.

 

Why are emergency departments overcrowded?  

The growing overcrowding of European emergency services is a real challenge for governments and health managers. There are several factors that are contributing to this problem, among which are:

Social factors: Mainly, the European population is increasing, as well as the proportion of elder people. This is making chronic diseases more prevalent

Economic factors: European governments are trying to reduce health budget by reducing the workforce and other resources. Health services are expected to do more with less.

Overtreatment: 1 in 10 patients receive a harmful, unnecessary or non-valuable treatment to their health outcomes.

Work organization: (we will focus more on these):

  • The work is organized around compartments of the human body instead of being organized around health processes, which results in a fragmented care (with more expenditure).
  • There is a poor communication between different professionals or areas.
  • After triage (mainly performed by nurses), patient’s diagnosis is usually left in the hands of junior physicians.
  • Lack of care standardization. Diagnosis and treatment variability threatens patient safety and increases overall spending.
  • When professionals get involved in several tasks at once, the workflow is hindered.
  • Mismatch of capacity and demand.
  • Inefficient distribution of the different spaces. This produces a lot of unnecessary movements of staff and patients, and should be addressed according to hospital engineering knowledge.
  • Poor organization of hospital admissions and discharges.

With Lean healthcare we cannot change economic or social factors, but surely we can act on work organization and standardization of care. This should be a main concern of  hospital managers, to ensure the safety of his/her patients, the satisfaction of his employees, and the efficient use of resources.

 

A pathway to implement lean management successfully   

To successfully go Lean, we will take into account the 5 Lean principles (define value, map the value stream, create flow, establish pull, pursue perfection) and adjust them to our own pathway.  After the managers have decided to go Lean, they should take a look to the institution culture. It’s important to remove the “culture of blame” and redirect it towards a culture of critical thinking and willingness to solve problems. Also, the staff should be informed and trained on the importance of patient safety.

Define value. As we said before, we need to decide what is value for us. The patient must be the reference according to which we decide what is valuable and what is waste.

Map the value stream. We need to map our current value stream and the ideal one. Thinking about the patient as the protagonist, we have to write down every single step of his/her pathway in our ED, and also the time he/she spends in every step.

Figure1. Value Stream

Create flow. Doctors often decide to evaluate new patients instead of discharging the ones that already have their tests done. In order to keep an adequate flow, we should follow FIFO principle “First In First Out”. If a patient can already be discharged, we should go for it immediately. Technology could help with this purpose, by providing tools like a screen where you can see the patient’s status, and the availability of the diagnostic tests performed.

Establish pull. The ED capacity must depend on demand, not on organizational preferences. Takt time can be used on each part of the ED to calculate the staff needs. Also we should make a statistical study about our ED’s patient flow each hour (daily) paying attention to our seasonal flow too. This way we would improve staff shifts to adjust them to demand.

Pursue perfection. This is based on continuous improvement (kaizen). In each work shift we should designate at least a doctor, a nurse, a radiology technician, a laboratory technician and a manager trained in Lean methodology to be able to carry out an adequate workflow. They should meet at least once daily to detect existing problems and solve them. Prior to installing Lean in our ED and from time to time, we should conduct few kaizen events to train our staff in the improvement culture and to teach them how Lean works. A good problem-communication informatic tool could be helpful to our purpose since all the workers can communicate problems they find in the field.

 

Other tools which can help us (lean or not lean):

Five S:

  • Remove anything useless from the workspace.
  • Set in order. Organize the workspace effectively.
  • Keep the workplace clean.
  • Standardize the processes used to sort, order and clean the workplace.
  • Keep improving.

 

New technologies: Telemedicine can help manage chronic patients more efficiently and avoid emergency attendance.  Digitalized X-rays and lab results can accelerate lead time. Lastly, a good electronic medical record shared by all health providers can avoid diagnostic tests duplication.

Checklists in critical activities.

Strengthening primary care and appointing case management nurses for the management of chronic processes.

Use of generic drugs.

Multidisciplinary improvement teams to centralize problem solving according to the scientific method.

PDCA cycle: Plan, do, act, check. Continuous improvement is not possible if we don’t evaluate what we do and plan improvements.

Work standardization, use of clinical guidelines. Implement fast tracks with stable work teams for the most serious and frequent pathologies (chest pain, stroke …).

Visual management: Colored paths (they will make easier patient’s journey in our ED)

 

References 

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