Leveraging Lean to drive efficiency and quality of care in the Emergency Department

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Emergency departments across the US are experiencing increased demands for services while the total number of hospitals and emergency departments are decreasing. To meet these demands, organizations must balance a myriad of components that may include volume, staffing, inpatient capacity, ancillary services, and finances. Healthcare organizations are continually seeking to increase efficiency to assure expedited quality care for their patients.


One option to improve efficiency is the implementation of Lean processes. Lean was originally utilized in manufacturing to eliminate waste and reduce variation. The concept has grown and is now incorporated into a multitude of businesses, including healthcare.


The Lean theory identifies eight types of waste that can be eliminated. The acronym “DOWNTIME” can be utilized to more easily remember each type:


  • Defects
  • Over-production
  • Waiting
  • Non-Utilized Talent
  • Transport
  • Inventory
  • Motion
  • Extra-Processing


Several of these types of waste are immediately applicable to the Emergency Department: Waiting, Non-Utilized Talent, Transport, Motion, and Extra-Processing. 


Lean utilizes a myriad of tools to minimize waste and create efficient processes. Some of these tools are as follows: Kaizens (improvement events), 6S (sort, set in order, shine, standardize, sustain, safety), value stream mapping, and daily visual management. Consider Lean a toolbox and the tools can be utilized as needed based on the organizational goal.

LEAN has been proven to be a leader in healthcare process improvement that can be woven into the culture of an organization."

Lowell Hardin

When patients arrive in many emergency departments, there is immediately a wait to sign-in. This sign-in may be conducted by registration personnel, unlicensed assistive personnel (techs), or Registered Nurses. This sign-in may be followed by an additional wait for triage. The triage is then many times followed by a wait for an exam room. This series of waiting times is frustrating for the patient and inefficient for the organization. This is an excellent opportunity to utilize a Kaizen event to modify and streamline the process.


Once a patient is placed in a treatment space, delays and over processing can again result in frustrations and inefficiencies. Some models “require” the RN to assess the patient before additional steps can be taken. The RN may or may not initiate treatment protocols. The patient is then seen by the provider who places orders and the patient waits for the orders to be initiated. Once the orders are initiated, the patient once again waits for the results which are ultimately delivered by the provider who dispositions the patient.


The Lean methodology was applied to the “front end” process of a rural emergency department in the Southeast. They were challenged with a high leave without being seen (LWBS) rate, throughput, and poor customer satisfaction. Through the consultant usage of value stream mapping, Kaizens, and daily visual management, the staff led teams were able to achieve significant improvements (decrease LWBS by 65%, decrease door to triage by 87.5%, and door to provider by 51.5%).*


As one can see from the brief process summary above, most emergency departments are full of inefficiencies that result in delays. These delays limit the potential volume of patients, create scenarios that can be unsafe, decrease patient satisfaction, and ultimately impact the financial bottom line of the organization. Each of these challenges can be addressed by Lean principles. Some organizations have internal departments tasked with Lean process improvement. Others utilize consulting organizations with expertise to improve processes.


To meet the patient needs in our modern emergency departments, each organization must assure efficiency, quality care, and financial stability. There are many methodologies that can be utilized to assure these foundational standards are met. Lean has been proven to be a leader in healthcare process improvement that can be woven into the culture of an organization. The tools discussed are a small portion of the overall Lean process. Many organizations attempt to utilize these tools without understanding the needed processes so often unsuccessful in sustaining meaningful change. If your organization does not have an active Lean change management team, consider bringing in external resources. Change is hard and must be done correctly to achieve the desired results.


 * Results from case studies are not predictive of results in other cases. Results in other cases may vary.

About the author

Lowell Hardin

Lowell Hardin, MSN, RN, NRP

Senior Consultant

Lowell brings 20+ years of emergency and trauma leadership experience, with particular expertise in performance improvement and staff and leadership development. His performance improvement focus extends to pre-hospital relationships to improve the patient experience and increase patient volumes.

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