Leveraging Lean in the Emergency Department: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation > Emergency Medicine

Features
•Supplies a functional understanding of Lean emergency department processes and quality improvement techniques 
•Identifies solutions specific to the needs of the emergency department
•Includes examples, case studies, and lessons learned from successful Lean deployments
•Provides authoritative guidance on implementing Lean in the emergency department

Summary

This book is part of a series of titles that are a spin-off of the Shingo Prize-winning book Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient Care Delivery System. Each book in the series focuses on a specific aspect of healthcare that has demonstrated significant process and quality improvements after a Lean implementation.

Emergency departments have become notorious for long wait times and questionable quality of care. By adopting Lean manufacturing concepts, hospitals can turn the emergency department into a valuable service for the hospital and the community it serves.

Leveraging Lean in the Emergency Department: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation supplies a functional understanding of Lean emergency department processes and quality improvement techniques. It is ideal for healthcare executives, leaders, process improvement team members, and inquisitive frontline workers who want to implement and leverage Lean.

Supplying detailed descriptions of Lean tools and methodologies, the book identifies powerful Lean solutions specific to the needs of the emergency department. The first section provides an overview of Lean concepts, tools, methodologies, and applications.

The second section focuses on the application of Lean in the emergency department within the confines of the hospital or clinic. Presenting numerous examples, stories, case studies, and lessons learned, it examines the normal operation of each area in emergency departments and highlights the areas where typical problems occur.

Next, the book walks readers through various Lean initiatives and demonstrates how Lean tools and concepts have been used to achieve lasting improvements to processes and quality of care. It also supplies actionable blueprints that readers can duplicate or modify for use in their own institutions. 

Illustrating leadership’s role in achieving departmental goals, this book will provide you with a well-rounded understanding of how Lean can be applied to achieve significant improvements throughout the entire continuum of care.

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Introduction to Lean
The Need for C​hange
National and Global Competition
Challenges for the Healthcare Worker
Lean and Layoffs
Traditional Healthcare Model
Introduction – So What is Lean? 
Lean and Hospitals
What Results can you Expect?
The CEO and Lean
Typical Lean Metrics and Outcomes
Potential Lean Returns by Department
Typical Results/Return on Investments (ROI) and Implementing Lean
Lean and Systems Thinking
Boiled Frog Syndrome
Systems Thinking Principles
Viewing the Hospital with Systems Thinking
What is a Lean Business Delivery System?
Lean Business Delivery System Vision
Understanding the Value of the Lean Business Delivery System
Just In Time: The First Pillar of the Toyota Production System Model
An Example of One of the Rocks—Short-Staffed
Jidoka—The Second Pillar of the Toyota Production System
Jidoka Means: Never Pass on a Bad Part or Patient
Applying Jidoka to Healthcare
The Top of the Toyota House—Respect for Humanity
Lean is a Journey

Batching vs. Lean Thinking and Flow
Batching vs. Lean Thinking and Flow
Batching vs. Flow in a Healthcare Environment
Bathing Examples
Process Definition
Batching Systems
Why People Love to Batch?
One-Piece/Patient Flow
One-Piece Flow Example
Group Technology
Productivity - Definition
Batching The Domino Effect
Peak Demand
Examples of Batching in Healthcare
Chart Preparation
Application of One-Piece Flow to Healthcare
Flow—One-Piece Flow or Small Lot

Lean and Change Management
Implementing Lean is about Balance
Lean Culture Change
Paradigms
Change Equation
C ∙ Compelling Need to Change
Why Change?
V ∙ Vision
N ∙ Next Steps
Change and What’s In It For Me
Lean and Change Management
Lean and Organizational Change - "Right Seat on the Right Bus"
Resistance to Change
Changes… Highs and Lows
Rule of Unintended Consequences and Bumps in the Road
Change is a Funny Thing
We are all Interconnected but not Typically Measured that Way
Horse Analogy
Comparison to Where We are Today
Employee Suggestion Systems
Barriers to Change
Most Loved Words
Does Your Organization have Sacred Cows?
Leadership and Organizational Changes
Communication, Change and Lean
Summary

Lean Foundation
Lean Foundation Baseline in the Basics Model
Think—See—Act Lean
System Lean Implementation Approach Utilizing the Basics Model
A Customer Service Story
Baseline Metrics
Data, Revenue, and Hospitals
The Impact of Data on Lean – Process Focused Metrics
Customer Satisfaction
Voice of the Customer Surveys
The VIP Visit
Easy to Do Business With
Centralized = Batching
What Does All This Have to Do with Hospitals?
Customer Value-Added Proposition
Customer Quality Index
Baseline the Process
Value Stream Map (VSM) the Process
Value Stream Discussion
Value Stream Mapping and Healthcare
Value Streams Objectives
Traditional Hospital Systems - SILOS
Lean Goals
Parts of a Value Stream Map
Value Stream Map Icons
Value Stream Map Definitions
Day 1
Day 2
Day 3
Day 4
Day 5
Current State Value Stream Mapping
Ideal State
Future State Value Stream Mapping
Value Stream Map Project Lists, Prioritization Matrix, and Tracking
Value Stream Layout Maps (sometimes referred to as Skitumi maps)
Baselining the Process—Data Collection and Analysis—Current State
Takt Time/Production Smoothing
Available Time
Customer Demand
Peak Demand
Cycle Time
Cycle Time and Takt Time—What’s The Difference?
Designing Cycle Time to Takt Time
Length of Stay (LOS)
Length of Stay (LOS)
Length of Stay is Directly Correlated to Inventory
Length of Stay—A Key Metric
Reducing Length of Stay
Number of Staff Required
Total Labor Time
Quiz
Weighted Average
Financial Metrics
Measuring Inventory and Cash Flow
Work in Process Inventory
Sales of Reimbursement per Employee
Contribution Margin
Cost Per Case
Data and What People Think
Sustainability and Accountability
Process Owners Do Not Always have the Skill Sets Necessary to Manage in a Lean Environment
Notes

Basic Lean Concepts and Tools – Assessment and Analyze
Levels of Waste
Low-Hanging Fruit
Five S Wastes
The Seven (Eight) Wastes
How do you Find Waste?
30-30-30 Exercise
People
Equipment
Communication
Visual Controls
Leadership
Cost of Waste
Baseline Entitlement Benchmark
Five Why’s
Example
Another Tool to Get Rid of Waste: The Five W’s and Two H’s
Root Cause Analysis—A3 Strategy
Fishbones and Lean
Problem-Solving Model
Problem Statements
Lean Tools - Analyze/Assessment
BASICS—Assess the Process
Step One: Understand and Assess the Overall Process
Value-Added
Non-Value-Added Activities/Work
Non-Value-Added but Necessary Work
Unnecessary Work
Idle Time
Warranted IDLE Time Exceptions
The Patient Physical Examination
Step 1: Process Flow Analysis (PFA)—Following the Product/Patient
Mapping the Process—Identifying Process Boxes
Product Process Flow Analysis Tool
The Four Components Of PFA - Tips Analysis
Basic Lean Tools Understanding Types of Storage
Raw Material Storage
Work in Process Storage
Finished Goods Storage
Further Delineating Storage—Types of Work in Process
Lot Delay
Potential Lean Solution Example #1
Potential Lean Solution Example #2
Between Process Delay
Within Process Delay
Why Break Down Types of Storage?
Total Throughput Time
Product Process Flow Worksheet
Product Flow Point-to-Point Diagrams
How to Do a Point-to-Point Diagram
Network of Process vs. Operations Defined
Group Technology Matrix—Stratification Analysis
Example: Group Technology Applied to a Surgical Services Unit
Step II: Assess the Process—Operator Analysis or Full Work Analysis
Why Make the Operator’s (Staff Person’s) Job Easier?
Total Labor Time
Workload Balancing
How To Balance The Work
Separate Worker from Machine
Machine Time vs. Labor Time
Diagrams: Spaghetti Diagramming—Operator Walk Patterns
How to Do a Spaghetti Diagram
Network of Process vs. Operations Defined
Motion Study—Just When You Thought You Were "There"
Time is a Shadow of Motion
100% Efficiency with Humans
Operator Resistance
Step III: Assess the Process—Changeover Analysis
Internal Vs External Time
Four Parts of a Setup/Changeover Process
Healthcare Setup Translation
Why Reduce Setups? Benefits of Smed/SMER (Single Minute Exchange of Rooms)
Summary

Putting It All Together
Understanding Demand and Resource Needs
Appropriate Resourcing Can Drive Metrics
True Bottlenecks
Cross-Training
How to Construct a Cross-Training Matrix
Heijunka—Sequencing Activities, Load Balancing
Standard Work
Story
Job Breakdown/Work Flow Analysis
Developing Standard Work
Standard Work Form
Work Standards
Eventually Standard Work Can Lead to Semi- or Complete Automation
Leader Standard Work
Capacity Analysis—Part Production Capacity Sheet
Layout Design
Master Layouts
Creativity Before Capital
Lean Layout Design—Configurations—Determining the New Flow for the Area
The "U-Shaped" Layout
Straight Line Layouts
Parallel Layouts
Other Layout Considerations
Guidelines to Layout Re-design—Non-Negotiable
How Do We Know When the Layout is Right?
Work Station Design
Stand Up vs. Sit Down Stations with Chart Flow
Work Station Design Summary
Master Layouts and Lean Design
Lean and Architects
Do We Really Need to Add More Rooms or Space?
Layouts Drive Waste in the Form of Increased Labor Costs—Consider Adjacencies
Some Practical Examples of Lean Designs
Nursing Floors
Other Design Considerations
Lean and Regulatory Environment
Rate Companies on the Ability to Sustain Continuous Improvement Plan for Every Part—Amount of Supplies/Inventory Needed
Labeling
Kanban
What Parts Do We Kanban?
Constant Time or Constant Quantity

Implementing Lean in a Healthcare Environment
How to Implement Lean Methodology
The Lean System Implementation—Are You Ready for It?
What Type of Commitment is Required?
What is Kaikaku?
Kakushin
Importance of Lean Pilots
Keep the Ownership with the Line Organization
Lean Implementation Objections and Retail Sales Techniques
Objections are Good!
Types of Closing Questions
General Overarching Lean Implementation Tips
Team Charters
Guidelines for the Supervisor
Train the Staff in the New Process
Types of Training
Overview Training
On the Job Lean Training
Executive Training
The Lean Implementation Model
General Discussion of the Four Methods
Kaizen (Method 3) vs. the Traditional Point Kaizen (Method 2) Event Approach
Kaizen
Point Kaizen Events
Potential Pitfalls of the Traditional Point Kaizen Approach
Disadvantages of Point Kaizen Events Used for First Time Implementation
Advantages/Results of Kaizen Events
Visual Management System Components
Five S
Visual Displays
Visual Controls
Story
Visual Management System
Lean Goal is Zero Defects—Difference Between an Error and a Defect
Poka Yoke
Types of Control and Warning Devices
Examples of Cause and Effect
Total Productivity Maintenance
Total Productivity Maintenance Goals
Overall Equipment Effectiveness
New Maintenance Paradigm
Lean and Maintenance in Hospitals
Construction Challenges
Hospital and IT Systems
BASICS—Checking the New Process
BASICS—Sustaining the Process
Sustaining Tools
Sustain Plans/Control Plans
Leader Standard Work
Visual Management
Accountability
Discipline
Staff Involvement
You Get What You Expect; You Deserve What You Tolerate
Additional Sustaining Tools
Repeat the Cycle!
Lean Practitioners.
Lean Hospital Implementation (System Kaizen and Point Kaizen) Lessons Learned
Create the Leadership Road Map
Make Sure Your Organization is Ready
Create a Lean Steering Committee—But Make It the Senior Leadership Team
Lean Consultants Should Report to the CEO
Create a Lean Organizational Infrastructure
Communication Plan
Training Plan
Leadership Cannot Stay in Their Ivory Tower
Leadership Must Lead and Drive Lean Changes, Not Just Support Them
Leaders Must Participate in Lean. You Cannot "Get It" in a Two hour or Four Hour PowerPoint Pitch
Don’t Let Lean Turn into Finance-Driven FTE Witch Hunts
Work to Establish the Lean Culture, Not Just the Tools
Insist On Updating Standard Work
Do Not Reward Work Arounds
Don’t Encourage the Victim Syndrome
Physician Resistance to Lean
Get Everyone Involved in the Analysis Phase
Give Lean System Implementation Time to Work Before Trying to Change the Underpinnings
Dedicate Resources Up Front
Include a Strategy for Accountability and Sustaining as Part of the Continuous Improvement Road Map
Listen to Your Lean Consultants/Experts
Adopt and Integrate Standard Work and Create a Suggestion and Reward Systems
Don’t Leave Managers in Place Who Aren’t Going to Get It
Don’t Lay People Off After Lean Implementation
Don’t Shortcut the Tools
Encourage Lean Architectural Designs
Include a "Go Forward" Person on the Team
Train, Train, Train
Create an Escalation Process
Identify the Process Owner and the Team Leader Up Front
Change Reward System
It’s Just a Bump in the Road
Multiple Site Rollout Strategies
Site/Area Selection
Trying to Implement Several Projects at Once without Sufficient Resources

Executives and Lean
Introduction
Been There, Done That
More than just a Competitive Advantage
Board of Directors Training
Differences Between Lean and Six Sigma
Define Reality for the Lean Initiative
Resources and Accountability
Lean Should Be Where the Action Is
Removing Barriers
Measurements to Drive Outcomes
Who is to Blame?
You are What You Measure
Control or Sustain Process
Lean and Audits
"Project-itis"
Human Error Factor
Fair and Just Culture
Communication, Communication, and more Communication
Gemba – Where the Truth Can Be Found
What Questions Should You Ask When Doing a Gemba Walk?
Meetings
Paying for Suggestions
Physician Engagement
The Cog in the Chain of Command
Value Stream Managers in the Lean Organization
Role of the External Consultant
Summary
Punch List of Considerations/Ideas for the Executive Leader

Roles and Responsibilities of Managers and Supervisors
Setting the Stage: Role of Managers and Supervisors
Do You Really Want to Know What I See? Do You Really Want to Know
What I Think
Key Responsibilities and Tools for Managers and Supervisors
Communication
Identify and Provide Resources
Time Management and the "Fires"
Standard Work and Healthcare
Following Standard Work Does Not Mean We Stop Thinking
Implementation
Problems with Behaviors
Understanding Employee Satisfaction
Management and Supervisor Performance
Delegation
The Journey of a Lean Sensei with a Star Wars Analogy
On-Line Lean Training

What It Means to Have a Lean Culture
Organizational Dissemination of Lean
Understanding what a Lean Culture Looks Like—"the People Piece"
Importance of the 50% People Piece
People vs. Task—We Need a Balance
Vision
Organizational Value Systems
Pearls of Advice
Managing Resistance to a Lean Culture Change
Lean Culture Assessment
Assessment Issues and Discussion
Motivation and Continuous Improvement
High-Level Steps to Implementing a Lean Culture
Step 1: Utilize Skip Levels to See What Your Employees are Thinking
Step 2: Education and Training
Step 3: Create a Pull for Lean
Step 4: Create a Lean Implementation Plan
Step 5: Create a Lean Steering Committee
Step 6: Baseline Metrics
Step 7: Implement a Pilot—Utilize the BASICS Model
Step 8: Gemba Walks
Step 9: Sustain—Hoshin and Suggestion System
Step 10: Continuous Improvement
Barriers to Continuous Improvement
Effort to Overcome Each Barrier Types
Work to Sustain and Improve with Lean
How Do You Get the CEO on Board?
Story...Lean in County Government 
Committing the Right Resources to Sustain
Human Resources and Lean
Sustaining the Continuous Improvement Culture


Leveraging Lean in the Emergency Department
The Typical ED
Long Wait Times for Overcrowded Emergency Rooms across the United
Total Time Spent in the ED
Patient Satisfaction with the ED
ED Visits in 2010
The Traditional ED Model
The Current Process is Broken
Current ED Improvement Ideas
Build More Rooms
Problems with Express Care and Fast-Track Models
"Doctor in Triage" Model
Providers See Patients in the Lobby
The Problem with Protocols
Adding Staff
Filter Patients and Send Low Acuity Patients to an Off-Site Urgent Care
The Lean ED System Approach
Value Stream Map
Product Process Flow: "The Patient"
Operator Full Work Analysis
Hypothesis
Consider the Family Physician Office Flow Model
The New ED Model
Goal
The New ED Model
Discussion
Emergency Clinical Pathways/Evidence-Based Medicine
Physician Scheduling
Other Paradigms Challenged
Resistance
Systems Impact of Implementation
Ambulance Patients
Triage Sorting Criteria
Results
Physician Benefits of This Process
Patient Benefits From the New Model
Benefits to the Hospital
Applying Lean in the Emergent – Acute Care Setting
External Forces on ED Throughput
Inpatient Floors
What a Traditional Inpatient Unit looks like
Typical Problems Encountered
Lean BASICS and Six Sigma Tools Applied—Baseline
Value Stream Mapping
Hospitalist Value Stream Mapping
Inpatient Value Stream Mapping
Care Coordination Value Stream Mapping (Includes Case Management)
ED Value Stream Map
Inpatient Process Improvement Initiative
Findings
Analysis
Suggest Solutions
BASICS - Implementation—Unit-Based Model (Geographic)
Housekeeping
5S
Resistance Encountered
Stakeholders Analysis
BASICS - Check/Sustain—Results
Length of Stay
Satisfaction
Sustain - Standard Work
Conclusion
Stage for you ED Lean Project Checklist

Appendix

Appendix: Glossary

Index