Leveraging Lean in the Emergency Department: Creating a

Cost Effective, Standardized, High Quality, Patient-Focused

Operation

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

Joyce Kerpchar • Charles Protzman • George Mayzell, MD

CRC Press
Taylor & Francis Group
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Contents
Preface: Leveraging Lean in the Emergency Department..............................................................xvii
Acknowledgments............................................................................................................................xxi
Authors.......................................................................................................................................... xxiii

SECTION I

Chapter 1 Introduction to Lean...................................................................................................... 3

The Need for Change.................................................................................................... 3
National and Global Competition..................................................................................4
Challenges for the Healthcare Worker..........................................................................5
Lean and Layoffs...................................................................................................... 5
Traditional Healthcare Model....................................................................................... 5
Introduction – So What Is Lean?..................................................................................7
Lean and Hospitals........................................................................................................8
What Results Can You Expect?................................................................................9
The CEO and Lean...................................................................................................... 10
Typical Lean Metrics and Outcomes.......................................................................... 11
Potential Lean Returns by Department.................................................................. 11
Typical Results/Return on Investments (ROI) and Implementing Lean................ 11
Lean and Systems Thinking........................................................................................ 16
Boiled Frog Syndrome........................................................................................... 16
Systems Thinking Principles.................................................................................. 16
Viewing the Hospital with Systems Thinking....................................................... 17
What Is a Lean Business Delivery System?................................................................20
Lean Business Delivery System Vision.................................................................. 21
Understanding the Value of the Lean Business Delivery System.......................... 21
Just In Time: The First Pillar of the Toyota Production System Model................. 22
An Example of One of the Rocks—Short-Staffed............................................ 23
Jidoka—The Second Pillar of the Toyota Production System................................24
Jidoka Means: Never Pass on a Bad Part or Patient...............................................25
Applying Jidoka to Healthcare...............................................................................25
The Top of the Toyota House—Respect for Humanity...............................................26
Lean Is a Journey........................................................................................................ 27

Chapter 2 Batching vs. Lean Thinking and Flow........................................................................ 29

Batching vs. Lean Thinking and Flow........................................................................ 29
Batching vs. Flow in a Healthcare Environment........................................................ 30
Batching Examples................................................................................................. 30
Process Definition.............................................................................................. 30
Batching Systems................................................................................................... 31
Why People Love to Batch?.................................................................................... 31
One-Piece/Patient Flow..................................................................................... 33
One-Piece Flow Example....................................................................................... 36

v
vi Contents

Group Technology.................................................................................................. 38
Productivity - Definition............................................................................................. 38
Batching the Domino Effect....................................................................................... 38
Peak Demand.............................................................................................................. 38
Examples of Batching in Healthcare...................................................................... 39
Chart Preparation.............................................................................................. 39
The Chart Problem............................................................................................40
Application of One-Piece Flow to Healthcare............................................................40
Flow—One-Piece Flow or Small Lot......................................................................... 42

Chapter 3 Lean and Change Management................................................................................... 45

Implementing Lean Is about Balance.......................................................................... 45
Lean Culture Change.................................................................................................. 45
Paradigms...............................................................................................................46
Change Equation....................................................................................................46
C ∙ Compelling Need to Change............................................................................. 47
Why Change?.......................................................................................................... 47
V ∙ Vision................................................................................................................ 49
N ∙ Next Steps......................................................................................................... 50
S ∙ Sustain............................................................................................................... 50
Change and What’s In It For Me............................................................................ 50
Lean and Change Management................................................................................... 51
Lean and Organizational Change - “Right Seat on the Right Bus”............................ 51
Resistance to Change.............................................................................................. 52
Changes… Highs and Lows................................................................................... 52
Rule of Unintended Consequences and Bumps in the Road.................................. 53
Change Is a Funny Thing....................................................................................... 53
We Are All Interconnected but Not Typically Measured That Way...................... 53
Horse Analogy........................................................................................................ 53
Comparison to Where We Are Today.................................................................... 54
Employee Suggestion Systems............................................................................... 54
Barriers to Change.................................................................................................. 55
Most Loved Words................................................................................................. 56
Does Your Organization Have Sacred Cows?........................................................ 56
Leadership and Organizational Changes.................................................................... 57
Communication, Change and Lean............................................................................. 58
Summary................................................................................................................ 59

Chapter 4 Lean Foundation.......................................................................................................... 61

Lean Foundation - The BASICS Model - Baseline..................................................... 61
Think—See—Act Lean......................................................................................... 61
System Lean Implementation Approach Utilizing the Basics Model......................... 61
A Customer Service Story......................................................................................64
Baseline Metrics..........................................................................................................66
Data, Revenue, and Hospitals.................................................................................66
The Impact of Data on Lean – Process Focused Metrics........................................... 67
Customer Satisfaction............................................................................................. 67
Voice of the Customer Surveys.............................................................................. 68
The VIP Visit.............................................................................................................. 69
Easy to Do Business With...................................................................................... 69
Contents vii

Centralized = Batching............................................................................................... 70
What Does All This Have to Do with Hospitals?.................................................. 70
Customer Value-Added Proposition............................................................................ 70
Customer Quality Index......................................................................................... 71
KANO Model......................................................................................................... 71
Baseline the Process.................................................................................................... 72
Value Stream Map (VSM) the Process.................................................................. 72
Value Stream Discussion........................................................................................ 74
Value Stream Mapping and Healthcare.................................................................. 74
Value Streams Objectives....................................................................................... 75
Traditional Hospital Systems - SILOS................................................................... 75
Lean Goals............................................................................................................. 75
Parts of a Value Stream Map.................................................................................. 76
Value Stream Map Icons........................................................................................ 76
Value Stream Map Definitions............................................................................... 76
Day 1.................................................................................................................. 78
Day 2.................................................................................................................. 78
Day 3.................................................................................................................. 78
Day 4.................................................................................................................. 78
Day 5.................................................................................................................. 79
Current State Value Stream Mapping.................................................................... 79
Ideal State............................................................................................................... 79
Future State Value Stream Mapping......................................................................80
Value Stream Map Project Lists, Prioritization Matrix, and Tracking..................80
Value Stream Layout Maps (Sometimes Referred to as Skitumi Maps)................84
Baselining the Process—Data Collection and Analysis—Current State...................84
Takt Time/Production Smoothing..........................................................................84
Available Time.......................................................................................................84
Customer Demand..................................................................................................84
Peak Demand.......................................................................................................... 85
Cycle Time.............................................................................................................. 86
Cycle Time and Takt Time—What’s the Difference?............................................ 86
Designing Cycle Time to Takt Time...................................................................... 87
Length of Stay (LOS)............................................................................................. 88
Length of Stay Is Directly Correlated to Inventory............................................... 89
Length of Stay—A Key Metric.............................................................................. 89
Reducing Length of Stay.............................................................................................90
Number of Staff Required...................................................................................... 91
Total Labor Time....................................................................................................92
Quiz........................................................................................................................92
Weighted Average...................................................................................................92
Financial Metrics......................................................................................................... 93
Measuring Inventory and Cash Flow..................................................................... 93
Work in Process Inventory.....................................................................................94
Sales of Reimbursement Per Employee..................................................................94
Contribution Margin............................................................................................... 95
Cost Per Case.......................................................................................................... 95
Data and What People Think................................................................................. 95
Sustainability and Accountability...............................................................................96
Process Owners Do Not Always Have the Skill Sets Necessary to Manage
in a Lean Environment...........................................................................................97
viii Contents

Chapter 5 Basic Lean Concepts and Tools – Assessment and Analyze......................................99

Levels of Waste...........................................................................................................99
Low-Hanging Fruit.................................................................................................99
Five S Wastes..........................................................................................................99
The Seven (Eight) Wastes.......................................................................................99
How Do You Find Waste?......................................................................................... 102
30-30-30 Exercise................................................................................................. 103
People................................................................................................................... 103
Equipment............................................................................................................. 103
Communication.................................................................................................... 104
Visual Controls..................................................................................................... 104
Leadership............................................................................................................ 104
Cost of Waste............................................................................................................. 106
Baseline Entitlement Benchmark.............................................................................. 106
Five Why’s................................................................................................................. 106
Example:............................................................................................................... 106
Another Tool to Get Rid of Waste: The Five W’s and Two H’s................................ 107
Root Cause Analysis—A3 Strategy.......................................................................... 107
Fishbones and Lean................................................................................................... 108
Problem-Solving Model............................................................................................ 108
Problem Statements................................................................................................... 110
Lean Tools - Analyze/Assessment............................................................................. 111
Basics—Assess the Process.................................................................................. 113
Step One: Understand and Assess the Overall Process................................... 113
Value-Added......................................................................................................... 113
Non-Value-Added Activities/Work....................................................................... 114
Non-Value-Added But Necessary Work............................................................... 114
Unnecessary Work................................................................................................ 114
Idle Time.............................................................................................................. 114
Warranted IDLE Time Exceptions....................................................................... 114
The Patient Physical Examination................................................................... 115
Step 1: Process Flow Analysis (PFA)—Following the Product/Patient................... 115
Mapping the Process—Identifying Process Boxes.............................................. 116
Product Process Flow Analysis Tool......................................................................... 116
The Four Components of PFA - Tips Analysis......................................................... 117
Basic Lean Tools Understanding Types of Storage................................................... 119
Raw Material Storage........................................................................................... 119
Work in Process Storage....................................................................................... 119
Finished Goods Storage....................................................................................... 120
Further Delineating Storage—Types of Work in Process.................................... 120
Lot Delay.............................................................................................................. 120
Potential Lean Solution Example #1.................................................................... 121
Potential Lean Solution Example #2.................................................................... 121
Between Process Delay........................................................................................ 121
Within Process Delay........................................................................................... 122
Why Break Down Types of Storage?................................................................... 122
Total Throughput Time........................................................................................ 122
Product Flow Analysis Worksheet....................................................................... 123
Product Flow Point-to-Point Diagrams................................................................ 123
How to Do a Point-to-Point Diagram................................................................... 125
Contents ix

Network of Process vs. Operations Defined......................................................... 125

Group Technology Matrix—Stratification Analysis................................................. 126
Example: Group Technology Applied to a Surgical Services Unit...................... 127
Step II: Assess the Process—Operator Analysis or Full Work Analysis................. 129
Why Make the Operator’s (Staff Person’s) Job Easier?........................................ 130
Total Labor Time.................................................................................................. 131
Workload Balancing............................................................................................. 131
How to Balance the Work..................................................................................... 132
Separate Worker from Machine........................................................................... 135
Machine Time vs. Labor Time............................................................................. 135
Diagrams: Spaghetti Diagramming—Operator Walk Patterns........................... 136
How to Do a Spaghetti Diagram.......................................................................... 136
Network of Process vs. Operations Defined......................................................... 137
Motion Study—Just When You Thought You Were “There”................................... 137
Time Is a Shadow of Motion................................................................................ 140
100% Efficiency with Humans............................................................................. 142
Operator Resistance.............................................................................................. 142
Step III: Assess the Process—Changeover Analysis................................................ 142
Internal vs. External Time.................................................................................... 143
Four Parts of a Setup/Changeover Process.......................................................... 143
Healthcare Setup Translation............................................................................... 143
Why Reduce Setups? Benefits of SMED/SMER
(Single Minute Exchange of Rooms).................................................................... 145
Summary................................................................................................................... 145

Chapter 6 Putting It All Together.............................................................................................. 147

Using the Future State “to Be” and Future State Analysis to Design the New
Process and Implementation..................................................................................... 147
Understanding Demand and Resource Needs........................................................... 149
Appropriate Resourcing Can Drive Metrics............................................................. 151
True Bottlenecks................................................................................................... 154
Cross-Training...................................................................................................... 154
How to Construct a Cross-Training Matrix.......................................................... 154
Heijunka—Sequencing Activities, Load Balancing................................................. 155
Standard Work........................................................................................................... 157
Story................................................................................................................. 159
Job Breakdown/Work Flow Analysis................................................................... 160
Developing Standard Work....................................................................................... 160
Standard Work Form............................................................................................ 161
Work Standards.................................................................................................... 163
Eventually Standard Work Can Lead to Semi- or Complete Automation........... 163
Leader Standard Work.......................................................................................... 163
Capacity Analysis—Part Production Capacity Sheet.......................................... 164
Layout Design........................................................................................................... 166
Master Layouts..................................................................................................... 166
Creativity before Capital...................................................................................... 166
Lean Layout Design—Configurations—Determining the New Flow
for the Area........................................................................................................... 167
The “U-Shaped” Layout....................................................................................... 168
Straight Line Layouts........................................................................................... 169
x Contents

Parallel Layouts.................................................................................................... 169

Other Layout Considerations................................................................................ 169
Guidelines to Layout Re-Design—Non-Negotiable............................................. 170
How Do We Know When the Layout Is Right?................................................... 173
Work Station Design............................................................................................. 174
Stand Up vs. Sit Down Stations with Chart Flow................................................ 175
Work Station Design Summary............................................................................ 175
Master Layouts and Lean Design.............................................................................. 176
Lean and Architects............................................................................................. 176
Do We Really Need to Add More Rooms or Space?............................................ 177
Layouts Drive Waste in the Form of Increased Labor Costs—Consider
Adjacencies........................................................................................................... 178
Some Practical Examples of Lean Designs.......................................................... 178
Nursing Floors...................................................................................................... 179
Other Design Considerations................................................................................ 179
Lean and Regulatory Environment........................................................................... 179
Rate Companies on the Ability to Sustain Continuous Improvement.
Plan for Every Part—Amount of Supplies/Inventory Needed............................. 181
Labeling................................................................................................................ 182
Kanban................................................................................................................. 182
What Parts Do We Kanban?................................................................................. 184
Constant Time or Constant Quantity.................................................................... 184

Chapter 7 Implementing Lean in a Healthcare Environment.................................................... 187

How to Implement Lean Methodology..................................................................... 187
The Lean System Implementation—Are You Ready for It?..................................... 187
What Type of Commitment Is Required?............................................................ 187
What Is Kaikaku?................................................................................................. 188
Kakushin.............................................................................................................. 188
Importance of Lean Pilots.................................................................................... 189
Keep the Ownership with the Line Organization................................................ 189
Lean Implementation Objections and Retail Sales Techniques................................ 189
Objections Are Good!.......................................................................................... 189
Types of Closing Questions.................................................................................. 190
General Overarching Lean Implementation Tips..................................................... 191
Team Charters........................................................................................................... 192
Guidelines for the Supervisor............................................................................... 192
Train the Staff in the New Process....................................................................... 193
Types of Training................................................................................................. 193
Overview Training................................................................................................ 193
On the Job Lean Training..................................................................................... 194
Executive Training............................................................................................... 194
The Lean Implementation Model.............................................................................. 194
General Discussion of the Four Methods............................................................. 195
Kaizen (Method 3) vs. the Traditional Point Kaizen (Method 2)
Event Approach.................................................................................................... 195
Kaizen.............................................................................................................. 195
Point Kaizen Events......................................................................................... 196
Potential Pitfalls of the Traditional Point Kaizen Approach................................ 196
Contents xi

Disadvantages of Point Kaizen Events Used for First Time

Implementation..................................................................................................... 197
Advantages/Results of Kaizen Events.................................................................. 198
Visual Management System Components.................................................................200
Five S....................................................................................................................200
Visual Displays..................................................................................................... 201
Visual Controls..................................................................................................... 201
Story.................................................................................................................202
Visual Management System................................................................................. 203
Lean Goal Is Zero Defects—Difference between an Error and a Defect............ 203
Poka Yoke.............................................................................................................204
Types of Control and Warning Devices...............................................................204
Examples of Cause and Effect..............................................................................204
Total Productivity Maintenance................................................................................205
Total Productivity Maintenance Goals.................................................................205
Overall Equipment Effectiveness.........................................................................205
New Maintenance Paradigm................................................................................205
Lean and Maintenance in Hospitals.....................................................................206
Construction Challenges.......................................................................................206
Hospital and IT Systems...........................................................................................206
BASICS—Checking the New Process.................................................................207
BASICS—Sustaining the Process........................................................................207
Sustaining Tools........................................................................................................207
Sustain Plans/Control Plans.................................................................................207
Leader Standard Work..........................................................................................208
Visual Management..............................................................................................208
Accountability......................................................................................................209
Discipline.............................................................................................................. 210
Staff Involvement................................................................................................. 210
You Get What You Expect; You Deserve What You Tolerate.................................. 210
Additional Sustaining Tools................................................................................. 210
Repeat the Cycle!.................................................................................................. 211
Lean Practitioners................................................................................................. 211
Lean Hospital Implementation (System Kaizen and Point Kaizen)
Lessons Learned....................................................................................................... 211
Create the Leadership Road Map......................................................................... 211
Make Sure Your Organization Is Ready.............................................................. 211
Create a Lean Steering Committee—But Make It the Senior
Leadership Team.................................................................................................. 212
Lean Consultants Should Report to the CEO....................................................... 212
Create a Lean Organizational Infrastructure....................................................... 212
Communication Plan............................................................................................ 212
Training Plan........................................................................................................ 212
Leadership Cannot Stay in Their Ivory Tower..................................................... 214
Leadership Must Lead and Drive Lean Changes, Not Just Support Them.......... 214
Leaders Must Participate in Lean. You Cannot “Get It” in a Two Hour or
Four Hour PowerPoint Pitch................................................................................. 214
Don’t Let Lean Turn into Finance-Driven FTE Witch Hunts.............................. 214
Work to Establish the Lean Culture, Not Just the Tools...................................... 214
Insist on Updating Standard Work....................................................................... 214
xii Contents

Do Not Reward Work Arounds............................................................................ 214

Don’t Encourage the Victim Syndrome............................................................... 215
Physician Resistance to Lean............................................................................... 215
Get Everyone Involved in the Analysis Phase...................................................... 216
Give Lean System Implementation Time to Work before Trying to
Change the Underpinnings................................................................................... 216
Dedicate Resources up Front................................................................................ 216
Include a Strategy for Accountability and Sustaining as Part of the
Continuous Improvement Road Map.................................................................... 216
Listen to Your Lean Consultants/Experts............................................................ 217
Adopt and Integrate Standard Work and Create a Suggestion and
Reward Systems.................................................................................................... 217
Don’t Leave Managers in Place Who Aren’t Going to Get It.............................. 217
Don’t Lay People off after Lean Implementation................................................. 218
Don’t Shortcut the Tools....................................................................................... 218
Encourage Lean Architectural Designs............................................................... 218
Include a “Go Forward” Person on the Team....................................................... 218
Train, Train, Train................................................................................................ 218
Create an Escalation Process................................................................................ 218
Identify the Process Owner and the Team Leader up Front................................. 218
Change Reward System........................................................................................ 219
It’s Just a Bump in the Road................................................................................. 219
Multiple Site Rollout Strategies................................................................................. 219
Site/Area Selection............................................................................................... 219
Trying to Implement Several Projects at Once without Sufficient
Resources.............................................................................................................. 219

Chapter 8 Executives and Lean.................................................................................................. 221

Introduction............................................................................................................... 221
Been There, Done That........................................................................................ 221
More Than Just a Competitive Advantage................................................................ 222
Board of Directors Training...................................................................................... 222
Differences between Lean and Six Sigma................................................................ 223
Define Reality for the Lean Initiative................................................................... 223
Resources and Accountability..............................................................................224
Lean Should Be Where the Action Is................................................................... 225
Removing Barriers............................................................................................... 225
Measurements to Drive Outcomes....................................................................... 225
Who Is to Blame?................................................................................................. 226
You Are What You Measure................................................................................ 227
Control or Sustain Process................................................................................... 227
Lean and Audits........................................................................................................ 228
“Project-itis”......................................................................................................... 228
Human Error Factor............................................................................................. 230
Fair and Just Culture............................................................................................ 231
Communication, Communication, and More Communication............................ 232
Gemba – Where the Truth Can Be Found............................................................ 232
What Questions Should You Ask When Doing a Gemba Walk?......................... 233
Meetings............................................................................................................... 234
Paying for Suggestions......................................................................................... 234
Contents xiii

Physician Engagement.......................................................................................... 234

The Cog in the Chain of Command..................................................................... 235
Value Stream Managers in the Lean Organization.............................................. 235
Role of the External Consultant........................................................................... 236
Summary................................................................................................................... 236
Punch List of Considerations/Ideas for the Executive Leader.................................. 236

Chapter 9 Roles and Responsibilities of Managers and Supervisors......................................... 239

Setting the Stage: Role of Managers and Supervisors.............................................. 239
Do You Really Want to Know What I See? Do You Really Want to Know
What I Think?...........................................................................................................240
Key Responsibilities and Tools for Managers and Supervisors................................240
Communication....................................................................................................240
Identify and Provide Resources............................................................................ 242
Time Management and the “Fires”...................................................................... 243
Standard Work and Healthcare.................................................................................244
Following Standard Work Does Not Mean We Stop Thinking...........................244
Implementation..........................................................................................................246
Problems with Behaviors........................................................................................... 247
Understanding Employee Satisfaction....................................................................... 247
Management and Supervisor Performance...............................................................248
Delegation.............................................................................................................248
The Journey of a Lean Sensei with a Star Wars Analogy......................................... 249
On-Line Lean Training........................................................................................ 250

Chapter 10 What It Means to Have a Lean Culture.................................................................... 251

Organizational Dissemination of Lean..................................................................... 251
Understanding What a Lean Culture Looks Like—“The People Piece”................. 252
Importance of the 50% People Piece................................................................... 252
People vs. Task—We Need a Balance.................................................................. 252
Vision.................................................................................................................... 253
Organizational Value Systems.............................................................................. 254
Pearls of Advice.................................................................................................... 256
Managing Resistance to a Lean Culture Change................................................. 256
Lean Culture Assessment..................................................................................... 256
Assessment Issues and Discussion....................................................................... 256
Motivation and Continuous Improvement............................................................ 256
High-Level Steps to Implementing a Lean Culture..................................................260
Step 1: Utilize Skip Levels to See What Your Employees Are Thinking............260
Step 2: Education and Training............................................................................260
Step 3: Create a Pull for Lean..............................................................................260
Step 4: Create a Lean Implementation Plan.........................................................260
Step 5: Create a Lean Steering Committee.......................................................... 261
Step 6: Baseline Metrics....................................................................................... 261
Step 7: Implement a Pilot—Utilize the BASICS Model...................................... 261
Step 8: Gemba Walks........................................................................................... 262
Step 9: Sustain—Hoshin and Suggestion System................................................ 262
Step 10: Continuous Improvement....................................................................... 262
Barriers to Continuous Improvement........................................................................ 263
Effort to Overcome Each Barrier Types...............................................................264
xiv Contents

Work to Sustain and Improve with Lean..................................................................264

How Do You Get the CEO on Board?..................................................................264
Story…Lean in County Government...............................................................264
Committing the Right Resources to Sustain........................................................ 265
Human Resources and Lean................................................................................. 265
Sustaining the Continuous Improvement Culture.....................................................266

SECTION II

Chapter 11 Leveraging Lean in the Emergency Department...................................................... 269

The Typical ED......................................................................................................... 269
Long Wait Times for Overcrowded Emergency Rooms across the United States....269
Total Time Spent in the ED.................................................................................. 270
Patient Satisfaction with the ED........................................................................... 270
ED Visits in 2010.................................................................................................. 270
The Traditional ED Model............................................................................... 271
The Current Process Is Broken................................................................................. 275
Current ED Improvement Ideas................................................................................ 277
Build More Rooms............................................................................................... 277
Problems with Express Care and Fast-Track Models................................................ 278
“Doctor in Triage” Model..................................................................................... 279
Providers See Patients in the Lobby..................................................................... 279
The Problem with Protocols................................................................................. 279
Adding Staff.........................................................................................................280
Filter Patients and Send Low Acuity Patients to an Off-Site Urgent Care........... 281
The Lean ED System Approach................................................................................ 281
Value Stream Map................................................................................................ 281
Product Process Flow: “The Patient”................................................................... 282
Operator Full Work Analysis............................................................................... 283
Hypothesis............................................................................................................284
Consider the Family Physician Office Flow Model............................................. 285
The New ED Model.................................................................................................. 286
Goal...................................................................................................................... 287
The New ED Model......................................................................................... 287
Discussion............................................................................................................. 289
Emergency Clinical Pathways/Evidence-Based Medicine................................... 290
Physician Scheduling............................................................................................ 290
Other Paradigms Challenged............................................................................... 291
Resistance............................................................................................................. 293
Systems Impact of Implementation........................................................................... 293
Ambulance Patients.............................................................................................. 294
Triage Sorting Criteria......................................................................................... 294
Results.................................................................................................................. 295
Physician Benefits of This Process............................................................................ 295
Patient Benefits from the New Model....................................................................... 295
Benefits to the Hospital............................................................................................. 296
Applying Lean in the Emergent – Acute Care Setting......................................... 296
External Forces on ED Throughput..................................................................... 299
Contents xv

Inpatient Floors.........................................................................................................300
What a Traditional Inpatient Unit Looks Like..........................................................300
Typical Problems Encountered..................................................................................300
Lean Concepts and Tools Applied—Baseline..........................................................302
Value Stream Mapping.........................................................................................302
Hospitalist Value Stream Mapping.......................................................................302
Inpatient Value Stream Mapping.......................................................................... 303
Care Coordination Value Stream Mapping (Includes Case Management).......... 303
ED Value Stream Map.......................................................................................... 303
Inpatient Process Improvement Initiative............................................................. 303
Findings................................................................................................................ 303
Analysis................................................................................................................304
Suggest Solutions..................................................................................................304
BASICS - Implementation—Unit-Based Model (Geographic)............................ 305
Housekeeping.......................................................................................................306
5S�������������������������������������������������������������������������������������������������������������������������306
Resistance Encountered........................................................................................306
Stakeholders Analysis..........................................................................................307
BASICS—Check/Sustain—Results..........................................................................307
Length of Stay......................................................................................................307
Satisfaction...........................................................................................................307
Sustain - Standard Work..................................................................................309
Conclusion.................................................................................................................309
Stage for you ED Lean Project Checklist............................................................. 310
Appendix........................................................................................................................................ 313
Appendix: Glossary...................................................................................................................... 325
Preface: Leveraging Lean in the
Emergency Department
This book is intended as guide for healthcare executives and leaders, managers, process improve-
ment team members, and inquisitive frontline workers who want to implement and leverage Lean
in the Emergency Department. Its foundation is based upon the Shingo prize winning book,
Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient-Care
Delivery System.1 The core chapters provide detailed information on the concepts, principles, and
implementation of Lean in the healthcare environment. We felt it was critical to provide the reader
with a broad foundation on the application of Lean in healthcare so one can see the how Lean can
be applied throughout the continuum of care from the emergency room to other support services.
Lean concepts and tools can begin in any clinical or non-clinical support area within an integrated
delivery system and universally applied.
High-Quality Patient Care is imperative in healthcare. We strive for the highest quality care
systems, in the pursuit of the triple aim:

1. improving health of the population,

2. enhancing the experience of care (quality and satisfaction i.e., value), and
3. reducing the per capita cost

Organizations must finds effective ways to maximize value. The Lean Business Delivery System
is one way to accomplish this.
Lean is a different way to think. It begins with understanding the voice of the customer and
focusing on delivering value. Lean provides the foundational concepts and tools to identify and
eliminate waste. We do not encourage working faster or harder, as “haste makes wastes”. We just
encourage working more efficiently.
Business means that Lean applies to anything that is a process, whether it is part of the physical
patient care, information systems, or business systems (i.e., accounting, billing, marketing, etc.).
All business processes should flow in order to reduce cycle times and waste throughout the entire
system.
Delivery refers to what it takes to deliver your product or service to the customer. The focus is
on what value is added to the customer. The emergency room is often the initial and key entry point
into the healthcare delivery system. The experience the customer has in the ED can leave a lasting
impression of the organization, additionally the timeliness of care in the emergency room can have
significant impact on that outcome.
System means the emergency room is part of an integrated delivery network or system and relies
on supporting infrastructure to evaluate, and deliver care. Understanding and looking at the overall
hospital or clinical System, not just the ED, means every process we try to improve is linked or inte-
grated with other processes. It is difficult to change one process without impacting several others.
For example, many patients the ED required inpatient surgery, radiology and lab resources.
When you put all these words together, it leads to a culture change that is powerful for any
organization. The culture change is such that if you REALLY apply Lean concepts and tools, you
can become a world-class leader. If you have started or are considering Baldrige, or the Shingo

1 Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient-Care Delivery System,
Proztman, Mayzell, Kerpchar.

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xviii Preface

Prize, Lean positively impacts virtually all the criteria. Baldrige, Shingo, and Lean are about never-
ending, continuous iterations of improvement.
The book is divided into two sections by design.

Section I is a broad overview of the application of Lean in healthcare.

Section II focuses on Implementing lean in the Emergency Room.

The chapters are designed, in most cases, to stand alone. Therefore, you will find some repetition
throughout the book.
Section I defines Lean, the concepts, tools and principles, and key components of implementing
Lean. It begins with descriptions of each of the Lean tools and concepts and how to apply them.
They are organized in typical order of use and hierarchical priority; however, it should be noted that
not all the tools are used all the time or necessarily in the same order. We use the tools when appro-
priate to solve the problems at hand. We have spent many years studying and implementing Lean
in small, medium, and large healthcare systems and organizations, and have found sharing lessons
learned can be extremely valuable.
Section II, focuses on the application of Lean in the Emergency Room within the confines of the
hospital (or clinic) with a focus on the interconnectivity with the inpatient units. The format begins
with the normal operation of each area from a traditional standpoint and where typical problems
occur. Then we walk through various Lean initiatives and show how we have used value stream
mapping, following the patient and staff, along with other Lean tools for process improvement. We
introduce actionable blueprints so results can be duplicated or modified for use at other institutions.
We also include examples, stories, case study/results, and lessons learned.
Between the authors, we have read more than 500 books on Lean, Six Sigma, and total quality,
many of them from Productivity Press, to which we owe a debt to Norman Bodek, a pioneer in this
field. We have been a customer of Productivity Press (now CRC Press) for many years and leverag-
ing their expertise. We use many of these books during our 1, 3 and 5 day Lean training sessions
where we have taught students from all over the world.
This book focuses primarily on Lean. It is our experience that the majority of initial productivity
improvements in healthcare come from implementing Lean. We recommend using Lean concepts
and tools first to streamline processes and eliminate waste, then applying Six Sigma tools to reduce
variation in process.
This book promotes a philosophy based on acting on fact, collecting measurable results which
define and drive clear improvements in quality and efficiency. We also point out the tangible and
intangible challenges around measuring return on investment (ROI).
Lean is not just an operations initiative. If implemented properly, the Lean philosophy will
encourage changes in all aspects and areas of your organization. There are too few pages here to
contain all the knowledge and techniques of implementing a Lean business delivery system. Instead,
this book strives to include the most basic information that will be common to most processes.
Adopting a Lean culture is discussed, which includes implementing continuous improvement
through both scientific management and a respect for people to enable one to make decisions based
on data vs. subjective opinions. The tools and implementation tips in this guide are designed to
take you out of your comfort zone and provide you with facts to base decisions on who and what is
ultimately value-added to your customer.
A journey of a thousand miles begins by taking the initial step.2
The pursuit of continuous improvement has no end. The book drives home the importance of
viewing your transformation as a Lean journey. After the process has had its first Lean imple-
mentation where we change the systems, it is then followed up with ongoing small improvements.

2 Laozi, http://acc6.its.brooklyn.cuny.edu/~phalsall/texts/taote-v3.html, http://www.religiousworlds.com/taoism/ttcstan3.

html Lao-Tzu, Tao Te Ching ch. 64.
Preface xix

Everyone has to make these improvements everyday. It is this ongoing focus on the process which
yields significant results over time. Some of these small improvements will turn into large improve-
ments. The good news is we are always searching for the “One Best Way”, yet always knowing there
more waste to be found and eliminated.
The reader should find encouragement and excitement with each success. We hope you will cre-
ate your own lessons learned whether by success or setback and share them with us. Your joy must
be found in the quest to becoming Lean, because there is no end to what you and your organization
can accomplish. We wish you all Good Luck on your Lean journey!
Acknowledgments
This book includes many of our own firsthand experiences over the years and also references the
work and experiences of many other reputable individuals who have worked in the world of Lean.
We have been influenced by a great many who have chronicled their own Lean experiences, some
of which we have incorporated into this work. We would like to thank all of those, too numerous to
mention here, who have worked with us on Lean teams in the past and the senior leadership whose
support made them successful. This book would not have been possible without your hard work,
perseverance, and courage during our Lean journey together. Again, it would be impossible to cite
all of them and, if we overlooked anyone, we truly apologize, but we hope each recognizes that this
book wouldn’t have come to fruition without their influence and expertise.
We would like to thank the following for their contributions to voluntarily co-author or contribute
to the original Shingo prize winning book Leveraging Lean in Healthcare as well as the addition of
others who made the breakout of the book series possible as listed by type of contributing content:

1. History of Lean—Kenneth Hopper, international consultant and writer on management

and industrial management history; co-author of book, The Puritan Gift
2. Finance, Marketing, and Our Hospitals—Brian Maskell, president of BMA Associates,
who read several drafts of this chapter and provided content, editing advice, and text on
the “Lean accounting” part of the chapter
3. Nutritional Services—Shawn Nose­worthy, RD, LD, MSA, director of Food and Nutrition
Services, Florida Hospital Memorial Medical System
4. Emergency Department
a. Jody Lazarus, RN, CMAS, CCTC, MBA, BS, manager Nurse Auditing, Patient
Financial Services, Adventist Health Systems
b. Jacob L. Kriedermann, Lake Erie College of Osteopathic Medicine at Seton Hill
University
c. John Lewis, President and CEO, AMCH Hospital
d. Joyce Wright MS, Executive Director Operational Excellence, AMCH Hospital
5. Inpatient Floors—Douglas C. Johnson, RN, Lean Six Sigma Black Belt and Susan Sanches,
RN, MA Lean Sigma Black Belt
6. Laboratory—Mauren Harte, Lean Six Sigma Master Black Belt, HartePro Consulting
Primary Care Clinics and Pharnacy—Steve Stenberg, president, Continuous Progress
7. Michael Hogan of Progressive Business Solutions, LLC, whose partnership on many of
these hospital projects has been invaluable. Mike’s project work and resulting ideas have
indirectly contributed to many parts of this book.
8. Special thanks to Rick Malik, Audrey Knable, and JoAnn Hegarty of ValuMetrix® Services
for their help and guidance. Business Improvement Group has had a very successful and
long-standing strategic partnership with ValuMetrix® Services, the division of Ortho-
Clinical Diagnostics that provides expert Lean consulting to hospitals. Working together,
we have been able to help healthcare organizations take the first steps along the path of
their Lean journeys as we work toward improving healthcare for all. Without ValuMetrix®
Services, this book would not have been possible.
9. Presbyterian Hospital in Albuquerque for their help and support: Alison B. Stanley,
Director of Process Excellence, Beth Smith, MBA, Director, Perioperative Services for
CNM, and Steve Griego, Master Black Belt.
10. Russ Scaffede for his insight into the Toyota System and for his contributions through
numerous e-mail correspondence and edits with various parts of the book. He is owner

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xxii Acknowledgments

of Lean Manufacturing Systems Group, LLC and Management Consulting Consultant,

vice president of manufacturing at Toyota Boshoku America, past general manager/vice
president of Toyota Motor Manufacturing Power Train, and past senior vice president,
senior vice president of Global Manufacturing at Donnelly Corporation. Russ is co-author
of the book, The Leadership Roadmap: People, Lean & Innovation, along with Dwane
Baumgardner.
11. Many thanks to Kenneth Hopper and William Hopper for their assistance and input into this
book. Kenneth and William are the authors of The Puritan Gift: Reclaiming the American
Dream amidst Global Financial Chaos; their bios can be found at www.­puritangift.­com.­It
was Kenneth who brought the Civil Communications Section’s (CCS) existence, mission,
and contributions to light. Kenneth interviewed Charles Protzman Sr. in the early 1970s,
which resulted in several articles on the CCS.
12. Joel Barker for his permission in referencing the paradigm material so important and inte-
gral to Lean implementations.
13. Thanks to Amy Evers, PhD, vice president of Type Resources, Myers-Briggs Type
Indicator® certified, for her help and editing suggestions on the MBTI section
14. Thanks to our Productivity Press editor, Kris Mednansky, who has been terrific at guiding
us through our first writing project.
15. Many thanks to Cheryl Fenske, Fenske Communications, LLC, for the initial professional
edit of the original book.
16. Tim Schindele, Lewis Lefteroff and Brigit Zamora for taking valuable time out of their
schedules to provide insightful thoughts, edits, and critiques of the initial drafts.
17. MaryBeth Protzman for her help in typing, editing, and reading over the many drafts of
this text. We could not have done this project without the many hours she has devoted to
this project. We are a good team.
18. Allison Waldmann for the hours of editing and formatting of the chapters.
19. MaryBeth Protzman, Lauren Protzman, and J.C. Protzman for their transcription support.
20. Daniel Protzman, Tim Schindele, Donna Fox, Jack Protzman, and Jon Banks for their edit-
ing assistance.
21. The AlliedSignal Bendix Communications Division “Hats” team for all their assistance and
support, which resulted in our initial successful Lean culture changes in manufacturing.
22. The families of all the authors for their support and contributions throughout the process
of this project.
23. There are many more individuals who contributed to this book, both directly and indi-
rectly. We have worked with a great many dedicated individuals—too many to list here—
who have shared their knowledge and experiences with us. While it is impossible to cite
them all, we hope they see this book as the culmination of our respect and appreciation for
all they have done.
24. William M. Tsutsui, associate dean for International Studies, professor of History, College
of Liberal Arts & Sciences, University of Kansas, for his assistance in Japanese Kanji
translation.