ED becomes 'lean' and cuts LBTC, LOS times
ED becomes 'lean' and cuts LBTC, LOS times
Methodology seen as ideal for problem-solving
The leadership at St. Luke's Episcopal Hospital in Houston has used "Lean" methodology to significantly improve performance in the ED, reducing median length of stay, frequency of diversions, and the percentage of patient who left before treatment was complete (LBTC).
"Lean," or lean manufacturing techniques, is part of the Toyota production system that several health care organizations are adapting to improve care processes.
"What our executive team discovered as they investigated Lean and how it may benefit us was that it provided the structure in which to do problem solving," says Andrew Eller, BSN, RN, clinical educator for the ED and project leader for Lean implementation in the ED.
They determined that Lean was a reliable process improvement methodology that would take variability out of the care equation, says Mike Reno, vice president of operations. "That is, the patient will receive the same exact care day in and day out, regardless of who is on staff or how many patients are in the ED." The decision to go with Lean was made after a six-month review of the Toyota production system that included a site visit, he says.
Eller says that Lean, which was implemented in the middle of 2007, showed the following improvements when comparing the last six months of the year with the first six months:
- Median patient length of stay (LOS). Pre-Lean was 446 minutes, and post-Lean was 390 minutes.
- Median percentage of LBTC patients. Pre-Lean was 7.73%, and post-Lean was 3.85%.
- Median percentage of time spent on diversion. Pre-Lean was 12.08%, and post-Lean was 6.62%.
Staff were receptive
To educate the ED staff about Lean, the hospital provided a 1½-day "mini-boot camp" that offered an overview of Lean and the methodology, including theory and structure.
"The staff has been very receptive," says Eller. "The way I always present it to them is that it provides them the opportunity to dream big: to describe their ideal work environment and what would make it easiest for them to care for their patients."
Training is repeated approximately once a quarter, Eller adds. "We also train staff through a PowerPoint presentation and modules offered online," he says.
One of the most effective Lean tools is the communication board, which is posted in the department, Eller says. "It displays our current status [with LOS, LBTC, and diversion] and where we see improvement, and illustrates what our target goals are," he says. "It also has an action item list, which provides a sort of comment box for staff to submit ideas they feel would improve the process."
The staff can make these notes, which also can include complaints about processes, and the department management team reviews them on a daily basis. "When they see us respond, they are motivated to put more ideas in, and this feeds the improvement cycle," says Eller.
One of the most effective tools in Lean methodology is called "current state," which involves following the patient through their ED experience and collecting timings at various stages of care to determine where the delays are, Eller says.
"Based on that process, we identified a need to create a 'Y' in the road for the ED," he says.
In the process that was in place before Lean was introduced, patients would come in, register, go to the waiting area, and then be called to triage, which could take 30 minutes to an hour. Then they would return to the waiting area. If they were a lower-acuity case, they could wait many hours, depending on patient load, to see a doctor.
Being a tertiary hospital, they saw a high volume of higher-acuity patients and did not have a fast-track unit, Eller says. "The two minor emergency centers down the street treated those patients," he says. "But we had seen an increase in the volume of patients with higher acuity status: ESI [Emergency Severity Index] levels I and II."
After the "current-state" exercise, the department decided to adopt a rapid assessment and disposition process in August 2007, which it was able to do using existing treatment rooms. "As the patient arrives, we use a set of criteria we developed to determine which of them are to be candidates for that process," says Eller. As the patient enters into triage, the nurse immediately determines whether they need a treatment room or if they are a candidate for rapid assessment and disposition.
"If the patient truly doesn't need a treatment room, we do not want to tie up any more beds than we need to, so we funnel them into the rapid assessment areas where they are seen by a doctor and a nurse," Eller explains. "If they need more testing, it can be initiated, and the patient is placed in a testing or 'results' area, which was also created from an existing treatment room."
Often an ED can be a chaotic environment, with multiple critical patients arriving at any given point in time, Eller notes. "Lean provides the tools and structure to create 'organized chaos' by ensuring processes in the ED are efficient and patient-centered," he says. "This enhances your ability to provide timely treatment and provide quality care to every patient."
For more information on using Lean methodology in the ED, contact:
- Andrew Eller, RN, BSN, Clinical Educator, Emergency Department, St. Luke's Episcopal Hospital, Houston. Phone: (832) 355-3147. E-mail: [email protected].
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