ED Benchmarking Success

Toyota’s tips drive dramatic ED improvements

Progressive emergency department (ED) managers increasingly are looking outside health care for cutting-edge ideas to improve quality and boost efficiency.

"It is important for us to look to other industries, because we haven’t been successful in reducing waste and errors with our status quo," says Cindy Jimmerson, RN, process improvement researcher at Community Medical Center, a 108-bed facility in Missoula, MT, and co-investigator in a research project funded by the Arlington, VA-based National Science Foundation on "Applying the Principles of the Toyota Production System to Healthcare."

Jimmerson says there is a lot that EDs can learn from the Tokyo-based Toyota Motor Corp. The automaker has mastered reducing waste; giving customers exactly what they want, when they want it; and eliminating defects, says Jimmerson. Here are three examples of Toyota principles that can be implemented in the ED:

1. Make changes without the addition of staff or technology. According to Jimmerson, changes are made from the "bottom up," with workers considered the experts. "This is not someone from the top telling people what to do," she underscores. The idea is to make changes as soon as possible after a roadblock is identified, she says. "You figure out why it occurred and what you will do about it," she says. "This is very different from reporting a problem to a supervisor, who takes it to a director, who takes it into a meeting."

She gives an example: A trauma patient arrives in the ED and needs a peritoneal lavage, but no tray is stocked. The nurse arranges to get one sent up from central processing, or runs to the operating room to borrow one. Jimmerson says that according to the principles of the Toyota Production System, the time spent in getting the tray is considered a "nonvalue-added" activity. Instead, the nurse would ask the following questions right after the event: Why was the tray not on the shelf? How do we stock shelves? What are the clear signals when the shelf is low and needs restocking? Who is responsible for stocking? "In other words, how do we fix this so that it doesn’t happen again, instead of just putting a [bandage] on a single event at hand," says Jimmerson.

At St. James Healthcare, a 100-bed facility in Butte, MT, ED staff used this Toyota principle to solve a problem with the laboratory, reports Pat McNeill, the ED’s patient representative. It was taking up to 90 minutes to complete necessary lab work, which increased the patient’s overall time in the ED, she explains. "Both the lab and ED personnel were angry and blaming each other," she says.

In using the "Toyota way" of understanding "how work happens," McNeill observed the process in the lab and the ED, and a committee of three ED nurses and three lab technicians met to discuss her findings. "The staff began to focus on the breakdown of the system, rather than on personalities," McNeill says. "Both the ED and lab staff felt some ownership in coming up with the solutions."

As a result, computer problems were identified, labeling changes were made, and a buzzer was used to alert the lab that new specimens have arrived. She reports that the lab results showed consistent improvement, with results within 10-30 minutes. "If there are any longer delays, the lab notifies the ED," McNeill says.

2. Solve problems from the perspective of individual patients. A key part of Toyota’s corporate culture is addressing problems from an individual customer’s point of view, says Jimmerson. For example, instead of addressing a general problem of "the lab never gets the work done on time," the Toyota method would address a specific scenario such as "Jones spent unnecessary time in the ED because his lab results were delayed by 30 minutes." She says that by fixing a problem for an individual patient, you wind up fixing that same problem for future patients. 

Another key concept is to solve a problem by observing a process, instead of placing blame on individuals or departments, Jimmerson says. "The idea is to look at how each person along the way can improve the process," she says. "Nobody has been personally attacked, and everybody takes some ownership in finding solutions."

3. Eliminate "nonvalue-added activities." She underscores a key Toyota concept: To identify and eliminate "nonvalue-added" activities. Jimmerson points to the work that the nurse did to locate a peritoneal lavage tray in the above example. "All of that activity did nothing to move the patient along," she says. "Only when the tray was delivered to the room did the work resume."

The idea is to avoid "work arounds," Jimmerson says, when you must work around a roadblock. "The goal is to find sources of frustration and get them out of the way," she says. "In this era of nursing shortages, we can’t afford to make people unhappy at work anymore, or to waste time doing anything that doesn’t add value to the patient."


For more information about principles of the Toyota Production System, contact:

• Cindy Jimmerson, RN, Community Medical Center, 2827 Fort Missoula Road, Missoula, MT 59804. E-mail: cjimmerson@communitymed.org.

• Pat McNeill, RN, Patient Representative, St. James Healthcare, 400 S. Clark, Butte, MT 59702. E-mail: pmcneill@sjch.org.