Emergency departments use lean principles in an effort to improve the patient journey

Continuous improvement efforts are most effective when the people directly involved in the work develop solutions to the problems they deal with every day. In healthcare, the result is better patient care at lower cost and greater professional satisfaction for staff.

But how do you directly involve the staff of sixty emergency departments scattered across a large state?

A team of eight independent facilitators working with the Michigan Hospital Association figured out how. They explained what they did in the book “Perfecting Patient Journeys”, a guide to using lean management principles in healthcare. Two of the authors recently talked about the improvement effort with Paul Akers, founder and president of the product development company FastCap and host of the program The American Innovator.

Judy Worth and Tom Shuker explained that it is not practical to bring teams from sixty emergency departments (EDs) to three-day lean training sessions or to send facilitators to train them at their workplaces, in each hospital. So the team of facilitators used a method they called value stream improvement (VSI).

Value stream improvement

“First, the facilitators created collaboratives by dividing Michigan, where all of their hospitals are located, into eight zones with roughly five to ten hospitals in each zone,” said Shuker. Two or three representatives from each emergency department met once a month to tackle the problem of how to reduce the average length of stay (LOS) for emergency patients who could be treated and released. Many teams focused on one part of the patient's ED stay, typically the initial part, known as “triage” or “door to doctor”.

These representatives learned to identify and select a problem for an improvement project, to define the scope of the project and to create a shared understanding of what was happening in the process. The main tool for this initial stage was value stream mapping, a representation – often hand-drawn – of each step in the information and patient flow of a process, together with the essential data. “From mapping we moved to the value stream improvement methodology,” Worth explained. “ It is really a group problem-solving approach, not just a current-state map, but a future-state map with an improvement plan by which you will begin to implement it. And from then on, we focused on rapid learning experiments and formal and informal reviews and check-ins. It is really much, much more than mapping”.

The methodology also included problem solving based on the plan-do-check-act process and visual management in the form of “huddles” or problem-solving meetings at the project tracking boards.

Worth said the value stream improvement approach also places a lot of emphasis on “socializing” the recommendations of the improvement plan, a process for sharing knowledge and gaining acceptance of those recommendations. So, at the end of the meetings, the hospital representatives had homework,which consisted of explaining to colleagues, including doctors and nurses, what they had just learned and asking for feedback on the suggestions. At first, Shuker said he was worried about the cross-functional makeup of the hospital improvement teams, which included not only doctors and nurses but also staff from radiology and the laboratories, as well as from the EDs.

“We were very afraid that this would be a session devoted to blaming one another, but within an hour everyone was focused on trying to map the work as it is, and you could hardly tell which person was from which department. They were all trying to solve the problems in front of them”.

The problems in reducing LOS included many delays, workarounds and bottlenecks, among other things. “There was a lot of wasted time and effort”. Said Shuker.

The participating EDs saw the number of patients who left the hospital without being seen reduced by about a third. And the number of patients who left against medical advice fell by a little more than a third. Shuker and Worth said it would take longer to see an overall reduction in LOS as the teams continue to work on other parts of the ED value stream, such as throughput. Surveys of doctors and nurses revealed greater engagement in the improvement efforts as a result of the collaboration.

Focus on the patient

The value stream improvement approach allowed everyone on the improvement teams to see problems, measure impact and agree on solutions quickly. “What we did through the collaborative was flesh out ideas that they could test with rapid improvement experiments,” he said.

In response to Akers' question, Shuker said healthcare professionals were “a little hesitant” at first when it came to applying lean concepts, which originated in manufacturing, but quickly began working together to solve problems. “Our phrase for this is see together, learn together, act together,” said Worth.

Akers said he likes the book “because it is focused on the patient – the customer – not on how the hospital makes more money. If you put the patient first, everything will fall into place”.

The authors said Perfecting Patient Journeys is aimed at healthcare professionals who have these roles: • Unit, department or value stream managers, as well as ED unit managers.

• Senior executives who are champions of the improvement effort.

• Continuous improvement facilitators.