Table Of ContentContents Contents
The Definitive Guide to
Emergency Department
Operational Improvement
The Definitive Guide to
Emergency Department
Operational Improvement
Employing Lean Principles with
Current ED Best Practices to Create the
“No Wait” Department
Second Edition
Jody Crane, MD, MBA and Chuck Noon, PhD
A PRODUCTIVITY PRESS BOOK
Second edition published in 2020
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Library of Congress Cataloging‑in‑Publication Data
Names: Crane, Jody, author. | Noon, Chuck (Chuck E.), author.
Title: The definitive guide to emergency department operational improvement
: employing lean principles with current ED best practices to create the
“no wait” department / Jody Crane, Chuck Noon.
Description: Second edition. | New York : Routledge, 2020. | Includes
bibliographical references and index.
Identifiers: LCCN 2019036080 (print) | LCCN 2019036081 (ebook) | ISBN
9781498774505 (paperback) | ISBN 9780367432331 (hardback) | ISBN
9781315151915 (ebook)
Subjects: MESH: Emergency Service, Hospital--organization & administration
| Quality Improvement--organization & administration | Efficiency,
Organizational | United States
Classification: LCC RA975.5.E5 (print) | LCC RA975.5.E5 (ebook) | NLM WX
215 | DDC 362.18068--dc23
LC record available at https://lccn.loc.gov/2019036080
LC ebook record available at https://lccn.loc.gov/2019036081
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
Contents
Preface ....................................................................................................................................xiii
Acknowledgments ....................................................................................................................xv
Authors ...................................................................................................................................xvii
1 Introduction to The Definitive Guide to Emergency Department Operational
Improvement ................................................................................................................1
Institute of Medicine Report ..............................................................................................1
The National Hospital Ambulatory Medical Care Survey: 2014 ........................................2
The American College of Emergency Physicians’ State of Emergency Medicine
National Report Card ........................................................................................................2
Center for Medicare and Medicaid Services (CMS) ......................................................2
The Safety Net No Longer Exists .......................................................................................4
Patient Demographics in Evolution ....................................................................................5
Patient Satisfaction ............................................................................................................9
Quality .............................................................................................................................10
The Centers for Medicare and Medicaid Services (CMS) Publically Reported Measures .....14
Other Challenges We Face ................................................................................................14
The Fix ..............................................................................................................................15
The Role of Lean Thinking in ED Operations Improvement ............................................16
A Focus on Creating Patient Value ....................................................................................17
Eliminating Waste ........................................................................................................18
Promoting Flow ...........................................................................................................18
Continuously Improving the Processes and the People .................................................19
Notes ...............................................................................................................................20
References .........................................................................................................................21
2 Value Stream Mapping ...............................................................................................23
Value Stream Mapping .....................................................................................................25
Muda—The Eight Wastes ................................................................................................28
Lead Time .......................................................................................................................29
The Value Stream Mapping Process ..................................................................................31
Step 1—Clearly Define Your Service Families ..............................................................31
Step 2—Gather Your Team and Walk the Process ......................................................32
Step 3—Complete Your Current State Map .................................................................33
Value-Added Ratios ................................................................................................37
Step 4—Identify Value and Waste Where Lean Tools Are Needed .............................38
Step 5—Complete Your Future State Map ..................................................................39
v
vi ◾ Contents
Step 6—Create Your Own Vision, Strategy, and Plan .................................................40
Conclusion .......................................................................................................................40
Suggested Reading ............................................................................................................41
3 Standard Work ...........................................................................................................43
Takt Time—Quantifying Demand .................................................................................44
Work Sequence and Cycle Times—Quantifying Capacity ...............................................47
Basic Approach for Improving Standard Work .................................................................47
Evaluating the Current State ............................................................................................48
Identifying Waste ............................................................................................................56
Modify Existing Processes ...............................................................................................58
Substantiating and Enumerating Improvements ..............................................................58
Implement New Standard Work ......................................................................................58
Standard Work in Process .................................................................................................59
SWIP Example—New ED ..........................................................................................59
Load Chart ......................................................................................................................60
Conclusion .......................................................................................................................60
Note .................................................................................................................................60
Suggested Reading ............................................................................................................61
4 5-S Workplace Organization ......................................................................................63
Seiri—Sort ......................................................................................................................64
Seiton—Simplify ..............................................................................................................65
Visual Management Types ..........................................................................................66
Visual Controls in Healthcare .....................................................................................72
Examples of Simplify ...................................................................................................74
Seiso—Sweep ....................................................................................................................74
Seiketsu—Standardize, and Shitsuki—Sustain ..................................................................74
Conclusion .......................................................................................................................78
Mary Washington Nursing Station 5-S Event .............................................................78
Note .................................................................................................................................86
Suggested Reading ...........................................................................................................86
5 Inventory Management Basics ...................................................................................87
What Is Inventory? ..........................................................................................................87
Push and Pull Systems .................................................................................................88
Inventory in Healthcare ..............................................................................................88
Continuous versus Periodic Inventory Review ........................................................89
Inventory Review Examples ....................................................................................90
Real-World Complexities in ED Inventory Management .................................................92
Calculating Reorder Points..........................................................................................94
Point-of-Use Supplies .......................................................................................................96
Kanban Systems ..........................................................................................................98
Mary Washington Hospital and Stafford Hospital Point-of-Use Supply/5-S Event ........100
Main ED Supply-Based Value Stream Map ...............................................................100
Spaghetti Diagram .....................................................................................................101
Conclusion ......................................................................................................................106
Contents ◾ vii
Appendix 5.A: Inventory Reorder Calculations ..............................................................106
Suggested Reading ..........................................................................................................109
6 Rapid Changeover ....................................................................................................111
The Approach to Changeover Improvement ....................................................................112
Identify All of the Steps in a Process ..........................................................................112
Classify Steps as Internal or External .........................................................................113
Eliminate Any Activities That Do Not Appear to Be Necessary or Add Value ...........113
Convert Any of the Remaining Activities from Internal to External When Possible ......114
Appropriately Staff, Choreograph, and Practice the Remaining Activities ..................116
An Example of This Decision-Making Process ...........................................................116
Conclusion ......................................................................................................................116
Suggested Reading ..........................................................................................................117
7 Mistake Proofing ......................................................................................................119
Brain-Deliberated Functions ...........................................................................................121
Approaching Mistake Proofing .......................................................................................121
Clearly Delineate the Intention of the Process ...........................................................122
Clearly Define the Problem as It Relates to the Intention ..........................................122
Brainstorm All of the Possible Defects Contributing to the Problem and
Classify Them into Subgroups and Types of Human Error .......................................122
Ishikawa Diagrams (Fishbone or Cause-and-Effect Diagrams) .............................123
Develop a System to Collect Information on Process Defects and Outcomes
Defects and Represent Them in a Frequency Distribution or Pareto Format .............124
Determine the Root Cause of the Defect ...................................................................125
Design the Appropriate Countermeasure Based on the Information Above ..............126
Examples of Mistake Proofing .......................................................................................128
Conclusion .....................................................................................................................130
Notes .............................................................................................................................130
Suggested Reading .........................................................................................................130
8 Lean Flow .................................................................................................................131
Background ....................................................................................................................131
Queues, Queues, Everywhere ..........................................................................................133
The Role of Utilization....................................................................................................139
Improving the Performance of a Queue ..........................................................................141
Reduce the Rate of Arrivals ........................................................................................141
Increase the Rate of Service ........................................................................................141
Reduce the Variation in Service ..................................................................................142
Reduce the Variation in Arrivals.................................................................................144
Before Adding Servers, Check the Alignment .................................................................144
Network of Queues .........................................................................................................150
Look for the Bottleneck Server .......................................................................................151
The Theory of Constraints ..............................................................................................153
Reduce the Number of Queues in a Process ....................................................................154
Concurrency Can Help ...................................................................................................156
Pooling Servers ...............................................................................................................156
viii ◾ Contents
Segmenting Flow ............................................................................................................158
Psychology of Waiting ....................................................................................................159
Appendix 8.A: Example Queuing Calculations Using Approximation Formulas ............159
Notes ..............................................................................................................................162
References .......................................................................................................................162
9 ED Flow as a Network of Queues—Matching Demand and Capacity.....................163
The Door-to-Doc Interval—Straightforward Queuing Analysis .....................................164
The Doc-to-Disposition Interval—Analyzing the Next Network of Queues ..................173
The Critical Servers in the ED ....................................................................................173
The Doctor Server ..................................................................................................174
The Nurse Server ...................................................................................................179
The Bed Server .......................................................................................................182
Ancillary Services .......................................................................................................185
Disposition-to-Departure—A Much More Complex Queuing System ...........................185
Conclusion ......................................................................................................................187
10 The Lean ED—Lean Applications in a 100,000‑Visit Emergency Department .......189
Background ....................................................................................................................189
The Lean Vision ..............................................................................................................192
Super Track .....................................................................................................................194
Rapid Assessment and Treatment in the Emergency Room “Rated ER” ........................202
Results ............................................................................................................................213
Conclusion ......................................................................................................................215
11 Best Practices—The Door‑to‑Doc Interval ...............................................................217
Fixing the Front End .....................................................................................................220
Fixing the Traditional ED .............................................................................................222
Door-to-Triage ..........................................................................................................222
Triage-to-Bed Assignment .........................................................................................224
Diagnostic Orders .................................................................................................225
Specimen Collection .............................................................................................225
Treatment Orders .................................................................................................225
Advanced Approaches to Fixing the Front End ..............................................................226
No Triage—“Direct Pullback” ..................................................................................226
Advanced Practice Clinician in Triage ......................................................................227
Patient Intake—Immediate Physician Assessment .....................................................228
Intake Systems ...........................................................................................................230
Redesigning the Front End .............................................................................................233
An Understanding of Patient Demand and Acuity .....................................................233
Appropriately Capacitated Triage Process and System ...............................................234
A System for Patient Segmentation .............................................................................235
Distinct Processes for Different Patient Segments .....................................................236
Dedicated Provider ....................................................................................................236
Point-of-Use Supplies ................................................................................................237
Radiology and Lab Services for the Front End ..........................................................238
Results Waiting Area .................................................................................................238
Contents ◾ ix
Method of Tracking Patients and Results ...................................................................241
A Method to Track Outcomes Data ...........................................................................241
Designing the No-Wait Emergency Department of the Future .......................................241
The Pivot or Quick-Look Nurse and Patient Segmentation .......................................243
Super Track Process Design.......................................................................................244
Designing an Intake System .......................................................................................247
Reception, Mini-Registration, Quick-Look Design ....................................................249
Mini-Triage Design ....................................................................................................250
Intake Team Design ...................................................................................................251
Results Waiting Area Design ......................................................................................252
Designing the Treatment Area ...................................................................................253
Other Innovations ......................................................................................................253
Conclusion .....................................................................................................................254
Notes .............................................................................................................................254
12 Best Practices—Doc‑to‑Disposition Interval ...........................................................257
Alignment of Your Critical Resources .............................................................................257
Patient Care Teams ........................................................................................................263
Critical Servers in the Emergency Department ..............................................................264
Physicians and Advanced Practice Clinicians as Critical Servers ....................................266
Nurses as Critical Servers ................................................................................................270
Understand Factors That Cause Variation around Nursing Staffing ...............................272
Beds as Critical Servers ...................................................................................................274
Conclusion .....................................................................................................................279
Notes .............................................................................................................................279
References ......................................................................................................................279
13 Best Practices—The Dispo‑to‑Departure Interval ...................................................281
Inpatient Utilization and the Effect on ED Boarding .....................................................281
The Boarding Problem ..............................................................................................282
Quantifying the Financial Impact of Walkouts and Diversions .................................286
Countermeasures for Hospital Overcrowding and ED Boarding ...................................288
If All Else Fails … Push Patients .....................................................................................291
If You Don’t Have An Inpatient Problem, Look At Your Process ...................................292
The Effective Disposition—Doctor ................................................................................294
The Effective Disposition—Nurse .................................................................................295
Clinical Decision Units ..................................................................................................295
Hospital-Wide Patient-Flow Teams ................................................................................296
The Rest of the Value Stream .........................................................................................298
Conclusion .....................................................................................................................298
Notes .............................................................................................................................298
14 Patient Experience ....................................................................................................299
Horizontal versus Vertical Patients .................................................................................303
How Do You Create Satisfied Patients? ..........................................................................304
Staff Satisfaction ............................................................................................................308
A Standardized Approach to Patient Experience and Culture .........................................310
