22: Implementation of “Lean” Methodologies Are Effective In Reducing Throughput In Pediatric Emergency Department

Abstract

To evaluate the impact of utilizing the “Lean” method in improving emergency department throughput and reducing time wasted in a tertiary care pediatric emergency department (ED). The “Lean” method eliminates waste by identifying and eliminating aspects of a process that do not add value to the process itself. This is done through rapid process improvement teams with quick turnarounds, making the method well suited to the temperament of ED staff and physicians. Lean has been highly effective in the manufacturing industries and is increasingly gaining popularity as a tool for health care quality and process improvement. An ED patient is subjected to many non-value added activities that lead to excessive waiting and delays. Lean is the ideal tool to study, implement and effectively remove wasteful processes related to wait in the ED. Data was prospectively collected between January 2008 and March 2010 in this tertiary care pediatric ED that sees over 45,000 visits/year. A group of ED nurses and physicians were trained in the Lean methodology in a previously established 2-day standardized program in July 2008. This group convened regularly, evaluated present ED flow, identified non-value added processes and eliminated processes that represented waste using rapid process improvement teams. Each week new processes were implemented and tweaked. Those that were associated with improvements were maintained and those that did not were eliminated in this ongoing effort. The outcomes of interest included a) Arrival to exit length of stay (LOS), b) patient satisfaction (using Press Ganey), c) 72-hour return rates, and d) left without being seen rates (LWBS). 2008 and 2009 data are compared in Fig.1; LOS reductions are sustained in the first 2 months of 2010 with mean LOS at 158 and median at 139 minutes. IQR for 2010 is at 87-210 minutes. Patient returns within 72 hours decreased from 2.69% in 2008 to 2.59% in 2009 while LWBS rates decreased from 0.87% to 0.73% and Press Ganey percentile ranking increased from 89 to 97 between 2008 and 2009. The Lean method can easily be learned by ED physicians and staff and can be used effectively to enhance pediatric ED flow with a positive and sustained effect on LOS, LWBS rates and customer satisfaction. Reduction in LOS did not have an adverse effect on return rates. Eliminating wasteful non-value added steps in ED care are increasingly important given the continued strain of ED crowding and lack of space. Enhancing throughput can effectively increase our ability to see a larger volume of patients without adding costly space.