Is it time to ‘Lean’ in emergency care?
Article Outline
On first glance it would seem that emergency care has very little in common with industry or car manufacturing. We all recognise the importance and significance of individualised and holistic care. Have you ever stopped and thought ‘why do we do this in this way?’ or ‘if only we could just cut out the layers of bureaucracy and make things more straightforward for our patients?’ If so then you are ready for the Lean management principles!
Lean management was first developed in the 1950s in car manufacturing by Toyota. Lean thinking and management principles have been widely employed in manufacturing and industrial settings subsequently with a great deal of success (King et al., 2006). While emergency nurses are past masters at seeing a queue and finding a solution; if we are truthful what we are not so good at is understanding the causes of the queue in the first place. A key element of Lean management principles is NOT to start with a potential solution to every problem but instead to develop a detailed understanding of how and what a complex process is actually undertaken; such as for example a patients journey through the minor end of the emergency department. When the processes are fully understood, it may become clear that many additional layers have been introduced over the years in order to ‘bypass’ problems. Lean principles in health care have been translated into an approach that seeks to improve flow in the patient journey and eliminate all forms of waste for patients and staff (including waiting!). You may be familiar with the ‘Productive Ward’ programme which has been rolled out across many wards with very positive results in terms of reducing waste and improving the experience of patients. While the underlying concepts can be applied to any healthcare setting the modules developed by the National Health Service (NHS) Institute for Innovation and Improvement are not really ideal for emergency care settings.
The NHS Institute for Innovation and Improvements aims are to ‘support the NHS to transform healthcare for patients and the public by rapidly developing and spreading new ways of working, new technology and world class leadership’ (www.institute.nhs.uk/). The productive ward initiative is a national initiative which aims to get teams to challenge and review the way in which they currently work, as well as to analyse the processes which are used daily. The goal is to remove any ‘wastes’ identified in the patient pathway and thereby release time to provide more direct patient care. It is a self directed modular programme consisting of eleven modules for example: medicines management; meals; shift handover. The programme provides tools and guidance for all healthcare professionals to identify blocks in the patient pathway and to make positive but simple changes to the clinical environment and working processes that will improve the quality of care and raise safety standards.
The department I work in had the opportunity to take part in a LEAN project and utilise the practical problem solving (PPS) approach when the local Primary Care Trust (PCT) who commission and purchase our services for the local population published a ‘stretch target’ (a target which is increased or stretched so that if achieved the target will deliver greater outcomes) of 85% of all ‘minors’ patient being seen and treated and discharged within 2
h of arrival in the department. You can imagine the looks on our faces at this news! With the support of the trust innovation team an interdisciplinary (nurses, receptionists, performance managers, ED consultants, radiographers and biochemists) group embarked on a practical problem solving training programme which was built upon the underpinning principles of LEAN. At one point the facilitators of the programme had to ask us all to sit on our hands as we were all so keen to point out solutions to problems identified in the early stages of the project! The beginning of the project meant that a great deal of data had to be collected and although we initially felt this was time consuming we reaped the rewards of the detailed information we gained from this exercise very quickly. Analysing the data and being taken through the practical problem solving process meant that we understood the ‘points of occurrence’ or identified bits of processes which simply did not work.
Some of the best results came from simply having a variety of professionals sitting in the same room so problems that were identified could be discussed and analysed. As a result of all of the data collection and analysis we discovered a great deal of previously unidentified knowledge about our emergency department! We found that there were 14 potential different patient pathways for ‘minors’ patients; including admission to the observation unit.
We discovered the simple administrative process which meant that a d-dimer request could take well over 2h to process (and addressed it! thus halving the length of time for the test result to be available to the department). One of the most positive parts of the project was not simply improving the department’s performance but was actually being given permission to look at a wide range of small issues which had needed to be looked at for some time. Issues with triage and streaming, as well as the availability of the minor end drug keys were addressed (simply by keeping the keys in a small safe which meant that we saved at least 3min for every patient who required medicines because it stopped us wandering around the department looking for the person who held the keys. When this information is extrapolated it means we are releasing over 2h of time at the minor end every 24h!).We even found ourselves looking at ‘queuing theories’; a must for every emergency nurse! We looked at ‘queuing theory’ which although initially appeared a difficult mathematical concept showed us that previous ways of working when the department became overwhelmed; such as implemented ‘double triaging’ meaning that two nurses took on a triage role actually just added to the queuing problem rather than solving it. When triage becomes overwhelmed now, we implement ‘streaming’ where a ‘see and treat’ stream is created and an experienced nurse practitioner or middle grade doctor will see patients before they have been triaged meaning that the patient is pulled through the emergency care system and the triage queue is reduced.
The changes have made the minor end of the department a much more pleasant area to work in and patients have commented on how happy, friendly and helpful the staff have been, something which did not tend to happen much before. The crux of this story is to say that it is good to embrace change especially when you and your team are involved and the changes implemented come from those working in the area who understand and know how the department works. What have we learnt as a department? Change can be for the better and queuing theory can actually be quite interesting!
Reference
PII: S1755-599X(10)00021-2
doi:10.1016/j.ienj.2010.02.003
© 2010 Published by Elsevier Inc.
