Jane Bishop, senior clinical lead with the Leading Edge Group, outlines the role that lean can make in a hospital Emergency Department and the urgent need to develop a national consensus amongst medical professionals, Government and academia.

Emergency Department overcrowding is a global issue which has been linked to increased mortality and morbidity for patients. Attempts to solve the issue have focused on the streaming out of patients with minor injuries, and more recently, a hospital wide systems approach. With neither method having yet provided a sustainable solution to ED overcrowding, some institutions are utilising a new approach by adopting lessons from manufacturing. Lean processing as a continuous improvement methodology has been gaining support in healthcare in recent years, but globally still remains in its infancy.

Many congestion issues within the ED are not due to the volume of patients attending, or to inadequate staffing levels, but are in fact attributable to poorly designed processes for patient throughput. This perpetuates a mismatch in capacity and demand. In real terms this means that no matter how hard the staff work, there will always be the potential for the ED to become overcrowded and for waiting times for patients to lengthen. Identifying which processes are causing congestion and realigning available capacity within the ED can alleviate some of the congestion experienced on a daily basis and assist you in achieving your targets.

A report issued in February 2002 (Report of the Committee on Accident and Emergency Services) stated that the design of ED does not always maximise patient flow. Design limitations can prevent maximum utilisation of ED facilities, compromise patient safety and confidentiality and lead to inefficient staffing and work practices within the department. The committee recommended that design and flow elements be considered when building new EDs in the future.

Increasing in-patient capacity and maximising the efficiency of diagnosis and discharge for in-patients are commonly cited as potential solutions to ED overcrowding. However ED could be made considerably more efficient and effective with the application of lean.

Some notable hospitals in the UK, USA and Australia have begun to explore how lessons from manufacturing can be applied to the ED in a bid to increase efficiency, while maintaining or improving quality of patient outcomes. The application of lean and six sigma methodology from disparate industries to healthcare has been gaining increased momentum across the United States, and to a lesser degree in the UK and Australia.

New ways of thinking about how healthcare is designed are beginning to emerge, and some hospitals have begun to apply the principles of process design and lean thinking into their everyday operations. While research has suggested a whole hospital approach is needed to solving the ED crisis, more recent studies are suggesting that looking only at efficiencies in the ED will also pay dividends. The Institute of Healthcare Improvement suggests that all work is a process, and advises looking at processes internal to the ED to elicit inefficiencies that could be eliminated. The practical application of this principle is that complex systems such as ED work better when the processes that comprise them are designed with fewer steps and fewer people.

No clear national strategy exists that could incorporate lean into healthcare as a means to improve quality while driving down costs due to errors and rework. While formal qualifications in lean can be attained, places on these courses to date have been dominated by engineers with a background in manufacturing or IT. In the past three years, however, healthcare students have started to study lean and are benefitting from exposure to practitioners in manufacturing and other industries who practice it on a daily basis in their workplace.

All hospitals need to improve the quality and safety of patient care they deliver, while reducing the cost of delivering that care. The taxpayers also need to be assured that the healthcare budget is being used as efficiently and effectively as possible. In the current political and economic environment, the importance of efficiency in the ED is not only about patient safety but also the need to improve quality of care despite diminishing resources.

Leadership is crucial. Driving the values of quality and efficiency strategically across all sectors of the healthcare system will require healthcare managers to engage in lean thinking and to visibly support programmes that attempt to improve quality and drive down costs. Frontline staff needs to be empowered to change and to champion quality initiatives.

It is in the country’s best interest to ensure that all healthcare workers are competent and efficient, and there is a need for general consensus between the medical profession, Government and academia to pursue this ideal. I contend that the application of a lean methodology will significantly contribute to a more efficient delivery of service.