By September 8, 2009 1 Comments Read More →

An Update on Lean in a New Zealand Emergency Dept

You might remember a 2008 blog piece about early Lean efforts in New Zealand hospital (Dunedin hospital), where the primary aim was reducing patient waiting time. I also previously posted a link to a video about the general emergency department problems — patient flow problems that are seen in hospitals around the world, really.

The same newspaper has a new story that discusses the root of problems in emergency department flow — problems with flow through the entire hospital (or the entire “value stream,” if you will).

The government is questioning if there are too many patients coming through the department (including non-urgent cases). Some are asking if the E.D. needs to be larger to accommodate the volume. A hospital leader (and physician) says “no.”

Dr Kerruish said doubling the size of the department would not necessarily work.

He referred to a situation in a big hospital in the United States where a 100-bed emergency department had doubled in size because it was always blocked.

The situation actually worsened, because nothing else in that hospital had changed.

Absolutely right, there is some “lean thinking.” I visited one hospital earlier this year where the interim Chief Nursing Officer had admitted making the same error. She had been convinced that the E.D. needed to be bigger and, through her power and formal authority in the organization, she forced the change through. In hindsight, she said nothing improved. She compared it to expanding a busy freeway and then more people start driving on it because there’s more capacity. But the bottleneck had not been fixed. She realized, after that experience, that the hospital needed to improve its overall flow.

Dr. Kerruish, from New Zealand, elaborates:

He was keen to see the work begun in the department – which used the lean thinking methods of the Toyota vehicle company to identify waste and make improvements – extended beyond the emergency department.

Until that happened, only limited gains could be made.

Some work has begun on this, with the support of the hospital advisory committee.

Dr Kerruish said it would be a matter of staff sitting down and working out over about three days, what the problems were and how they could be fixed.

There would not be one answer, but a whole lot of small solutions which would improve the way patients travelled through the hospital, he said.

It would be only when there was engagement with the programme right across the organisation that hospital-wide improvements would result, he said.

Emergency department flow problems can often be traced to problems getting inpatients discharged. Beds are not available when needed. Instead of expensive capital expansion projects, some relatively inexpensive process improvement work can make a huge difference.

It sounds like the Dunedin Hospital might be doing a “kaizen event” over a few days… but they described just the observation and analysis phases. The real question is about when they will start piloting some improvements after they identify some root causes. Is it the discharge process? The bed assignment process? What countermeasures will they put in place?

I hope we continue reading about their progress in the news. Thanks, Google News!


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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