You Can’t Turn Customers Away, Can You?


    STLtoday – News – Science & Medicine

    This was sent to me by blog reader Joe. He was appalled to read about this and I understand where he's coming from. It's hard to understand that hospitals can throw their hands up and say “we're too busy” and turn away ambulances. The lean solution, the right solution, of course is to make sure you are flexible enough to handle whatever customers get thrown your way at busy times. You can't “level load” the ambulances that arrive at your hospital.

    From the St. Louis area, a scene that's repeated far too often around the U.S.:

    More than half of St. Louis-area hospitals turned away ambulances at the same time one night this year.

    Dispatchers reporting patients with chest pain, seizures, stroke, gastrointestinal bleeding, pregnancy problems, abdominal pain and injuries from motor vehicle accidents were told to find another emergency room.

    It doesn't take an industry expert or a lean person to point out that this is bad:

    National experts say hospitals should not divert ambulances at all.

    Diversions can be disastrous, said Dr. Robert R. Bass, an emergency room physician and president of the National Association of State EMS officials.

    “It means ambulances have to travel farther, and that can delay care to the patient,” Bass said. “It also delays the amount of time that an ambulance is out of service, and that means it is not available to other people in the community who might need it.”

    A recent Institute of Medicine report says there are only two reasons a hospital should divert an ambulance: a crisis within the hospital, such as a fire or power outage; or a mass casualty incident, such as a plane crash.

    As I've written about before, it's not strictly an ER problem. You have to look at the “extended value stream”, if you will. If the ER is backed up, it's often because the hospital has trouble getting patients admitted into rooms. Or, it's because they have horribly inefficient processes for getting patients DISCHARGED. You can't admit a patient if you can't get one discharged. When the rooms are full, flow in must equal flow out.

    Hospitals often discharge patients late in the day or in the early evening, exacerbating the bed shortage.

    Ah, a lack of level loading! Now there is a lean lesson. Many lean efforts in hospitals are focused on spreading out, or leveling, patient discharges throughout the day. This level loads the effort required by nurses and housekeeping staff. The level loading reduces the delay between discharging one patient and getting another one in.

    “The patients haven't left their beds yet, but more are coming in,” Larson said. “We run into this situation between 3 p.m. and 7 or 8 p.m., when we are in a crunch from both sides.”

    Years ago, when hospitals were 40 percent full, efficiency wasn't so critical, said Bass, of the association of EMS officials. But now that hospitals have reached occupancy rates of 80 percent and higher, it's important for them to get patients in and out efficiently.

    80%. That number stands out because if you're an Industrial Engineer or if you've studied “Factory Physics” (the outstanding book by Hopp and Spearman, two of my professors from Northwestern University), you know that the waiting time or cycle time in a system tends to explode when utilization reaches 80%. Very crowded systems have long waiting times. You can't have 100% utilization of a resource (as accountants and cost thinkers would want) without long waiting times (the bane of lean thinkers).

    The good news — lean methods CAN help. Lean can't level load the arrival of ambulances, but lean CAN make hospitals more flexible in handling the demand that does come their way.

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. Wow, what a scenario and happening in a hospital where events are a matter of life and death. I hope the healthcare industry will go lean soon.

    2. What I have found fascinating about the ER and diversion:
      – Root cause most times is related to moving patients to the floor (~60% of the time – an estimate)
      – Rest revolves around lack of ‘fast track processing’ for the ‘minor’ emergencies (perceived or real).
      The mentality seems the more the menial the job or emergency the ‘less’ the urgency becomes. If it isn’t exciting then I don’t want to deal with it (i.e. adrenaline junkie). This becomes a case of a ‘mixed’ model line. Imagine being a patient who needs a couple of stitches, but is pre-empted by a patient who is having dizzy spells. All you want is a needle & thread & to be sent on your way. Where as the dizzy patient may need observations for a few hours. The LEAN way to deal with this is via mixed model paths. The effort then becomes motivating the resources (sometimes you find Doctors paid on acuity level of patient instead of # of patients seen) which is part of the problem as well.
      I will stop rambling now.

    3. Some of it is process and lean improvements. But there are also some structural problems. Many cases beds is not the issue, its resources. And there will always be peaks in demand. You can’t ask a for profit organization to hold enough capacity to handle a spot spike in demand for a single night and 364 days have overcapacity. The same problem exists in the utility business. You can’t ask the power company to spend hundreds of millions on new power plants just for the 5 days a year they need them. This involves some complicated and difficult problems and questions, such as is healthcare a right or an benefit?


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