Before any of you give a knee jerk reaction about how “pull is good, push is bad” — I agree with you… pull is better than push. For manufacturing. In a factory, a “push” system pushes production and inventory along so it just piles up and queues up regardless of downstream demand. A pull system, where operation A only produces what operation B can handle can keep WIP down, as long as operations are pretty balanced in cycle time and are always available, from an uptime standpoint.
I saw this question today in the “Healthcare Management Engineers” Yahoo Group.
We are in the process of building a new Emergency/Urgent Care facility. We would like to develop a pull system where it is possible. I am wondering if any of you have used lean methodology in your Emergency Departments. Were you able to achieve a successful pull system in the ED? How did you accomplish this? What were some of the strategies and tools that were used to create a pull system?
This seems like the internal hospital consultant is looking to use a tool (pull) — it's actually more of a concept than a tool — for the sake of using a tool… because pull is good, right?
What is the business problem being solved? I've worked with hospitals that have horrible patient flow. The emergency department is “boarding” patients, which means you're stuck in the hallway. Why is that? Is it the ER's fault? No…. there aren't beds available for you to be admitted into. The beds are full, or they're closed down because there aren't enough nurses. The ER is so full that the hospital is “on diversion“, which means they aren't accepting ambulances except in severe life threatening emergencies. Bad bad bad. These are huge problems that we need to solve.
So is “pull” the answer?
With the current state…. we HAVE pull. The ER isn't “pushing” patients up to the inpatient units. They are only moving a patient when a bed is freed up (when a patient is discharged — hopefully, they're going home, not here). Space downstream (bed) opens up, bring a patient from upstream (the ER). That's pull. And that's totally broken.
I'm not saying the ER should push patients to lay in the hallways of the inpatient floor instead of the ER.
If anything, the pull should be patients pulling on resources. When a patient needs a medication, the pull system gets it there ASAP. Likewise, when a patient needs an inpatient room, the patient is “pulling” on that resource (sending a signal that it's needed), although the room isn't physically pulled to the patient.
What we need is the following:
- Balancing of capacity (beds) with demand (patients). This means having enough rooms, enough nurses, and making sure that we're flexible enough to put patients in rooms that aren't excessively specialized (having the “wrong” kind of rooms open).
- Standard work: we need predictable, consistent processes to make sure that patients are discharged without delay, thus freeing up beds for new patients.
- Flow: we need to reduce delays and waiting time between process steps
- Visual management: how does the ER know when a bed is open, so they can immediately bring a patient up?
There are a number of lean tools that I would think about using first before “pull.” Looking to use any one lean tool, rather than solving the problems at hand, brings potential for ineffectiveness. It's a bad sign when I hear anyone saying, “how do I use this tool?” instead of “how do we fix this problem??”
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