The Need for Lean Healthcare: ER


    Portrait of an ER at the Breaking Point – Newsweek Health

    Here is an incredibly sad case study of an Emergency Room that's a mess… as well as the hospital it is attached to. It's overly simplistic to say “the ER is messed up” since they are squeezed in between excess demand for services and a dearth of downstream rooms and beds for admitted patients.

    A bottom-line overview of Grady Memorial Hospital in Atlanta:

    The facility is losing $3 million per month. It's 120 days behind in paying some creditors.

    It lost more than $20 million last year, up from $13 million in 2005 and $10 million the year before.

    The ER is overwhelmed. They don't have space. Patients are stacked up, or “boarded,” in the hallways. Beds aren't available. The hospital “cries uncle” (as the article says) and goes “on diversion” (where it tries to get ambulances to take patients elsewhere, but this is just a request since ER's are legally required to accept patients).

    It's not just Grady, it's other hospitals in the area that are frequently “on diversion.” In fact, there's even a website that shows, for the area, a live view of who is on diversion, the “Georgia Hospital Resource Report.” Right now, midnight Eastern, as I type this, three hospitals are on diversion, due to “saturation” of different units. There's also a table with a bunch of blank fields, where it appears that hospitals are supposed to post their bed availability, but all but three hospitals on the list has blank data, with “UPDATE REQUIRED” in red letters. Bad process? Bad compliance? Ok, back to the main story.

    Where are you supposed to go if you're a patient? If you're hurt, you can't always get into the nearest/closest hospital, which sometimes brings bad results:

    Scott Cathcart, a Grady EMS supervisor, said it's common for an ambulance to be forced to bypass a closer hospital because it's on diversion. He recalled the case of an 8-year-old hit by a car who was turned away from two ERs before arriving 20 minutes later at a third that could take her. Often, as soon as one hospital begins diverting ambulances, others quickly follow suit. In which case, “we've got a rule,” said Cathcart. “Once all are on diversion, none are on diversion.”

    Patients are in the waiting room (over 50), waiting on gurneys in the hallways (30). They're waiting eight hours (or more) to be seen and hours (or days!) to get into a room.

    By now, the ER's hallways were jammed with patients. Some had gaping wounds and were spilling blood. Others moaned in agony. A note taped to one wall—”No procedures in hall”—seemed like a pointless plea.

    The situation was so bad, an oversight agency “ordered” them to reduce the number of patients “boarded” in the hallways. Just as effective as “ordering” (via sign) staff to not perform hallway procedures? What was their solution?

    Grady responded by trying to limit gurneys to one side of the hallway. But during Saturday night's onslaught, that proved impossible.

    Telling people “don't” isn't exactly root cause problem solving is it? Back to that in a minute.

    So what are the employees to do? They're stressed and overwhelmed:

    The frenetic pace was exacting a toll on the ER personnel, who looked frazzled and exhausted. Some overstayed their shifts—by eight hours, in one nurse's case—to help ease the pressure. That helps explain the difficulty Grady and other hospitals have in recruiting nurses. With a 25 percent nursing-vacancy rate in the ER, Grady is almost always understaffed. Nurses burn out quickly on the conditions—caring for 10 or 12 patients at a time when half that should be the norm, racing from one crisis to another, feeling guilty for taking a bathroom break.

    Yikes. You can only imagine what impact this all has on morale and quality:

    “You want to give quality care but you can't,” said Charge Nurse Sherika Kimbrough. “We're at our breaking point.” Same goes for the physicians, who also have malpractice suits to worry about. Two years ago, Kellerman received a resignation letter from a top-notch doctor. “I can't take it anymore,” she told him. “I am so afraid of making a mistake that I'm vomiting in my driveway before I go to work.”

    It's amazing that people have such a passion for helping others that they can put up with (well, most of them can) conditions like these.

    Now, looking at root causes of the ER congestion, there are many, but the article does finally start to look beyond the ER itself:

    To better understand the ER crisis, however, you have to look beyond the ER itself—starting with the floors above it. The ICU beds on Grady's seventh floor are regularly as packed as the ER.

    Inpatient beds are full, so what is the ER to do? Many hospitals struggle with getting patients discharged in a timely way, so patients who could be or should be going home are clogging up the system (either waiting for lab results, waiting for a nursing home to be lined up, waiting for a family member to pick them up, etc.).

    The closest thing to a Lean-sounding solution was the establishment of a parallel “value stream” (my words, not theirs) in the ER:

    And just off the waiting room below, the hospital established a fast-track section staffed by physician assistants and nurse practitioners to treat mild conditions like cuts and coughs.

    So to review, the patients are waiting, employees are beyond stressed, and the hospital is hemorrhaging cash. What the hospital turn to? COST-CUTTING! Is this typical “mass production” management thinking? What's the first thing we cut? People!

    Earlier this year, it offered buyouts to 560 older and more experienced personnel; 420 of them accepted.

    Then, let's cut services!

    Grady is studying a host of other potential cuts, including its dialysis program and its neighborhood health centers.

    You're already understaffed (at least in certain key roles) and you're slashing people? I would hope and pray they aren't cutting ER nurses and ER staff. Were they cutting what you often hear referred to, in government circles, on a snow day as “non-essential personnel?” Wherever the cuts come from, cutting staff doesn't magically cut the workload that still needs to get done.

    I'm not saying Lean is a panacea, but you'd have to think that there would be a lot of good to come from:

    • Improving processes
    • Reducing waste
    • Improving flow

    There are many other systemic problems, but instead of just hiring consultants who tell us to fire people, can we afford to try something else instead? Can we afford NOT to?

    Here's a companion piece on what some are trying to do to fix the ER problem.
    One process-focused solution cited is a hospital that boards patients in the inpatient specialty care hallways instead of the ER hallways. That's still not the ultimate solution. Another solution cited hearkens to “heijunka” or level loading, applied to surgical schedules:

    …if elective surgeries like angioplasty or hip replacement could be scheduled in a more organized way, the ER might not get so backed up. Christy Dempsey, vice president for surgical and emergency services at St. John's Hospital in Springfield, Mo., put Litvak's plan to work in 2002. Surgeons began “smoothing” their elective surgeries throughout the week, rather than bunching them together on Mondays, Tuesdays and Wednesdays. They also carved out blocks of time to ensure that ER patients requiring surgery would have the beds and operating rooms they needed. The reforms created 59 percent more available space for inpatients—without actually adding any beds, says Dempsey. And they helped unclog the ER, resulting in better patient and staff satisfaction and less overtime. “It was a win-win for everybody,” she says.

    Win-win, to say the least! Now that's Lean thinking and what we need more of. Now let's get to work.

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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. A cause of this situation is the scarcity of qualified nurses, which is in turn driven by a process problem in universities and community colleges. Apparently, the allocation of funds to departments is typically driven by student count, without proper consideration for the fact that it is more expensive (per-student) to run a nursing department than to run an English department.

      Scarcity of nurses drives salaries higher, which in turn drives the cost of instruction up, since these salaries must be competitive.


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