Using Lean Simulations to Spur Emergency Room Improvement


Institute for Healthcare Improvement: Getting Lean in the ED

Here is a story that includes examples of Lean improvements at Rockford Health System in Rockford, Illinois.

“The simulation embodied the difference between a classroom lecture and a psycho-motor experience,” explains Berg, whose ED is at Rockford Memorial Hospital, a Level 1 trauma center designated to lead health care disaster response in northern Illinois. Berg says the simulation helped him gain a better appreciation of team dynamics and “a better understanding of how to bring others on board.”

They were first exposed to Lean concepts through a simulation exercise conducted by the IHI. One improvement was the creation of an “Express Care” track (creating a separate “Value Stream” for patients with relatively simple cases):

At Rockford, the principle focus of change in the ED has been the Express Care unit for non-urgent problems such as wrist or ankle sprains or simple lacerations. Despite best intentions, says Jeff Berg, the four-bed unit was far too dependent on the main ED. “There was no dedicated waiting area, registration, or even staff. We drew everything from the main ED. The closest physician sat about 30 feet away.” The newly redesigned Express Care space has only three beds, but its own registration/discharge area, waiting room, and supply closet. There's a nurse assigned exclusively to this unit and by June 2008 there will be a dedicated physician as well. During a one-week measurement period in February 2008, the redesigned Express Care unit produced shorter-than-usual waits for patients and no patients left without being seen, says Berg.

It's those results that matter — reduced wait times for patients and they're no longer “bailing out” and leaving before receiving care. We have to hope the improvements have been sustained beyond the initial week.

There other “kaizen” improvements being made:

Smaller efficiencies have also been tried ― though not officially adopted ― in Express Care, such as getting rid of the bed pillows. “These patients don't need them and it takes 30 seconds to change a pillowcase for the next patient,” says Berg, “so by eliminating pillows, every 30 patients or so, we could save 15 minutes, which is enough time to see an extra patient.” Another time-saver might come from the dispensing of medications, says Berg. “Instead of giving patients their first dose, along with their prescription we could just give them the prescription unless there's an urgent need, for pain-killers for instance.” This would mean that, most of the time, the nurse wouldn't have to fetch the medication or record the event in the patient chart.

The pillows — that's a case where care should be taken to make sure patients really don't use them, that the efficiency isn't based on staff needs or a staff assumption. Maybe pillows are still available, if requested?

A few other kaizen examples given in the article, examples of Lean methods:

  • Visual aids such as neon-colored band-aids to show that a patient's blood cultures have been drawn or paper flags that signal the arrival of test results;
  • Materials management, including centrally located supply closets for less commonly used supplies and pre-assembled equipment carts for frequently performed procedures so they can be stored near their point of use;
  • Standardization that leads to treatment guidelines for specific complaints (protocol checklists); and
  • Load-leveling or coordinating staff schedules to correspond with demand, and balancing workloads among nurses, technicians, and physicians to enhance flow.

A final thought. I think we can hope that hospitals and ED's are not just implementing Lean tools. Hopefully they are also learning about the Lean management system and behaviors for leaders and employees. How do you get all employees engaged in continuous improvement? How do you get all leaders to listen to their staff, making sure they are respected? That's the long-term improvement challenge (as well as being the opportunity).

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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.


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