Another Annual Update on a New Zealand Emergency Department


It seems to be an annual event to see a news story about a New Zealand emergency department, Dunedin Hospital (not pictured at left) as reported by the Otago Times.

It's year three and the board “wants some traction” and some are warning that Lean “might not get much further without a change in the hospital culture.”

Let's review the last two years and the latest report:

Back in 2008, I blogged about the first report I'd seen in my post “Lean in a New Zealand E.R.

My conclusion was that it “Sounds like they are off to a good start!” based on their focus on reducing waste, engaging everybody, and breaking down silos.

In 2009, I blogged about the second article in my post “An Update on Lean in a New Zealand Emergency Dept.

That story discussed some of the ongoing discussions about whether doubling the size of the E.D. would improve flow (it often does not, because it's a broader systemic value stream problem).

A doctor was making the case, correctly I'd say, that they needed to move beyond a department view to an end-to-end patient flow focus if they were to make real progress.

And now, the 2010 article: “Board wants traction on lean-thinking idea.”

From the article:

Dr Malcolm Macpherson said he was concerned the Southern District Health Board was “borrowing the terminology” but doing the “same old stuff”.

Yes, that would be a concern – new words, same actions. Maybe the board is frustrated with not getting enough progress or results?

The same doctor stated:

He said it was worrying to see a report in the Otago Daily Times this week about nurses and their concerns about the emergency department when the hospital should have been “well down the track” on ways to resolve some of the issues.

Patients are still being boarded in the hallways, it says, and nurses are still under pressure. I wouldn't expect everything to be fixed after 2.5 years, but you'd want to see some progress and signs of improvement.

The doctor who started the program added this:

While some gains were made by the project, its clinical leader, Dr Tim Kerruish, warned in May last year that it might not get much further without a change in the hospital culture.

Yes, culture. I don't know exactly what they did at Dunedin, but if they were doing some value stream maps or dabbling with 5S – results won't be as good or as sustained without a culture change.

Some in the article were calling for more leadership from the top of organization while the organization was doing “lean activities.” Activities are great, but the culture and management system play a major role in lean transformation (look at John Toussaint and his successor Dean Gruner at ThedaCare).

The article talks about more mapping and computer simulation and prioritizing exercises – is that what the board is getting impatient with? Again, from the article:

The project would involve almost every aspect of the hospital and would require some staff to be fully involved, so there would be some “back-filling” required.

Yes! Fully involved staff – you need staff members to participate fully and you have to create time for them (they can't do 30 seconds of kaizen in between caring for patients). Back-filling the people who are working on analysis and improvement is a tactic I've used everyplace I coached people on Lean. This might mean short-term overtime costs, but that's part of the investment in improvement.

Activity and effort is good – but any board or any senior leadership team is going to want to see results, not just a lot of analysis and study. I wish Dunedin well and I hope they get results, the right leadership, and the right culture change to provide the best patient care.

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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. […] In 2008 (as Mark blogged about), Dunedin Hosptal launched their ‘Putting Our Patients First’ project, looking to leverage the 6 hour rule to provide better care to their patients. By 2009 (new post), it had become clear that despite good strides toward improvement in the ED, accomplishing their goal of reducing ED wait times would only be achieved by the engagement of other departments in the hospital. ‘Lowering the stream’ revealed a new set of stakeholders. Did they then pause to make sure they had gained the necessary agreements? Without these in place, it is tough to craft countermeasures that will work and be accepted. See this recent blog post with a 2010 update on the hospital’s lean journey. […]


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