How Can a Story Like This Occur in Any E.D., Yet Alone a Hospital With a Lean Program?


This story was sent to me by somebody I know with a Lean manufacturing career. It's shocking, but it could happen anywhere, I suppose. I'm not going to name names… the author of this has allowed me to share it, without mentioning him or the health system.

How can something like this happen in any hospital, yet alone one that has had a “Lean program” for a number of years?

What questions would you ask about their priorities and approach to Lean, given this story? Do they have the wrong focus? Are they maybe not changing the culture and the management significantly enough? Have they just not fixed every problem in their health system yet? Was the Emergency Department having a bad day?

How does a hospital fix the systems and processes that lead to these scenarios without blaming so-called “bad apples” or throwing people under the bus?

We can only speculate… but I'd be curious to hear your comments or questions.

We moved late last year to an area that was equidistant between two hospitals that are part of two competing health networks. Both are big hospitals, with good reputations.

On the night of my wife's emergency, I needed to choose which hospital to take her to, and I chose the hospital I knew to have started a Lean program. I knew this because I was offered a position by the head of their Lean program about a year previously, but chose to pursue a different opportunity.

They heavily advertised their “15 minute ER pledge,” so I thought that was the best option for getting her seen quickly, given that she was in extreme pain from a torsed ovary. She's given birth to four kids, two without pain management, and nothing had ever come close to this level of pain.

Needless to say I chose the wrong hospital. Highlights (or lowlights) from the night include:

No one would help me get her from the car to the front door. It took 15 minutes, and I had to eventually carry her.

No triage at the front desk. She had a potentially life-threatening condition from the risk of hemorrhage, but a guy with a sore knee and a kid with a cold were taken before my wife.

No pain management for over three hours, even after she lost consciousness several times. Nurse said they had recently implemented a new EMR system and things just took longer because they weren't trained properly.

Speaking of the nurse… she gave zero care to my wife other than doing her charting. When she vomited from the pain, I had to clean her up and help her with the gown while the nurse watched. She then told my wife, “It wouldn't hurt so bad if you'd stop screaming so much.”

No radiology technician to perform the ultrasound needed for the diagnosis. We had to wait until one was called in from home.

No surgeon to perform the emergency surgery she needed. They wanted to transfer her to another hospital in their network about 30 minutes away.

And, despite the severity of her condition, we didn't see a doctor until we were ready to leave the ER. He apologized for being too busy dealing with other emergencies on our way out, forgetting he spent at least 45 minutes earlier in the night directly across the hall from us talking tennis with the guy with the sore knee.

Luckily, when they told me they wanted to have her transferred after the diagnosis, I was able to reach her OB/GYN. Despite it being 3 AM, he had her transferred immediately to the hospital he operates out of — the one I should have chosen to begin with — and that made all the difference in the world.

For six hours at the first hospital, her pain was not under control.

When we arrived at the second hospital, her doctor met the ambulance at the door, medication in hand.

The team worked like a well-oiled machine. It was absolutely amazing. In 15 minutes, her pain was under control and two of the team members worked with me to collect her information, while the others helped prep her for surgery. Everyone knew their role and she was taken back to the operating room in short order. Surgery went well, but but the ovary had to be removed due to the long time without blood flow (which turned out to be a godsend once the pathology report came back).

I got to speak later to the head nurse on the team who prepped her for surgery and commented on how well they worked together. I asked if he ever heard of Lean, but said was familiar but they didn't “do it.”

So, I posed the question to him of why he thought there was such a difference between the two hospitals.

What he said really stuck with me. He said that they were just as short-staffed as the other hospital and worked just as long of hours, but that they were a TEAM. He said the people on the team worked the same days/shifts in general and played the same roles day in and day out. And that his role as the leader of the team was to help them work together so that each person on the team could play their role a little better each day.

Sound familiar?

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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. Comments from LinkedIn:

    Lori Grosse: Interesting story. Sounds like Lean and other measures don’t exclude the need for patient centered care given by a qualified team that communicates effectively. Many of us have seen that to some degree, local (unit based) practices vary within institutions making some service lines great ones and others in need of alignment.

    My thoughts: As Dr. Don Berwick said, Lean and patient-centered care are the same thing. Or they should be. But many organizations have only viewed Lean as a cost or efficiency thing, which is unfortunate. We should be solving problems that matter with Lean in healthcare, not implementing Lean tools for the sake of “implementing” something (if that’s even what the problem was at that hospital).

    Trevor Waldo: Very unfortunate series of events for this patient. I highly recommend this patient’s spouse send his letter with this information directly to the chief quality officer of this health system. This will enable focused work to take place that can prevent this series of errors from stacking up against future patients.

    My thoughts: I’d hope that would make an impact. I’d ask if any employees in the E.D. were “pulling the andon cord” or asking for help when service and care breakdowns like this occur. Are they encouraged to speak up and ask for help? Are they encouraged to speak up with suggestions and improvement ideas? I’d hope any hospital, especially a “Lean hospital” would listen to the voice of the customer and respond appropriately.

    • Good question, I’ll ask and try to get a response.

      Maybe there’s a fear of “they’ll be getting to us soon, so if we bail out and leave it will take LONGER to get care than if we just stay put a bit longer”?

    • As the source of the story, I find myself asking this same question quite often in hindsight. The decision to “stick it out” was not an easy one; every second of every minute I watched my wife experience that pain, I questioned whether it was wiser to stay or whether to go. I actually did attempt to leave after the triage staff informed me that her expected wait would be 1-2 hours; I asked to use the phone and proceeded to call the other local hospital and request that they send an ambulance to the ER to pick her up and have her transferred. That was enough for them to decide to take my wife and get her setup in a room. After we were back, the thought process was very similar to what Mark described. The mindset was a combination of desperate optimism (they HAVE to see her soon, look at how much pain she’s in) and fear of the unknown (what if her condition worsens while I’m taking her somewhere else? what if it takes even longer at the other ER?). Hindsight is of course 20/20, but in the moment I was blind to the future. I did not know ahead of time it would take 30 minutes to see the nurse then another hour until the resident came to begin the diagnosis, an hour for the radiology technician to drive in from home to do the ultrasound, another hour for the results to be communicated to back to the resident, etc . . . Like Mark said the hope that it could be over soon kept us there. Until it became absolutely clear that we couldn’t wait. When we received the diagnosis and that she would need to be transferred to have the surgery she needed I asked to call my wife’s doctor, but the resident suggested that brining in an outside opinion would only muddy the waters and slow things down. At that point I had lost hope in the place and was able to make contact with her Ob/Gyn in the middle of the night who took control of the situation and righted he ship very quickly. Every day i am grateful for that man for my wife’s sake and for our 4 children.

      The big take awat for me in reading the feedback to the post is the difference between the two hospitals in the ratings. Based on reputation alone, I had no idea that there was that big of a difference. Had I been aware, my decision at the time likely would have been very different.

  2. Thanks for sharing another reminder of how far we have to go, and I say “we” because this could be any of the three systems where I’ve worked, on a bad day, even though we’d started down the lean path and were having successes. There’s so much we don’t know in this case — staffing levels, turnover, unique circumstances, staff engagement, and whether or not the ED had been a focus area of the organization’s lean activities. One could look at the system’s quality metrics on Hospital Compare to get an indication of whether this was typical or an outlier for them.

    • Looking at the details behind the Star Ratings:

      The long wait hospital has “Below the National average” for patient experience, timeliness, and safety of care. That doesn’t mean every patient gets bad care or that average is good.

      Both hospitals have “Above the National Average” for mortality.

    • ED waiting time data shows they perform about the same, these two hospitals:

      Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient
      A lower number of minutes is better
      402 minutes at the first hospital, 322 at the second (national average is 346, state average is 332)

      Average (median) time patients spent in the emergency department before leaving from the visit
      200 min at the 1st, 150 at the 2nd (national average is 172, state average is 159)

      Average (median) time patients spent in the emergency department before they were seen by a healthcare professional
      37 min at the 1st, 50 at the 2nd (national average is 30, state average is 29)

      Had the author and his wife chosen the hospital based on the CMS star ratings and data, they would have made the “right” choice – but is that always the case across the country?

  3. Leapfrog Group and their Hospital Letter Grades / Safety Score:

    The first hospital has a “C” and the second has a “B” for their grade.

    That’s a different set of data and different criteria, not including ED waiting times.

  4. Here’s a more positive story about a Lean thinker’s experience in healthcare (the University of Michigan Health System):

    When Lean Gets Personal
    by Jim Morgan

    My initial consultation put my mind at ease and I sailed through appointments experiencing a precise, efficient and ultimately successful treatment regimen that was patient focused and professional through every step. And this was no accident. It was the result of many months of lean work by Department Chair, Dr. Ted Lawrence, Director Kathy Lash and the rest of the Radiation Oncology team. Together they used value stream mapping to improve flow and significantly reduce lead times. Their teams used rigorous A3 problem solving leading to root cause-based countermeasures and powerful standards and checklists that helped to create a consistent, high-quality experience for each patient.

  5. I talked to a friend of mine who is in Lean at a hospital and he said that his hospital doesn’t put much stock in the Medicare Compare Quality Rating because the data error is so high. He suggests that what is really needed is “to get more reviews on-line or through social media – ultimately I think that is what is needed.”

    What would happen if this story was posted on the hospitals Facebook site or shared through social media? I think that would give the hospital a high urgency for change.


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