The practice of emergency medicine/review article
Lean Thinking in Emergency Departments: A Critical Review

Presented as a poster at the Agency for Healthcare Research and Quality (AHRQ) National Research Service Award (NRSA) Trainees Research Conference, June 2010, Boston, MA.
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Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking. This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space. Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change. Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.

Introduction

The need for improvement in emergency departments (EDs) with respect to the cost of care, the speed of service, crowding, and patient safety is now widely accepted.1, 2, 3, 4 In an attempt to achieve broad improvement, health care organizations worldwide increasingly adopt an approach called “Lean thinking” (see Figure 1 for a description of Lean).5 In a 2009 survey of US hospitals, 53% reported having implemented Lean to some extent; of those hospitals, 60% reported implementing Lean in the ED.6 Furthermore, some public health care systems, including the UK National Health Service,7 have adopted or are planning to adopt Lean as a key lever for decreasing costs and improving the quality and safety of care.

Lean thinking is a bundle of concepts, methods, and tools derived from the Toyota Production System, the production philosophy of Toyota Motor Corporation. Lean was first implemented in US auto manufacturing in an attempt to replicate Toyota's success and has subsequently spread to other manufacturers (eg, Boeing), to service industry (eg, Tesco), and to the public sector (eg, UK National Health Service). Key principles of Lean are listed in Figure 1. Chief among them is the need to eliminate unnecessary waste. Waste is anything that does not add value to the customer. For example, if the ED patient is the customer, 2 wastes might be waiting to be seen or undergoing (and paying for) a duplicate test. As waste is eliminated, products (or patients) flow smoothly, continuously, and without errors from one step to another. After work is completed at one step, it is not pushed to the next step; instead, work is pulled when it is ready to be processed at the next step so that work does not pile up. Problems that arise in the process are to be identified immediately, their causes understood, and a solution applied. Both frontline workers and management are responsible for the quality of work, and both are involved in the problem solving process, often by participating in rapid continuous improvement sessions called kaizen. Indeed, although the support and participation of leadership is crucial, contemporary prescriptions of Lean insist that workers be involved and empowered to inspect and improve their own work. Workers and management have at their disposal numerous tools and methods to implement the above principles (Figure 1).

The much-celebrated success of Lean in manufacturing8 and success stories of Lean in the National Health Service and other health care systems9, 10, 11, 12 have resulted in a strong push for introducing Lean to health care13, 14, 15, 16 and more particularly to the ED.17, 18, 19, 20, 21

Given enthusiasm about Lean as an approach to improving emergency care, this article critically reviews and analyzes the empirical literature on the implementation of Lean in the ED. The present review differs from previous work9, 22, 23, 24, 25 in 5 ways. First, it focuses specifically on the ED. Second, it reviews how Lean affects health care employees in addition to patients. Third, it assesses previous studies for evidence of undesirable and null effects of Lean in addition to desirable effects and in general takes a much-needed critical approach.25, 26, 27 Fourth, it analyzes the factors that may contribute to variability in Lean's success. Fifth, this study systematically analyzes each previous study according to an analytic framework, rather than using studies to build a narrative about Lean in health care. That framework, described below, is based on human factors/systems engineering principles and on occupational research on Lean outside of health care.

Section snippets

Methods

The analytic framework used to generate the core research questions for this review (Figure 2) depicts Lean as having transformative effects on the structure and process of ED work. Structure refers to work system elements such as tools and technology, worker factors (eg, education/training, responsibilities), organizational factors (eg, policy, staffing, incentives), communication systems, and the physical environment (eg, spatial arrangement, noise, lighting).28, 29 Process refers to the

Results

Eighteen articles describing Lean initiatives in 15 EDs met inclusion criteria (Table 1).

Study sites tended to be larger teaching hospitals in the United States, Australia, or Canada. Project team composition varied among sites, but with one exception (Dickson et al75), all Lean involved frontline staff in some way. The staff involved ranged from clinicians to clerks, assistants, engineers, and representatives of the patient community. Their involvement ranged from providing suggestions to

Discussion

Five years have passed since the first well-publicized Lean initiatives in US health care at Virginia Mason Medical Center.11, 15, 86 In that time, many EDs, among other health care delivery units, have begun to apply Lean as a way to fight problems such as errors, delays, and crowding. This review revealed robust opportunities for improvement in EDs and hospital-wide using Lean but also revealed considerable limitations in Lean implementations and in reports thereof.

Lean is often characterized

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    Supervising editor: Richard C. Dart, MD, PhD

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Funded by the US Agency for Healthcare Quality and Research, 5 T32 HS000083-11.

    Publication dates: Available online October 29, 2010.

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