Lean in Health Care

Case for Change

• Connolly, C. “Toyota Assembly Line Inspired Improvements at Hospital.” Washington Post, June 3, 2005, p A01.
• Institute for Healthcare Improvement. “Going Lean in Health Care.” 2005. Available at www.ihi.org.

Project Description

Objectives

Project Team

Construction Process

Status

Tool Kit

Iowa Health Care Contacts

Iowa Industry Contacts

Iowa Government Contact

Iowa Community College Contacts

Lean Consultants

Resources

Articles

• "Lean in Healthcare." (Website) Elizabeth Saunders. IAbiz Online, February 5, 2008.

• "Creating an Environment for Caring Using Lean Principles of the Virginia Mason Production System." (PDF 2.06 MB) Dana L. Nelson-Peterson & Carol J. Leppa. The Journal of Nursing Administration, Volume 37 Number 6 2007.
  
  
• "Dentist Drills Down to the Root Causes of Office Waste." (PDF 536 KB) Lean Enterprise Institute.
  
  
• "Mistake-Proofing the Design of Health Care Processes." (PDF 1.5 MB) John Grout. Agency for Healthcare Research and Quality, Publication No. 07-0020 May 2007.
  
  
• "Pulling Lean Through a Hospital." (PDF 1.7 MB) George Taninecz. Lean Enterprise Institute.

• "Apply 'Lean' Principles in the Health-Care Industry." (Website) Donna Daniel. Puget Sound Business Journal, October 28, 2005.
  
  
• "Decoding the DNA of the Toyota Production System." (Website) Steven Spear & H. Kent Bowen. Harvard Business Review, September-October 1999.
  
  
• "Fixing Healthcare from the Inside, Today." (Website) Steven Spear. Harvard Business Review, September 2005.
  
  
• "Going Lean in Health Care." (PDF 137KB) Institute for Healthcare Improvement, 2005.
  
  
• "Lean Sigma – Will It Work for Healthcare?" (PDF 341KB) James Bahensky, Janet Roe, & Romy Bolton. Journal of Healthcare Infection Management, Winter 2005. 19(1): 39-44.
  
  
• "Lean Thinking for the NHS" (PDF 471KB) Daniel Jones and Alan Mitchell. NHS Confederation, 2006.
  
  
• "Learning to Lead at Toyota." (Website) Steven Spear. Harvard Business Review, May 1, 2004.
  
  
• "Maximizing Hospital Outcomes with Tips from Toyota: Using Less to Do More." (Website) Gary S. Kaplan. Physician's Weekly, October 3, 2005.
  
  
• "Power of Lean in the Laboratory: A Clinical Application." (PDF 69KB) Jennifer Blaha & MariJane White. GE Healthcare White Paper, 2006.
  
  
• "Reducing Waste and Errors: Piloting Lean Principles at Intermountain Healthcare." (PDF 558KB) Cindy Jimmerson, Dorothy Weber & Durward K. Sobek II. Journal on Quality and Patient Safety. 31(5): May 2005.

Books

Presentations

• Dean Bliss, St. Luke's Hospital, Cedar Rapids, IA (PDF 777KB)
  Lean Overview
  
  
• Sarah Pavelka, Quality Management/Organizational Development Specialist (PDF 1.1MB)
  Lean Paradigm- 5S tool- used to develop the most efficient workspace and eliminate waste in day-to-day operations.

• Lean Basics (PDF 370KB)
  Dean Bliss, Director of Lean Improvement, St. Luke's Hospital, Cedar Rapids
  This presentation provides a basic understanding of the Lean methodology, including terminology and acronyms.
  
  
• Reinventing Health Care: Improving Quality as a Determinant for Reducing Cost (PDF 1.94MB)
  Karen Wolk Feinstein, PhD, President/CEO, Jewish Healthcare Foundation and Pitts burgh Regional Health Initiative, Pittsburgh, PA
  This presentation examines the way in which quality improvement leads to cost reduction and the innovative way in which health care institutions in Pennsylvania are using process engineering to achieve improvements.
  
  
• Non Healthcare Approach to Lean (PDF 27KB)
  Teresa Hay McMahon, Performance Results Director, Iowa Department of Management, Des Moines
  Jeff Ruiter, Director of Demand Distribution, EDS, Des Moines
  These two presentations describe how Lean methodology has been successful in non-health care environments in reducing costs, increasing productivity and achieving greater customer and employee satisfaction.
  
  
• Creating a Culture of Improvement at Mercy Medical Center-Des Moines (PDF 889KB)
  Dan Varnum, MBA, Vice President of Performance Improvement, Mercy Medical Center – Des Moines
  This presentation will walk you through how Mercy Medical Center – Des Moines had continued to develop its culture of process improvement, and share successes and lessons learned.
  
  
• Improving Processes to Decrease Cost and Improve Service (PDF 82KB)
  Jay Christensen, Administrator; and Les Martin, Director of Continuous Improvement, Mahaska Health Partnership, Oskaloosa
  This presentation illustrates how the Mahaska Health Partnership decreased costs and improved customer service through simple organizational changes.

Websites

• American Society for Quality is a membership organization devoted to quality. "We have the knowledge, tools, expertise and resources to inspire you and your organization."
  
  
• Association for Manufacturing Excellence is a not-for-profit organization dedicated to cultivating understanding, analysis and exchange of productivity methods and their successful application in the pursuit of excellence.
  
  
• Gemba Research produced a useful Lean Manufacturing Toolkit.
  
  
• I Six Sigma is a site that provides information on Six Sigma process improvement.
  
  
• Lean Enterprise Academy is a source of Lean information for those in the United Kingdom.
  
  
• Lean Enterprise Institute is a nonprofit education and research organization founded in 1997 to promote and advance the principles of lean thinking in every aspect of business and across a wide range of industries.
  
  
• Lean Healthcare West is a group of experienced healthcare professionals that serve as implementation consultants for Lean in health care.
  
  
• Productivity Press is a publisher of Lean improvement books.
  
  
• Quality Press is a publisher of books on subjects such as quality improvement and Lean.
  
  
• Star Thrower provides innovative training materials.
  
  
• Superfactory offers resources supporting lean manufacturing and lean enterprise best practices.
  
  
• University of Michigan College of Engineering Center for Professional Development offers a one-week Lean Healthcare Certificate Program.

Success Stories

• SPENCER HOSPITAL: A 99-bed acute care hospital located in the northwest corner of Iowa Lean Processing at work in Spencer Hospital is known as SHAPE: Spencer Hospital Achieving Performance Excellence
  
  
  
  Background:
  Our Lean journey began in October 2005; strong leadership and support from the CEO, the Executive Team, & the Board of Trustees plus the dedication of front line managers and staff make the process work. The focus is always on eliminating waste and achieving results in quality, service, operations and employee engagement. As of this month:
  • 40% of @ 500 staff have participated on rapid improvement teams
  • Plus, "Voice of the Customer", patients, families & physicians are involved at key times
  The customer, ultimately patients and families define "value". And we value internal and external customers. We use Lean principles: 1. Value; 2. Value stream; 3. Flow; 4. Pull; 5. Ideal; and, fundamentals: 1. On-Demand; 2. Defect-Free; 3. One-by-One; 4. Lowest Cost
  
  We make use of an abundance of Lean tools: process mapping, spaghetti diagrams, communication circles, 5S-ing, standard work, A-3 problem solving, visual controls, and appreciation for the worker, and full review of the existing work process. At the foundation of all the work is measurement; metrics provide the understanding of where we are and where we need to be and if, in our changes, we are getting there.
  
  We are dedicated to being "people-oriented, process-focused and results-driven". SHAPE is not a quick fix; it is a commitment to excellence through open-mindedly having the courage to see the waste and to call it that…. and then doing something about it. SHAPE is not just a process; it is a way of doing business. We have just scratched the surface and look forward to long term success.
  
  
  *****
  
  
  Success Stories – Results: Quality Improvements and Cultural Impact: 1. Topic: Surgery – Central Sterilization Assembly & Work Flow
  Scope: Review Central Sterilization Cell assembly flow; i.e. items coming out of the washer and continuing through placement of items on sterilization racks after coming from the autoclaves; motion from decontamination process to placement in storage racks, then prepared for surgery use.
  
  Before:
  Initial state review:
  • Layout was spread out, revealed waste in steps and excess space allocation; table set up perpendicular to work flow and material not lined up for ease and efficiency
  • Data: 4.6 miles traveled/person/day
  
  
  During:
  Mapped current flow, ideal, and future flow;
  • Try-stormed (trialed) 6 rapid improvement experiments to shorten distance traveled and optimize ease of assemble of sterile packs
  Results:
  Developed continuous flow in the direction of the work by
  • Moving configuration to line up with flow
  • Freeing up space to move sterile supplies closer to assembly
  • Relocating autoclave rack, battery charger, biological test tubes
  • Rearranging materials– point-of-use supplies and holders
  • Marked "parking" areas for case carts to be returned and maintained
  • Data: Saved 181 miles/person/year –or .7mile/person/day
  Freed up 200 square feet of space
  
  After:
  Central Sterilization staff continued to work to free up the remaining 66 sq feet of space needed to allow the movement of sterile supplies into the Central Sterilization area, saving them from having to travel to the lower level of the hospital each time they needed these items.
  
  
  
  Lessons Learned:
  • This 4-day event enabled a team to focus, study and make significant changes – all within a week.
  • We need to test new ideas, break paradigms.
  • The solution to a problem is not through more space or more resources, "creativity before capital".
  • Lean principles do apply to healthcare.
  
  
  Another Success Story: 1. Topic: Mental Health Intake Process
  Scope: Review and streamline Mental Health process of admitting patients
  
  Before:
  Initial State Review:
  • Disconnect of communication, cumbersome process with excessive tasks/steps, and lack of standardization
  • Data: Average cycle time = 2 hrs 38 minutes
  
  
  During:
  Mapped the flow of the patient from Emergency Department (ED) to Inpatient room; also, ideal state map
  
  
  • Current total process steps = 53; significantly non-value added steps
  • Performed 14 rapid experiments and measured results
  
  
  Results:
  Streamlined the admission process
  • Established admission path from ED to patient floor, more direct via elevator across from intake room
  • Set up a new, secure admission room
  • Stocked supplies at point-of-use
  • Created standard work, processing orders etc. in the computer medical record; created standard screens and maximized use of the EMR (electronic medical record)
  • Resolved the wireless computer issues – installed new WAPs (wireless access points)
  • Data: Average cycle time reduced to 2 hrs, a 24% savings
  
  
  Lessons Learned:
  • Lean really works.
  • This is hard work----but achieves results quickly.
  • Doing experiments during the week really helps.
  • It is often difficult to move people's cheese, i.e. change their world.
  • We have a new appreciation of the complexity of processes.
  
  
  Teams in action:
  We involve the staff from the areas "where the work happens" – putting up an Issues and Ideas poster for them to contribute before the Kaizen event; we also have the process owner bring staff to the SHAPE work room to review the information on poster paper "covering the walls" so they are in the loop and engaged to accept the changes as best as possible.
  
  This process has helped staff and leaders work together on real engagement and results, promoting further drill down and stressing the need to hold the gains. This is a great opportunity and investment for the staff and community. The driving force for all our work is "What is in the best interest of the patient"!
  
  
• St. Luke's – Cedar Rapids
  Getting Control of Supplies in Imaging Services
  As in many hospital departments, Imaging Services recognized a problem with supplies – they were hard to find, they were stored in too many places, and it was sometimes difficult to know when we needed to order more.
  
  To remedy this situation, a Lean project was initiated to coordinate supplies ordering and management. Leadership and front-line staff worked together to identify where supplies were stored, who was ordering supplies in each area, and how and how often ordering was done. The team created a kanban system, which identifies the locations, quantities, re-order points, as well as defining the ordering process. They also consolidated the common supplies into a central area, to minimize the duplication of both inventory and ordering. The system was tested and adjusted to ensure that the new inventory levels were correct for the supply usage.
  
  The bottom line? From June 2007 to January 2008, the number of supply items held in Imaging Services decreased by over 8,000 items, a 38% decrease in the number of things purchased and stored. Ordering has been consolidated and standardized, so fewer associates are spending time ordering, and those that do, have a specific order quantity and order procedure to follow. And the number of outdated and lost supplies has been drastically reduced.
  
  Swarming in the Lab
  An ongoing issue faced by the Lab has been the early-morning collection of blood specimens. To meet the desire of physicians that the test results are posted on the patients' charts by 0700, there has been a mad scramble to get specimens collected, received, tested, and resulted.
  
  To address the situation, the Lean team in the lab tested a technique called "swarming", which sends a roving group of phlebotomists to the nursing units, rather than one or two phlebotomists making the rounds. In addition, those in the "swarm" would send specimens to the lab more frequently, rather than collecting many specimens and sending them in a batch. The method was tried, tested, adjusted, and retested. Adjustments to staffing for those times was tested and adjusted. And some dramatic results were realized.
  
  The amount of time, on average, from collection to result decreased by over 50%. The percentage of specimens resulted within 23 minutes of receipt in the lab in the early morning increased from 63% to 94%. All the changes resulted in smoother flow of specimens, a steadier pace of work, fewer missed collections, and a more reliable collection process.
  
  Submitted by Dean Bliss, Director of Lean Improvements, St. Luke's Hospital, Cedar Rapids, IA 02/25/2008
  
  
• St. Luke's Hospital – Cedar Rapids
  Two projects:
  1. Saving 37 Miles – Reviewing Physical Arrangement of OB Triage
     
     A Lean activity was held in the Center for Women’s and Children’s Health that focused on the admission and triage area for expectant mothers. As we reviewed the area, we saw several opportunities for efficiency, the most notable being the physical arrangement of the rooms and equipment required to triage a patient. By tracking the steps of the triage nurses, we discovered that moving a few things around and changing the usage of a couple rooms would help considerably.
     
     To analyze this, we created a team of nurses, techs, and supervisors to study the situation. We discovered that some functions that were not critical to the triage operation could be moved to other areas of the building to create space for the testing room, which was 20 steps away, and was visited 3 times for every triage patient. We could also create efficiency by updating the filing system, adding a computer in the area for charting, and rearranging the utility rooms.
     
     The results of this activity were a pleasant surprise. We measured the steps that nurses took to complete the task before and after the changes, and noted that the travel distance to serve one patient was reduced by an average of 380 feet. If you multiply that number by the average number of patients the CWCH serves every month – which is about 525 – we found that by using this new process, nurses would walk 37 fewer miles per month. Other efficiencies were gained by updates of the filing system and the utility usage. This project exemplified a great job by the CWCH Lean team, and how Lean can help make life better for the associates. These positive results will help us serve our patients better.
     
     
  2. Supplies in the ED
     
     As we reviewed the Emergency Department for Lean opportunities, and as we talked to the nurses and techs, one theme kept coming up: supplies. We didn’t know where things were, how much we had, how many places things were stored, where things were kept in each exam room – essentially, we needed to create a better way to manage supplies.
     
     We created a team of nurses and techs (and a materials person), and we attacked the problem. We set aside a day to go through all the supplies in the area – we went through every closet, every storage area, every place where supplies were stored. We determined where things would be stored, how much we would keep, and what we had that was excess and could be either disposed of or returned to central supply. We returned over $3,000 worth of supplies. We then informed the entire department of our efforts.
     
     Next, we looked at the materials that are kept in the exam rooms. Though there are several different room configurations in the area, we determined where supplies would be stored in each room. For example, the left hand drawer in each room would always contain the same thing. This part was done over a two-week period as the rooms were available and the techs had time. The results of both of these activities is a more organized Emergency Department, a more satisfied staff who feel more in control of their area, and a cost savings to the hospital.
  
  
  
• Mercy Medical Center – Cedar Rapids
  Mercy’s Lean initiative was begun in February 2005 as an important addition to our continuous improvement efforts in quality, safety, and efficiency. We were introduced to Lean by the collaborative project between the Iowa Hospital Association and the Iowa Business Council, as well as by our business partners at Rockwell. We were sold on Lean’s focus on the customer; its high level of staff involvement, and its demonstrated results. We realized that Lean could deliver the quantum-level improvements our stakeholders were demanding, and would also help us develop new ways of delivering health care services in the face of upcoming baby boomer retirements and the resulting serious health care professional shortages.
  
  Our executive team evaluated potential areas for application of Lean using criteria such as strategic importance; the potential for improvement in patient, physician, and employee satisfaction; cost savings potential; and leadership strength. To date, the following value streams have been initiated:
  • Emergency Department
  • Planned Surgical Admissions
  • Patient Care Documentation
  • Lab Operations
  • Revenue Cycle
  • Inpatient Medical-Surgical Care
  • Care Coordination
  "Do its," projects, and events have successfully been implemented in clinical, support, and office environments, demonstrating the universal application of Lean. As of August 2006, we have completed a total of 31 events. Some of the results in the Emergency Department are as follows:
  
  

  General x-ray cycle time	Reduced 50%
  CT scan cycle time	Reduced 38%
  Fast Track patient visit cycle time	Reduced 50%
  First pass clean claims	Increased 81%
  Patient satisfaction	Increased from 38th to 95th percentile
  Staff Distance Traveled	Reduced by 510 feet per triage patient

  
  
  We have successfully utilized several classic Lean tools in our journey. Kanban systems have been implemented in our OR and our nursing units, reducing inventory levels and decreasing storeroom requisitions by 34%. The implementation of a pull system for IV Pumps decreased monthly rental costs by $7,500. We have applied “6S” techniques to our Laboratory, freeing up 48 square feet of floor space.
  
  We have had the opportunity to extend the application of Lean beyond the Mercy organization through joint Lean events with Wellmark on the medical record request process. The process improvements developed by this team are being piloted plan-wide. Mercy’s medical requests from Wellmark have been reduced from 60 per month to 20 per month. The plan-wide pilot reflected a 56% reduction in the number of medical records requested by Wellmark. Also, Wellmark projects a reduction of 14,000 – 15,000 suspended claims per year as a direct result of these process changes, effectively reducing costs for both providers and Wellmark.
  
  We also have seen benefits beyond quantifiable cost savings and patient satisfaction improvements. Lean is the most effective problem solving technique that we have used in our organization, particularly for issues that cross departments. Selecting processes that have been historically frustrating to employees for improvement efforts validates the importance of their everyday issues. The Lean process has allowed employees from different departments to walk in each others’ shoes. Time and time again, misperceptions about the role of employees in other departments were shattered, and true understanding of the impact of one department’s work on another’s were realized. The process allows a focus on what’s best for the customer, rather than fostering a battle of one department’s needs versus another’s.
  
  We also have seen the value of Lean as a professional development system. Lean facilitator roles have been created both to increase the capacity of Mercy to implement Lean, as well as to develop leadership skills in the organization’s up and coming leaders. These individuals will be trained to apply all of the Lean tools, to effectively use data to guide decisions, and to deal with change management issues needed to hardwire and sustain positive improvements.
  
  As we travel on our Lean journey, we continually realize that health care is overflowing with complex and fragmented processes that too often get in the way of fulfilling our mission to care for the sick and enhance the health of the communities we serve. We owe it to our patients, and to the health professionals that dedicate their lives to serving them, to continue to strive towards perfection.
  
  
• Mercy Medical Center – Des Moines
  Mercy Medical Center, Des Moines, a 917-bed acute care, not-for-profit Catholic hospital, located on three Des Moines campuses, began introducing Six Sigma early in 2004 as part of its recommitment to the performance improvement efforts in which Mercy has been engaged in for many years. By December 2004, 15 healthcare professionals were trained to be full-time, dedicated project leaders – called Six Sigma Black Belts. In addition, Mercy currently has 60 employees trained as Green Belts, devoting approximately twenty percent of their work time to practicing the Six Sigma methodologies as project leaders in their specific departments. Employing more than 6,600 people, with a medical staff of 800 physicians and allied health professionals, Mercy is using Six Sigma tools in a quest toward world-class quality.
  
  Six Sigma methods have been used to improve customer satisfaction, make processes more efficient, reduce errors and improve financial performance throughout the hospital. To date, 375 Mercy employees have participated on more than 130 process improvement projects. Most projects have involved business and patient care support. However, Mercy is also seeing these process improvement tools used in more clinical applications.
  
  After just two years of implementation, Mercy has already reaped many benefits – including nearly $12 million in project savings/increased revenue and many improved processes impacting patient safety and/or patient satisfaction. Today’s Six Sigma is not limited to the DMAIC (Define, Measure, Analyze, Improve, Control) method. Instead, Mercy has expanded its efforts to include DMAIC and Lean events under the umbrella of Six Sigma encompassing a philosophy based on a wide range of techniques and performance improvement methodologies. Mercy’s Six Sigma efforts focus on four principles: the pursuit of perfection, continuous process improvement, customer/patient focus, and teams/collaboration.
  
  The newest technique being introduced at Mercy is Rapid Process Improvement (RPI) methodology. Similar to a Lean event, with RPI, team members spend five days focusing on a particular process and developing improvement strategies. During this very intense week, the team maps the current process with process flow diagramming; identifies and analyzes process barriers to the process mission; prioritizes the barriers to be addressed; brainstorms and selects solutions to the identified barriers; develops a plan to implement the solutions; and develops control measures to ensure results, continued success and sustainability. In addition to the DMAIC and RPI methods, Six Sigma teams also use a variety of other strategies including: Design for Six Sigma (DFSS), change management techniques; and Voice of the Customer (VOC) methodologies that help guarantee that the needs of patients and other customers continue to drive Mercy’s process improvement efforts.
  
  Below are a few project examples related to Six Sigma Projects at Mercy Medical Center - Des Moines, Iowa:
  1. Wasted Medications: In an effort to reduce wasted medications, one improvement project focused on the reduction of wasted Natrecor, an expensive IV medication used in the treatment of congestive heart failure. As a result of the team’s recommendations, the process used in Pharmacy changed to prepare only the amount of medication needed for each patient. The change did not affect the amount of Natrecor given to the patient for the treatment of their heart failure, but rather how the medication was drawn and prepared, and the communication around patient schedules. By preparing Natrecor on a demand basis for each case, there were nine straight months of zero percent medication waste; this was down from the baseline waste levels of 28%.
     
     
  2. Returns to ICU: Another improvement project aimed to decrease patient returns to the Intensive Care Unit (ICU). Mercy’s return to ICU data compared to similar hospitals nationwide showed a higher rate of patients returning to the ICU. Different assessment processes, including a checklist, were implemented to address patient stability before leaving the ICU and a new standard order set was created for use after transfer. Project efforts resulted in decreased patient returns to ICU from 7.8 percent to 3.7 percent. These changes also produced better care outcomes for the patients and a reduced length of stay.
     
     
  3. Improved Diabetic Urder Usage: An interdisciplinary group of clinical staff and physicians applied the Six Sigma methodology to the process of care for our diabetic patients. Their work produced a 61% increase in utilization of American College of Endocrinology guidelines and a significant lowering of average glucose (blood sugar) levels in the study group. By utilizing the diabetes management protocol and order sets, there has been a decrease in costs, decreased length of stay, and improved glycemic control for patients.
     
     
  4. Improve Pre-Surgical Evaluation Process: Prior to a Six Sigma project, Mercy’s Pre-Surgical Assessment Department (PSA) had been experiencing difficulty getting charts ready for outpatients having surgery. Through the use of a standardized cover sheet, there was an improvement from 30% to 79% for having the appropriate patient information on the chart, such as a current history and physical, lab work, EKGs and cardiac clearance, without requiring additional nursing intervention. This project has also helped decrease delays in surgical cases and improved patient, physician and staff satisfaction.
  
  
  
• University of Iowa Hospitals and Clinics
  Diagrams describing two of UIHC’s Lean initiatives can be viewed below.
  PowerPoint Presentation
      Part One (PPT 1,381KB)     —     Part Two (PPT 3,120KB)
  
  PDF Presentation
      Part One (PDF 88KB)     —     Part Two (PDF 321KB)
  
  
• Allen Hospital - Waterloo
  In October of 2004, Allen Hospital, a part of Iowa Health System, was awarded the exclusive contract with John Deere to provide health care to their employees, family members and their retirees. As a result of this relationship, John Deere approached Allen to participate in a process improvement team activity to improve quality for the benefit of all involved. The decision was easily made to focus on Emergency Room Throughput, since the Allen Emergency Room is currently undersized, emergency room visits are increasing at 2% per year, and waiting times were greater than the state average.
  
  A team was convened with Deere and Company consultants which resulted in a reduction of 11 minutes per patient encounter. This also resulted in a calculated cost savings of $382,000 per year because fewer personnel are required to attend the ever-increasing patient volumes. The mid-year outcome approaches the “best practice” nationwide of patient lengths of stay. The team consisted of ER management, medical director radiology, laboratory, transporter and patient advocacy personnel.
  
  The “bed ahead” concept is touted as a “best practice” in the literature and was implemented in March 2005 at Allen. Each nursing unit always has at the ready the next identified bed for the next appropriate patient in need of care. An audit conducted in July indicated nine out of ten requests by ER could be met for a bed due to the “bed ahead” concept.
  
  A Discharge Process Team is also being established to begin August 14 as a spin-off of the Lean ER Throughput Team due to the results of patient satisfaction surveys as well as data collection throughout the facility which indicates the need to pre-plan discharges.
  
  The Lean Team is moving to a Phase II operation with internal changes intended in the workflow of the emergency room in the second half of the year. Timelines are being developed to assure alterations recommended by Emergency Room staff are put in place to improve the work environment and the patient flow of the department.
  
  

IHC would like to thank the Lean Steering Committee: