Redesigning Emergency Department Processes by Applying Lean Principles - Literature review Example

REDESIGNING EMERGENCY DEPARTMENT PROCESSES BY APPLYING LEAN PRINCIPLES Student’s Name Course Professor’s Name University City (State) Date Redesigning Emergency Department Processes by Applying Lean Principles 1. Background Of Lean 1.1 A Brief History Of Lean It is undeniable that the healthcare institutions are under intense pressure to be efficient. Magalhães et al. (2016, p. 3) argued that a lot of the population is aging thus increasing the demand for health care services. Nevertheless, the health care systems are not improving at all and in fact, are worsening. On the other hand, in this century, the health care services are expected to be affordable, safe, cost-effective, and accessible and at the same time efficient. The necessity has led the institutions to look for methodologies can bring out the most effective ways of providing care. As a result, most end up adopting the Toyota Productions System, Lean Healthcare Management, which seeks to improve the performance. Apparently, lean does not alter the existing processes but rather improves on them so that they can work better. In short, the lean approach does not bring about substantial reorganization to the hospital but rather improves the processes with meager investments. Throughout history, many views are related to the lean thinking. Magalhães et al. (2016, p. 4) stated that the Lean approach has its roots from the Toyota Production System (TPS) in the 1970s. Evidently, lean production methods first appeared in the book The Machine That Changed the World by Womack and Jones in the 1970s. Nonetheless, the majority of the institutions and industries apply the lean approach nowadays. Moreover, there is the substantial development of the concept over the decades. The majority of the authors and scholars have developed different features to describe the lean approach. Moraros, Lemstra, and Nwankwo (2016, p. 155) stated that the Womack and Jones were the first authors to propose that the health care industry can utilize the lean techniques in treatment. Womack and Jones argued that the first method of applying the Lean approach in the medicine is through putting the patient time and comfort as the key performance measurement. In the process, the different multi-skilled healthcare practitioners were to involve the patient in devising the appropriate health services. Since then, it is evident that there have been many applications of lean approach in the medical industry. In particular, this document looks into how lean approach has been applied in the emergency department (ED) over the decades. In short, the paper gives a literature review of utilization of the lean approach in the ED. 1.2 The Principles Of Lean A study by El Sayed et al. (2015, p. 94) shows that the lean thinking is applied in the healthcare system including the ED through issues such as eliminating the errors, inappropriate procedures, repeat visits, and waiting times. On the other hand, Rutman et al. (2015, p. 362) suggested that empowering employees with the right knowledge and tools would ultimately improve the work produced. In short, a knowledgeable employee will not only focus on taking care of the patient but will also find a way that they can make the process more successful. Since Lean approach enhances the processes steps that are undertaken in the treatment process, it can be applied in which stage to provide more valuable patient care. Additionally, the lean technique enables the ED to eliminate the unnecessary processes. As a result, most of the employees end up satisfied with their jobs and give the substantial outcome. According to Moraros, Lemstra, and Nwankwo (2016, p. 155), Womack and Jones first identified the five principles that apply to the ED as follows; “Seek perfection, Create flow, Establish pull, Map the value stream, and Specific value from the standpoint of the end customer.” 2. Lean In The Service Sector 2.1 The Types Of Waste In The Service Sector The number of patients visiting the ED has increased over the recent years. According to Chan et al. (2014, p. 27), between April 2011 and March 2012, there was an average of 350 patients that were taken to the ED which means that was a maximum of 463 patients daily. Apparently, these patients spend one to one and a half hours in the ED before they are discharged or even admitted to the hospital. Remarkably, there are time wastes times in all the activities that are included in the admission of the patients. The following processes spend a lot of time before the patient care is concluded in the ED; registration, blood tests, nurse triage, radiographs, physician examination, discharge among other necessary observation characteristics. According to Uriarte et al. (2015, p. 1), patients and their guardians feel a lot of time is wasted during this processes, and it is very irritating. Hence, it is necessary to understand what the patients want since it is a significant factor within the ED to create a satisfaction and quality healthcare. According to Al-Balushi et al. (2014, p. 144), the overall performance within the ED department is facilitated by some factors which fall into the organization changes sustainability. Notably, the health institutions are complex since they house many functional units that operate widely across the departments thus requiring coordination throughout. Apparently, even the simplest task still involves more than one skilled personnel within the health institution. As a result, combination and leveraging of the skills and facilities are very crucial to achieve the long-term goal. Notably, both the organization and staff factors determine the efficiency of the ED performance. The authors stated that the factors are ED overcrowding, triage, skill workforce availability, training, management involvement, decision making, cultural shift, and supportive and clinical services coordination, both internal and external communication. Others are aware of the indicators of critical performance, role clarity, and processes involved. Another study by Vermeulen et al. (2014, p. 429) showed that the ED overcrowding is as a result of the following factors which even the ED staff have no control over. These issues are insufficient patients’ beds, a lengthy and complicated process of admission, lack or difficulty in getting non-ED physicians consultations, and complication diagnostic procedures and reports. Rutman et al. (2015, p. 264) observed that the ED before the implementation of the Lean approach is characterized by long delays for the physician evaluation. Non-critical patients primarily experience the longest delay because first, they have to go to the nurse so that they can conduct the medical screening examination (MSE). The MSE is quite detailed and has many questions such as the history of a particular infection. Consequently, after MSE the patient is sent to the hospital's clerk for the registration. After the registration, the patient goes back to the waiting room to an ED bed is available. Before given a room, a second examination is done before been assigned to the ED physician. Evidently, the process is not only tiresome for a patient who is placed in ED care but also time-consuming which can lead to death even before the treatment of the patient. 3. Lean Implementation 3.1 Critical Success Factors for Lean Implementation During the implementation of the lean approach in the ED system, the literature identifies three key steps which are lean training, pilot testing, and change applications. According to El Sayed et al. (2015, p. 94), the employees must be taught about the lean principles, tools, and methodologies. The process enables the selection of the appropriate lean tools that can initiate the practical work. Additionally, the institution can identify the group of health practitioners to train first, the lean facilitators, and the leaders. The trained group offers training to the other groups within the organization. Notably, the commitment, knowledge, and creativity of the staff are what determine the success of the lean training amongst the staff. Consequently, the pilot testing is done during the first training where the employees that are involved in the training are mandated to carry out the skills that they are learning practically. In this step, the nurses and all the other staff involved in the training are allowed to implement one of the lean tools such as Value Stream Mapping so that they can understand how it works. The overall necessity of this process is to identify the lead time and at the same time come up with ways through which the involved people can save the wasted time (Al-Balushi et al. 2014, p. 142). The plan acts as the framework for the consecutive lean implementation within the organization. The other implementation stage is to get all the other employees into the whole ED lean implementation. This stage includes more than one application tools. Also, this process is commonly referred to the Kaizen Event. Most importantly, no particular method has been identified as the successful one when it comes to lean approach within the ED department. Notably, lean is not one-time change strategy and requires work in process approach. There is little chance that lean would be successful if the health institution implement it at once and that is why it should be taken in bits. Apparently, it is hard to take ideas from one organizational culture and plant them into another culture that is entirely different from the initial one (Magalhães et al. 2016, p. 6). Vermeulen et al. (2014, p. 428) suggested that an appropriate way of implementing the lean is through the adaption-orientation where any health institution identifies the tools and approaches that are consistent with what they have within their system. An ED planning to implement the lean strategy must identify which tools and techniques that are appropriate for their culture. In short, the lean implementation is successful, if the implementation methods, tools, and values are in line with those of the ED that is adopting it into their systems. Therefore, a critical review of the organization culture leads to long-term and sustainable lean implementation. 3.2 Challenges of Lean Implementation Each process has its difficulties, and so does the lean implementation process. C Bucci et al. (2016, p. 4212) identified the first and most critical challenge of the lean implementation as the ability to enable the staff to adopt the lean in their daily operations. First of all, it is good to understand that lean in healthcare is not similar to TPS because human is not cars. The employees need the training to understand the benefits of using this process in the healthcare system. Unfortunately, even the training itself is another challenge for the institution. Notably, in the health industry, few people are even aware of the existence of the lean strategy, tools, and methods. In short, there is the lack of lean trainers within the medical industry, and therefore, facilitators and trainers are hired from other sectors such as manufacturing. These teachers use different terms mostly from their field of expertise which makes it difficult for the health staff to understand and implement in their area (Chan et al. 2014, p. 26). In short, it increases the assimilation period of the lean approach. Another challenge of the lean implementation process is the lack of the clear consumer focus. Apparently, one of the lean principles requires that the institution can describe and understand the customer value. The value of the customer in the healthcare is ambiguous since they deal with patients who want to be healthy rather than gain any economic advantage. Additionally, there are other users involved such as the patient's family members whose value must be accounted for in the implementation process (Arbune et al. 2014, p.6). Uriarte et al. (2015, p. 2) identified the other challenge as the healthcare organizational structure. Notably, the healthcare institution is highly hierarchical with the doctors acting in autonomy since they have much more professional knowledge. The structure contradicts with lean because the lean advocates for team work communication and collaboration which has not be dealt within the vocational training of the healthcare professionals. Finally, several authors agree that the implementation of lean within the ED department faces issues from the other departments because of interdependency. The whole organization must be redesigned to allow the positive outcome of the implementation of the lean processes within the ED system. In short, when implementing the lean in the ED, the implementers should undertake a holistic approach for the whole organization. 3.3 Lean Tools and Techniques El Sayed et al. (2015, p. 94) identified that the first lean tool to facilitate lean implementation is processing mapping of the patient's flow from when they arrive at the hospital to when they are seen by the physician. According to the author, mapping involves the value system by identifying the value added by reducing the waste time at each step of treatment. When this process is observed critically, then the hospital can do modifications accordingly. The metric measure in this situation is to identify the door to doctor time for every patient stay. The cause of every obstacle within the process of treatment is analyzed and optimized respectively. For instance, if the hospital faces staff insufficiency in the registration thus causing delay, then it can increase the number of these nurses. According to Arbune et al. (2014, p.12), another tool used in lean implementation is the value stream mapping. The authors also emphasized the use of Kaizen during application process. On the other hand, C Bucci et al. (2016, p. 4216) prefers the standardization of work which is achieved by assessment of the better strategy of offering the care. This tool allows the staff to limit the unexpected variation while giving care to the patients. It is mostly based on the triage procedure and management of the patient's flow to ensure positive impact amongst the patients in the ED. Also, the authors suggested the use of team during problem-solving and the pull system. Finally, there is the Kanban, 5S, and A3. All this methods target efficiency in the ED processes. 3.4 Benefits of Lean Implementation All the articles show that the ED causes substantial benefits within the ED department both in the organizational and healthcare benefits. Radhakrishnan and Nandini (2014, p. 5) noted that the lean approach led to increased efficiency and productivity amongst the employees, minimization of the patient care time, care practices little variability, cost-efficiency, better service quality, and increased satisfaction amongst the patients. Uriarte et al. (2015, p. 6) noted that there are other benefits such as the employee satisfaction, earlier hospital discharge, increased access to care, more patient safety, low mortality, reduced employee overtime, less medical errors, and sustainable use of the hospital beds. In short, the benefits realized by the use of lean within the ED are inexhaustible. They range from time to satisfaction in the jobs and even visiting the hospital. Therefore, the lean approach benefits not only the patients but also the health professions, and other workers within a health institution such as the management. 4. Lean Healthcare 4.1 Lean in the Emergency Department The outcomes of lean in the ED can be categorized into groups. The first category describes how it improves the overall performance while the second shows how the work environment and the staff benefit from it. According to Magalhães et al. (2016, p10), the lean approach allows improved patient's outcomes within the ED. In short, this means that the lean ED is more accessible, there is less treatment time, and reduced waiting for the patients. Further, Moraros, Lemstra, and Nwankwo et al. (2016, p.159) argued that lean implementation increases employee attention and a proactive attitude when involved in treating the patients. The workers will stop wasting time and work fights and instead take the initiatives of resolving the ED problems. Consequently, the Lean will lead to organized and calmer environment. The process achieves such practices through the elimination of the non-value activities and time that is wasted within the work processes. As a result, the staff in the ED can predict the work they are to do and hence becomes less stressful. In short, the ED healthcare workers are more involved in their work assignments that are receptive to what the patients need. 5. The Role of Simulation in Lean Due to the challenges associated with the lean implementation process, it is advisable to use analytical techniques such as simulation model to find the major solutions. Uriarte et al. (2015, p. 2) stated that the utilization of the simulation which mostly evaluates creates, maintains, and improves systems dates back to five decades in the healthcare system. At that time it was used for analyzing the efficiency of the resource use. Nowadays, the primary use of the simulation method is in "what –if" scenarios. In the lean approach, the simulation model analysis the different procedures were undertaken to ensure that they are the best possible solutions. For instance, if the hospital believes that fewer beds are the reason for the long queues, the simulation model helps analyze what if the beds are increased. This way the hospital is sure whether or not the lean initiative is efficient. In conclusion, the lean approach in the ED is used for process improvement mostly. Mostly, the Value Stream method is more preferred because it shows on which process to improve. Though the lean implementation is still little in the ED and other healthcare units, it is crucial that as many as possible organizations adopt these processes. The lean approach comes with many benefits such as improved and quality care services for the patients which are the ultimate goals for any health care institutions. In short, it is advisable to implement the lean approach in the ED departments to realize the long-term purpose of delivering adequate, quality, and cost-effective care for the ED patients. References Al-Balushi, S., Sohal, A.S., Singh, P.J., Al Hajri, A., Al Farsi, Y.M. and Al Abri, R., 2014. Readiness factors for lean implementation in healthcare settings–a literature review. Journal of health organization and management, 28(2), pp.135-153. Arbune, A., Wackerbarth, S., Allison, P. and Conigliaro, J., 2014. Improvement through small cycles of change: Lessons from an academic medical center emergency department. Journal for Healthcare Quality. C Bucci, S., De Belvis, A.G., Marventano, S., De Leva, A.C., Tanzariello, M., Specchia, M.L., Ricciardi, W. and Franceschi, F., 2016. Emergency Department crowding and hospital bed shortage: is Lean a smart answer? A systematic review. Eur Rev Med Pharmacol Sci, 20(20), pp.4209-4219. Chan, H.Y., Lo, S.M., Lee, L.L.Y., Lo, W.Y.L., Yu, W.C., Wu, Y.F., Ho, S.T., Yeung, R.S.D. and Chan, J.T.S., 2014. Lean techniques for the improvement of patients’ flow in emergency department. World journal of emergency medicine, 5(1), p.24. El Sayed, M.J., El-Eid, G.R., Saliba, M., Jabbour, R. and Hitti, E.A., 2015. Improving emergency department door to doctor time and process reliability: a successful implementation of lean methodology. Medicine, 94(42). Magalhães, A.L.P., Erdmann, A.L., Silva, E.L.D. and Santos, J.L.G.D., 2016. Lean thinking in health and nursing: an integrative literature review. Revista latino-americana de enfermagem, 24. Moraros, J., Lemstra, M. and Nwankwo, C., 2016. Lean interventions in healthcare: do they actually work? A systematic literature review. International Journal for Quality in Health Care, 28(2), pp.150-165. Radhakrishnan, M.J. and Nandini, A.S., 2014. LEAN THINKING FOR EFFECTIVE CARE DELIVERY OF EMERGENCY DEPARTMENT–A CASE STUDY. Asia Pacific Journal of Research Vol: I Issue XII. Rutman, L., Stone, K., Reid, J., Woodward, G.A.T. and Migita, R., 2015. Improving Patient Flow Using Lean Methodology: an Emergency Medicine Experience. Current Treatment Options in Pediatrics, 1(4), pp.359-371. Uriarte, A.G., Zúñiga, E.R., Moris, M.U. and Ng, A.H., 2015. System design and improvement of an emergency department using simulation-based multi-objective optimization. In Journal of Physics: Conference Series (Vol. 616, No. 1, p. 012015). IOP Publishing. Vermeulen, M.J., Stukel, T.A., Guttmann, A., Rowe, B.H., Zwarenstein, M., Golden, B., Nigam, A., Anderson, G., Bell, R.S., Schull, M.J. and Team, E.I., 2014. Evaluation of an emergency department lean process improvement program to reduce length of stay. Annals of emergency medicine, 64(5), pp.427-438. Read More