Lean manufacturing applying the lean principles of the toyota production system to reduce wait times in the emergency department

MINISTRY OF EDUCATION AND TRAININGFaculty For High Quality Lean Manufacturing APPLYING THE LEAN PRINCIPLES OF THE TOYOTA PRODUCTION SYSTEM TO REDUCE WAIT TIMES IN THE EMERGENCY DEPARTMEN

MINISTRY OF EDUCATION AND TRAINING

Faculty For High Quality

Lean Manufacturing APPLYING THE LEAN PRINCIPLES OF THE TOYOTA PRODUCTION SYSTEM TO REDUCE WAIT TIMES IN

THE EMERGENCY DEPARTMENT

Part class code: LEAN420806E_02CLC

Lecturer: Nguyễn Thị Ánh Tuyết

Authors:

Semester 2 _ School year 2022-2023

Ho Chi Minh City, May of 2023

Lecturer s comments ’

Lecturer’s signature

Nguy n Th Ánh Tuy t ễ ị ế

TABLE OF CONTENTS

LIST OF ABBREVIATIONS ii

LIST OF FIGURES iii

ABSTRACT 1

CHAPTER 1 INTRODUCTION 2

1.1 Overview about Rsearch Paper 2

1.2 Lean and Apply 2

CHAPTER 2 METHODS 4

2.1 Setting and Design 4

2.2 Intervention 4

2.3 Outcome metrics 5

CHAPTER 3 RESULTS 7

CHAPTER 4 DISCUSSION 11

4.1 Flaws of the Current State Value Stream Map 11

4.2 Solutions with the future value stream map 12

CHAPTER 5 CONCLUSION 13

5.1 Summary of research paper 13

5.2 Objective of research pap 13 er REFERENCES 15

LIST OF ABBREVIATIONS

LIST OF FIGURES

Box 1.1 The 7 sources of waste, with selected examples relevant to the emergency department 3Figure 3.1 Emergency department wait time and length of stay before and after intervention 7

ABSTRACT

Objective Despite not receiving any more cash or beds, we set out to reduce patient wait times and enhance staff and patient satisfaction in our Emergency Department (ED) Methods In order to reduce ED wait times and enhance the standard of service, Hôtel-Dieu Grace Hospital’s whole team started a change in 2005 The foundation of our project was built on lean principles, including value stream mapping, just- -time (JIT) delivery, inworkplace organization, the elimination of systemic waste, the utilization of the worker as the source of quality improvement, and continuous improvement of our process steps Results Without adding any extra ED or inpatient beds, our ED has significantly improved departmental traffic From 111 minutes to 78 minutes, the average time from registration to physician visit has decreased Patients who departed without being seen areseen less frequently now—4.3% versus 7.1% Patients that were released had shorter lengths

of stay (LOS) The time ranged from 3.6 to 2.8 hours, with patients who were triaged using the Canadian Emergency Department triage and acuity scale at levels 4 or 5 experiencing the greatest reduction After using lean concepts, we saw an increase in ED patient satisfaction ratings

Conclusion Lean manufacturing concepts can enhance patient flow through the ED, resulting in higher patient satisfaction and less time spent in the ED

Keywords: ED administration, lean principles, length of stay, time to physician, wait time

CHAPTER 1 INTRODUCTION

In this chapter, the authors have posed the problem that the waiting time of ED is too large and proposed to solve this situation by applying principles originating from the Toyota Production System

1.1 Overview about Rsearch Paper

Wait times in emergency departments have become a focus for the Canadian public, the media, and the government To enhance ED patient flow, external factors such as enhancing access to inpatient beds, adopting overcapacity protocols, adding clinical decision units, and rearranging ambulance services have been recommended ED overcrowding and ambulanceoffload delays have been growing at our location, as they have at most Ontario hospitals, due

in part to a lack of available inpatient beds Previously, our ED had tried a variety of strategies

to improve wait times and meet the approved Canadian ED Triage and Acuity Scale wait time standards We expanded the number of triage nurses and stations, added medical directions,boosted physician staffing, hired a nurse practitioner, and built a fast track section, among other things Despite these efforts, the overall ED wait time was not reduced significantly In September 2005, our ED began a transformation of our departmental operations based on Toyota Motor Corporation’s lean manufacturing concepts

1.2 Lean and Apply

Lean approaches are frequently utilized in the manufacturing business to enable just- -intime delivery and, ultimately, to provide value for the consumer while utilizing the fewest resources These strategies are especially relevant to Canada s present medical system, wher’demand outstrips capacity to deliver timely care Some hospitals have implemented lean techniques The ED product can be considered prompt, accurate, and compassionate medicalcare The term “lean” refers to principles originating from the Toyota Production System The primary goals of a lean system are to standardize work in order to smooth workflow and eliminate wasteful processes If a phase adds no value or creates redundancy for the next user

in the process, it impedes quality and flow and is removed (Box 1.1) Quality and productivity improve by reducing wait times between phases and providing exactly what the next user in the process requires Lean thinking emphasizes determining the core cause of a delay or problem by visiting the worker and workplace to understand the work demands Front-line employees are taught to identify waste and to enhance and standardize their process stages

Box 1.1

The 7 sources of waste, with selected examples relevant to the emergency department

• Overproduction: creating more work than is required by the next step (e.g., ovtriaging)

• Motion: extra steps for the worker or moving machinery around (e.g., “Where’s the

IV pole?”)

• Waiting: time spent waiting for the next step in the process to occur (e.g., waiting for

an available bed, consultant, lab, and diagnostic imaging results)

• Conveyance: moving materials around (e.g., lab results on paper)

• Processing: non–value added work steps (e.g., shuffling patients and stretcheaccommodate new arrivals)

• Inventory: excessive stockpiling of materials (e.g., 1000 tongue depressors idrawer and no gel)

• Correction: reworking or scrapping work that has already been done (e.g., triage nursereassessing patients in the waiting room)

IV = intravenous

Although many causes of ED overpopulation are beyond the ED’s direct control, such as hospital inpatient capacity, there are elements within the department's control that could be adjusted to improve efficiency and patient satisfaction The goal of our study was to improve the interdepartmental movement of patients released from an Ontario tertiary ED Approximately 85% of patients in our ED are treated and discharged We projected that by applying lean principles to the group of dischargeable patients, we would increase ED efficiency and productivity, ultimately reducing ED wait times and improving patient satisfaction

CHAPTER 2 METHODS

2.1 Setting and Design

Researchers conducted a before-and-after investigation A regional referral center for trauma, cardiac, neurosciences, renal, and psychiatric care, the ED of the Hôtel-Dieu Grace Hospital in Windsor, Ontario, serves a population of 450,000 In the ED, there are roughly 55,000 visits per year

2.2 Intervention

Dr John Long, a Lean consultant, led a scoping exercise to establish the project's limits, participants, and objectives Emergency room doctors, nurses, nurse practitioners, porters, clerks, cleaners, administrators, the ED director, unit manager, educator, senior vice-president

of the hospital, and representatives from diagnostic imaging, laboratory, respiratory therapy, home care, and information services were among those who took part Everyone decided that the focus would be on CTAS-2 to -5 patients who were classified as “dischargeable during ”initial triage Patients who presented to the ED with mostly psychiatric concerns were disqualified

In September 2005, the group gathered for a three-day value-stream mapping kaizen session The first day was devoted to developing a current-state map for patients who could

be discharged The future-state map of the ideal ED process was created on the second day.The improvement initiatives that would move us closer to this goal were described on the last day:

Day 1: The current-state value-stream mapping exercise produced a view of the actual process steps involved in patient care for dischargeable patients From registration until post-discharge, our group sequentially placed each task on the current-state map We identified the suppliers (i.e., those who provide the work) and consumers (i.e., those who get the work) for each process stage We calculated the process time, the prestep queue time (also known as the wait time), and the frequency for which that step was both correct and complete for each step using our expertise Senior hospital managers and physicians made composed the decision panel to which the group presented the current-state map and data The committee received approval to move on to the future-state map after responding

to queries and accepting criticism

Day 2: The future-state value-stream map was created on Day 2 of the workshop

We looked over the current-state map and divided successive actions into care components, or “chunks Within each chunk, we either eliminated or consolidated ”monotonous processes and work tasks We noted the suppliers, clients, inputs, and outputs between each chunk

We created common agreement on what inputs were needed to start each step and whatoutputs were needed at the end of each step to ensure the process steps inside a chunk movealong without a hitch Finally, The estimated lead time for each chunk, which was decided upon by the group, was designated as the ideal goal The deciding panel was subsequently provided with these findings

Day 3: The project planning step was covered on the workshop s final day ’Projects were developed around the future-state map’s “sort” “, discharge , and ”

“postdischarge sections Three overarching priorities were established: ”workplace organization to enhance the ED s layout; the development of standard ’work that every employee was required to complete consistently; and the dissemination of Lean ideas and projects to the ED employees Each project received a set of project managers, deadlines, goals, and outcome metrics The decision board was then provided with the projects and implementation plans for approval

The ED leadership team established a Lean education and project board, planned staff training sessions, selected front-line employees to serve as project team leaders, and met weekly to evaluate metrics in order to implement and sustain the projects Every two to three months, a full-group Kaizen project review is conducted New initiatives were developed based on suggestions and comments from the workforce and put into action on suck- -up “ itWednesdays On this day, new projects were being tested, and the ED staff was obliged to ”try the change before giving feedback to the team leaders, the Lean facilitator, or the information graffiti boards

Mean time to see a physician, defined as time from registration to documented time of physician encounter for all patients (i.e., door to doctor time)

Mean length of stay (LOS), defined as time of registration to the time that the patient physically left the department, for dischargeable patients

Mean LOS for all ED patients, including admitted patients

Proportion of patients who left without seeing a physician, defined as patients who left the ED before physician contact

Overall patient satisfaction score (based on the NRC Picker survey)

Overall ED volumes

Number of admitted inpatients in the ED at 6:00 am

Figure 3.1

Emergency department wait time and length of stay before and after intervention

Note Mean wait time (from registration to physician encounter) and length of stay (from registration to exiting department) for discharged patients and for all patients are displayed

on a month-by-month basis

Emergency Department Triage and Acuity Scale We noted an improvement in ED patient satisfaction scores following the implementation of Lean principles

Conclusion: Lean manufacturing principles can improve the flow of patients through the

ED, resulting in greater patient satisfaction along with reduced time spent by the patient in The ED Medical service, delivering printed laboratory results to the paper charts and escorting Non ambulance patients into the ED The lack of an ED information system and a central visual signal made it difficult to identify empty beds in the department By directing patients to the next available bed, a nurse could be asked to care for patients of varying complexity, delaying the care of the patients requiring less intensive care Nurses wasted time

looking for equipment that was misplaced, in disrepair, inappropriately stocked or in the wrong location

Often-used materials such as intravenous (IV) solutions and opioids were stocked in central locations to ease the work for the hospital supply staff and pharmacy, but not for the main users of the material, namely the nurses Porters escorted ambulatory patients to the diagnostic imaging department in batches, adding to patient wait times There were no visual signals on the chart to indicate when investigations were complete Physicians wasted time searching for charts, laboratory results and hospital records, causing unnecessary delay andfrustration

On discharge, patients could linger in their beds for up to 45 minutes waiting for a nurse

to deliver a prescription, to remove an IV lock, find a wheelchair or organize transport home The entire flow of work within the ED was uneven and lurched from those waiting for things

to be done to those having too many tasks to do The chaos precluded staff finding time toinstitute workplace improvements The value-stream mapping exercise revealed much waste of effort and material in our ED

The value stream exercise allowed a series of bottleneck reduction projects to be identified concurrently Workplace organization projects had an immediate impact on efficiency The front-line staff was asked to reconfigure these areas with the appropriate stock and ergonomics Projects included stocking all physician required material to the patient’s right, reorganizing stock carts such that 90% of the most used stock were within steps of the patient, negotiating with stores and pharmacy to deliver stock to required areas in the required amounts, reducing stocking to maxi mum and minimum control levels (such as in a supermarket), Foot printing or marking the ED floor with designated locations for necessary equipment to be placed after use(Such as the previously wandering ECG machine) The entire department was reconfigured so that all dischargeable patients were seen in one area All patients in the department were classified as “admitted,” “uncertain” or “dischargeable” on presenting to the ED, and

Their charts would be placed in these respective boxes Incorrectly assigned patients could be reassigned at any ti me during their visit to the appropriate value streams The nurses assigned to the dischargeable area were responsible for filling their own beds based on the visual cue of the charts in the inbox This signal was akin to the Kanban box,