Improving the quality of Emergency Research paper

Research paper
Improving the quality of Emergency
Department care by removing waste
using Lean Value Stream mapping
David Cookson MBChB
Academic Doctor, Emergency Medicine and Clinical Leadership, University Hospitals of Leicester NHS
Trust and University of Leicester, Leicester, UK
Colin Read FRCS FCEM
Consultant, Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
Pro Mukherjee MRCP FCEM MBA
Consultant, Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK.
Matthew Cooke PhD FCEM DipIMC RCSEd
Director of Emergency Care and Systems Improvement Group, Warwick Medical School, Warwick, UK
With the NHS facing the prospect of having to operate
within a constrained financial environment, it is essential to provide efficient high-quality care with minimal
waste. Clearly, a favourable option is to reduce the time
spent by staff engaged in inefficient processes by removing, where possible, steps that are non-value adding.
These principles are encompassed within the NHS
quality, innovation, productivity and prevention challenge agenda launched by the Department of Health
(2010) and expounded by the NHS Institute for Innovation and Improvement (2010) in their Productive
Ward work, which concentrates on Releasing time to
care. At University Hospitals of Leicester NHS Trust,
Lean techniques were felt to offer an opportunity to
create a more productive Emergency Department.
This article describes how Value Stream mapping
can be used in the initial stages of a Lean implementation project to identify waste in processes and generate
ideas for improvements. We also explore the approach
healthcare leaders and managers can take to facilitate
the introduction of Lean Thinking principles in an
Emergency Department based on our experience.
Lean Thinking was originally developed by Toyota
in the 1950s as an improvement approach to and improving flow
within a system. Its use in healthcare is becoming
increasingly common although there is little published information on its formal application to
Emergency Departments in the UK. With increasing financial pressures, high service demand and
target pressures, Lean offers a potential approach to
maintaining a high-quality efficient clinical service
for patients and staff. Using Value Stream mapping,
a tool originally developed for manufacturing, we
identified over 300 instances of waste and potential
improvements in processes within the majors area
of our department. This work allowed us to reduce
the time to initial assessment and has highlighted a
number of projects that are now being taken forward with directorate backing. With the support of
healthcare leaders and managers who embrace the
Lean philosophy, Lean Thinking offers huge potential for identifying waste and Value Streams leading
to improvements in quality of care in the emergency
Keywords: Emergency Department, Lean Thinking, process mapping, Value Stream, waste
The International Journal of Clinical Leadership 2011;17:2530 # 2011 Radcliffe Publishing
26 D Cookson, C Read, P Mukherjee et al
Lean Thinking is a philosophy, management culture
and set of tools for process improvement that focuses
on reducing waste and improving flow within a
system. It was initially developed by Taiichi Ohno at
Toyota in Japan in the 1950s as the Toyota Production
System and aims to reduce muda (non-value-adding
work), muri (overburden) and mura (unevenness of
In their work on Lean Thinking,Womack and Jones
(2003) have identified the five key features of Lean as:
understanding value, developing the Value Stream,
improving flow, encouraging pull and pursuing perfection. Another important principle underlying Lean
Thinking is that it is the customer, not the producer,
who ultimately defines what is of value to them. Value
is a complex interaction of experience, clinical quality
and safety.
In his initial work, Ohno described seven basic
wastes for manufacturing. Health examples have
been described by Westwood et al(2006), and Bicheno
(2008) subsequently described wastes for service industries.
The Lean approach in healthcare
Lean Thinking has been used in the commercial sector
since its inception at Toyota in the 1950s. Since this
time, a number of manufacturing, service and retail
industries have incorporated Lean Thinking into their
work. Although elements have been seen in healthcare
in the past, Lean Thinking has only been more
formally introduced into healthcare systems within
the last few years.
Although the similarities between healthcare and
industry may not be immediately apparent, both
involve multiple departments, long sequential complex processes with varying cycle times, queuing and
the sharing of resources to produce an end product.
Both sectors also typically have nine times more nonvalue-adding activity than work that actually meets
the needs of the customer (Jones and Mitchell, 2006).
It has therefore been estimated that 80% of Lean tools and
mechanisms can be applied to healthcare (Ward, 2006).
When thinking about Value Streams, several authors
in Lean Thinking have used the analogy of a motorway
with in both lanes
reducing the overall flow of vehicles along the road
(Figure 1) (Jones and Mitchell, 2006; Westwood and
Silvester, 2007) and the benefits of active traffic management a form of traffic streaming (Highways
Agency, n.d.).
The same principle can be seen in the Emergency
Department, where patients with similar Value Streams
(or process steps with varying cycle times) are separated into minors, majors and resuscitation areas. A
stream will contain groups of patients who have
similar processes (e.g. simple assessment or routine
investigations or complex evaluations). This differs
from separating patients by clinical presentation, e.g.
chest pain, as clinical groups can have different process
steps and cycle times for different patients. Maintaining separate Value Streams has been shown to improve
flow through the Emergency Department and reduce
waiting times and overcrowding (Cooke et al, 2002;
King et al, 2006).
Value Stream mapping in the
Emergency Department
In autumn 2009, Leicesters Emergency Department
secured the support of external Lean specialists in
starting our journey into Lean Thinking. A Lean project
Box 1 The seven WORMPIT Lean wastes:
W Waiting
O Overproduction
R Rework/defects
M Motion
P (Over) Processing
I Inventory
T Transportation
Figure 1 Value Streams on a motorway
Improving the quality of Emergency Department care 27
team was established within the department comprising nursing, medical, managerial and academic staff.
The project started with training in Lean principles,
common improvement tools, such as Value Stream
mapping (also known as process mapping), and types
of waste for project team members. Elements of this
training were then cascaded to other members of staff
within the department.
Over the course of a week, members of the Lean
team were assisted to build up a high-level Value Stream
map (VSM) of the steps associated with a patient
passing through the majors area of the department.
The map was created by direct observation and timing
of patient journeys through the department and supplemented by staff participation. Each step, movement,
intervention, investigation, piece of documentation
produced and staff contact was recorded and displayed
visually on a map using Post-it1notes, with arrows to
and string to demonstrate communication lines. More detailed, low-level
process maps were also created for nursing assessment, medical assessment, radiology processes and
clerical support work, e.g. ward clerk. These VSMs were
supplementedwith observations of the LeanWORMPIT
wastes encountered and suggestions for possible improvements placed at the appropriate place along the
VSM (Box 2).
Figure 2 illustrates a simple VSM that was created as
a pilot in our Emergency Department prior to mapping the entire majors area.
Box 2 Examples of Lean wastes identified
W Waiting Patients waiting for assessment. Staff waiting for results.
O Overproduction Recording the same information multiple times.
of patients by several members of staff.
M Motion Staff walking to reception and back to use the photocopier.
P (Over) Processing Staff ordering unnecessary investigations.
I Inventory Stock being unavailable when required or out of usable date.
Untangling ECG cables.
T Transportation Patients going to CT scan which is distant to the Emergency Department.
Figure 2 An example Value Streams map Majors arrival process
28 D Cookson, C Read, P Mukherjee et al
During a week-long period of Value Stream mapping
at Leicesters Emergency Department, over 300 observations of waste and suggestions for improvements
were identified, with all staff groups contributing,
including porters, security, clerical and managerial,
medical and nursing staff of all grades. All staff on duty
during the week were able to contribute to the development of the map (Figure 3).
At the end of the Value Stream mapping week, a list
of potential projects was identified and divided into
quick easy wins, medium-term projects and more
long-term issues. It was also acknowledged that not
all of the could be
eliminated from the overall majors process.
The high-level majors area VSM document was
presented to the senior medical directorate management team to get buy-in to the project and facilitate
cross-directorate working within the trust. In addition, it
was important to obtain agreement for potential
short-term reductions in performance while projects
were initiated to create long-term improvements.
An early example of the results of introducing Lean
Thinking at Leicester has come from modifying our
majors arrival process (illustrated in Figure 2). A
retrospective audit, comparing 100 randomly selected
patient notes from one week before and one week
four months after this modification, demonstrated
a mean reduction of 20 minutes from Emergency
Department arrival to initial nurse assessment.
The majors Value Stream mapping exercise was a
simple but effective way of demonstrating different
Value Streams and identifying waste within emergency department processes. Although this tool was
originally developed in an industrial setting, we found
that its use in healthcare did not require any major
We found that developing the VSM was not difficult, but did require us to step back from the clinical
situation and make notes about what we saw. The high
level of staff acceptance of our presence and involvement in helping us develop the map was not only
pleasing, but was also felt to be crucial to our success in
identifying so much process waste.
Involving healthcare leaders and managers when
initiating a Lean project such as ours is critical to its
success. Initially, staff need to feel both reassured
about the projects motives and empowered to openly
Figure 3 Finished high-level majors VSM (value stream map)
Improving the quality of Emergency Department care 29
challenge the status quo and make suggestions for improvement. In our department, we did this by educating staff during handover meetings and by the
project team explaining their work during the mapping exercise.
Leaders also need to facilitate staff to step back from
the clinical coalface and learn about Lean Thinking so
that they can make observations about their working
environment. Projects developed as a result of the Value
Stream mapping exercise will need to be supported
and facilitated by healthcare leaders, particularly across
departments and directorates, where they have a potential impact on performance. Negotiating approval for
short-term potential dips in performance in order to
achieve long-term efficiency improvements was a
key Emergency Department requirement, particularly
given the pressure to deliver against targets.
A specific focus for those healthcare leaders and
managers working at directorate and trust level should
be to introduce pull systems upstream from the Emergency Department. Flinders Medical Centre in Australia
developed specialty-based pull systems from their
Emergency Department and dismantled their take
system, which they found led to inpatient team workload variability. These interventions reduced patient
outlying and length of stay, in addition to improving
patient flow within their Emergency Department
(Ben-Tovim et al, 2008).
Finally, healthcare leaders should focus on developing a Lean Thinking philosophy within their organisations. Embracing Lean as a philosophy, empowering
staff, delegating decision making, communicating a
clear vision, employing multiple Lean tools, viewing
Lean as a long-term journey (rather than a short-term
initiative) and looking for continuous improvement
would overcome many of the reasons for failure
identified in the literature (Bhasin and Burcher, 2006;
Randor et al, 2006).
Further plans
Aside from the other benefits of Lean Thinking
mentioned above, the Value Stream mapping exercise
has generated a number of project ideas which the
department can now take forward. Staff involvement
in the mapping work and waste reduction has
generated enthusiasm for change and identified people
to take projects forward. The Value Stream mapping
work is only the start of a continuous drive to make the
emergency department more Lean, and significant
improvements are expected over the coming months
and years.
Value Stream mapping is a simple and effective way
of starting to apply Lean Thinking, which can help
identify clinical Value Streams and waste in processes
within the Emergency Department. Clinicians wishing
to use this Lean tool in healthcare must learn to think
in terms of process groups, and differentiate these
from clinical groups to maximise the benefit from
Value Stream mapping.
The role of healthcare leaders in Lean Thinking is
largely one of support to staff within departments and
bridging silos within the complex healthcare system of
the NHS. Importantly, healthcare leaders should focus
on developing and sustaining a Lean philosophy and
avoid using Lean as an initiative for short-term firefighting, particularly in times of economic constraint.
Ben-Tovim DI, Bassham JE, Bennett DM, Dougherty ML,
Martin MA, ONaill SJ, Sincock JL and Szwarcbord MG
(2008) Redesigning care at the Flinders Medical Centre:
clinical process redesign using lean thinking. Medical
Journal of Australia 188:S2731.
Bhasin S and Burcher P (2006) Lean viewed as a philosophy.
Journal of Manufacturing Technology Management 17(1):
Bicheno J (2008) The Lean Toolbox for Service Systems.
Buckingham: PICSIE Associates.
Cooke M, Wilson S and Pearson S (2002) The effect of a
separate stream for minor injuries on accident and
emergency department waiting times. Emergency Medicine Journal 19(1):2830.
Department of Health (2010) The NHS Quality, Innovation,
Productivity and Prevention Challenge: An Introduction
for Clinicians. London: Department of Health. Available from:
(accessed 17 May 2010).
Highways Agency (n.d.) Active Traffic Management. Available from:
(accessed 17 May 2010).
Jones DT and Mitchell A (2006) Lean Thinking for the NHS.
London: NHS Confederation. Available from: www.nhs
aspx (accessed 17 May 2010).
King DL, Ben-Tovim DI and Bassham J (2006) Redesigning
emergency department patient flows: application of Lean
Thinking to health care. Emergency Medicine Australasia
NHS Institute for Innovation and Improvement (2010) The
Productive Ward: Releasing Time to Care, Learning and
Impact Review, Final Report. Warwick: NHS Institute for
Innovation and Improvement. Available from: www.
(accessed 16 February 2010).
30 D Cookson, C Read, P Mukherjee et al
Randor Z, Walley P, Stephens A and Bucci G (2006)
Evaluation of the Lean Approach to Business Management
and Its Use in the Public Sector. Edinburgh, The Scottish
Government. Available from:
Resource/Doc/129627/0030899.pdf (accessed 3 December
Ward S (2006) Thinking Lean. Health Service Review 65:12
Westwood N and Silvester K (2007) Eliminate NHS losses by
adding some Lean and some Six Sigma. Operations Management 5: 2630.
Westwood N, James-Moore M and Cooke MW (2006)
Going Lean in the NHS. Warwick: NHS Institute for
Innovation and Improvement.
Womack JP and Jones DT (2003) Lean Thinking. Banish
Waste and Create Wealth in Your Corporation. London:
Simon & Schuster.
The authors declare that they have no conflict of
interests in relation to this article. Ethics committee
approval was not required. Our external Lean specialists (LMR Manufacturing) provided their services free
of charge and had no involvement in the writing of this
article. This article was not commissioned. Funding
was not required for the work detailed in this project.
Funds for subsequent work have been provided from
within University Hospitals of Leicester NHS Trust
existing budgets.
Dr David Cookson, c/o Emergency Department Secretaries Office, University Hospitals of Leicester NHS
Trust, Emergency Department, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK.
Email: [email protected]
Accepted 12 August 2010
Copyright of International Journal of Clinical Leadership is the property of Radcliffe Publishing and its content
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