Incorporating Kaisen in Everyday Practice and the rise of LEAN in Emergency Care.

As a child, I remember my father would come home with stacks of spreadsheets, charts and graphs with the words “throughput”, “bottlenecks” and “LEAN” on them. Growing up in Detroit and being the son of a “Big Three” employee, I just assumed this was normal jargon in the automotive world. My father made many an attempt to school me on these concepts, but they always fell on deaf ears. I could not for the life of me see the relevance of such obscure concepts. 

Fast forward 20 years, and I sometimes laugh at the irony of my dad’s many attempts to engage me. Terms such as “LEAN”, “queuing theory” and “theory of constraints” are no longer strictly engineering and manufacturing material, but now have become the topic of much discussion about process improvement in Emergency Departments.

LEAN management principles were first developed in the 1950s by Toyota, but have since become a mainstay in many different industries. It is a management philosophy aimed at eliminating waste and improving overall customer value. In short, it is about delivering quality medical care quickly, efficiently and consistently, and with no waste. Simple, right?

One of the main concepts with LEAN addresses “value”. But how do we as emergency providers define value? Value can be viewed from several perspectives. From a provider perspective, value may mean how much of their typical workday is spent in patient-centered activities. These may include patient evaluations, discussions with family, procedures, discussions with consultants etc. All of these steps may be considered to adding to a patient’s care and are “value-added” steps.

What about non-value added steps? These are steps that offer zero value to a patient’s care, but may occupy a significant amount of your normal day. These are often annoying tasks that not only decrease patient-centered activity, but contribute to lower job satisfaction. Excessive charting, time spent waiting to see patients, time waiting for consultants to call back, and time spent looking for supplies are just a few examples of non-value added steps that we routinely encounter in the ED. LEAN methods aggressively attack these non-value added steps and aim to reduce or eliminate them entirely. This philosophy in LEAN terms is otherwise known as “kaisen,” or Japanese for “change for the better.”

Kaisen aims for continuous improvement at all levels of the ED – from the physician staff to the housekeeping staff. It is a philosophy that encourages all employees to offer process improvement ideas on a daily basis. It encourages innovation and creativity, and empowers each employee. In most cases these are not ideas for major changes. Kaisen is based on making small changes, which over time make a big difference. The philosophy boils down to: “fix it, even if it isn’t broke, because if we don’t, we can’t compete with those who do.”

For example: suppose during a typical shift, you notice that patient charts are difficult to find. Although it is a minor nuisance, you may spend up to 10 minutes of your shift looking for charts. Assuming 5 providers all have the same issue per day, there are close to 50 minutes per shift spent looking for charts by all providers. Over a year, this translates to 18,250 minutes by staff looking for charts. What seems to be a minor inconvenience has now become a huge roadblock in the LEAN process.

Once you have addressed the area for process improvement, not only have you “saved” 18,250 minutes, but you have also “added” 18,250 minutes for patient care or a some other value-added process. Your seemingly minor process change has now translated into more than $50,000 of increased productivity.

Incorporating LEAN methods into our everyday practice is not only beneficial to ER docs as providers, but to patients as well. Aiming for an environment that seeks perfection by delivering safe, consistent services by people who are continuously looking to improve processes results in better care, cost saving and improved satisfaction for everyone. Next time you are working in the ED, remember to go LEAN!

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