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The Daily Record, a 121-year-old Maryland-based community newspaper, had amassed an impressive group of outside-the-box thinkers among its 26 nominees, including representatives from education, healthcare, technology, transportation, government and more.

And the Winner Is..

Enter the Lean Team from St. Joseph Medical Center, Towson, MD. This multi-functional team of nurses, physicians, technicians, systems analysts, registration personnel and others emerged as innovators of the year by applying "lean" techniques to trim 25 percent off the door-to-treatment time it takes to move patients through the emergency department. And that was just the beginning.

Like most hospitals, St. Joseph Medical Center had been trying to improve flow time in the ED for years. "We were making small gains, but not the substantial improvements we needed," said Durenda Juergensen, MHA, BSN, RN, NE-BC, leader of the Lean Team and the center's assistant vice president of nursing. "Specifically, we wanted to decrease the number of hours we were on diversion, because if we were diverting patients, we were not delivering the care they needed. We came to understand we could only improve that number after improving ED processes which were causing a bottleneck in the first place."

Meet 'The Lean Guy'

In a move that can best be described as "innovative," the hospital hired an auto industry expert, Dave Norton, who had no healthcare background whatsoever. What he did have was experience working with Toyota.

"Toyota has contributed a lot to process improvement, but healthcare hasn't really embraced that type of precision. We decided to give it a try," explained Juergensen. "And we began by learning what it meant to be lean."

For St. Joseph, it meant getting rid of waste - wasted effort, time and energy - while at the same time increasing quality and value for patients. How? By adopting consistent best practices in an organized workplace and maintaining a collective mindset trained on continuous improvement, known at Toyota as "kaizen spirit."

Norton, nicknamed "the lean guy," said the hospital demonstrated commitment to kaizen spirit by bringing him on staff. "The norm is to hire a consultant who teaches lean principles then leaves," said Norton. "At St. Joseph there was frustration with that 'seagull mentality' - flying in and flying out again, without reaching full implementation of improvements."

It's a 'Curse'

Norton saw "so many things right away" that could stand improvement, he told ADVANCE. "Lean is a curse in a way. It's like seeing an angel on someone's shoulder and not being able to convince the person it's there," Norton said. "Once you start to think lean, you see the flow and waste in every process. You see it virtually everywhere and in everything."

Of course the trick is to get others in the hospital to see it as well.

"Dave taught us process mapping via something called '20 minutes in the box,'" explained Juergensen. That meant members of the Lean Team would take turns standing in one spot in the ED and just observe. There was no conversation - simply intense observation to see how things really worked, what the rhythm and flow of operations were.

"We wrote down everything we saw and time-stamped it. Then we transferred these observations onto a flow map. We defined 'value,' to ED patients, as seeing the doctor as quickly as possible. When we looked at our flow map, we realized we weren't giving patients a lot of value! So we asked ourselves, 'How can we cut out wasteful steps that slow patients down?'"

Norton was quick to assert, "To get speed in a process you need quality built into the process, not corner-cutting or rushing. We had to find what a normal person with normal effort could do with the least amount of wasted time. For answers, we had to walk the process. That means Lean Team members had to gain an appreciation of the challenges by being right there, on the spot - you can't do this from a boardroom!"

Problems & Solutions

It was apparent to the Lean Team that patients traipsing through the ED to get to security to ask directions to other parts of the hospital were really hampering efficiency. Solution? Move security to the front of the ED. Then there was the fact registration was located through a maze of waiting areas. Another relocation diverted another human traffic jam. Those online registration screens with endless questions? Streamlined, shortened. Made lean.

"It seems so logical in retrospect, but you don't always see the problems when you are in the middle of daily activity," said Juergensen. "When you step back, you say, 'Why do we do it like that?'"

Erin Sadler, BSN, RN, CEN, took the lead in leaning down the nurses' digital documentation system. "This lean concept really changes your view," said Sadler. "I looked at everything, analyzing every screen, every line, every question, every keystroke. I'd think: 'Can I cut a step here? Can I improve something there? Oh, here's something I can fix!' In the big picture, this helped nurses chart faster and decrease length of stay for patients."

Similar fine tuning was repeated in every ED process. "We'd look at the process, define the problems, brainstorm, form initiatives and put them into 'buckets,'" said Norton using lean vernacular. "We had so many changes that a month later another bucket would arrive.

"Communication of these changes was key to the effort," Norton continued. "We had to get messages out to all staff. Durenda pushed it, tracked it, made sure everyone got the message personally. Then we conducted audits to see if the initiatives were understood and implemented."

Standard Practices

Initiatives ran the gamut from simple to complex. For example, one initiative simply involved putting an instrument back into its designated place, always. No exceptions. It sounds deceptively easy.

"How do you convince 600 nurses they all must put their handhelds back into the same location every single time?" asked Norton. "It takes a lot of elegant thinking to get hold of this 'obvious' and make the case. But we found, for example, drawing blood was taking us too long, largely because nurses were wandering a path trying to find a working, charged handheld and a working printer, and then locate the blood cart, wherever it happened to be, and get the right number of tubes out and then go find the patient. That all mounted to a huge delay."

Consistency is a hallmark of lean, and one that meets with some resistance on higher levels of compassionate care. "Clinicians will push back and say, 'But Dave, every patient is different and requires a different approach,'" said Norton. "Yes, they are. But individual process steps require standardization - you wouldn't calculate heparin injections in different ways, would you? It's essential to build an appreciation of standard work. We're getting there."

Impressive Results

Tackling the top ED diagnoses in terms of lean, the team has effectively crunched the following length-of-stay numbers:

• Chest pain: 42 percent reduction - an improvement of more than 3 hours!

• Abdominal pain: 25 percent reduction

• Fever: 25 percent reduction

• Behavioral health: 20 percent reduction

• Dyspnea: 35 percent reduction.

In addition, they reduced the cycle time needed to get an ED patient into an assigned inpatient bed from 120 to 60 minutes, while still working with kaizen spirit to get that number down to 45.

And remember that goal to decrease diversions? "I can't remember the last time we went on divert," said Marian Rongione, RN, patient care coordinator. "Recently we had our biggest day, 191 patients; that was our record high. Yet we didn't go on divert.

"Why?" she asked rhetorically. "It wasn't by some fluke. It was because we didn't need to, thanks to all the changes we've implemented. It is truly amazing."

Rongione mentioned another plus built into the lean world: "Our time is maximized now; life on the job is easier for our nurses because we're working more efficiently."

On It Goes

The leaning of St. Joseph Medical Center is continuing in other units now. Norton mentioned an effort to decrease late starts on surgeries in the OR. "The next step is getting all surgeons in at a standard time, every time. It has never happened before," said Norton with a chuckle.

Valerie Neff Newitt is senior associate editor at ADVANCE.