Building a LeanER ED

In 2009, Sharp Memorial Hospital in San Diego opened a new patient-centered emergency department.

The facility, more five-star hotel than the traditional gurney and curtain style ED, invigorated staff. They were excited to provide excellent patient care and administrators were eager to see an improvement in patient satisfaction scores and throughput.

“When we moved into the new building, we thought the design of the new ED and increase in the number of beds would drive an overall culture shift and improve patient satisfaction. What we found was that when you bring the same process, you don’t really find new results,” explained Susan Stone, PhD, RN, NEA-BC, chief nursing officer.

One year after moving into the new facility, the ED suffered from long wait times, poor patient satisfaction scores and broken team processes.

“Something had to be done,” Stone said. “Instead of doing a performance improvement project, our executive team decided it would be a good place to try a Lean process project.”

What Is Lean?

Kurt Hanft, Lean Six Sigma master black belt, was assigned to the ED Lean project as a mentor and facilitator.

“Lean is looking at the flow of a product, in our case a patient, and taking out all the process wastes leaving only the value-added time. In healthcare, we begin with an ill patient who goes through a process and the ultimate end product is a healthy patient,” he said.

Within that process, Hanft noted, are very specific value-added activities such as examinations, ECGs, X-rays or blood draws. The in-between time is all waste.

Some examples would be waiting to see a physician, looking for supplies, transporting patients or waiting for test results. By eliminating waste, nurses and physicians can spend more time with patients, and patients spend less time in the ED.


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The LeanER Project

The ED set out to raise patient satisfaction to the 90th percentile by focusing on the patient experience, increasing efficiency and decreasing patients’ length of stay.

Lean promotes a frontline staff approach, so a cross-section of physicians, nurses, healthcare aids and administrators gathered for a 2-day “Kaizen” event.

Staff observed and then mapped out current processes to identify wastes.

The “perfect world” was imagined and strategies were developed to meet this ideal state. However, the beginning was not without its glitches.

Need for Trust

There was much skepticism about Lean’s methodology. Past unsuccessful changes had marred morale. Hanft decided to focus on building trust between staff and executives.

“Our first hurdle was the frontline team feeling that they really did have their executives’ support and the longevity for putting forth all this effort.”

Hanft used Lean tools to demonstrate “quick wins” that made a big impact on staff.

Clinical staff and Hanft used what Lean calls “5S” events to sort, store, shine, standardize and sustain work areas, which greatly improved staff’s work flow and increased nursing efficiencies. The same was done to all storage areas and patient treatment rooms. These changes to the environment empowered staff because it demonstrated that Lean was capable of making positive changes.

Another quick win involved examining staffing levels. By looking at the daily census, Christopher Walker, MS, RN, CNS, CCRN, director of emergency services, adjusted staffing levels based on department needs.

“By looking at our census patterns we realized we needed to staff certain areas of the ED earlier in the day in order to be ready to meet the influx of patients that occurs during our busy times,” Walker said. He noted that, by being prepared for patients before they arrive, the team was able to get rid of the bottleneck that occurred during busy times and decrease patients’ wait time in the lobby.

Changing the Process


Another improvement was the creation of the “team leader” position.

“The team leader acts as the float nurse and throughput coordinator for (an) area. They are responsible for helping team members complete tasks to remove as much wait time for patients as possible,” explained Michelle Robinson, RN, advanced clinician.

“We also developed a charge assist role, which facilitates patient throughput within the entire department. They coordinate which room a patient is placed in and makes sure an RN is available to meet them in the room.” This ensures patients get to treatment rooms quickly so physicians can see them sooner, she added.

Although the extra staff caused an increase in full-time equivalents (FTE), Walker justifies the cost. “Because of improved efficiency and patient volume, we earned additional FTEs that could be reinvested to create further growth opportunities.”

Having a team leader that’s accountable for a certain area improves efficiency. And the less a patient has to wait for something, the happier the patient is and the faster the patient can be discharged or admitted to the hospital.

“When patients arrive at the ED, all they want is to be in a bed and see a physician,” said Walker. “They don’t want to wait in a lobby, or be triaged, or even to see a nurse, initially. So why not just give them that.”

It is this kind of innovation that led the Lean Team to what they call bedside triage.

“As long as we have open beds available, patients are brought back to treatment rooms at the point of check-in,” Robinson said. “The triage process occurs, but it occurs at the bedside and often with the physician in the room.”

Robinson calls this “shoulder-to-shoulder work” and it allows for earlier physician assessments and ordering of diagnostic exams. “The RN and MD complete the triage and assessments as a team,” she said. “This way, patients are assessed once and don’t need to answer questions repetitively.”

This kind of workflow has caused a shift in work practice and culture. “Staff communication has improved and staff work more as a team now,” said Robinson.

To keep situational awareness high, the Lean Team implemented hourly “huddles.” These are physician-led gatherings where the healthcare team briefly discusses each patient’s plan of care. This allows tasks or needs to be dispersed by the group and completed quickly. Again, decreasing the time a patient has to wait for something.

Over the past year and a half, Lean has proved its ability to quickly improve and sustain ED throughput, patient satisfaction and quality of care.

For the past 12 months, the patient satisfaction mean score is 89.3 and the ED ranks in the 99 percentile of Press Ganey’s EDs with 30 beds or more. The median patient length of stay is 3.2 hours and physician and nursing work satisfaction has improved.

Staff comments include: “Now I have more time to spend with my patients.” “I was actually able to be a charge nurse.” “We have come leaps and bounds from where we were.”

Developing a Culture for Continuous Improvement

The ED has developed a culture of continuous improvement although Walker admits, “changing culture takes time – more time than you’d think.”

The Lean Team meets twice a month and the staff room has a “Muda Board” where staff are encouraged to write down any concerns or suggestions for improvements. Frontline staff continue to develop and champion new processes and a staff RN chairs the Lean Team meetings.


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Walker credits “keeping the frontline engaged” as one of the largest key factors in the Lean projects success. Hanft supports this idea. “As far as making improvements go, you need to get out on the floor and do them . not in the boardroom,” said Hanft.


Walker explains the need for leadership to support the change and remove barriers. “Whether I see it or not, I keep supporting the change. If that means taking people out of staffing to champion a change, then do it. I have seen a number of changes that I thought would have never worked. I was wrong.”

Other key success factors include the need to educate the staff on Lean methodology. Hanft accomplished this with computer-based learning and a monthly LeanER newsletter. “Huddle news” was also incorporated into huddles as a brief Lean educational moment or update.

Walker emphasizes the importance of an internal Lean facilitator. “Have a Lean facilitator to learn from and guide you while keeping an open mind for possible differences.”

Hanft stresses the importance of executive training, participation and engagement. “Executive involvement will make it really happen. To be able to say, we’re a Lean organization means executives and leadership understand Lean and are driving it.”

Finally, there is the need for data. Getting daily/weekly data helps monitor processes and drive change. “One of our biggest hurdles was overcoming staff’s preconceived ideas. Data collection and reporting was imperative in proving what worked and what didn’t.”

The ED Lean experience is summarized nicely by Michelle Robinson, RN, “We will continue to look at our processes through the eyes of our patients; always looking for waste and ways to make this a lean ER department.”

Charlene Anderson-Dean

is a registered nurse and chairperson of the ED Lean team at Sharp Memorial Hospital in San Diego. Over the past 11 years, Anderson-Dean has worked in numerous EDs throughout the country and has been involved in Lean Six Sigma projects since 2010 when she realized her passion for change process. Learn more about the use of Lean in healthcare at

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