The big idea: Innovations in emergency-department management at a southwest Virginia hospital — Lynchburg General Hospital — have much to teach us about the best ways to manage resources to serve more patients.
The scenario: The hospital is busy, treating 90,000 patients in 2013, and it serves a broad, mostly rural geographic area. When Chris Thomson started as medical director in 2010, the emergency unit was operating well above its benchmarks. The 42 beds served close to six patients per bed per day and 2,143 patients per bed per year. In the industry, 1,200 was considered the upper limit of what was possible.
The resolution: Through Thomson’s creative application of lean production principles, the hospital served more people with a high standard of care. He deployed several strategies.
Thomson worked with his leadership team to map the emergency department’s processes. From the maps, he and process engineer Jennifer Stowers realized that the most critical constraints were capacity — both physical (beds) and nursing (work hours).
Therefore, any lean solution would seek to optimize the use of these constraints.
“Going to the gemba” is a phrase meaning “going to the location of a problem to better understand it.” That’s what Thomson and Stowers did, wandering the hospital to figure out why patients were not being transferred to various departments. They noticed inefficiencies, both logistical and cultural, that created a backlog of emergency patients who might wait five or six hours before being moved to a department in the main hospital.
To process patients more quickly, Thomson set up a Rapid Admit Unit. He set aside eight of the 42 beds to hold patients as soon as it was determined that they would be admitted. Thomson trained dedicated staff to quickly repeat the same functions over and over: draw blood work, monitor intravenous fluids, start antibiotics and complete initial paperwork. As this care was standardized, it became more consistent.
SMED is a manufacturing term that refers to the optimization of machine “run” time. In the emergency unit, the patient’s machine run time was the time spent waiting for the physician.
Thomson used SMED-like thinking to reduce this time. Historically, an emergency doctor saw a patient twice. First, the doctor examined the patient and then ordered specific tests. When the results came in, the doctor consulted with the patient again. Thomson established a new system: When a patient arrived, the triage nurses ordered the tests the doctor was likely to need, based on protocols set by physicians. This reduced the average time a patient waited and improved work flow.
The lesson: Innovation in health care and other sectors often is driven by adaptation. Others might consider borrowing a few tricks from one very busy rural Virginia hospital.
Goldberg is a strategy consultant at Goldberg Leadership and Weiss is a business professor at the University of Virginia’s Darden School of Business. Thomson is president of the medical staff at Lynchburg General Hospital and chairman of emergency medicine at Liberty University.