Lean the ED Way

Marc Taub , MD, FACEP

Published August 08, 2012

As we continue in our Lean journey, much of what we are experiencing and learning so far relates to the methods of Lean, such as the vocabulary and multi-day improvement events. It's now time to develop further expertise with an equally important aspect of Lean: The Lean mindset. The Lean mindset refers to an underlying focus on continuous improvement and problem-solving. The great news is that the method of problem solving is similar to what you already use during a standard patient evaluation. After reading my blog and reviewing the table below, I hope this is clear enough to apply to a problem you're having in your ED.

First, I would like to introduce another Lean term-- The Improvement Kata. Kata is the Japanese term for routine. In Lean, the routine, or kata, we aim to repeat involves constantly defining new target conditions, or desired states, then using problem solving and PDCA (plan-do-check-act) in short cycles to get there.

Problems may come to our awareness through personal observation, a staff member or patient bringing an issue to our attention, or when we are consistently missing a key performance measure. Fortunately (or not so fortunately), there is no end to the problems available to address in our industry.

The first critical step is to properly grasp and define a problem before jumping to solutions. This always involves direct observation, data collection, and analysis. It includes determining whether the issue at hand is really the problem, or just a symptom of a problem.

Once you have properly grasped and defined the problem to the point where you can articulate a clear problem statement, we do root cause analysis (RCA). During RCA, we dig deeper to understand the causes of the problem so that our solutions address fundamental issues. A common technique used in this step is "The 5 Whys"-- once we have a problem, we try to ask "why?" at least 5 times to get to root causes.

Only after we have studied and defined our problem, developed a problem statement, and completed RCA, are we ready to consider the solutions that can take us from our current state to our desired state. This all comprises the "P" of Plan-do-check-act. You notice we spend more time researching and planning in this mindset. Yet, being very confident in understanding the problem and root causes, we can then rapidly proceed into doing/implementation.

In summary, the Lean mindset involves the Improvement Kata, or routine, of continuous problem solving and use of PDCA to advance us to improved performance. Lean problem solving has direct parallels to clinical decision-making in the ED, as I outline in this table. I encourage you to immediately apply this framework to a relatively simple problem you are addressing in your ED. As you will see, practice will eventually make this second-nature, and the Lean mindset will become routine.

P L A N	Step 1: Problem Awareness	Patient	Problem in a Process
	Step 1: Problem Awareness	Obtain chief complaint	Identify potential problem from data, reports, complaints
	Step 2: Clarify problem	Take detailed history	Ask many questions of those doing the work and customers
	Step 3: Support with physical evidence	Perform physical exam	Go observe the process
	Step 4: Collect data to support hypothesis	Order and analyze tests	Collect and analyze process data
	Step 5: Define the problem	Differential diagnosis	Problem statement
	Step 6: Root Cause Analysis	Consider underlying causes of problem (e.g. severe hypertension as cause of the stroke)	Use the 5 Why's or other RCA tool
Do	Step 7: Implement a change aimed at achieving the desired state	Provide medical treatment	Implement change in process
Check	Step 8: Assess impact of change	Reassess patient for response to treatment	Collect data, assess improvement
Act	Step 9: Take additional action to maintain/continue improvement toward the next desired state	Continue or modify therapy	Adjust process further based on data results

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