Lean the ED Way

Marc Taub

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.






Step 1: Problem Awareness


Problem in a Process

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


Step 7: Implement  a change aimed at achieving the desired state

Provide medical treatment

Implement change in process


Step 8: Assess impact of change

Reassess patient for response to treatment

Collect data, assess improvement


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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