Lean Approach Helps Children’s Hospital Increase Patient Satisfaction

In 2008, Children’s Healthcare of Atlanta saw more than 170,000 patients across all three of its three emergency departments. That kind of volume demands an effective and efficient process, and staff spent the past three years developing a master facility plan to do just that. However, moving into a larger space didn't yield the expected results.

“We increased the size of our departments, thinking capacity would resolve turnaround time issues,” says Marianne Hatfield, director of Children’s emergency services. “But what we found was we didn’t really get any better once we moved into the bigger space; we got slower. We really had not examined whether or not our process needed to change.”

A team of Children’s Healthcare of Atlanta's physicians, nurses, technicians, and administrators—including Lauren Timmons, Keri Wintter, Alyson Couch, and Dr. Michael Shaffner (left to right)—analyzed and streamlined flow processes from the time a patient arrives in the emergency department until they are discharged.

A visit to Seattle Children’s Hospital convinced Hatfield that Children’s Healthcare of Atlanta’s processes had to change to truly improve performance. Seattle Children’s Hospital is a leader in lean management principles—a set of tools derived mostly from the Toyota Production System and widely used in manufacturing— that helps identify and steadily eliminate waste from an organization’s operations. In April 2008, Children’s contacted Atlanta-based Georgia Tech’s Enterprise Innovation Institute for assistance in implementing lean principles in its emergency department.

“We knew we had to do something for turnaround time in our emergency department and we began interviewing people to teach lean. We thought Georgia Tech was the best fit. They were nearby and we could see what they had done with some other hospitals,” Hatfield recalls. “The week they spent with us changed the lives of the physicians and the frontline staff; they all think differently now. There was so much impact to that week together, where everyone really started to examine waste in our system. I don’t think we would have been able to do that on our own.”

Kelley Hundt and Matt Haynes, lean specialists with Georgia Tech’s Healthcare Performance Group, led a team of Children’s physicians, nurses, technicians, and administrators to analyze and streamline flow processes from the moment a patient arrives in the emergency department until he or she is discharged. The team, which implemented lean principles primarily on Children’s Scottish Rite campus, identified value-added and nonvalue-added activities and made a number of observations.

“By studying the processes, we learned that time was being wasted because of searching, rework, travel, and variation in processes,” observes Jeff Rehberg, manager of clinical process improvement at Children’s and a 1996 industrial engineering graduate of Georgia Tech. “Our goal was to reduce the length of time children who did not need to be admitted waited in the emergency department. Using lean principles, the team developed a model for pulling rather than pushing the patients through the emergency department.”

In a push system, the emergency department tries to push a patient through triage regardless of whether or not the physician is available. The new system, dubbed TAPP (Team Assessment Pull Process), anticipates emergency department demand and has a physician and a nurse ready before the patient is called back.

"Before, as soon as we had an empty room, we would put patients in it—regardless of whether we had enough staff or physicians—because we thought people were happier if they weren’t in the waiting room but in an exam room,” Hatfield says. “Now we match the two resources before the patient comes back. When the patient comes into the exam room, both the physician and nurse are there and the work starts immediately.”

The new process noticeably reduced the time patients spent waiting for a physician assessment, enhanced physician and nurse partnering, eliminated order confusion, and allowed discharge from the first room if no other treatment was needed. Most important, it improved the patient-family experience by providing a more timely initial interaction with a physician.

“I am always trying to be more efficient and take out the waste in my own practice and patient care interactions without sacrificing quality,” says Dr. Michael Shaffner, a physician who helped develop the new process and a 1987 industrial engineering graduate of Georgia Tech. “There were no new concepts, but the implementation was fresh and greatly appreciated.”

From September 2007 to January 2008, the median length of stay in Children’s main emergency department was 190 minutes. A year later, length of stay had decreased to 163 minutes during the same season. In addition, the median time patients wait between being greeted and being seen by a provider has decreased by 37 percent.

“We did a one-month trial from mid-June to mid-July 2008, and we saw some frustration because physicians had to leave some rooms in search of supplies,” Hatfield recalls. “So we took a separate 5S team another four to six weeks to standardize all the rooms so the physicians have everything they need.”

The 5S refers to improving organization of the work space in five steps: sort, set in order, shine, standardize, and sustain. As a result of the 5S project, all hospital carts are labeled and stocked in the same way, blood pressure cuffs are organized by size, and small items frequently used by physicians are easy to grab and keep clean. Visual cues signify when it is time to restock a certain supply. The cumulative effects have been good for hospital staff and patients, according to Hatfield.

“The way customer service scores normally work is when there is high volume, the score drops, but with low volume, customer satisfaction goes way up,” she observed. “September through January we were at the 99th percentile and this has been maintained month after month. We have to believe it’s the process because we’ve not really done anything different.”

Hundt says that a critical component of Children’s success was the support and involvement of top management.

“Management would not let the team fail; they stuck with it. They followed the model of plan, do, study, and adjust, and have seen tremendous benefits,” she says. “Before there was a lot of wasted time with interruptions and now they are working in an uninterrupted fashion. They developed a process that allows them to eliminate interruptions.”

To continually improve the lean process, Children’s is also implementing a lean education program that focuses on transforming all employees into problem solvers that can identify and eliminate waste. Ultimately, says Rehberg, lean principles will be applied to other areas of patient care, such as operating room, inpatient units, and radiology.

“After other staff members heard about the great things going on in the emergency department, they started banging down our doors,” Rehberg says. “The more people that understand the concept, the better the process flows.”

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