Applying Lean Principles to Reduce Wait Times in a VA Emergency Department

• Published in: Military medicine Vol. 184; no. 1-2; pp. e169 - e178
• Main Authors: Vashi, Anita A, Sheikhi, Farnoosh H, Nashton, Lisa A, Ellman, Jennifer, Rajagopal, Priya, Asch, Steven M
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01.01.2019
• Subjects: Emergency medical care; Emergency Service, Hospital - organization & administration; Emergency Service, Hospital - statistics & numerical data; Humans; Lean manufacturing; Quality Improvement - statistics & numerical data; Quality of Health Care - standards; Quality of Health Care - statistics & numerical data; Six Sigma; Time Factors; Total Quality Management; United States; United States Department of Veterans Affairs - organization & administration; United States Department of Veterans Affairs - statistics & numerical data; Veterans; Veterans health care; Waiting Lists; United States; United States > US; lean management; Emergency Department; Veterans; quality improvement; VHA
• ISSN: 0026-4075; 1930-613X
• DOI: 10.1093/milmed/usy165

Abstract Introduction We describe the use of Lean quality improvement methodologies at a Veterans Affairs (VA) medical facility to redesign Emergency Department (ED) front-end operations and improve ED flow, specifically to reduce time from Veteran arrival to provider evaluation. Materials and Methods The intervention, a Rapid Process Improvement Workshop (RPIW), took place during January 2014 at the VA Palo Alto Health Care System (VAPAHCS). Key changes made as a result of the RPIW included standardizing and streamlining evaluation and hand-off processes, better-delineating roles for RNs and MDs, more efficiently utilizing beds and improving team communication. We collected 13 months of pre-intervention and 13 months of post-intervention data. The primary outcome was the change in “Door to Doctor” time between the pre-intervention and post-intervention periods at VAPAHCS compared with contemporaneous national control facility sites. Secondary outcomes included the change in “Door to Triage” time and the rate at which patients left without being seen (LWBS). Data analyses were performed using a regression-adjusted difference-in-differences approach. This was a quality improvement project and the institutional review board determined that this project does not meet the definition of human subject research. Results Overall, “Door to Doctor” time at VAPAHCS decreased 12.6 minutes after the intervention, compared to 3.7 minutes in the control sites. Regression-adjusted difference-in-differences estimates for “Door to Doctor” time and “Door to Triage” time showed a significant reduction at VAPAHCS compared with control sites (8.9 minutes and 5.0 minutes, respectively), during the same time period (standard error = 3.5 min; p = 0.01 and standard error = 1.7 min; p = 0.004, respectively). Regression-adjusted difference-in-differences estimates for LWBS rates showed that LWBS did not significantly change at VAPAHCS compared with control sites (0.1% vs. 0.3%, p = 0.8). Conclusions Using Lean principles, VAPAHCS was able to improve Veteran flow in the ED. Use of Lean methods foster interdisciplinary teams and problem-solving across departments and are one approach VA EDs can use to address systemic factors and contributors to ED crowding and improve care for Veterans. Future study should incorporate additional measures of quality to determine the effect of Lean on Veteran outcomes and should evaluate the long-term sustainability of the improvement.