Applying Lean Thinking Speeds Emergency Department Discharges

Michael J. Beck MD, FAAP, SSGB Department of Pediatrics Milton S. Hershey Medical Center and the Pennsylvania State University College of Medicine, Hershey, Pennsylvania Interview with:
Michael J. Beck MD, FAAP, SSGB

Department of Pediatrics
Milton S. Hershey Medical Center and the Pennsylvania State University College of Medicine, Hershey, Pennsylvania

Medical Research: What is the background for this study? What are the main findings?

Dr. Beck: Many hospitals are trying to improve patient discharge times. The benefits of this result will improve several valuable metrics within the organization’s value chain, namely improved access, reduced lost referrals, reduce emergency department boarding, to name a few.

As our region’s only tertiary care children’s hospital, that serves an expanding demographics and geographic population, access to our facility is becoming both a priority and challenge. Since many hospitals and hence hospital service lines work with a fixed number of beds, serving a growing population is going to lead to or exacerbate hospital access issues and emergency department boarding. The latter of which may carry financial penalties in the future based on Joint Commission standard LD 04.03.01 (revised 2013). We sought to applying elements of Lean and constraint theory, which postulate that flow can be created by eliminating waste, and that a process can move only as fast as its scarcest resource, respectively. From a lean perspective, why should  “dischargeable” patients who were seen on AM work rounds still be occupying a valuable bed at 3 or 4PM when they were deemed safe for discharge hours earlier? Why should patients and organizations continue to tolerate this waste? Applying Lean thinking  forced our service to reconfigure, re-sequence, and re-staff rounds in a way that could better meet patients’ and our organization’s needs and requirements.  Since the discharge process output is an open bed, not having an open bed when it is needed, creates an organizational constraint. One constraint to creating an open bed, is the attending physician, ie a patient cannot be discharged until he/she is seen by the attending physician. However, another constraint is the model that one attending sees in excess of 13 patients per day (patient: provider ratio of 13:1). We hypothesized that by adding an attending  to reduce the  patient: provider ratio by 50% during predictable high volumes, we could do all of the discharge paperwork on rounds, at the time the decision to discharge is made by the attending.  By advancing discharge order entry time, we should be able to advance the time patients get discharged, create an open bed earlier in the day, and ultimately reduce lost referrals and emergency department boarding.

Our service line median time of discharge order entry and time of patient discharge was compared to our own historical controls and to the same discharge behaviors of the remainder of our hospital services. The main intervention was staffing reallocation, creation of standard workflow expectations, and a discharge checklist. Finally, we also implemented a discharge huddle to occur before the day of anticipated day discharge.

Over the 6 month intervention period, the median time of discharge entry decreased from 2:05PM to 10:45 AM and the median time of patient discharge decreased from 3:58PM to 2:15 PM.  The hospital  control group did not change from baseline.

Our LOS went form 3.1 days to 3.0 days, and our 7, 14, and 30 day readmission rates did not increase. Emergency department boarding time was decreased by 30%, and lost referrals decreased 70% during the study period.

Medical Research: What should clinicians and patients take away from your report?

Dr. Beck: We calculated that by advancing patient discharge times, we can calculate the number of virtual beds the intervention created, and additional admissions we could accommodate as a result. We found that by advancing the discharge time by 1.5 hours, every day, we could create about 0.35-0.40 virtual beds and create the opportunity to accommodate 25 more admissions/year.

We need to embrace the idea that if all hospitals are feeling the same capacity pressures, that will undoubtedly increase in the future, then perhaps we are all using similar antiquated models and processes that have ceased to serve our patients and system in a meaningful way.  We need to recognize that these models helped generate individual provider volume (RVUs),but they fail to generate value and impede any organization’s call to improve quality (timely, safe, personalized, efficient, effective, equitable care).

The model has proven to be sustainable, Our results have persisted for an additional 12 months, despite the fact that had all new interns and residents, and 3 new faculty since our initial publication.  From a lean perspective, it proves the value in creating standard workflow in reducing variation that accounts for waste. It also demonstrates that if we focus on improving the processes, the desired results will follow, since lean is process-focused, the results are provider independent.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Beck: Since system-thinking dictates that a system is a series of inter-related processes separated in space and time, we should monitor if this process change has impacted other processes within our system.

Specifically, if this improved Emergency department boarding, or on boarders that exceed 4 hours, PACU stays, or lost referrals.


Beck, M. J. and Gosik, K. (2014), Redesigning an inpatient pediatric service using Lean to improve throughput efficiency. J. Hosp. Med.. doi: 10.1002/jhm.2300

[wysija_form id=”2″] Interview with: Michael J. Beck MD, FAAP, SSGB (2015). Applying Lean Thinking Speeds Emergency Department Discharges