Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

The Lean Management System: Driving Accountability and Value for ED Teams

6/23/2015 12:07:22 PM | 4 comments

For hospitals, embracing lean methodology can pay big dividends in terms of quality and patient and staff satisfaction. And for practitioners of lean, the quest for continuous improvement never ends. Here's how one committed organization took its lean practice to the next level. The following is adapted from a poster presented at CEP America's 2014 annual conference.


Saddleback Memorial Hospital - Laguna Hills has a 10-year history as a lean organization. Throughout this journey, our emergency department (ED) has often been first to implement new lean methodologies. Based on our past successes, Saddleback Memorial Hospital's administration approached us about becoming first in the organization to adopt a Lean Management System (LMS).
LMS is a leadership approach that supports continuous improvement through collaborative problem solving. Rather than leading from the top down, lean managers strive to actively engage their teams in the improvement process in order to promote personal and organizational success. Rewards come to staff though validation and recognition of the efforts they contribute toward the goal.
The basic components of LMS are:
  • Standard work (SW). Tasks are broken into a series of steps that are followed by all team members at all times. Standard work is continuously adjusted to decrease waste and add value until a state of perfection is reached.
  • Visual controls. Team members have an opportunity to track their own performance in real time and make adjustments.
  • Daily accountability process. The group comes together to review progress, refine processes and chart next steps.
Typically in lean, we define value from the patient’s perspective, because our ultimate goal is to improve the experiences of our patients and their families. We implemented LMS to engage our people, from senior management to front-line providers, in problem solving as close to the bedside as possible to improve daily performance.



Set the Direction

Implementation began with a one-week workshop involving the ED and hospital senior leadership. Using strategic deployment, we defined and outlined the current state of each leader’s responsibilities, looking for areas of overlap (i.e. waste).

Define Measurable Target Conditions

The leadership identified three areas to focus our lean management efforts on:
  1. STEMI standard work: We already had a process for these patients in place, and our door-to-balloon times were very good. We chose to target this goal first, reasoning it would be a success story that would create energy for the process.
  2. Stroke standard work: Our challenge in this area was to meet The Joint Commission Primary Stroke Center Certification criteria for documentation compliance, which was part of Saddleback Memorial's strategic plan.
  3. Diversion hours: Our goal was to decrease our daily diversion times. This would improve access for the community and help our hospital meet its strategic goals.

Build New Capability for Significant Improvement

Next, we designated and trained lean leaders who in turn educated staff. (In addition to our clinical leaders, several front-line staff members were eager to get involved and requested training.)
We designed standard work for all of our leaders in order to create routine accountability and habits. Each leader's SW included periodic audits using checklists to remind them what to look for and to provide a written archive that could be analyzed for trends.

Daily Management

To help sustain incremental improvement, we implemented both control (process) and visibility (progress) boards. The idea behind these displays is to show at a glance what we're working on and how well we're doing it. An administrator passing through our ED can take a quick pulse on the department just by glancing at the boards.
Here's an example of a control (process) board:

And here's our visibility wall, which was updated daily by the charge nurse:

Teams held daily huddles (stand-up meetings) around the visibility wall to present and discuss visual data. Senior leadership was invited to at least one huddle a month to see the team's progress and view the process in action.
To ensure the quality of our SW, leaders utilized the plan-do-check-act (PDCA) coaching protocol during their gemba walks. PDCA emphasizes learning and reinforcement over correction.



One of the most exciting changes we noticed after LMS implementation was a much higher level of engagement among our front-line team members. They clearly enjoyed having a routine that fostered accountability and motivation to solve issues in real time. Their input helped us to frequently check our "current condition" and adjust accordingly.
As a result:
  • Our median STEMI door-to-balloon time dropped from 58.5 minutes to 48 in the first year — despite the fact that we made no process changes.
  • Stroke documentation started at 55 percent compliance in July 2013 and improved to a consistent 100 percent compliance to all data elements by August 21, 2014.
  • Diversion hours reduced from 428 hours in 2012-2013 to 196 hours in 2013-2014. (Our annual measurement cycle begins on July 1).
The target conditions created stretch, showing we could go beyond current process capabilities. This linked the degree of learning, fulfillment and motivation to the level of challenge (Rother, 2010). Both easy and complex targets can provide team members with motivation and fulfillment. However, it is when those targets achieve breakthrough, as demonstrated in the improvement of stroke documentation, that a provider's motivation and desire to take on more challenges increases.
The process has improved team communication. Prior to LMS, daily huddles could be hit or miss. After LMS, huddles were consistently held to show staff the results of their efforts and identify areas of needed improvement.
In many ways, the process has been self-reinforcing. Several of our leaders signed up for more advanced training to enhance their knowledge and methodology. Nurses and physicians also began engaging in A3 work together to solve process problems identified through LMS — without direction from management.



Here are some keys to LMS success based on our experience:
  • Start by working with your team to create a compelling vision.
  • Begin by enhancing and evolving existing systems. Focusing first on our successful STEMI process showed the team how their standard work translated into improved outcomes for patients.
  • There is no “one best way” to do things (Macfie, 2014). To encourage change, create an environment in which all voices are heard.
  • Speak “Toyota” by having a lean mindset each time you problem solve with staff. It helps make lean philosophy part of the organizational culture.
  • Offer lean leadership training to key people. Training isn't just for senior leadership. Once team members experience it, they want to participate.
  • Challenge teams to “stretch” (Macfie, 2014). You can’t reach your targets if you stay at status quo, and you won’t feel the zing of accomplishment without stretch.
  • Engage physicians to champion lean concepts and quality improvement.
  • Involve all team members in data collection, and make it visible to everyone. (Our staff asked their managers, “Where is the data? You forgot to post the data!” They now keep their management team on task, knowing that our standard work brings meaning to them.)



Two years after LMS implementation, the ED team at Saddleback Memorial continues to be energized and engaged in the process. Using LMS methodology, they have successfully completed several new improvement projects, including the creation of sepsis standard work.
Other departments within the hospital are now in various stages of replicating the LMS model.



Macfie, H. (2014). Transformational leadership in the culture of safety. [PowerPoint slides]. Retrieved from

Rother, M. (2010). Toyota kata: Managing people for improvement, adaptiveness, and superior results. New York: McGraw-Hill.

[Image credit: "Fort Belvoir Community Hospital astounds with groundbreaking technology and devotion to patient care" by Army Medicine licensed under CC BY 2.0]

Yvette Martin, RN
Fantastic article! Thank you for breaking the LEAN process down so eloquently, as well as being a champion of the process. Your staff appreciates your experience and vision as we continue to learn and grow within the emergency department as well as the Saddleback organization.
6/27/2015 3:55:23 AM

Marc Taub, MD
Its such a joy working collaboratively with our ED nursing leadership and staff using Lean methods to constantly improve our processes! Great explanation of the system Karen.
6/26/2015 3:01:20 PM

Kevin Riggs
Thank you for the post! It is great to see the whole team being involved and engaged. Keep up the great work!
6/24/2015 3:55:24 PM

Jon Brummond
Ms. Sharp, Excellent article! Thank you for contributing.
6/24/2015 12:31:58 PM