An effort to reduce waste in a hospital’s emergency department led to a new system that increased nursing availability, patient safety and fiscal responsibility.
ABSTRACT: An effort to reduce waste in a hospital’s emergency department led to the use of a timed-delivery Kanban card system to increase nursing time, patient safety and fiscal responsibility. Implementation of the system decreased nurses’ need to call for materials or leave the ED to retrieve them. As a result, the materials team was able to track real-time use and gain improved knowledge of inventory and replenish as needed.
Lean management principles first were developed in the manufacturing industry and take several forms that are used to identify and eliminate waste.1-5 These principles have successfully been used across the health care spectrum to increase patient safety, increase patient flow and decrease cost.1,6-11 As reimbursements decline and health care costs increase, identifying and eliminating waste will continue to become increasingly important10 — especially in the emergency department, as crowding, patient throughput, patient safety and cost have been recognized as areas in significant need of improvement.12-16
However, beginning a Lean project can be daunting, and knowing where to start can be difficult. Physician leaders should be well aware of the reasons why Lean projects either succeed or fail, and should realize the potential pitfalls before encountering them. Comparative studies among successful and unsuccessful Lean implementation found the most important project characteristics predicting outcome are managerial commitment, formal mechanisms to enable and encourage autonomy, highlighting transparent mid- to long-term goals, providing sustainability, highlighting quick wins and ongoing auditing.17,18 The most critical key to success is managerial/C-suite involvement, engagement and encouragement.17,19
The key component of Lean implementation is identifying waste or any involved component that does not add value to the customer.4 The Japanese word muda is a term common to the Lean manufacturing process, meaning “waste.” Muda has seven types:8
- Unnecessary inventory.
- Inappropriate processing.
- Excess motion.
Muda can be identified effectively with a current-state process flow map, also known as a CSM, that can be converted into a value stream map. Also known as a VSM, it is a Lean tool in which an entire process is mapped step by step to identify waste.5 VSMs have proved useful in manufacturing as well as in medicine, and they are an effective starting point in the Lean process.3,5
Many Lean experts also advise focusing on waste of inventory as an initial step because inefficient materials flow makes efficient process flow difficult, unnecessarily binding excess capital.5 Running a code or putting in a chest tube in the ED is difficult without the proper materials, and a delay in these materials can prove disastrous for the patient. Materials also tend to carry a large economic footprint, and eliminating materials waste can lead to concrete monetary gains for an institution.5 Indeed, certain hospital department budgets dedicated to inventory can be as high as 56 percent.10
Not only is effective materials management financially smart, but it also helps increase patient safety. When nurses are pulled away from patient care to be involved in materials management, patient safety is likely to suffer.11 In fact, up to 20 percent of nurses’ time has been found to be involved in logistics such as traveling, delivering, retrieving and waiting — and much of that involves materials.11,20
Effective materials management leads to fewer expired supplies and the decreased likelihood of running out of supplies. Using a timed-delivery Kanban card system can support Lean implementation in ED materials management to mitigate risk and improve fiscal responsibility. It can be designed to function in facilities of any size.
Kanban is a Japanese word common to Lean management, and it translates roughly to “signboard” — a visual signal that triggers an action. Often used in manufacturing, this system consists of cards associated with inventory, and when inventory is used, a corresponding card is placed in a collection area. A materials professional collects these cards on a scheduled basis, gathers replenishments, and delivers the supplies as well as the cards to the original site.
In an ED setting, the system can decrease stockouts and nursing logistics time.
Initially, a current-state process flow map was constructed through multidisciplinary team meetings to identify waste in the ED (see Figure 1). The first area for improvement was nurses leaving the ED or waiting an average of 10 minutes every hour to get frequently used supplies that weren’t readily available. This issue was mentioned in team meetings and confirmed by direct observation for one month by the ED nurse manager. The process (see Figure 2) was consistent over all shifts. Then, root-cause analysis tools determined the cause of supply stockouts in the ED (see Figure 3).
After obtaining institutional consent, a Plan-Do-Study-Act project was implemented in the form of the timed-delivery Kanban card system. The system focused on high-volume materials that frequently need replenishment. In manufacturing, getting the correct parts to the correct place at the correct time can be difficult,5 so Lean solutions were used.
An “ED supermarket” was developed, where frequently used materials were kept for easy accessibility and identifiability. Once frequency and volume of highly used materials were known, and the inventory was in place, the Kanban card system began.
The system allows for information to travel from the nurses to the materials department and gives real-time information about use of materials. Individual cards were assigned to specific materials, such as pillows and urinals. When one of the materials was used, the corresponding card was placed in a bin near the supermarket.
A route was then developed to allow this information to be carried to the materials department (see Figure 4). Materials management employees checked the card bin and restocked the supermarket every two hours on a first-in, first-out basis — meaning older materials were used before newer materials. The route began with six frequently used items and the route was then audited for improvement. As improvements were made, the number of materials in the Kanban system increased.
As the route began, the time nurses spent leaving the ED to get supplies quickly dropped — to nearly zero minutes an hour, as confirmed through the ED nurse manager’s direct observation. The nurses were able to devote more time to patient care.
The system seemed to be working well and more items were added. As more items were added, the system began to fail and the nurses again were being tasked to leave the ED to get supplies. An audit of the system revealed the problem: The Kanban cards were kept near, but not adjacent to, the materials. This led to the nurses having to spend time finding the cards as they pulled the materials and also forced the materials team to spend more time replacing the cards. Cards became jumbled together and disorganized. The card repository was determined to be too far from the supermarket, requiring excess work — waste in the system. The system grew cumbersome, and the nurses felt there was no time to spend in the supermarket. Materials were used, but the cards were not, thus wiping out any benefits previously gained.
The system was redesigned to attach the cards to the materials, making it significantly easier to pull the card when the material was pulled. The card repository was repositioned to minimize excess movement in the supermarket. Once redesigned, the system began to work again. The nurses no longer had to leave the patient care area to get materials, and inventory tracking became more manageable. Auditing of the system by the nurse manager revealed the wait time for materials was eliminated.
The methodology behind the Kanban card system has several advantages, including:
- Improved use of nursing care.
- Improved patient safety.
- Improved efficiency of materials personnel.
- Enhanced fiscal responsibility.
- Smaller footprint of materials in the ED.
- Fewer expired materials.
- Minimal implementation cost.
Arguably, the most significant benefit of this materials flow system is increasing patient safety by decreasing nursing logistics time. Before implementation, 10 minutes per hour of the nurses’ time was devoted to materials management. After implementation, it fell to zero minutes.
Nurses seldom receive formal training in materials management. Consequently, material gathering is a poor use of their time and skills. This system allows nurses to devote their energies to patient care commensurate with their training, which likely leads to improved patient safety.11 Patient perception and satisfaction will likely increase as well, when nurses have more time to spend with patients and the patients spend less time awaiting needed supplies.
Asking nurses to gather supplies is expensive and inefficient. A nurse being away for 10 minutes every hour equals 240 minutes of lost productivity — or four hours a day. That’s 1,460 hours a year. Assuming a base pay of $25 an hour, that’s $36,500 spent solely on materials gathering each year.
Applying a standardized route also increases efficiency of the materials team. Before implementation of the route, ED materials were stocked infrequently and based on par levels. It didn’t account for increased periods of patient flow, which led to running out of materials, and the materials team had to be called multiple times each day to bring supplies. After introducing the route, the team was able to supply items every two hours based on real-time data (the cards) from the ED. This drastically decreased the on-demand runs, or single-item runs, from the materials department to the ED.
Gathering supplies is a poor use of nurses’ time, energy and skills, and interferes with patient care. In this Kanban card system, patient safety, perception and satisfaction will likely increase.
The Kanban card system allows inventory to be monitored perpetually rather than periodically.10 The periodic system, which counts inventory at scheduled intervals and uses par levels, leads to increased costs from excess supplies, inaccurate inventory levels and materials in multiple locations.10 In contrast, the perpetual system uses real-time data, allowing for better analysis of use that leads to more-informed ordering and increased materials turnover.10 Frequent turnover results in less waste and less on-hand inventory, leading to increased fiscal responsibility, because on-shelf materials do not generate revenue.10,20 The perpetual inventory system eliminates the need for time-consuming and cost-intensive inventory counts.10,20
The Kanban card system has advantages compared to other inventory systems. The supermarket leads to improved use of space and a smaller supplies footprint in the ED.5 By running the route every two hours, fewer supplies are needed to be kept in the ED. This allows for better management of the physical space in the ED, which can be used for other purposes. It also requires no additional personnel to implement and maintain.5 The system is inexpensive to set up and sustain. The initial cost includes staff time for data gathering, setting up the route and rearranging the materials flow, as well as the cost of the cards. Other systems require hiring new staff or expensive technology.5,10,20 Maintaining the cards and auditing the route help identify ways to improve the system and ensure continued efficiency. Also, this system is well-known in the manufacturing industry, and it is continually updated and perfected by perhaps the world’s most-efficient production organization: Toyota.21
The system has near-infinite scalability and application, regardless of complexity. Here, the system was designed to begin in a 72-bed hospital, and its complexity is reflective of that. As the system grows in complexity, its design must be examined.
The system route must be designed for the cards to be collected on a schedule, whether the pulled cards are in one area or several. A proper addressing system, which is beyond the scope of this article, is paramount as the system grows. As the number of cards increases, automation of the card sorting can occur with use of card readers and bar codes or radio frequency identification. This information would be sent to the materials department in a succinct form, relaying what has been used and what needs to be ordered and delivered.
The key in scalability is thoughtful and careful route design, planning and auditing. This system has been successful in settings both small and huge.
Lessons and Limitations
Despite several advantages, disadvantages do exist. The relationship between the ED staff and the materials staff was cordial and respectful, but trust was uncertain. There also was doubt about whether the system would work and if it would create more work for the nurses, which was a barrier to implementation. However, in discussions, it became evident the nursing staff was willing to try the system.
Similar issues have been found in other studies on Lean implementation.20 It became obvious that building trust between the departments was essential for success. Therefore, the system began with six frequently used items. That allowed trust to build and also allowed easy auditing to identify problems. After a few days, the nurses hadn’t had to leave the ED to get supplies, and trust in the system began to build.
Studies show “quick wins,” such as seeing the system work on a small scale, are important in initiating and building trust.22 Eventually, more items were added, Lean team meetings continued and the system was audited. The importance of systematic auditing cannot be overstated, as this led to uncovering a problem not realized with a small number of items.5 Systematic auditing allows the system to evolve and maintain efficiency as the route grows and stabilizes.5 If the system destabilizes or grows inefficiently, users are less likely to continue participating and more likely to revert to previous work habits. Also, if the system fails, getting staff on board for another attempt is likely difficult.
As the system grew and evolved, the Lean meetings revealed widespread acceptance. Nurses no longer were leaving the ED to retrieve materials and had more time to provide patient care — helping reduce stress and provide more job satisfaction. The materials team also noticed benefits. Tracking inventory became more manageable with real-time data, and staffers no longer had to worry about excessively counting inventory in the storeroom to see what items had been removed without their knowledge. The system was beneficial to all involved.
As identifying and eliminating waste becomes more essential in health care, physician leaders probably will need to play an active role. Being involved in materials management allows physician leaders to not only contribute to success in the supply chain but also assume significant roles in the reduction of materials costs.23,24
Physician leadership in Lean implementation is likely to become more important as this methodology becomes more prominent. Physician leadership will benefit not only the hospital but also physicians by allowing them to help implement the change rather than be subject to it.
Using Lean principles in materials movement, such as a Kanban card system and a materials supermarket, can lead to multiple benefits at minimal cost. An implementation team consisting of engaged and willing members is crucial to effective implementation. Institutions are encouraged to consider similar implementation in the ED and other departments as well.
Andrew M. Harris, MD, is the endourology/robotics fellow and a clinical instructor at the University of Kentucky Medical Center.
- Cima RR, Brown MJ, Hebl JR, et al. “Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center.” J Am Coll Surg. 2011;213:83-92; discussion 93-84.
- Harris C, Harris, AM, Harris, R. “The Blessings of a Level Schedule.” Industrial Management. 2015;57.
- Harris C, Harris AM. “Using Lean Manufacturing to Improve Patient Care in a Rural Urological Practice.” Physician Leadersh J. 2015;2:18-20.
- Harris C, Harris R. Lean Connections: Making Information Flow Efficiently and Effectively. Boca Raton: CRC Press; 2008.
- Harris R, Harris C, Wilson E. Making Materials Flow: A Lean Material-Handling Guide for Operations, Production-Control, And Engineering Professionals. Brookline, MA: Lean Enterprise Institute; 2003.
- Jones D MA. “Lean Thinking for the NHS.” NHS Confederation. 2006.
- Collar RM, Shuman AG, Feiner S, et al. “Lean management in academic surgery.” J Am Coll Surg. 2012;214:928-936.
- Kasivisvanathan R, Chekairi A. “The productive operating theatre and lean thinking systems.” J Perioper Pract. 2014;24:245-248.
- Leslie M, Hagood C, Royer A, Reece Jr. CP, Maloney S. “Using lean methods to improve OR turnover times.” AORN J. 2006;84:849-855.
- Park KW, Dickerson C. “Can efficient supply management in the operating room save millions?” Curr Opin Anaesthesiol. 2009;22:242-248.
- Vesely R. “Linking patient safety and the supply chain. Health care systems are integrating new patient-centered processes into delivery.” Health Facil Manage. 2015;28:37-39.
- Holden RJ. “Lean thinking in emergency departments: a critical review.” Ann Emerg Med. 2011;57:265-278.
- Berger E. “A $9,000 bill to diagnose shingles? Doctor's ED visit highlights cost of care issues.” Ann Emerg Med. 2010;55:A15-17.
- Kellermann AL. “Crisis in the emergency department.” N Engl J Med. 2006;355:1300-1303.
- Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
- Smits M, Groenewegen PP, Timmermans DR, van der Wal G, Wagner C. “The nature and causes of unintended events reported at 10 emergency departments.” BMC Emerg Med. 2009;9:16.
- Maike Scherrer-Rathje TAB, Patricia Deflorin. “Lean, take two! Reflections from the second attempt at lean implementation.” Business Horizons. 2009;52:79-88.
- Teich ST, Faddoul FF. “Lean management: The journey from Toyota to health care.” Rambam Maimonides Med J. 2013;4:e0007.
- Sim K, Rogers J. “Implementing lean production systems: barriers to change.” Management Research News. 2009;32:37-49.
- Graham J, Brewer MS, Byrd VT. “Automating the supply chain in the OR.” AORN J. 1999;70:268-276.
- Krafcik J. “The triumph of the lean production system.” Sloan Manage Rev. 1988:41-52.
- Bilyk C. “Don't break the chain: importance of supply chain management in the operating room setting.” Can Oper Room Nurs J. 2008;26:21-22, 30-24.
- Feistritzer NR, Keck BR. “Perioperative supply chain management.” Semin Nurse Manag. 2000;8:151-157.
- Williams J. “Dollars and sense engaging physicians in supply-cost control.” Healthc Financ Manage. 2007;61:62-68.