One of the key principles of Lean Thinking is to eliminate delays which consume up to 95% of the total cycle time. If you've ever been a patient in a hospital emergency room or bed, you know there are lots of delays. Over the years, health care has made tremendous strides in reducing cycle time in various aspects of care. Outpatient surgeries are one example: arrive in the morning and leave in the afternoon. No bed required. But there is still room for improvement.
Goal: Accelerate the Patient's Experience of Health Care
Lean thinking focuses on a key metric called takt time. Takt means rhythm. For the sake of simple analysis, let's say that your ER handles:
- 120 patients/day
- That would equate to 5/hour
- Or one every 12 minutes
Unfortunately, patients don't arrive in a rhythmic fashion, they arrive in waves. The biggest wave is between 3pm and 9pm due to rush hour traffic accidents, parents picking up sick kids from daycare and so on. The smallest wave is usually 3am to 9am. So let's say patients arrive 2-3/hour at off-peak times and 10/hour at peak times.
That's one every six minutes at peak times.Staffing
Most ERs of this size, at peak demand, have:
- 1 Triage Nurse to evaluate walk-in patients by level of acuity
- Takt Time: 6 minutes/patient
- 1-2 Registrars to handle insurance and hospital paperwork
- Takt Time: 6-12 minutes/patient
- 2 M.D.s (one off-peak)
- Takt Time: 12 minutes/patient (some less, some more based on acuity) One trauma patient can completely consume one or both M.D.s.
- 1 Lab technician to collect blood samples (60% of patients require lab work)
- Takt Time: 10 minutes/patient
- 1 Nurse for every two patients (sometimes with 1:1 nursing for traumas)
- Takt Time: 12 minutes/patient alternating
Lab work often takes 45-60 minutes start to finish. Many of these patients will also need some sort of medical imaging (X-Ray, CT scan, etc.) Which also takes 45-60 minutes.
Estimate that 25% of ER patients will be converted to inpatients.
That means 30/day or 5/unit. Traumas go to ICU. Chest pain patients go to telemetry. The rest go to medical/surgical beds.
How long does it take to move an admitted patient to an inpatient bed? Shouldn't be any longer than 30 minutes althougth most hospitals run longer than this. Why? Trying to sync up the ER and floor nurse to give "report" on the patient's condition and diagnosis.
Solution: Fax or voice mail the report and transport the patient to the floor as soon as a bed is ready.
Most hospitals of this size have at least:
- 1 ICU (6-12 beds)
- 1 Telemetry unit for monitoring heart patients (12-20 beds)
- 2 Medical/Surgical unit (15-30 beds)
Length of stay (e.g., takt time) in most of these units is 2-3 days.
Patients also arrive from the operating room (3-5 per day) and direct admissions from local physcian offices (3-5 a day).
On a peak day, any unit can admit 10 or 12 patients and discharge 10-12. The sum of these two is called the "bed turn" rate (20-24).
How long does it take to discharge a patient once the order is written?
Takt time: 2-6 hours. (Delays for lab, radiology, oxygen, medical equipment, family or other transportation.) Target: 60 minutes.
- Get physicians to discharge "pending" improved results 24 hours in advance. This allows nurses to do the paperwork and "teaching" required to prepare the patient for ongoing recovery at home.
- Prioritize discharge lab/radiology work ahead of other inpatients and after ED/OR.
- Set up home health requirements (e.g., oxygen, walker, etc.) in advance.
- Get at least two phone numbers of family members who can pick up the patient during the time when they are most likely to be discharged (when the doctors do their rounds).
Dirty Beds How long does it take to clean a bed after a patient leaves?
Takt time: 20-30 minutes (delay in starting 15-90 minutes).
Solution: Eliminate the delay. Are you staffed for peak bed turnover times? Probably not.
Here's my point:
Take the pulse of your hospital or business. What's your rhythm? What's your takt time?
© 2008 Jay Arthur, the KnowWare® Man, works with managers who want to plug the leaks in their cash flow.
Rights to reprint this article in company periodicals is freely given with the inclusion of the following tag line: "© 2008 Jay Arthur, the KnowWare® Man, (888) 468-1537, firstname.lastname@example.org."