Lean Healthcare - Over-processing in the EDIt’s four o’clock on a Monday afternoon in the emergency department. The line for the triage nurse is now 10 deep.  “It must be Mary – this always happens when she works the triage desk,” whispers a co-worker.  “I just don’t understand why she can’t complete the triage faster.  After all, it is only 55 questions. I have it memorized so I can do it in a matter of minutes.”

This scenario plays out in many American emergency departments every day.  Is the problem that we don’t have qualified nurses that can triage a patient in a matter of minutes?  Or have our rules, regulations, and processes evolved so that it’s nearly impossible to accomplish? This is a perfect opportunity to apply Lean thinking to uncover root cause and find a solution to the problem.

First, let’s define the process.  The word triage comes from the French verb trier, which means to sort, sift, or pick over.  The word triage is most often used in medical situations to mean the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties. Thus, in an emergency department, the act of triage should mean to sort patients based on the degree of urgency to wounds or illness and decide the order of treatment.

Perfect.  But, does that take 55 questions to accomplish?

The 55 question triage process perfectly highlights the Lean Healthcare concept of excess processing, or doing more than is required to accomplish work.  Do we need to obtain the information from the 55 questions? Absolutely.  Do we need it to determine the order of treatment?  Absolutely not.  Over time the patient assessment has been gradually pushed from the back of the ED to the front, meaning that what should be done, when it should be done, and where it should be done in the best interest of the patient all take a back seat to paperwork.  By only doing what is absolutely necessary at each step, patients can be kept flowing through the process, receiving the appropriate care at the appropriate time, providing required information in a way that doesn’t impede with their care, and summarily reducing the time it takes to receive care.

So the next time you see your emergency department wait time exceeding your goal, ask yourself, “Are we over-processing?”


Today’s blog was written by Dan Littlefield, Director at HPP.

Dan has 30 years of healthcare experience in many clinical and leadership roles. He leads Lean and process improvement consulting engagements for HPP.  His experience includes deploying Lean across numerous healthcare disciplines including Imaging, Laboratory, Nursing, Pharmacy, and Physician Offices.  Dan began his healthcare career as a nuclear pharmacist and has also severed as Director of Operations, responsible for 13 facilities.  He has been a featured speaker at a variety of healthcare industry events.

Dan holds a Master’s Degree in Business Administration from the University of Pittsburgh, Bachelor’s Degree in Pharmacy from Purdue University and a Specialty Certification in Nuclear Pharmacy from Butler University.

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