Health policy/original research
Evaluation of an Emergency Department Lean Process Improvement Program to Reduce Length of Stay

https://doi.org/10.1016/j.annemergmed.2014.06.007Get rights and content
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Study objective

In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care.

Methods

We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted.

Results

In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (–14 minutes [95% confidence interval {CI} –47 to 20]) but decreased after wave 2 (–87 [95% CI –108 to –66]) and wave 3 (–33 [95% CI –50 to –17]); median ED length of stay decreased after wave 1 (–18 [95% CI –24 to –12]), wave 2 (–23 [95% CI –27 to –19]), and wave 3 (–15 [95% CI –18 to –12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI –0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone.

Conclusion

Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.

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Please see page 428 for the Editor’s Capsule Summary of this article.

Supervising editor: Brendan G. Carr, MD, MS

Author contributions: MJV, TAS, AG, and MJS were responsible for the study design. MJV and MJS were responsible for data collection and article preparation. MJV and TAS were responsible for statistical analysis. All authors provided input into the design of the study and interpretation of the results. TAS, AG, BHR, MZ, BG, AN, and GA contributed to the editing of the article. MJV takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was funded by the Ontario Ministry of Health and Long-Term Care (04601T) and the Canadian Foundation for Healthcare Improvement (RC2-1603-06). Dr. Guttmann is supported by a Canadian Institutes of Health Research Applied Chair in Child Health Policy and Services Research (APR 126377). Dr. Rowe is supported by the CIHR as Tier I Canada Research Chair in Evidence Based Emergency Medicine (950-222864). Dr. Schull is supported by a CIHR Applied Chair in Health Services and Policy Research (200807ACH-190329-52431).

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