LEAN, NOT MEAN: Nurse Brooksie Arrington is shown with a standardized supply cart in the Lean Care Track area of Le Bonheur Children's Medical Center. -- Photo By Scott Shepard

The Emergency Department at Le Bonheur Children's Medical Center is taking a lesson from Toyota in how to treat patients with maximum efficiency.

In its first month, the strategy, which is designed to identify patients' problems quickly and then send them through a pre-determined course of treatments, not only has increased doctors' productivity by 54 percent, but also sliced half an hour off the time patients and parents spend just waiting around.

Three years ago, Le Bonheur named David Schlappy as vice president of quality management. Schlappy set out to remake the hospital, adopting the Lean Care Track, which uses motion studies to eliminate wasted steps. It's a concept long understood in manufacturing, Schlappy said, but is only slowly being adapted in service industries such as health care.

The same process already has revolutionized surgery and pathology labs at Le Bonheur.

It turns out that part of what makes an emergency room seem exciting - all the commotion - is also a serious cost center than can be managed.

"When someone comes to an emergency department, their goal is to be seen by a physician and be assessed," said pediatrician Barry Gilmore, director of emergency services. "Our principle purpose was to reduce the time it takes to the degree possible."

Picking up the pace

Le Bonheur averages about 70,000 ER visits a year, nearly double what the facility was designed for in 1989, so speeding the flow of patients means serious savings in labor costs and expenses. It also improves patient satisfaction, said nurse Carolyn Jackson, administrative director of emergency services.

Although just 20 percent of patient volume now goes through the three Lean exam rooms, the lessons learned are helping shape the design of Le Bonheur's new hospital, a $327 million facility to open in 2010 at Poplar Avenue and Dunlap Street.

In the new place, Gilmore expects up to 70 percent of volume to go through the Lean process. Because Le Bonheur is an academic hospital, there always will be inefficiencies because of teaching, he said, and there always will be complex cases, true life-or-death emergencies that demand the time of a lot of people. But the vast majority of cases can go through a defined treatment process.

What doctors once derided as "cookbook medicine" now is being embraced as "critical care paths," which quickly diagnose a patient and send him or her through a pre-determined course of procedures. Adult Emergency Departments, for example, now divide up chest pain cases: Determining up-front if it's a heart attack or just a bad case of indigestion saves more lives.

Alleviating clutter

Reinventing the Le Bonheur ER started with videotapes recording the existing processes for analysis by management. Any organization that evolves over time, Jackson said, tends to take on inefficiencies. New equipment is plopped down where it fits and employees tend to hoard their favorite supplies.

Videos showed that the staff was constantly walking back and forth in wasted steps: doctors with patients at the opposite end of the hall and nurses hunting down supplies.

"We also taped this from the patient's perspective, calculating how much time they spend sitting and waiting, for labs, X-rays or to see a doctor," Jackson said. "Patients spend up to 80 percent of their time just waiting. There's no value-added service to that."

The Lean treatment area's three exam rooms and procedure room are identical, from where the light switch is placed to which drawer holds the 2cc syringes. Rooms are designed and equipped so everything that is needed is at hand and easy to find, Gilmore said. Also, things that are not needed have been purged.

It's staffed by one doctor and two nurses. Everyone's duties are clearly defined.

"When I'm in the Lean area, I don't have to go back and check if my lab results are ready," he said. "I have a nurse who does that. All of us concentrate on our own job."

Just like clockwork

The full staff rotates through the Lean area so they'll be ready when they move into the new hospital. While a doctor working in the regular Emergency Department may treat two or three patients an hour, the Lean doctor is caring for five or six. The average length of stay for patients has gone from 225 minutes to 195 minutes when they are treated in Lean.

When the labs at Le Bonheur went through the same process, the motion study looked like the kitchen of a busy Chinese restaurant, Schlappy said. It took 15 steps to conduct six tests on a single specimen, with results ready in 59 minutes. Labs were reorganized with testing stations and supplies in sequence. The lab saved $175,000 in inventory and operates with 5.9 fewer full-time positions, saving $248,000. And, test results are ready in just 26 minutes.

One of Schlappy's rules up front is that nobody loses their job. Reductions in the lab, for example, came from attrition and retirement. It's simply inappropriate, he said, to ask people to work hard at eliminating their own jobs.

Gilmore and his staff spent six months planning the project, with November as the first full month of operation - it's so new that the wall around the physicians' station still awaits some drywall finishing.

Lean Track will test its mettle soon. The department averages 210 patients a day, but that will creep up to 300 during the winter. When people spend most of their time indoors, they develop more respiratory problems, such as asthma and flu.

One step ahead of government

The process also should help the rest of the hospital during peak demand periods. Emergency departments are often the front door of a hospital and account for the majority of acute admissions.

One chronic cause of back-ups in the ER is the lack of a vacant bed elsewhere. If the rooms in Gilmore's 44-bed department are occupied by someone waiting for admission, he has no place to treat others.

"We hold patients every day, and sometimes we are holding up to 25 who are waiting for a bed," he said.

There might be a perverse incentive in improving ER efficiency, Gilmore conceded. Many people use the facility for convenience because they don't want to wait to see their regular doctor. Speeding the process can be an incentive to overuse the Emergency Department.

Parents are strongly urged to go to their regular providers for follow-up care, he said. Also, federal politicians are starting to scrutinize the nationwide problem of ER crowding and patient diversion. Hospitals have to tackle the problem or they'll face another load of regulations.

"At the federal level the only thing they can do is increase our regulations or decrease our funding," he said. "It's better if we figure this out ourselves."