• Eric W Dickson, Zlatko Anguelov, Diana Vetterick, Andrew Eller, and Sabi Singh.
• Department of Emergency Medicine, University of Massachusetts Medical School, and UMass Memorial Medical Group, UMass Memorial Medical Center, Worcester, MA 01655, USA. eric-dickson@uiowa.edu
• Ann Emerg Med. 2009 Oct 1;54(4):504-10.

Study ObjectiveWe describe the effects of Lean, a process improvement strategy pioneered by Toyota, on quality of care in 4 emergency departments (EDs).MethodsParticipants in 2 academic and 2 community EDs that instituted Lean as their single process improvement strategy made observations of their behavioral changes over time. They also measured the following metrics related to patient flow, service, and growth from before and after implementation: time from ED arrival to ED departure (length of stay), patient satisfaction, percentage of patients who left without being seen by a physician (2 EDs), the time from ordering to reading radiographs (1 ED), and changes in patient volume.ResultsOne year post-Lean, length of stay was reduced in 3 of the EDs despite an increase in patient volume in all 4. Each observed an increase of patient satisfaction lagging behind by at least a year. The narratives indicate that the closer Lean implementation was to the original Toyota principles, the better the initial outcomes. The immediate results were also greater in the EDs in which the frontline workers were actively participating in the Lean-driven process changes. A factor that considerably affected the outcomes in the second and third year postimplementation was the level of continuous leadership commitment to Lean.ConclusionLean principles adapted to the local culture of care delivery can lead to behavioral changes and sustainable improvements in quality of care metrics in the ED. These improvements are not universal and are affected by leadership and frontline workforce engagement.

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