Vol. 00 No.
0 xxx 2014 1
Improvement through Small Cycles of
Change: Lessons from an Academic Medical
Center Emergency Department
Amit Arbune, Sarah Wackerbarth, Penne Allison, and Joseph Conigliaro
Awareness of and emphasis on patient safety
and quality of care has been growing since
the 1999 Institute of Medicine (IOM) reports
To Err is Human-Building a Safer Health System.
The IOMs follow-up report, Crossing the Qual-
ity Chasm, sounded a call to arms to improve
healthcare quality and efficiency. The use of
lean management strategies has shown promise
as a means to accomplish the IOMs recommen-
dations (Jimmerson, Weber, & Sobek, 2005;
Toussaint, 2009; White, 2006). The IOMs 2006
report, Hospital-Based Emergency Care at the Break-
ing Point, focused specifically on emergency
care that further motivated efforts to improve
emergency department (ED) services.
Researchers have applied lean principles to
ED services, with many using the concepts
and measures proposed by Solberg, Asplin,
Weinick, and Magid (2003). Reducing lengths
of stay (LOS) is a frequent focus of such stud-
ies (Burstrom et al., 2012; Dickson, Anguelov,
Vetterick, Eller, & Singh, 2009; Dickson et al.,
2009; Eller, 2009; Horng et al., 2013; King,
Ben-Tovim, & Bassham, 2006; McHugh et al.,
2013; Murrell, Offerman, & Kaufmann, 2011;
Ng, Vail, Thomas, & Schmidt, 2010; Sharieff
et al., 2013). Evaluative studies of ED improve-
ments designed via lean projects provide an
optimistic view of opportunities while outlin-
ing gaps in knowledge (Ben-Tovim et al., 2007;
Holden, 2011; Mazzocota et al., 2012; Naik
et al., 2012).
Responding to this call for improved ED
care quality, the University of Kentuckys
(UK) Chandler Hospital launched the ED
Operational Efficiency Project in August 2009
with the goal of reducing LOS for low-acuity
patients. A 500+ bed academic medical center,
the UK Chandler Hospital provides primary,
emergency, and advanced care to residents
of Kentucky and beyond. UKs ED has been
verified as a level 1 trauma center for both
pediatrics and adults by the American College
of Surgeons. The ED Operational Efficiency
Project established a goal of a 30% reduction
in LOS for low-acuity patients by December 15,
2009, followed by a goal of a 50% reduction in
Abstract: This article describes the experiences of a quality im-
provement team that used small cycles of change to improve the
emergency department (ED) of an academic medical center. The
role of EDs in the provision of healthcare continues to increase
in importance. ED bottlenecks contribute to long waits and di-
minished outcomes for ED patients as well as more system-wide
issues, such as inefficiencies in inpatient admission processes.
The purpose of this ED Operational Efficiency Project was to re-
duce lengths of stay (LOS) for low-acuity patients. The team used
lean management techniques to both improve services and shift
the ED culture to prioritize continuous quality improvement. The
goal to reduce LOS by 30% was met as the result of several inter-
related projects (or small cycles of change). Key lessons include
monitoring metrics, communicating with teams and target popu-
lations, learning from initial failures, using small wins to increase
momentum, and anchoring changes.
LOS by April 15, 2010. The goal was based on Keywords
the performance of benchmark institutions, delays
and an intermediary goal was used to main- efficiency
tain motivation through small wins. It was emergency department
estimated that this improvement would impact crowding
13,600 low-acuity patients seen annually by the lean management
UK ED. left without being seen
year 2008, the ED had around 48,000 vis- length of stay
its, with a daily average of 11 boarding inpa- throughput
tients. Ambulatory patients accounted for ap-
proximately 70% of visits, with air and ground
ambulance transports constituting the remain-
ing 30%. At the time of this project (2009),
UKs ED had 40 treatment spaces that were ar-
ranged into four major care areas: trauma, criti-
cal care, acute care, and express care. The acute
care area had a psychiatric subunit, and express
care included a specialized pediatric care area.
Peak-time staffing comprised 10 nurses (five as-
signed to trauma care, three assigned to critical
care, two assigned to acute care, and one as-
signed to express care) and six physicians. The
medical staff included attending physicians as
well as resident physicians completing an emer-
gency medicine residency program.
By 2009, the ED was operating at capacity
and faced increasing LOS and declining rates Journal for Healthcare Quality
of patient satisfaction, and it required an av- Vol. 00, No. 0, pp. 111

C 2014 National Association for
erage of 150 hr of ambulance diversion each Healthcare Quality
2 Journal for Healthcare Quality
Figure 1. Project A3. The A3 Document of the ED Operational Efficiency
Project Displays the Aim of the Project, Measures, and Anticipated
Changes in the Measure
month. The delay in patient care resulting
from long wait times represented both a patient
safety and quality-of-care issue (Bernstein et al.,
2008; Huang, Thind, Dreyer, & Zaric, 2010;
Johnson & Winkelman, 2011; Vieth & Rhodes,
2006). The ED bottleneck also had significant
organization-wide implications, as more than
50% of admissions originated from the ED. An-
other serious consequence of long LOS was the
high percentage of patients who left without
treatment (or left without being seen). Addi-
tionally, the entire regional healthcare system
experienced the downstream effects of long ED
LOS when the UK Chandler Hospital ED di-
verted patients to other facilities.
Methods
To address their goals for reducing LOS, the
project team employed lean tools and com-
pleted a pre-/postimplementation evaluation
of changes to the ED. The multidisciplinary
team included representatives from the ED,
from related service lines (Laboratory and Ra-
diology), and from the hospitals Quality Im-
provement Office (Center for Enterprise Qual-
ity and Safety, CEQS) as well as an external
lean facilitator provided by the Toyota Motor
Corporation. The team, pictured in Figure 1,
included both clinical (e.g., two physicians, five
nurses, two technicians) and nonclinical (e.g.,
four facilitators and four administrators) per-
sonnel. We included additional nurses, radiol-
ogy IT support, and laboratory IT support staff
members on an as-needed basis, and the ex-
ecutive sponsor of the project was the Chief
Medical Officer for UK Chandler Hospital. The
team included representatives of each target
populationthe group likely to be affected by
an operational change. The team used a stan-
dard A3 Problem Solving approach (Simon
& Canacari, 2012; Sobek & Jimmerson, 2006).
The A3 document (Figure 1) illustrated the
aim of the project, measures, and anticipated
changes in the outcome measure (LOS). The
team met weekly to review the agenda and data,

brainstorm ideas for small cycle of change pi-
lot testing, and discuss feedback from each pi-
lot. During the second weekly meeting, team
members were trained in the use of lean tools,
terms, the seven wastes, and the Plan-Do-Study-
Act (PDSA) model of small cycles of changes
(Simon & Canacari, 2012; Varkey, Reller, &
Resar, 2007).
To monitor and communicate daily perfor-
mance toward the project goal, the team de-
signed and implemented an ED dashboard
(Figure 2). Formatted to fit on a single sheet of
paper, this at-a-glance tool provided the team
(and target population) with a real-time means
to monitor LOS by acuity level (broken down
into substeps, such as presentation time to res-
ident time). The dashboard also displayed re-
lated metrics, such as volume of ED patients,
number of patients in different disposition cat-
egories (e.g., admitted to hospital, discharged
home, left without being seen), and number of
boarders. Acuity levels were measured with the
Emergency Service Index (ESI) already used by
the ED. The ESI is a system for triaging patients
into five categories, from level 1 (most urgent)
to 5 (least urgent; Gilboy, Tanabe, Travers, &
Rosenau, 2011). The level 3 category was fur-
ther divided by discharged and admitted status.
The dashboards were e-mailed as attachments
team members on a daily basis and printed for
distribution during weekly team meetings. The
dashboards were updated from automated re-
ports generated by the EMR, and there was a
24- to 48-hr data collection time lag. To assist
the target population in monitoring progress
toward the LOS goal, the tool was designed us-
ing tenets of visual management, such as depict-
ing outcomes below goal numbers in red text
(Graban, 2012).
After the monitoring system was established,
the team focused on understanding the cur-
rent process for managing low-acuity patients
and developed a value stream map (VSM) of
the current process. VSMs are visual depictions
of the flow of a process that highlight steps
that do and do not add value (Graban, 2012;
Jimmerson, 2010; Rother & Shook, 2003; Simon
& Canacari, 2012; Varkey et al., 2007). Next, the
team completed a go-see to better understand
the current process and determine how best to
achieve the LOS reduction goal. Go-see is a lean
technique based on the concept of going to
the gemba, or real place of work (Rother &
Shook, 2003). The team spent time observing
the processes of the ED and evaluating prob-
Vol. 00 No. 0 xxx 2014 3
lems and examples of waste. Team members
from radiology and the laboratory department
observed the work performed in different areas
of the ED and vice versa.
With input from the target population and
data collected during the go-see, the team iden-
tified process bottlenecks and potential areas
of improvement. Using PDSA, the team tested
small cycles of change to continuously define
a future VSM. The dashboard allowed them to
monitor the LOS metric and track progress to-
ward the goal while completing small cycles of
change.
Results
The VSM (Figure 3) depicts the ED visit from
patient arrival to discharge at the time the
project was launched. Key points from the go-see
observations are displayed in Table 1. Via go-see
data collection, the team identified problems
with triage as well as bottlenecks associated with
laboratory and radiology.
The first small change focused on the lowest-
acuity patients (ESI level 5). For this effort,
nurses identified patients who could be treated
in the triage area to decrease LOS and preserve
bed capacity for higher acuity patients. The re-
sulting average LOS did not meet the goal of a
30% reduction in LOS for ESI 5 patients.
The second small change was the introduction
of a chair-centric model that involved treat-
ing low-acuity (ESI level 4 and 5) patients in
recliners. The chair-centric model was imple-
mented on November 1, 2009, after a period of
physician and nurse staff training. The model
was piloted in a hall adjacent to the ED and
functioned during peak hours (3:00 p.m.12:00
a.m.). One week after implementation, the tar-
geted 30% reduction in LOS was met for ESI
5 patients and a substantial (though not target-
level) reduction in LOS was realized for ESI 4.
This pilot was expanded to include ESI 3 pa-
tients when medically appropriate. To ensure
the proper flow of patients through the ED, the
team converted an existing position into a flow
nurse function.
The third small change focused on the triage
process as a potential area for improvement,
and a subteam began to examine the patients
initial encounter with the ED. The subteams
goal was to reduce the time from first contact
to triage to the national average of 15 min. The
subteam made several changes, including mov-
ing the physical location of charts and equip-
ment. These changes resulted in meeting the
 4

Figure 2. Emergency Department (ED) dashboard. This At a Glance Tool Depicts LOS (Broken Down into Substeps, such as
Journal for Healthcare Quality

Presentation Time to Resident Time), Volume of ED Patients, Number of Patients in Different Disposition Categories
(e.g., Admitted to Hospital, Discharged Home, Left without Being Seen), and Number of Boarders; by Acuity Level
(Emergency Service Index, ESI)

Note. All the LOS numbers are in minutes.

Figure 3. Current State Value Stream Map (VSM), Emergency Department (ED) Visit from Patient Arrival to Discharge. Those
Involved in the Process are Listed along the Left-Hand Side in Blue Boxes. Similar to a Swim-Lane Flowchart, the VSM
Shows the Staff Involved at Each Stage of the Process by Arranging the Steps (e.g., Yellow Boxes) in the Process in
Imaginary (Swim) Lanes Aligned with the Left-Hand Column of Staff Members. Examples of Waste (Depicted in Pink
Boxes) Include Patient Waiting and Excess Walking Time for Staff
Vol. 00 No. 0 xxx 2014
5
6 Journal for Healthcare Quality

Table 1. Observations from Go-See

Emergency department (ED) Nurses do a lot of walking to take patients back in the patient rooms
triage area Lack of effective way to call patients to next area
Nurses did not always have thermometers
Nurse using manual blood pressure equipment
Lack of standardized work
Nurse care technicians not always available
Triage status board cannot be seen from triage rooms
ED Poorly organized
All physicians in just one area
Physicians observed sitting at desks during a busy period
Physicians are not connected to patient flow
Radiology Long wait times
Does not change staffing to accommodate ED workload
Laboratory Uses two computer systems
Processes and stores extra tubes sent from the ED
Has trouble communicating with ED

triage goal and contributed to reduction of the
average LOS.
During the go-see, it was noted that ED staff
members were sending extra blood samples to
the laboratory, which required additional labo-
ratory resources to process and therefore con-
tributed to LOS. Although the intent of the
practice was to prevent repeated blood draws
in the event that physicians ordered more tests,
data collected by the team revealed that the
need for extra tests was infrequent. Based on
this finding, the fourth small change (suspend-
ing the practice of collecting extra blood sam-
ples) further supported decreases in the ED
LOS.
To understand the contribution of turn-
around time (TAT) for radiologic procedures
on the LOS of ED patients, the radiology
department began collecting ED-specific TAT
data for imaging studies. More precisely, the ra-
diology department started maintaining a log
to document delays in the completion of imag-
ing studies for ED patients. Through discussion,
review of radiology data, and go-see findings, ra-
diology found that abdominal CT scans repre-
sented a bottleneck that could be improved.
In particular, patients receiving abdominal CT
scans with contrast were identified as a signif-
icant blockage to CT scan patient flow. Team
brainstorming and discussion about this bottle-
neck resulted in changes to the radiology pro-
tocol, including not automatically giving con-
trast to patients receiving abdominal CT scans.
This fifth change decreased the time required
to receive a CT scan and contributed to further
reductions in average ED LOS.
Figure 4 displays a snapshot of LOS (for ESI
level 4 and 5 patients) during the course of this
project. To illustrate how the impact of spe-
cific changes on LOS would have appeared to
the team, the pre- and postintervention metrics
are depicted for the first two of the five small
cycles of change projects. Progress toward the
goal could be monitored by comparing whether
current performance fell into the shaded areas.
For comparison, the metrics at baseline and at
the two goal dates also are shown. By December
2009, process changes produced a 30% reduc-
tion in LOS for patients with ESI levels of 4 and
5, and by April 2010, there was a 48% reduction
in LOS for ESI level 5 and a 37% reduction for
ESI level 4.
Discussion
The purpose of this project was to reduce the
LOS for patients who were treated and dis-
charged from a busy academic medical center
ED. The use of lean philosophy and tools led
to an approximately 48% and 37% reduction
in the average LOS for ESI level 5 and 4 pa-
tients, respectively, over a 4-month period. No
evidence of unintended consequences was ap-
parent in other ED metrics charted over the
same time period (Figure 5). Patient volumes
remained high, as did the percentage of ED ad-
missions to the hospital and patient satisfaction.
The percent of leavers (e.g., patients who left
without being seen) fluctuated from 1.1% to
11.7%.
Key lessons learned from this project in-
clude the importance of monitoring metrics,
 Vol. 00 No. 0 xxx 2014 7

Figure 4. Average Length of Stay (LOS, Minute), Acuity Levels 4 and 5. This Run
Chart Depicts the Change in LOS over the Project Period. Although the
Temporal Information Is Displayed, the Time Frame Displayed on the
Horizontal Axis is Not to Scale. The Goals Areas for Each Acuity Level
Are Shaded

communicating with teams and target pop-
ulations, learning from initial failures, using
small wins to increase momentum, and anchor-
ing changes. Staff members were resistant to
change, and it took time for them to feel that
changes needed to be made. Communicating
meaningful metrics and involving the process
owners in problem-solving was critical to our
success. For example, when the appropriate-
ness of triage was called into question, a triage
subteam was charged with examining the pro-
cess. The triage subteam identified a need for
training in assigning acuity as well as gener-
ated ideas for improving signage, reducing staff
movement, and improving communication.
For the first small cycle, the team decided
to focus on the lowest acuity (ESI 5) patients.
Although few level 5 patients are seen, the pro-
posed change was viewed as likely to impact
other patients by increasing the availability of
nurses and beds. Initially involving the treat-
ment of level 5 patients in the triage area, the
initial pilot showed only a slight improvement
during the first week. When minor changes in-
spired by target population feedback did not
improve outcomes, the pilot was abandoned
during the second week. As the team discussed
the pilot, lack of physician buy-in was identi-
fied as a critical barrier. A closer examination
of the process revealed that physicians often
8 Journal for Healthcare Quality
Figure 5. Emergency Department (ED) Performance Metrics during Project
Period. Depicted on this Run Chart Are Other Critical ED Metrics
during the Project Period
100
90
% Paents rang overall
care as "Excellent"
80
ED Volume
70
60
50
% Admied
40
30
20
% Leavers
10
0 1,500
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
were occupied and not available to treat level 5
patients in the triage area. Learning from this
feedback, the department chair reiterated to
physicians the projects goal of providing the
best care to patients. The next change, which
included the introduction of a flow nurse to
ensure proper triage and help patients navigate
the ED, proved to be a success in large part be-
cause it responded to issues identified during
implementation of the first change.
A larger impact on LOS was realized with
the chair-centric model (Figure 6) to add ca-
pacity and thereby decrease LOS. Although this
change did not require additional resources for
capital expenses (e.g., existing furniture and
equipment was used), approval did take time to
secure. During the wait, the team maintained
momentum by developing guidelines and a
staffing schedule. The new staffing schedule
employed existing personnel and resulted in no
net changes in total personnel costs. The model
was piloted on ESI 4 and 5 (and, when appro-
priate, some ESI 3) patients. Care was provided
by a dedicated physician, nurse, and nurse
care technician. The planning, approval, and
2,500
2,400
2,300
2,200
2,100
2,000
1,900
1,800
1,700
1,600
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
launch of the chair-centric pilot took 6 weeks to
complete.
The chair-centric model was continuously re-
vised based on feedback collected during the
pilot. For example, the target population rec-
ognized that the guidelines regarding what type
of patient would be appropriate for treatment
in the chairs was not sufficient, as patients with
higher acuity were sometimes placed in chairs.
The downstream effect of this misuse became
manifest when chairs were filled with high-
acuity patients, causing lower acuity patients
to wait or to be placed in a bed. This prob-
lem was solved with education and continued
reminders in the ED newsletter. Another issue
with the chair-centric model concerned patient
privacy. This problem was remedied by separat-
ing chairs as much as possible and muffling the
conversation with music. Additionally, a script
was prepared for staff members to recite to pa-
tients who were directed to the chair-centric
area, stating that they could be seen faster in
a chair rather than waiting for a bed and, if
needed, they would be moved to a bed and that
conversations in that area were not completely

Figure 6. Chair-Centric Model in the New ED. A Photograph of the Chair-Centric
Model in the Facilities New ED (Photo Taken September 2010)
private. If they preferred a bed, then one would
be provided as soon as possible. Finally, signage
was displayed in the chair-centric area, indicat-
ing that it was not a private space and that pa-
tients could request to be seen in a private area.
Initial physician resistance to the chair-
centric model was overcome during the pilot
test by providing consistent messages about the
importance of adopting the patients perspec-
tive on the triage process. An area was identi-
fied for private examinations and consultation,
and a process for escorting the patients back
and forth between areas was established. This
process increased the efficient use of the chair-
centric area for patients who needed private
examinations.
Given the importance of sustaining improve-
ments, the team completed tasks to anchor
changes into standard workflows. For exam-
ple, protocols for laboratory and radiology or-
ders were updated, and changes were commu-
nicated to all ED staff via reminders in the ED
newsletters. To ensure the staffs understand-
ing of the importance and impact of ceasing to
send extra blood samples to the laboratory, re-
minders included data on the number of times
extra tests were ordered and the time and re-
Vol. 00 No. 0 xxx 2014 9
sources spent by the laboratory to process the
extra samples.
Implications and Recommendations
This project necessitated significant stake-
holder and target population input and buy-in
to ensure success. The initial meeting with ED
administration and the executive sponsor to ob-
tain approval of the A3 report and determine
appropriate baseline metrics assured a smooth
launch of the project. The project required sup-
port for the team to get them through the chal-
lenges of data collection and continued moti-
vation throughout the project timeframe.
Every lean project should begin with identify-
ing a measureable aim with a specific deadline.
It also is important to have support from top-
level executives in the organization to ensure
buy-in from staff members who might other-
wise perceive new projects as extra work that
does not support larger organizational goals.
Securing baseline metrics before launching the
project is vital, as is ensuring data integrity and
developing a means of monitoring and com-
municating progress through small cycles of
change to motivate continued efforts.
10 Journal for Healthcare Quality
This project provided opportunities to
strengthen future process improvement efforts.
One such opportunity concerned a limitation
associated with metric selection. Although the
ED team successfully identified and monitored
a quantifiable metric (LOS), the subsequent
statistical analysis was limited because the team
retained only the average daily LOS data. This
experience provided a concrete example of the
importance of preserving raw data for poten-
tial follow-up analysis as well as ongoing per-
formance monitoring. Additionally, the project
was completed without the direct input of pa-
tients. The project team framed the improve-
ment process from the patients perspective in
order to help align the interests of all stake-
holders and reduce resistance to change; how-
ever, involving patients in actual data collec-
tion and construction of the VSM might have
enhanced the teams ability to achieve patient-
centeredness goals as well as changes in clini-
cal metrics (LOS). Despite the limitations they
pose to the current project, these experiences
provide concrete strategies to improve future
improvement initiatives and change implemen-
tation efforts.
Using small cycles of change and celebrating
progress toward goals can help maintain the
momentum of a team involved in a long-term
quality improvement project. The success of the
project was recognized at UK HealthCare. After
achieving the targeted 30% reduction in aver-
age LOS in December 2009, the ED celebrated
by recognizing all staff members involved in the
project. The results of the project were used
to inform the redesign of the ED in the new
UK HealthCare Hospital that opened in May
2010. The culture of improvement cultivated
by this project has continued to thrive in the
ED as metrics are monitored and new projects
are launched.
Acknowledgments
We are grateful to the members of the ED Op-
erational Efficiency Project team for their sup-
port on this project and their continued efforts
to improve patient care. We acknowledge and
thank Arik D. Schadler for his methodological
consultation, Margaret McGladrey for her ed-
itorial assistance, as well as the reviewers for
their insightful feedback. Their support was in-
strumental in assisting our efforts to share the
results of the project team.
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Authors Biographies
Dr. Amit Arbune is completing his internal medicine resi-
dency at St. Elizabeth Health Center (Youngstown, OH) af-
ter earning a masters degree in Health Administration at
the University of Kentucky (Lexington, KY). During this
project, he was completing an internship with UK Health-
Cares Center for Enterprise Quality and Safety (Lexington,
KY).
Dr. Sarah Wackerbarth is an Associate Professor of Health
Management and Policy at the University of Kentuckys
College of Public Health (Lexington, KY). She is a faculty
member in the masters degree in health administration pro-
gram and completes healthcare process improvement projects
and research.
Penne Allison was the Director of Emergency/Trauma Ser-
vices at University of Kentucky Chandler Hospital, UK
HealthCare (Lexington, KY) during this project period. She
currently serves as Vice President at Memorial Health Uni-
versity Medical Center (Savannah, GA).
Dr. Joseph Conigliaro currently serves as Division Chief,
General Internal Medicine at the North Shore-LIJ Health
System (Manhasset, NY) and Professor of Medicine at the
Hofstra North Shore-LIJ School of Medicine (Hempstead,
NY). During this project, he directed UK HealthCares Cen-
ter for Enterprise Quality and Safety (Lexington, KY).
For more information on this article, contact Sarah Wacker-
barth at sbwack0@uky.edu