title: Creating a leaner pediatric emergency department: how rapid design and testing of a front-end model led to decreased wait time.
abstract: OBJECTIVE
  To use Lean methodologies and the Model for Improvement to rapidly redesign and pilot test a new pediatric emergency department (ED) front-end model that reduces time to a licensed independent provider to 30 minutes or less.
  
  
  METHODS
  Lean improvement methodologies were applied during a 5-day multidisciplinary model of care redesign event. The new ED front-end model of care included: (1) placement of a registered nurse in the lobby; (2) direct patient rooming with elimination of traditional triage; 3) early documentation of home medications; 4) Team-based immediate assessment; 5) "early Initiation" providers to place orders when a team was not available. An observational, cohort controlled before-and-after study design was used. The new model was tested over 2 pilot periods and compared to a similar period of control days, defined as the "current state."
  
  
  RESULTS
  The ED census and patient acuity were similar during both pilot periods. Eighteen patients were included in pilot 1, and 80 patients were included in the expanded second pilot. Patients seen within 30 minutes improved from a baseline of 33% to 93% in pilot 2. Time to a licensed independent provider, to a room, and to visual assessment by a nurse all decreased. The largest decrease was in median time to provider, from 43 minutes in the current state to 7 minutes during pilot 2.
  
  
  CONCLUSIONS
  Rapid process improvement methodology was used to design and test a front-end model that reduced patient waiting time. Our experience demonstrates the feasibility of employing Lean principles and the Model for Improvement in actual practice environments to rapidly improve care delivery processes in pediatric emergency departments.
authors.affiliation: From the Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA.
authors.forename: Lori E
authors.initials: LE
authors.lastname: Rutman
authors.forename: Russell
authors.initials: R
authors.lastname: Migita
authors.forename: George A
authors.initials: GA
authors.lastname: Woodward
authors.forename: Eileen J
authors.initials: EJ
authors.lastname: Klein
mesh_terms: D017598:Efficiency, Organizational; D004635:Emergency Medicine; D016529:Emergency Nursing; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006749:Hospital Design and Construction; D006776:Hospitals, Pediatric / Q000458:organization & administration*; D006801:Humans; D008962:Models, Theoretical; D010348:Patient Care Team; D010362:Patients' Rooms; D010865:Pilot Projects; D017064:Process Assessment, Health Care; D058996:Quality Improvement; D013997:Time Factors; D014218:Triage; D014861:Washington; D057188:Workflow