Since the introduction of lean in 2017, the Emergency Department of the Hospital Comarcal de l'Alt Penedès (HCAP), which is part of the Consorci Sanitari Alt Penedès-Garraf, has undergone a major overhaul of its operations.

Our emergency room, which receives about 200 patients daily, needed to find a way to better utilize the limited space available. As a first step in our Lean process, we did a Value Stream Mapping exercise, which gave us a better understanding of the process and the need to reorganize our spaces.

We had patients waiting in the two largest rooms in our emergency room without regard to their condition, while two other rooms were used for patients who needed to be admitted and patients who had completed their treatment and could be discharged soon. The system did not work, because it meant that we had to sacrifice precious space that could have been used for patient examinations - a particularly big problem at peak times. So we decided to divide our work spaces by condition.

Our approach to triage was also in need of renewal. It was based on specialties: we triaged patients not based on how long they should wait given their condition, but on whether they should see a specialist. It was not the best model of what triage should be, and frictions and discussions between team members were commonplace. We corrected the focus of Triage - reducing to wait times - which allowed us to speed up care significantly.

Another important realization for us was that we were not working in teams. Doctors and nurses had no relationship while doing value-added work, and communication was scarce. So we created EDITs (Emergency Department Integrated Team), with one doctor and one nurse, to work more closely together. Another action was to define their responsibilities more clearly. For example, transferring patients is no longer the prerogative of doctors, but of nurses. We also avoid batching processes and instead try to work in a single flow. More importantly, we can now assign a physician and a nurse to a patient as soon as they enter the emergency room. This has really changed everything, because it means our patients no longer have to wonder who is going to take care of them and our doctors and nurses know exactly what they need to work on. The work is now better distributed and the service to our patients has clearly improved. In fact, all of our KPIs have improved.

Even though the introduction of Lean Thinking was a shock to many in the emergency room (it is difficult to move away from old ways of working), the change the methodology has brought about is incredible.

The authors