Post Module Assignment Submission and Declaration form

The post module assignment submission and declaration form includes guidelines on plagiarism/cheating, use of Automated Source Matching Software, and declaration of originality. The form also includes a critical review of a research article on the effectiveness of lean management strategies in reducing door-to-doctor time in emergency departments. The study provides valuable insights into the application of lean management principles in healthcare settings. The study is relevant for courses related to healthcare management, quality improvement, and lean management.

Post Module Assignment Submission and Declaration form
MODULE TITLE: Quality and Productivity in Health Service Systems
MODULE DATES: 6th-10th November 2017
MODULE CODE: WM087-15 01HO
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Table of Contents
1 CRITICAL REVIEW 4
1.1 Title page and Author as they appear in the paper 4
1.2 Introduction 4
1.3 Summary 5
1.4 Critique 9
1.5 Conclusion 12
2 QUALITY IMPROVEMENT 13
References 15

1 CRITICAL REVIEW
1.1 Title page and Author as they appear in the paper
Improving Emergency Department Door to Doctor Time
and Process Reliability
A Successful Implementation of Lean Methodology
Mazen J. El Sayed, MD, MPH, Ghada R. El-Eid, DHA, Miriam Saliba, MPH, Rima Jabbour,
RN, and Eveline A. Hitti, MD, MBA
1.2 Introduction
The study aimed to determine the effectiveness of lean management methods in
reducing the door to doctor time in emergency situations. The author compared the
effects of lean interventions on the number of minutes that is spent during patient
arrival to a see a doctor, over a period of 20 months. Lean management strategies often
involve organisations to simultaneously exert their efforts in different directions. This
helps in creating improvements that are considered sustainable in the long run. The
length of stay during pre-intervention and post-intervention stages was measured. The
author reported a statistically significant reduction in the mean doctor to door time
measure during post-intervention period. Furthermore, a significant drop was noticed in
the length of stay for admitted and discharged patients. Thus, the study concluded that
lean management techniques were effective in reducing the door to doctor time in
emergency departments (El Sayed et al. 2015).

1.3 Summary
Abstract
Is the topic of the paper appropriate for the journal?
Yes. The topic clearly demonstrates the effectiveness of lean management
principles and philosophy for quality improvement in emergency departments at a
hospital setting. Hence, it is appropriate for the journal.
Is it on an important or significant topic?
Yes. Patient safety is always a matter of concern for all healthcare settings. An
increased door to doctor time results in higher rates of adverse events and increases the
rates of morbidity and mortality. Therefore, implementation of an effective strategy that
reduces this time will help in improving quality of care that is delivered to patients.
What is the authority or expertise of the authors?
The authors were from the Department of Emergency Medicine, American
University of Beirut Medical Centre, Beirut, Lebanon. Thus, they had the expertise to
research on the topic and present the findings (El Sayed et al. 2015).
Does the abstract offer a clear overview of the research article?
Yes. The abstract highlights the primary aim of the research that was directed
towards implementing lean management strategies to reduce the length of hospital
stays and the mean door to doctor duration. The abstract addresses the research
question well. However, it fails to provide detailed information on the research design
and does not mention the number of participants who were recruited for the study
setting. It contains information on the primary outcome and also reports the statistically
significant results that were obtained post-intervention. Although, recommendations
were made on the effectiveness of lean management techniques and the conclusion of
the research study was well explained, there was no mention of the limitations of the
study.
Introduction
Is the purpose of the study clearly identified?
Yes. The article begins with a short overview of lean management procedures
and their application in healthcare settings. The authors provide a clear description of
the different lean management techniques such as, patient flow modification, facility
redesign, and lean thinking target works (Radnor, Holweg and Waring 2012). The
introduction establishes the aim of the paper of removing unnecessary waste or steps in
the journey of a patient through emergency departments. It provides a sound
description of the strategies that can be adopted to reduce the time a patient takes to
arrive at the ED.

Is everything flowing well – do the authors tie up the ideas they bring
up in various sections?
There is a logical flow of information in the study and the authors are able to
correlate the ideas that focus on the key elements needed for implementation of lean
management strategies. The authors clearly describe the factors that influence patient
flow through EDs.
Aim & Objectives
Are these clearly stated?
There exists a small section on the goals of the investigation, which states that
the goal of the study is determination of the effectiveness of lean management
technologies on improvement of door-to-doctor time at tertiary care hospitals.
Do authors clearly define the terminologies they use? Do they define the concepts they
use?
Adequate description of the door-to-doctor time is provided and the authors
clearly establish their ideas. The authors describe the term as the time taken from the
arrival of a patient at the ED to the time when they are examined by a doctor.
Furthermore, they also describe the different lean management techniques that will be
used such as, clear process mapping, leadership involvement, small enhancements and
engaging frontline staff for workforce.
Methodology / Study design/ Plan of study
Is the study design clearly identified?
An extensive explanation is provided on the 3 sections to which the patients
were triaged depending on their age and acuities. All the 3 sections ED1, ED2 and ED3
are well explained. The study design also contained comprehensive information on the
registration and payment options and the dashboard system used in the EDs (El Sayed et
al. 2015).
Are steps of data collection clearly described?
The data collection method is distinctly explained in the article. Data is collected
regarding the time of patient arrival, student time, resident time, intern time, and
attending time. The authors describe the primary outcome as the door-to-doctor time
and the secondary outcome as the length of patient stays. Detailed explanation is
provided on the methods used for collecting data on the primary and secondary
outcomes.
Does the paper include any description of the setting within which the study is
conducted?
The article clearly defines the study design that was conducted at the American
University of Beirut, Emergency Department. It also mentions the number of patients
who visit the ED every year.
Is the intervention they use clearly described?

The authors clearly describe the intervention and state that value-driven lean
techniques were used in place of expense reducing strategies. They also explained the
lean management tools, of which one was based on process mapping the journey of the
patient from arrival to assessment by a physician. Detailed information was provided on
metric baseline, root cause analysis and structural setup. Furthermore, the key
interventions that were implemented on the participants were described in a tabular
form.
What type of statistical analysis was undertaken? Do they give any justification as to
why they used that method of analysis? Do they indicate the significance of the
findings?
The authors make a mention of the fact that the Statistical Package for Social
Sciences, version 21.0, was used for entry and analysis of the data. Although,
information is provided on the types of statistical analysis that was undertake, which
include the Pearson Chi-square test, Student’s t-test, Mann–Whitney U test, the authors
failed to provide justification for the reason for using these methods. The significance of
the findings was adequately described (El Sayed et al. 2015).
Do authors provide a description/ understanding of the population from which the
sample is drawn?
Adequate explanation is provided on the patient population that was recruited
for the study. The authors mention that patients belonging to ED1 section were adults
with high acuity; ED2 were adults with low acuity and those in ED3 were pediatric
patients.
Results / Analysis
Do you feel the results were tied up to what was presented in the literature section?
Yes. The results provided an accurate comparison of the effects of lean
management strategies, at pre- and post-intervention stages. The effects of the
intervention on door-to-doctor time were adequately represented by the results.
Did the finding(s) support what they set out to demonstrate?
Yes. The research findings were able to support the objective that stated that
lean management strategies can reduce the door-to-doctor time in ED.
Can the results shown be applied in different settings?
The door-to-doctor time is a benchmark of Emergency Department services.
Thus, these lean management strategies are effective for application in ED settings.
Further studies need to be conducted to determine their effects on different settings.
Do you agree / disagree with the recommendations made?
I agree with the lean management recommendations that had been made during
the study. Adoption of lean methodologies at Emergency Departments is indeed an
effective recommendation that will reduce door-to-doctor transportation time for
patients.

What were the strengths of the study?
The study strength lies in the use of lean methodology among patients that in
turn shows overall improvement in ED operations and reduction of mean length of
hospitalisation. The study was effective in making modifications based on the age and
acuity of patients (El Sayed et al. 2015).
What were some of the limitations of the study in your view?
The study limitations were associated with use of convenient samples for
examining the impacts of the intervention. Unavailability of research assistants during
overnight shift at post-intervention period was another limitation. In addition, small
sample size might have also contributed to the bias in the statistical results.
References
The references used in the research study were relevant and updated.

1.4 Critique
The purpose of the study was to determine the possible effect of lean
management methodologies on reducing the door-to-doctor time among patients who
get admitted at the Emergency Departments of tertiary care hospitals. The objective or
purpose of the article is relevant as overcrowding in the Emergency Departments has
become a global concern and it affects the quality of health services that are delivered
to the patients. The authors displayed a correct selection of the research question owing
to the fact that increased door-to-doctor time in hospital settings increases the waiting
time for patients and this result in a delay in providing therapeutic interventions to the
concerned patients. Therefore, issues related to providing timely care often arise in the
hospital settings. Furthermore, lean management strategies aim at creating values
without wasting. Thus, they include activities that get coordinated and expanded, while
adding customer value. The authors demonstrated a good practice in applying the basic
principles of lean management to the health scenario (El Sayed et al. 2015).
The key lean management strategies that were applied in this research were
useful in influencing the time it took for patients to report of their health abnormalities
till they were inspected upon by a physician. The nature of the study was a cohort study.
A pre- and post-intervention analysis was carried out to compare the 2 patient cohorts,
who were considered as samples for the ED visits. The authors displayed accordance to
ethical principles by conforming to the Declaration of Helsinki provision. The researchers
carried out the study among patients who had been grouped into three different
emergency departments based on their age and acuity.
The authors demonstrated an accurate application of the lean management tools.
While, they mapped the patient journey from their arrival at the ED to the time they
were examined by a physician, the authors used a Value Stream Mapping to identify and
the value added and non-value added waste time that was generated in each step. In
addition, the authors demonstrated a correct research procedure in establishing a
metric baseline for the door-to-doctor time and the length of stay of patients at
hospitals (El Sayed et al. 2015).
I consider this as a good research step as baseline measurements refer to the
‘before’ measurements. It is imperative for determining the beginning point for the
research study. The metric baseline helped the authors to determine the progress of
their research. Furthermore, they performed a root cause analysis of the bottleneck,
which in turn helped them to understand the various factors that affect the performance
of their research system, thereby assisted them to identify the root cause of the major
issues.
Although, the researchers focused on optimizing several factors such as,
responsibility of the staff present at the Emergency Department, recruitment of staff,
dashboard tracking communication system and the physical environment, the sample
size was very small. The inability of the researchers to enroll adequate patients who visit
the Emergency Department, might have contributed to the occurrence of differences in
the statistical results, during the pre and post-intervention period.
A larger sample size would have enhanced the data analysis, particularly when the
researchers were looking for the effects of the lean management strategies on the door-
to-doctor time.
Furthermore, 2 research assistants documented the patient arrival time, attending
time and resident time among 252 patients, prior to the lean management intervention,

and among 135 patients after the intervention. The statistical differences in the results
would have been more significant if similar number of patients had been compared
during the pre and post-intervention period. One correct research methodology was
related to the inclusion of patients from all the 3 hospital shifts during all days,
throughout the week.
The primary outcome, door-to-doctor time was accurately measured by
calculating the time from which the patient walked in to the ED till the time a physician
attended the patient. The researchers also demonstrated a good research methodology
in retrieving the length of hospitalization from QlikView, electronic business intelligence
software. The software calculated the difference between the electronically recorded
registration time and the discharge time from the ED. In addition, the study was also
correct in collecting the number of patient complaints for a period of 6 months, prior to
and after the completion of the intervention. This acted as a follow-up period.
Although, the researchers used several statistical tests and software to measure
the significance of the observed results, it was necessary to provide a justification for the
use of student’s t test and Pearson chi square test. Adequate justification would have
been helpful in establishing their reliability.
The results were accurately represented in the study and a significant
improvement was observed in the mean door-to-doctor time. It showed a considerable
reduction by 37% during the post-intervention period. Thus, the research findings
suggested that the researchers were able to accurately implement lean management
strategies at the Emergency Departments. Improvements in other ED operation metrics
during the post-intervention period also suggest that the research methodology was
carried out accurately.
Although, other studies failed to demonstrate the effectiveness of lean tool
implementation on the door-to-doctor time at Emergency Departments, this study was
effective in showing its effects. Furthermore, it can also be stated that some studies that
created fast tracks for low acuity patients displayed a reduction in waiting time, only
among patients who suffered from less complications. However, this study was
successful in reducing the waiting time for patients in all sections and provided
statistically significant improvements among patients who faced more delays during the
pre-intervention period. Moreover, the 31.6% reduction in door-to-doctor time,
demonstrated by this study was greater than previously reported findings. Therefore, it
can be stated that the authors carried out the study efficiently and were successful in
obtaining results that were in accordance with their objectives (El Sayed et al. 2015).
Furthermore, the research was first of its kind that investigated the impact of lean
methodologies on the reliability of the intake process of Emergency Department, which
was measured by the door-to-doctor time. The reliability of the study was also
established by the presence of upper and lower control limits during the post-
intervention period of the research. The cumulative change end results also helped in
concluding that the research was a high reliability process.
Thus, it can be stated that the lean management strategies were successful in
reducing the waiting time, owing to the presence of different factors such as, presence
of a multidisciplinary team at the ED that was ready to accept changes made in the
management. In addition, equal levels of engagement from the key stakeholders and
frontliners also ensured effective implementation of the strategies.
The fact that the researchers created provisions for the medical and nursing staff
to provide timely feedback also increased the effectiveness of the intervention. The

authors also demonstrated a good research practice in securing support from the top
management for their research initiatives. Although convenience samples were used for
the study, bringing in more samples from the overnight shift would have resulted in
more significant results.
In addition, use of advanced electronic information system for measuring the door
time and doctor time would have reduced the manual labour as well as time. The
authors should also have measured the impact of the reduction in waiting time on
overall patient satisfaction, after they had been discharged from the ED.

1.5 Conclusion
The lean manufacturing strategies were originally formulated by Taiichi Ohno,
father of Toyota Production System. These principles were based on systematic methods
that were related to waste minimisation without hampering the productivity. Although,
the lean management principles were initially designed with the aim of eliminating
automobile production inefficiencies, they have recently been applied to healthcare
settings as well. The implementation of lean management strategies at the Emergency
Department of the American University of Beirut, was effective in producing shorter
waiting time at the Emergency Department (ED).
The research was carried out in the ED that had more than 49,000 annual visits of
patients and a series of lean management principles were applied over a time period of
20 months. While, they measured the mean door-to-doctor time as the primary
outcome, the secondary outcome was based on the length of hospitalisation for patients
who were either admitted or discharged. On comparing convenience samples from the
pre-intervention and post-intervention period helped in evaluating the effects of the
implemented strategies.
A statistical analysis of the observations showed that there was a significant
decrease in the mean waiting time during the post-intervention period (40.0
minutes±53.44 versus 25.3 minutes±15.93 P<0.001). In addition, drop in upper control
limits during the post-intervention period was also effective in demonstrating the
benefits of the implemented principles. A considerable reduction in the length of
hospital stays also suggests that the lean management strategies were effective in
eliminating factors that resulted in the wastage of time, money and effort. This can be
attributed to the fact that a reduction in the length of stay at hospitals considerably
reduced the associated healthcare costs as well.
Thus, this systematic method can be applied at real time hospital settings to reduce
patient waiting times at EDs and can therefore help in enhancing the quality of care
provided to patients.

2 QUALITY IMPROVEMENT
Fall and injury prevention continues to be a considerable challenge across the care
continuum. This is a persistent problem. More than 7.7% of the total population of India
is made up of people aged more than 60 years. Such patient falls are defined as
unplanned descents to a floor that may or may not cause injury to the patient. These
incidents often result in lacerations, fractures, and internal bleeding. This leads to an
increase in the utilisation of healthcare services. However, evidences from research
shows that one-third of such falls in hospital settings can be prevented (Dsouza et al.
2014).
Therefore, quality improvement interventions or strategies are required to reduce
the incidence of such falls among patients across healthcare service centres in India. Fall
prevention strategies need the adoption of an interdisciplinary care approach to care.
There is a need to develop a highly structured fall prevention care practice. Adopting a
lean management technique will help in tailoring to the specific risks of each patient.
Lean principles will help in eliminating activities that do not provide excellent patient
care (Loria and Bhargava 2013).
Such management techniques will also focus on the adoption of technologies that
will reduce manual labour and will utilise technology that will improve the overall
efficiency of the hospitals to reduce the rates of inpatient falls. Furthermore, these lean
principles will empower the healthcare employees in India to directly interact with the
patients, rather than relying on the administration or management (Radnor, Holweg and
Waring 2012). Thus, it can be said that the fall management program is a major quality
improvement approach that can be adopted in Indian healthcare settings.
Patient safety is a top priority for all hospitals across India. The ultimate goal should
be prevention of events that can create negative impacts on patient stays at the
hospitals. Owing to the fact that patient fall rates are quite high in the country, attempts
should be taken to embark on lean management techniques that would help in
preventing such falls (Teich and Faddoul 2013).
Although several measures have been taken in the hospital settings, patient falls are
a major problem. Therefore, a robust lean management methodology should be applied
for measuring the factors that contribute to patient falls. Evidences from research state
that the hospital staff often faces competing priorities. Patient falls are generally
encountered when the healthcare teams fail to embed standard quality of service in the
workflow (Gowen III, McFadden and Settaluri 2012). The Six Sigma Lean Fall Project can
be implemented at Indian hospitals, in the form of a fall reduction initiative.
This lean management tool can be applied in hospitals by forming separate teams
that would understanding the basic principles of designing, measuring, analysing,
improving and controlling the processes, concepts of care mapping, and analysis of data.
The frontline staff can be engaged in using the Morse Fall Scale across all geriatric wards
for assessing and evaluating the likelihood of a patient towards falling (Forrest et al.
2013). The frontline staff comprises more than 80% of the workforce at hospitals. They
can be engaged in determining in using the pain assessment scale by valuing the unique
patient insight that they gain, while working closely with the latter.
Creating provisions that would enable the workforce to provide regular feedback
will also help in increasing their participation in monitoring risk factors associated with
inpatient falls. Patients with low fall risk will be subjected to universal fall precautions.
On the other hand, patients who show an increased likelihood of falls will be subjected

to a robust plan of care. The engaged staff will help in creating provisions for increased
rounding, thereby preventing fall related injuries.
Other lean management tool that can be applied in this context includes readiness
for change. It is necessary to implement readiness for change in healthcare
organisations as that would help the hospital administrators to initiate changes, exhibit
greater persistence, and exert more effort and cooperative behaviour in order to
prevent the occurrence of inpatient falls (Drotz and Poksinska 2014). The hospital
authorities are often not aware of the fall prevention requirements and fail to
implement them properly. Creating awareness on the harmful effects upon patients due
to such falls and facilitating their understanding of the existing procedures and policies
will act as an essential fall prevention strategy. More engagement from the workforce
will help in effective implementation of the fall prevention procedures.
Furthermore, the other lean management tool that can be applied in this context
encompasses enhancements that are sustainable over the long term.
Research evidences suggest that alarm malfunctioning, staff alarm fatigue, failure to
activate the alarm on time, patients showing noncompliance to alarms are some of the
risk factors that increase the likelihood of fall related injuries (Heinze, Dassen and
Grittner 2012). Thus, using enhancements such as, installation of bed rails and alarm
systems will acts as important lean management tools, which will help in preventing
patient falls in hospital settings. The mobility needs of respective patients can be written
on the whiteboards present in each room and can be highlighted, in order to distinguish
them from other information.
Hospital side rails or bed rails can be installed in the geriatric wards. This will
prevent bedridden or hospice patients from falling or rolling out of the beds, thereby
showing a reduction in fall among the elderly. An engaged workforce will help in
increasing the adaptability of patients to the adjustable beds, thereby reducing their
discomfort and preventing falls (Chadha, Singh and Kalra 2012). Therefore, this lean
management tool will help in maintaining patient safety.
Keeping the hallways clutter free and ensuring that the lighting in the wards and
bathroom is adequate, will also acts as lean management tools that will provide benefits
in the long run. Often the hallways of Indian hospitals are cluttered with excess hospital
supplies or equipments (Flores 2012). Moreover, absence of adequate lighting in the
bathrooms also contributes to a considerable amount of patient falls. Therefore, all
excess equipments or furniture should be removed from the hallways and from the path
between the bed and the bathrooms.
Furthermore, assuring the presence of adequate lighting and placing signage to
indicate the presence of wet floors can also be implemented as effective lean
management tools in Indian hospitals (Díaz, Pons and Solís 2012).
Thus, it can be stated that applying lean management strategies encompass a long
term approach that would bring about continuous improvement of the hospitals and
help in quality improvement of patient falls in hospital settings.

References
Chadha, R., Singh, A. and Kalra, J., 2012. Lean and queuing integration for the
transformation of health care processes: a lean health care model. Clinical Governance:
An International Journal, 17(3), pp.191-199.
Díaz, A., Pons, J. and Solís, L., 2012. Improving healthcare services: Lean lessons from
Aravind. International journal of business excellence, 5(4), pp.413-428.
Drotz, E. and Poksinska, B., 2014. Lean in healthcare from employees’
perspectives. Journal of health organization and management, 28(2), pp.177-195.
Dsouza, S.A., Rajashekar, B., Dsouza, H.S. and Kumar, K.B., 2014. Falls in Indian older
adults: a barrier to active ageing. Asian J Gerontol Geriatr, 9(1), pp.1-8.
El Sayed, M.J., El-Eid, G.R., Saliba, M., Jabbour, R. and Hitti, E.A., 2015. Improving
emergency department door to doctor time and process reliability: a successful
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Flores, E.K., 2012. Falls risk assessment and modification. Home Health Care
Management & Practice, 24(4), pp.198-204.
Forrest, G.P., Chen, E., Huss, S. and Giesler, A., 2013. A comparison of the functional
independence measure and morse fall scale as tools to assess risk of fall on an inpatient
rehabilitation. Rehabilitation nursing, 38(4), pp.186-192.
Gowen III, C.R., McFadden, K.L. and Settaluri, S., 2012. Contrasting continuous quality
improvement, Six Sigma, and lean management for enhanced outcomes in US
hospitals. American Journal of Business, 27(2), pp.133-153.
Heinze, C., Dassen, T. and Grittner, U., 2012. Use of physical restraints in nursing homes
and hospitals and related factors: a cross sectional study.‐ Journal of clinical
nursing, 21(7 8), pp.1033-1040.‐
Loria, G. and Bhargava, A., 2013. Prevention of patient falls–A case study. Apollo
Medicine, 10(2), pp.175-180.
Radnor, Z.J., Holweg, M. and Waring, J., 2012. Lean in healthcare: the unfilled
promise?. Social science & medicine, 74(3), pp.364-371.
Teich, S.T. and Faddoul, F.F., 2013. Lean management—the journey from Toyota to
healthcare. Rambam Maimonides medical journal, 4(2), e0007.