The Definitive Guide to Emergency Department Operational Improvement: Employing Lean Principles with Current ED Best Practices to Create the “No Wait” Department, 1st Edition (Paperback) book cover

The Definitive Guide to Emergency Department Operational Improvement

Employing Lean Principles with Current ED Best Practices to Create the “No Wait” Department, 1st Edition

By Jody Crane, MD, MBA, Chuck Noon, PhD

Productivity Press

353 pages | 262 B/W Illus.

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In a unique and integrated approach, The Definitive Guide to Emergency Department Operational Improvement: Employing Lean Principles with Current ED Best Practices to Create the "No Wait" Department exposes you to the academics behind managing the complex service environment that is the ED. The book combines applied management science and ED experience to create a model of how to improve your emergency department operations.

After summarizing the current state of emergency medicine, the book offers an in-depth presentation of Lean tools used in the ED along with basic and advanced flow principles grounded in queuing theory and the theory of constraints. It then shows how these concepts are applied in the emergency department and why they work, supported by a comprehensive case study in which Lean principles were used to transform an underperforming ED into a world-class operation.

The authors highlight three commonly referenced intervals in the ED: door to doc (input), doc to disposition (throughput), and disposition to departure (output). After reviewing best practices, the authors explain how to achieve excellence in your own environment by discussing change management, leadership, dealing with resistance, and other critical elements of creating a culture of change. Under any scenario realized by healthcare reform, this book provides the tools and concepts to improve your ED for patients, staff, the organization, and ultimately, society.


… for practical reasons there is value in translating TPS to the healthcare arena. Jody Crane and Chuck Noon do this well, providing meaty examples and a level of technical depth that go beyond other Lean healthcare books that I have seen.

—Jeffrey K. Liker, Professor of Industrial and Operations Engineering, University of Michigan, and Shingo Prize-Winning Author of The Toyota Way

… this book will help you and your leadership team create a culture where ‘a community of scientists’ continually improves and better serves patient, hospital, and societal needs— improving quality while simultaneously reducing cost.

—Mark Graban, MS, MBA, Shingo Prize-Winning Author of Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction

… will open your eyes to cutting-edge concepts that drive ED operations…

—Maureen Bisognano, President and CEO, Institute for Healthcare Improvement

Table of Contents

The Current State of Emergency Medicine and the Need for a New Operations Paradigm

ED Overcrowding

Danger Waiting

Hospital-wide Flow

US Healthcare System

The Need for Change

Part I: Academic Topics Critical to Understanding ED Operations

Lean Healthcare

Introduction and History of Lean

Patient Value

Service Families and Value Streams

Value Stream Mapping


Seeing waste from the patient’s perspective

7 wastes

Lean Tools Critical for ED Operations

Workplace Organization/5S

Visual Workplace

Standard Work


Inventory and Supply Management

Flow in Healthcare Systems

Flow in Healthcare Settings

Queuing Theory


The Simple Queue

Arrival Rate

Arrival Distribution

Poisson Distribution Pattern

Service Rate

Service Distribution

The Effect of Variation in Healthcare

The Effect of Server Utilization in Service Industries with Diverse Variation Patterns

Achieving Lean Flow

The Approach to Reducing Flow Times through Queues

Reducing Arrival Rate

Reducing Variation in Arrivals

Reducing Service Times

Reducing Variation in Service Times

Adding Capacity

Using Data and Simulation to Solve Complex Queuing Problems in Healthcare

Examples of Applied Queuing in ED Settings

Healthcare as a Network of Queues

Patient’s Perspective

Server’s Perspective

Conservation of Flow

Volunteer Walk-in Clinic

Approach to Reducing Waiting Through a Network of Queues

Lean Design in Queuing Networks

Principle 1: Reduce the Number of Queues

Combining Steps


One-Piece Flow

Principle 2: Pooling

Principle 3: Pull Systems

Principle 4: Segmentation

Reduction of Service Times

Reduction of Variation

Radically Different Segments

The Psychology of Waiting

Part II: A Step-by-Step Guide to Fixing Your Emergency Department

Defining key Intervals in Emergency Operations

Door to Doc





Chief Complaint Based, Directed

Bed Placement

Patient Segmentation

Doc to Decision

Initial RN Evaluation and Assessment

Initial MD Evaluation

Ancillary Services

Patient-specific In-ED Treatment

The Relationship between Service Capacity in the ED

Load Leveling

MD, RN, Bed, Ancillary Balancing

Virtual Beds

Decision to Departure

Decision to Admit to Bed Assignment

Inpatient Utilization as a Function of ED Holds

The difference between Staffed Capacity and Licensed Capacity

Forecasting Demand

Surgical Smoothing

Finding Critical Inpatient Capacity

The Value of Patient Flow Teams

Bed Assignment to Departure


Calling Report – The Games People Play

The Effect of Incentives on Throughput

Faxed Reports

Full Capacity Protocol

Making Change Happen


Change Management

Picking the Right Project

Picking the Right Team

Define Current Process

Analyze the Data

Listen to Patients

Improve Process

Define Future Process

Rapid Cycle Testing


Dealing with Resistance


Case Studies in ED Improvement

Mary Washington Hospital

Ochsner Health System

Banner Health

Florida Hospital





About the Authors


Jody Crane

Fredericksburg, Virginia, United States

Learn more about Jody Crane >>

About the Authors:

Joseph T. Crane, MD, MBA is one of the nation’s leading experts in emergency department (ED) operations. He is an emergency physician practicing at Mary Washington Hospital in Fredericksburg, Virginia. In addition to his clinical responsibilities, from 2002 to 2009, he served as the business director of his group, Fredericksburg Emergency Medical Alliance. In 2004, he graduated from the Physician Executive MBA Program (PEMBA) at the University of Tennessee, where he is currently an adjunct professor teaching physician-led operations improvement.

Dr. Crane’s work focuses on innovative approaches to ED and hospital-wide operational and patient flow improvement, specifically addressing the application of Lean manufacturing concepts within the healthcare environment. He also specializes in leadership and change management for operational and clinical improvement. Dr. Crane is an emergency medicine faculty member of The Institute for Healthcare Improvement. His company, X32 Healthcare, teaches and consults with organizations on process improvement using Lean applications. Through these engagements, Dr. Crane has worked with hundreds of EDs from around the world on adopting innovations in the delivery of emergency care. He has taught and worked in a wide variety of settings in the United States, Canada, Europe, South America, and the Middle East, including courses or sessions at The University of Tennessee, The University of Kansas, George Mason University, and Harvard University.

Charles E. Noon, PhD is a professor of management science in the College of Business at the University of Tennessee. He is a founding member of the highly ranked Physician Executive MBA Program and continues to teach in the program. He holds a PhD in industrial and operations engineering from the University of Michigan. His teaching interests include operational improvement, business modeling, simulation, and decision analysis and support. His applied research concerns computer-based models and process improvement, and his papers in these areas have appeared in Interfaces, Journal of Healthcare Management, and Networks and Spatial Analysis. Dr. Noon also teaches in the full-time MBA program, the Management Science PhD program, and various nondegree executive education programs, including a new offering entitled Lean for Healthcare. He is the recipient of numerous teaching awards and serves as a teaching mentor for junior faculty. To stay current, he periodically consults with hospitals on process improvement, capacity planning, and staff scheduling.

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Quality Control
BUSINESS & ECONOMICS / Industries / Service Industries
MEDICAL / Administration