Using Lean methodology to improve admission processes: HM17 case study

Hospital Medicine 2017 brought hospitalists and other healthcare professionals together at Mandalay Bay Resort and Casino in Las Vegas from 1 to 4 May 2017. The conference offered research, practical guidance and continuing medical education across hospital medicine, patient care and clinical innovation. Its programme included Using Lean Methodology to Improve Admission Processes: HM17 Case Study, which examined how a structured approach to workflow can reduce delays while preserving clinical judgement. Learn more about Managing Acute Kidney Injury In The General Ward Updated Criteria From The Meeting.

For Australian clinicians, the subject is immediately relevant. Public hospitals in Melbourne, Sydney and other metropolitan centres operate under sustained emergency department pressure, including the national Emergency Department Access Target of seeing 70 per cent of patients within four hours. Smaller regional services face a different problem: limited staffing, reliance on telehealth and transfers to larger centres. The same improvement method must therefore work across very different markets, budgets and clinical environments.

The transferable lesson from HM17 is that admission delay is rarely a single failure. It is usually the visible result of fragmented decisions, unclear ownership, interrupted handovers and workarounds created under time pressure. Lean methodology helps teams examine that work, identify waste and test safer ways to coordinate care without treating speed as the only measure of success.

Start with the patient journey

A Lean case study should begin with the actual pathway followed by patients, not with the organisation chart. Teams need to follow a referral from the emergency department or general practitioner through assessment, admission, bed allocation and transfer to the ward. Every wait, repeated question, telephone call and undocumented decision should become visible. The HM17 archive’s Jackpot Celebration Casino feature provides a useful service-industry parallel: high-volume operations depend on clear handoffs, visible demand and reliable standard work.

The improvement team should then distinguish essential clinical steps from activities that add no value to the patient. A duplicate phone call may be necessary when information is missing, but it becomes waste when two teams collect the same details. Likewise, a bed request sent before the patient is medically ready can distort decisions across the hospital. Mapping makes these system failures observable and therefore more likely to be corrected.

Set a narrow improvement aim

A strong aim gives the team something specific to test. The scope might be referrals from the emergency department to the medical assessment unit, rather than every admission across the hospital. A practical aim could reduce the median time from accepted referral to a documented admission decision without increasing transfers, readmissions, missed clinical reviews or complaints.

Measures should cover several dimensions. Operational measures include assessment time, bed-request time, discharge time from the emergency department and ward transfer delays. Clinical measures include deterioration after transfer, unplanned readmission and adherence to specialty recommendations. Patient experience measures can capture whether people understand where they are going, what happens next and who is responsible for their care.

Australia’s mixed public and private health market shapes what can be achieved. Medicare supports public hospital treatment, while private hospitals operate under different admission, discharge and bed-management arrangements. Teams should adapt the case study to their own funding and governance environment rather than importing another jurisdiction’s targets. A measure that works in a major Melbourne hospital may need more local interpretation in a rural Australian service.

Observe the work before redesigning it

Lean improvement depends on direct observation. Clinicians should spend time with emergency department staff, nurses, bed managers, allied health professionals and ward teams to see how admissions actually happen. Interviews reveal reported frustrations, while observation reveals repeated workarounds. For example, a senior doctor may personally chase a bed because the electronic request does not show who owns the next step.

Observations must respect privacy, consent and clinical urgency. The objective is not to judge individuals or slow down care, but to identify where the current process creates avoidable risk. Teams can record the time spent obtaining unavailable information, waiting for senior review and reconciling medication or equipment requirements. These moments often reveal that the delay belongs to the system rather than to one uncooperative department.

Geography should shape the map. In metropolitan Melbourne or Sydney, the main issue may be balancing emergency demand with inpatient capacity. In regional Queensland, a medical assessment may depend on Retrieval Queensland, the Royal Flying Doctor Service or telehealth support. Those transfer pathways require explicit triggers, escalation times and contingency plans. Standard work should remain useful in both settings by defining what happens next, not prescribing one identical pathway for every hospital.

Test changes in short cycles

Once the pathway is mapped, the team should run small Plan-Do-Study-Act cycles. A first test might introduce a structured referral, a daily admission huddle or a bed request that includes expected discharge timing. Each test needs an owner, a starting date, a clearly defined measure and a scheduled review. Small cycles create evidence quickly and allow teams to revise the process before wider implementation.

Clinical evidence must move alongside operational changes. A meeting report on acute kidney injury criteria illustrates why updated diagnostic guidance can affect assessment, escalation and placement. If referral forms, escalation rules and ward responses remain based on outdated criteria, a faster pathway can still direct patients to the wrong service or delay necessary treatment.

Testing should include edge cases as well as straightforward admissions. Teams need to examine medically complex patients, people requiring isolation, frail patients at risk of functional decline and patients whose discharge depends on medication, transport or a residential care placement. A process that performs well for uncomplicated cases but fails under complexity is not a reliable admission system.

Measure flow and safety together

A simple run of waiting times should be paired with balancing measures that show whether quality is being protected. Team leaders can review daily demand, referral volume, acceptance times, assessment outcomes, bed availability and delayed discharges. Run charts make ordinary variation visible and help teams distinguish a genuine shift from normal day-to-day fluctuation.

Safety measures should remain close to the improvement work. Teams should monitor unexpected clinical deterioration, transfers to higher-acuity areas, medication errors, readmissions and staff injuries. Patient feedback also matters, particularly when a streamlined process becomes impersonal. The goal is reliable flow, not the removal of conversations or clinical deliberation that patients genuinely need.

Measurement systems must reflect Australia’s uneven digital maturity. Some services can integrate referral, bed and discharge data in real time; others still rely on telephone calls, spreadsheets and paper task lists. A workable dashboard should use information already available and specify who checks it, how often and what action follows. Standard measures are useful across hospitals, but local thresholds should reflect staffing, geography and service complexity.

Build capability and cultural safety

Lean works when the people doing the work help design it. Medical teams, nursing staff, allied health clinicians, patient-flow coordinators and administrative staff should all participate in testing and reviewing the new process. Champions can support new routines, while leaders provide time, resources and permission to stop obsolete steps. Standard work should explain the purpose of each action so it can adapt to clinical circumstances rather than become a rigid checklist.

Cultural safety needs equal attention. Aboriginal and Torres Strait Islander patients may require additional time, trusted relationships, coordinated communication and involvement of Aboriginal health services or community practitioners. Processes that measure efficiency only in elapsed minutes can miss these needs. Consumer representatives and interpreters should help test whether information, transport and discharge arrangements work for people facing barriers beyond the hospital.

Training should combine practical simulations with daily coaching. Staff need to know who makes each decision, how to escalate delays and what to do when the expected pathway is unavailable. Huddles should surface capacity risks without turning into blame. Over time, teams can turn successful tests into documented standard work and recruit improvement leaders who can support other wards or hospitals in the local network.

Convert the case study into a local test

The HM17 case study should be used as a model for disciplined inquiry rather than copied as a ready-made solution. Its value lies in the sequence: observe the pathway, agree on an aim, test a small change, examine operational and clinical effects, then standardise what works. A local team can reproduce that sequence within a defined service and produce evidence relevant to its own patients.

A ninety-day pilot can provide enough time to establish baseline data, run several improvement cycles and reach a cautious scale decision. The pilot should include daily flow discussions, weekly review of measures and a formal assessment at the end of each month. If results are favourable, the team can extend the work to another ward or referral stream. If results are mixed, the team should analyse why before changing the aim or expanding the scope.

The first concrete step is fixed: within five working days, the medical director, director of nursing and bed-flow coordinator should hold a 45-minute value-stream session, trace ten recent admissions from referral to ward transfer, and record the first test in the local improvement log.