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Cited by 516Emergency and Acute Care StudiesHealthcare Operations and Scheduling OptimizationHealthcare Quality and Management

Lean Thinking in Emergency Departments: A Critical Review

Open access
Holden, Richard J.·2011·Annals of Emergency Medicine
DOI 10.1016/j.annemergmed.2010.08.001PMC PMC6548198
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Abstract

Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking. This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space. Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change. Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.

AI snapshot

Written from the paper’s full text.

TL;DR

This critical review of 18 papers on Lean implementation in 15 emergency departments in the US, Australia, and Canada found that Lean usually improved ED processes and patient care metrics such as length of stay, waiting times, and leaving without being seen, but quality/safety and employee outcomes were rarely measured. Success appeared contingent on frontline staff involvement, management support, and readiness for change, while many questions remain about Lean’s effects on patient health and employees.

Key findings

  • Across 18 papers describing 15 EDs, Lean produced numerous process changes—often separate patient streams, fast track, triage redesign—and structural changes such as new technologies, communication systems, staffing changes, and physical space reorganization.
  • Patient care usually improved: many EDs reported decreases in length of stay, waiting times, and proportion of patients leaving without being seen; few null or negative patient care effects were reported. However, patient quality or safety outcomes beyond patient satisfaction were rarely reported, and safety was measured only indirectly in one study.
  • Employee effects were rarely discussed or measured systematically; some studies indicated positive effects on employees and organizational culture, but only one study measured staff satisfaction and did not report numeric values or statistical tests.
  • Success factors included employee involvement, management support, and preparedness for change; Dickson et al. proposed “context + mechanism = outcome,” with frontline staff involvement and leadership commitment as key contingencies.

Methods

  • Critical review of empirical literature from January 2005 to January 2010, searching PubMed, ABI/INFORM, Google Scholar, 12 specific journals, and reference lists; excluded non-empirical papers, conference abstracts, hospital-wide studies, pre-ED triage only studies, and non-English papers.
  • Included 18 articles describing Lean initiatives in 15 EDs, mostly larger teaching hospitals in the US, Australia, and Canada.
  • Used an analytic framework based on human factors/systems engineering and occupational research to generate six core questions about Lean’s effects on ED work structures and processes, patient care, employees, and contingency factors.

Limitations

  • Stated in paper: reviewed studies often lacked quality and safety outcome measures, rarely measured employee effects, and had methodological/reporting weaknesses such as no statistical tests, unreported metrics, no comparison groups, limited longitudinal data, and possible selection bias.
  • Stated in paper: publication bias may explain the dominance of positive results; one reviewed study noted a reporting bias toward positive and often immediate results.
  • Evident from text: only one included study compared Lean across multiple EDs, so contingency conclusions rely heavily on that single case series; the review also excluded non-English and hospital-wide studies, limiting generalizability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.annemergmed.2010.08.001

Cites

67 of 67 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 113 cited sources checked · 0 supported · 0 flagged

  • Findingown data
    § 3. Results

    Changes in average patient health outcomes from pre- to post-Lean were never measured in the reviewed studies.

    “Changes in average patient health outcomes from pre- to post-Lean were never measured, even though timelier care would be expected to result in better outcomes.”
    Quote in the paperSubstantial claim
  • Findingreasoning
    § 3. Results

    New or transformed processes were accompanied by new standard operating procedures.

    “New or transformed processes were accompanied by new standard operating procedures, consistent with the focus of Lean on creating standard work.”
    Quote in the paperNot a substantial claim
  • Findingcitation
    § 3. Results

    Lean implementation in reviewed emergency departments was associated with decreased proportion of patients leaving the emergency department without being seen.

    “Decreased proportion of patients leaving ED without being seen [ 72 ] [ 75 ] [ 76 ] [ 77 ] [ 81 ] [ 83 ]”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [72] King, 2006, Redesigning emergency department patient flows: application of Lean thinking to health care, Emerg Med Australas source

      Not checked in the free run.

    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

    • cites [76] Eller, 2009, Rapid assessment and disposition: applying Lean in the emergency department, J Healthc Qual source

      Not checked in the free run.

  • Findingcitation
    § 3. Results

    With one exception, all Lean initiatives involved frontline staff in some way.

    “Project team composition varied among sites, but with one exception (Hospital C in [75]), all Lean involved frontline staff in some way.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

  • Findingown data
    § 3. Results

    Eighteen articles describing Lean initiatives in 15 emergency departments met inclusion criteria.

    “Eighteen articles describing Lean initiatives in 15 EDs met inclusion criteria (Table 2).”
    Quote in the paperSubstantial claim
  • May combine two claims. 29
  • Classified as probably not a substantial claim. 27
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingcitation
    § 3. Results

    Three studies combined Lean with Six Sigma, and another also borrowed from many other manufacturing philosophies.

    “Three studies [69, 82, 83] combined Lean with Six Sigma, a quality improvement method based on minimizing variability, while another also “borrowed from many other manufacturing philosophies” [71].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [69] Al Darrab, 2006, Application of Lean Six Sigma for patients presenting with ST-elevation myocardial infarction: the Hamilton Health Sciences experience, Healthc Q source

      Not checked in the free run.

    • cites [82] Parks, 2008, Dissecting delays in trauma care using corporate Lean Six Sigma methodology, J Trauma source

      Not checked in the free run.

    • cites [83] Schooley, 2008, No longer waiting for answers: hospital's process changes inspire new workplace culture, Qual Prog

      Not checked in the free run.

    • cites [71] Ben-Tovim, 2008, Redesigning care at the Flinders Medical Centre: clinical process redesign using “Lean thinking.”, Med J Aust source

      Not checked in the free run.

  • May combine two claims.

    Findingown data
    § 3. Results

    Usually, a quality improvement facilitator or Lean consultant was involved and management or senior staff was often involved throughout Lean initiatives.

    “Usually, a quality improvement facilitator or Lean consultant was involved and management or senior staff was often involved throughout Lean initiatives.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 3. Results

    Studies predominantly reported improvements and there were few reported decrements in patient care or failures to achieve improvement.

    “Third, studies predominantly reported improvements and there were few reported decrements in patient care or failures to achieve improvement.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 3. Results

    Patient outcomes often improved as well, but such improvements were rarer, and patient outcomes were less commonly measured compared to process improvements.

    “Second, patient outcomes often improved as well but such improvements were rarer, and patient outcomes were less commonly measured compared to process improvements.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation
    § 3. Results

    Patient safety changes were only measured in one study, and even then only indirectly.

    “Patient safety changes were only measured in one study, and even then only indirectly [71].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [71] Ben-Tovim, 2008, Redesigning care at the Flinders Medical Centre: clinical process redesign using “Lean thinking.”, Med J Aust source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § 3. Results

    Not every study adequately reported pre- and post metrics; in some cases measures of success were taken but not reported, patient satisfaction was not described, statistical tests were not used, or no numerical data were given.

    “Fourth, not every study adequately reported pre- and post metrics. In some cases, “measures of success” (e.g., door-to-balloon time, door-to-needle-time) were taken but not reported [69]. In others, measures such as patient satisfaction were not described [83], statistical tests were not used to test pre-post differences [20, 75], or no numerical data were given to support reported changes [83]”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [69] Al Darrab, 2006, Application of Lean Six Sigma for patients presenting with ST-elevation myocardial infarction: the Hamilton Health Sciences experience, Healthc Q source

      Not checked in the free run.

    • cites [83] Schooley, 2008, No longer waiting for answers: hospital's process changes inspire new workplace culture, Qual Prog

      Not checked in the free run.

    • cites [20] Kulkarni, 2007, Going Lean in the emergency department: a strategy for addressing emergency department overcrowding, MedGenMed

      Not checked in the free run.

    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data
    § 3. Results

    Study sites tended to be larger teaching hospitals, usually situated in the United States, with the remaining sites in Australia or Canada.

    “Study sites tended to be larger teaching hospitals, usually situated in the United States, with the remaining sites in Austrialia or Canada.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 3. Results

    Lean implementation in reviewed emergency departments was accompanied by numerous work structure changes, including new data collection and monitoring systems, education and training, changes to tools and technologies, new systems for communication and teamwork, changes in staffing, roles, and responsibilities, and reassignment or reorganization of physical space.

    “in the reviewed studies, numerous work structure changes accompanied process change. These included (a) new data collection and monitoring systems, (b) education and training, (c) changes to tools and technologies, (d) new systems for communication and teamwork, (e) changes in staffing, roles, and responsibilities, and (f) reassignment or reorganization of physical space.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given
    § 3. Results

    After Lean, most emergency departments saw reductions in length of stay, proportion of patients leaving without being seen, and waiting times.

    “After Lean, most EDs saw reductions in length of stay, proportion of patients leaving without being seen, and waiting times.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingcitation
    § 3. Results

    Lean implementation in reviewed emergency departments was associated with decreased emergency department length of stay.

    “Decreased ED length of stay [ 72 ] [ 73 ] [ 75 ] [ 76 ] [ 79 ] [ 80 ] [ 81 ] [ 83 ] [ 85 ]”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [72] King, 2006, Redesigning emergency department patient flows: application of Lean thinking to health care, Emerg Med Australas source

      Not checked in the free run.

    • cites [73] Dickson, 2008, The sustainable improvement of patient flow in an emergency treatment centre using Lean, Int J Six Sigma Competitive Advantage source

      Not checked in the free run.

    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

  • May combine two claims.

    Findingnone given
    § Abstract

    Success factors included employee involvement, management support, and preparedness for change.

    “Success factors included employee involvement, management support, and preparedness for change.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning
    § 4. Discussion

    Process changes and accompanying protocols served to standardize care.

    “Process changes and accompanying protocols served to standardize care.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 3. Results

    Reported working conditions resulting from Lean-driven changes included better utilization of staff, more time available for supervision and education, communication improvements, perceived loss of autonomy due to standardization, and an increased sense of control.

    “Further, better utilization of staff; including more time available for supervision and education; communication improvements; (perceived) loss of autonomy due to standardization; and an increased sense of control were among reported working conditions resulting from Lean-driven changes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Abstract

    The effects of Lean on employees were rarely discussed or measured systematically but there were some indications of positive effects on employees and organizational culture.

    “The effects of Lean on employees were rarely discussed or measured systematically but there were some indications of positive effects on employees and organizational culture.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given
    § 4. Discussion

    Patient care typically improved as a result of Lean-driven process and structure changes.

    “Patient care typically improved as a result of Lean-driven process and structure changes, implying the possible value of Lean.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given
    § 3. Results

    Less commonly, the introduction of Lean was associated with at least initial resistance and concern over possible changes.

    “Less commonly, the introduction of Lean was associated with at least initial resistance and concern over possible changes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § 3. Results

    Only one reviewed study, Dickson et al., included multiple Lean implementations across multiple EDs and therefore only this study was able to directly address contingencies.

    “Only one study, Dickson et a1 [75], included multiple Lean implementation across multiple EDs and therefore only this study was able to directly address contingencies.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

  • May combine two claims.

    Findingreasoning
    § 3. Results

    Managers learned to defer to their frontline staff and to value their input.

    “In turn, managers learned to defer to their frontline staff and to value their input.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § 3. Results

    Only one reviewed study measured staff satisfaction using surveys, and it did not report numeric values or statistical tests.

    “only one study actually measured staff satisfaction (using surveys) and even so did not report numeric values or statistical tests [83].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [83] Schooley, 2008, No longer waiting for answers: hospital's process changes inspire new workplace culture, Qual Prog

      Not checked in the free run.

  • May combine two claims.

    Findingreasoning
    § 3. Results

    Most of the employee effects described in the review were not systematically assessed and were either implied by articles' authors or based on anecdotal evidence.

    “Unfortunately, most of the employee effects described above were not systematically assessed and were either implied by articles’ authors or based on anecdotal evidence.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning
    § 4. Discussion

    Process change was a key component of Lean in the ED.

    “process change was a key component of Lean in the ED.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given
    § 3. Results

    Some reviewed studies noted that after changes were made, staff were less prone to aggression, more courteous, more satisfied with their job and less likely to leave, and faced lower workloads.

    “Some studies, however, noted that after changes were made, staff were less prone to aggression, more courteous, more satisfied with their job and less likely to leave, and faced lower workloads.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given
    § 4. Discussion

    This review revealed robust opportunities for improvement in EDs and hospital-wide using Lean but also revealed considerable limitations in Lean implementations and in reports thereof.

    “This review revealed robust opportunities for improvement in EDs and hospital-wide using Lean but also revealed considerable limitations in Lean implementations and in reports thereof.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given
    § 4. Discussion

    Resources such as staffing, technology, and communication often need to be allocated to support new processes.

    “Further, resources (e.g., staffing, technology, communication) often need to be allocated to support new processes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingcitation
    § 3. Results

    Based on a comparison of four EDs, Dickson et al. proposed that the two key contextual contingencies were involvement of frontline staff in Lean initiatives and leadership commitment to Lean.

    “Based on a comparison of four EDs, Dickson et a1 proposed that the two key contextual contingencies were (a) the involvement of frontline staff in Lean initiatives, and (b) leadership commitment to Lean.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given
    § 4. Discussion

    Employees can be affected in two distinct ways, indirectly and directly.

    “Employees can be affected in two distinct ways, indirectly and directly, hut most reviewed studies tended to avoid measuring those effects or even discussing their possibility.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § 4. Discussion

    Desirable patient care effects of Lean dominate both in the presently reviewed ED literature and in health care more generally.

    “Desirable patient care effects of Lean dominate both in the presently reviewed ED literature and in health care more generally [93].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [93] Joosten, 2009, Application of Lean thinking to health care: issues and observations, Int J Qual Health Care source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § 4. Discussion

    Only one reviewed study repeatedly mentioned the aim to improve employees' working conditions and was the only study to systematically measure changes in job satisfaction.

    “Only one study repeatedly mentioned the aim to improve employees’ working conditions and this was the only study to systematically measure changes in job satisfaction [83].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [83] Schooley, 2008, No longer waiting for answers: hospital's process changes inspire new workplace culture, Qual Prog

      Not checked in the free run.

  • May combine two claims.

    Findingnone given
    § 4. Discussion

    Studies differed in which components of Lean were implemented, the nature of worker involvement and management support, and the types of changes implemented.

    “For example, studies differed in which components of Lean were implemented, the nature of worker involvement and management support, and the types of changes implemented.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning
    § 4. Discussion

    EDs in this study differed in their characteristics and they implemented Lean in different ways.

    “Finally, EDs in this study differed in their characteristics and they implemented Lean in different ways.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § 1. Introduction

    Emergency departments face problems with overcrowding, delays, cost containment, and patient safety.

    “The need for improvement in emergency departments (EDs) with respect to the cost of care, the speed of service, overcrowding, and patient safety is now widely accepted [1–4].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [1] 2007

      Not checked in the free run.

    • cites [2] Berger, 2010, A $9,000 bill to diagnose shingles?, Ann Emerg Med source

      Not checked in the free run.

    • cites [3] Kellerman, 2006, Crisis in the emergency department, N Engl J Med source

      Not checked in the free run.

    • cites [4] Smits, 2009, The nature and causes of unintended events reported at ten emergency departments, BMC Emerg Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § 1. Introduction

    In a 2009 survey of US hospitals, 53% reported having implemented Lean to some extent; of those hospitals, 60% reported implementing Lean in the ED.

    “In a 2009 survey of US hospitals, 53% reported having implemented Lean to some extent; of those hospitals, 60% reported implementing Lean in the ED [6].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 1. Introduction

    Health care organizations worldwide increasingly adopt Lean thinking.

    “health care organizations worldwide increasingly adopt an approach called “Lean thinking” (see Table 1 for a description of Lean) [5].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Young, 2008, A critical look at Lean thinking in healthcare, Qual Saf Health Care source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 1. Introduction

    Some public health care systems, including the UK National Health Service, have adopted or are planning to adopt Lean as a key lever for decreasing costs and improving the quality and safety of care.

    “some public health care systems, including the UK National Health Service (NHS) [7], have adopted or are planning to adopt Lean as a key lever for decreasing costs and improving the quality and safety of care.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Jones, 2006

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given
    § 3. Results

    Timelier care would be expected to result in better patient outcomes.

    “even though timelier care would be expected to result in better outcomes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § 2. Methods

    The effects of Lean are contingent on how and where Lean is implemented.

    “This has led researchers to propose that the effects of Lean are contingent on how and where Lean is implemented [33, 37, 41].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [33] Parker, 2003, Longitudinal effects of Lean production on employee outcomes and the mediating role of work characteristics, J Appl Psychol source

      Not checked in the free run.

    • cites [37] Sprigg, 2006, Call centers as Lean service environments: job-related strain and the mediating role of work design, J Occup Health Psychol source

      Not checked in the free run.

    • cites [41] Mehta, 2005, Characteristics of a work organization from a Lean perspective, Eng Management J source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationcitation
    § 4. Discussion

    Lean's role is as a philosophy and an approach to change rather than as a specific process solution.

    “This is indicative of Lean’s role as a philosophy and an approach to change rather than as a specific process solution [88].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [88] Ballé, 2007, Lean as a learning system in a hospital ward, Leadersh Health Serv source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation
    § 3. Results

    Dickson et al. proposed that Lean's variable success could be understood as "context + mechanism = outcome," where context refers to the local context of the ED and mechanism refers to Lean.

    “more formally proposed that Lean’s variable success could be understood as “context +mechanism = outcome,” where context refers to the local context of the ED and mechanism refers to Lean [75].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning
    § Abstract

    Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.

    “Many questions remain about Lean’s effects on patient health and employees and how Lean can be best implemented in health care.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation
    § 3. Results

    When staff carry out improved work processes, they may exhibit increased courtesy toward patients.

    “In turn, when staff carry out improved work processes, they may exhibit increased courtesy toward patients [73].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [73] Dickson, 2008, The sustainable improvement of patient flow in an emergency treatment centre using Lean, Int J Six Sigma Competitive Advantage source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 4. Discussion

    Over-standardization can make a system brittle and less able to adapt to unexpected variation.

    “In routine situations anticipated by protocols, standardization can be of great benefit, but safety scientists contend that over-standardization can make a system brittle and less able to adapt to unexpected variation [89, 90].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [89] Woods, 2009, Escaping failures of foresight, Saf Sci source

      Not checked in the free run.

    • cites [90] 2006

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation
    § 3. Results

    Reductions in delays can improve employees' quality of work life.

    “This suggests that reductions in delays can improve employees’ quality of work life.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 3. Results

    Patients' irritation with delays can result in displaced anger aimed at nurses and physicians, which deflates staff morale.

    ““Patients’ irritation with delays can result in displaced anger aimed at nurses and physicians, which deflates staff morale” [83].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [83] Schooley, 2008, No longer waiting for answers: hospital's process changes inspire new workplace culture, Qual Prog

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 3. Results

    Quality improvement is intimately linked to how individual providers interact with patients on the frontlines.

    ““quality improvement is intimately linked to how individual providers interact with patients, on a day-to-day basis in the outpatient clinic and inpatient unit frontlines” [73].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [73] Dickson, 2008, The sustainable improvement of patient flow in an emergency treatment centre using Lean, Int J Six Sigma Competitive Advantage source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § 4. Discussion

    The possibility of direct employee effects, those related to "mere exposure" to Lean, is reminiscent of the Hawthorne effect.

    “The possibility of direct employee effects, those related to “mere exposure” to Lean, is reminiscent of the Hawthorne effect, the phenomenon that change efforts bring about positive effects in workers merely because more interest is paid to the workers.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § 4. Discussion

    There is a current trend of reporting bias toward publishing positive-and more often than not immediate-results because hospitals who failed to achieve intended behavioral changes do not come forward to openly analyze reasons for failure.

    ““there is a current trend of reporting bias toward publishing positive—and more often than not immediate—results because hospitals who failed to achieve the intended behavioral changes do not come forward to openly analyze the reasons for their failure” [75].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [75] Dickson, 2009, Use of Lean in the emergency department: a case series of 4 hospitals, Ann Emerg Med source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation
    § 4. Discussion

    The most successful change efforts are ones that attend to both humanistic needs and the operational needs for well designed work.

    “Subsequent work, for example that of Sociotechnical Systems Theorists and macroergonomists, demonstrated that the most successful change efforts are ones that attend to both humanistic needs and the operational needs for well designed work.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 4. Discussion

    A recent study found a link between ED overcrowding and medication errors.

    “Indeed, a recent study found a link between ED overcrowding and medication errors [91].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [91] Kulstad, 2010, ED overcrowding is associated with an increased frequency of medication errors, Am J Emerg Med source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § 4. Discussion

    Disregard of Lean's employee effects reveals an underestimate of the power of Lean to empower workers and to improve working conditions.

    “Disregard of Lean’s employee effects reveals an underestimate of the power of Lean to empower workers and to improve working conditions.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationcitation
    § 4. Discussion

    It is possible that a publication bias, not universally positive effects of Lean, is behind the lack of null and negative results.

    “It is possible that a publication bias, not universally positive effects of Lean, is behind the lack of null and negative results [22].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] Vest, 2009, A critical review of the research literature on Six Sigma, Lean and StuderGroup's Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare, Implement Sci source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § 4. Discussion

    The Hawthorne effect is typically regarded as a confound, meaning that improvements in Table 4 and those reported in other Lean studies may not be the result of better designed work; as the spotlight on Lean fades, so may the improvements.

    “First, the Hawthorne effect is typically regarded as a confound, meaning that the improvements in Table 4 and those reported in other Lean studies may not be the result of better designed work; as the spotlight on Lean fades, so may the improvements.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning
    § 4. Discussion

    According to the Human Relations school of thought, Lean can achieve real improvements if it is worker-centered.

    “thus, according to the Human Relations school of thought, Lean can achieve real improvements if it is worker-centered.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning
    § 4. Discussion

    Undesirable employee effects may not show up in reports on Lean in health care either because of how Lean is implemented in health care or because studies in health care simply do not measure employee effects.

    “These undesirable employee effects are well documented in the broader Lean literature [32–39, 94–97] but may not show up in reports on Lean in health care either because of how Lean is implemented in health care or because studies in health care simply do not measure employee effects.”
    Quote in the paperSubstantial claim
53 of 53

  • The paper relies on this without support.

    Improvements in length of stay, waiting times, and other commonly reported efficiency measures should be accompanied by improved patient health, fewer errors, or more appropriate care.

    “One would expect improvements in length of stay, waiting times, and other commonly reported efficiency measures to be accompanied by improved patient health, fewer errors, or more appropriate care.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Patient safety measurement attributed to only one study

    Minor

    The text says patient safety changes were measured only in study [71], but Table 4 reports a finding about perceived patient safety in study [72].

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 20

  1. Spear, 2005, Fixing health care from the inside, today, Harv Bus Rev, 83, 78
  2. Cooper, 2008, Lean thinking for medical practices, J Preclin Clin Res, 2, 88
  3. Ben-Tovim, 2007, Letters, BMJ, 334, 169, 10.1136/bmj.39101.389271.1F · DOI
  4. Eitel, 2010, Improving service quality by understanding emergency department flow: a white paper and position statement prepared for the American Academy of Emergency Medicine, J Emerg Med, 38, 70, 10.1016/j.jemermed.2008.03.038 · DOI
  5. Kulkarni, 2007, Going Lean in the emergency department: a strategy for addressing emergency department overcrowding, MedGenMed, 9, 58
  6. Cooper, 2008, Lean thinking in a healthcare system—innovative roles, J Preclin Clin Res, 2, 110
  7. Holden RJ. Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety. Cognition Technol Work. In press. doi:10.1007/s10111-10010-10141-10118 . · DOI
  8. de Treville, 2006, Could Lean production job design be intrinsically motivating?, J Operations Management, 24, 99, 10.1016/j.jom.2005.04.001 · DOI · Paper page
  9. Travers, 2006, Avoiding prolonged waiting time during busy periods in the emergency department: is there a role for the senior emergency physician in triage?, Eur J Emerg Med, 13, 342
  10. Leaver, 2009, Qualitative results from an Ontario hospital patient flow improvement program pilot to improve emergency department waiting times [abstract], CJEM, 11, 259
  11. Stratton R, Knight A. Utilising buffer management to manage patient flow. 16th International Annual EurOMA Conference; June 14-17, 2009; Goteborg, Sweden.
  12. Weinstock, 2007, How one hospital slashed ED waits, Hosp Health Netw, 81, 22
  13. Foster, 2007, Windsor Regional Hospital emergency department revolutionized, Hospital News, 20, 1
  14. Burkitt, 2009, Toyota Production System quality improvement initiative improves perioperative antibiotic therapy, Am J Manag Care, 15, 633
  15. Slunecka, 2008, Lean principles provide opportunities for Catholic health care organizations, Health Prog, 89, 46
  16. Kulkarni, 2008, A reader and author respond to “Going Lean in the emergency department: a strategy for addressing emergency department overcrowding.”, Medscape J Med, 10, 25
  17. Schooley, 2008, No longer waiting for answers: hospital's process changes inspire new workplace culture, Qual Prog, 41, 34
  18. Stephens-Lee, 2006, Work flow analysis of admitted patients, Can J Nurs Informat, 1
  19. Furman, 2005, Implementing a Patient Safety Alert System(TM), Nurs Econ, 23, 42
  20. Gamm, 2007, Organizational technologies for transforming care: measures and strategies for pursuit of IOM quality aims, J Ambul Care Manage, 30, 291, 10.1097/01.JAC.0000290397.58790.b9 · DOI · Paper page

Cited by

Sorted by citations

Authors
Holden, R. J.
Affiliations
University of Wisconsin–Madison (US)
Corresponding author
Holden, Richard J.
ORCID
Holden, Richard J.
Venue
Annals of Emergency Medicine
Publisher
Elsevier BV
Published
2011-03
Volume
57
Issue
3
Pages
265-278
ISSN
0196-0644 (ISSN-L)
DOI
10.1016/j.annemergmed.2010.08.001
PMC
PMC6548198
OpenAlex
W2109172622
Cited by
516
References
67
Citations by year
2026: 16 · 2025: 8 · 2024: 19 · 2023: 22 · 2022: 30 · 2021: 71 · 2020: 34 · 2019: 36 · 2018: 40 · 2017: 41 · 2016: 41 · 2015: 55 · 2014: 50 · 2013: 22 · 2012: 21
FWCI
3.13
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Annals of Emergency Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
Agency for Healthcare Research and Quality (5 T32 HS000083-11, T32HS000083)
Topics
  • Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
  • Health Sciences › Health Professions › Emergency Medical Services › Healthcare Operations and Scheduling Optimization
  • Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
Keywords
lean thinking, emergency department, emergency department overcrowding, patient flow, length of hospital stay, waiting time, patient safety, employee participation, organizational culture, implementation success factors, human factors engineering, healthcare process improvement
MeSH terms
Workforce, Emergency Service, Hospital, Humans, Job Satisfaction, Length of Stay, Quality of Health Care, Patient Satisfaction

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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