Table 1. Lean Admissions Project at Komfo Anokye Teaching Hospital.

Step	Activities
Lean Team Formation	After approval by Medical Director and CEO, 14 person Lean team was formed from various hospital departments:
	3 EM residents 3 EM nurses EM pharmacist EM accountant EM business manager ICU nurse	Internal medicine resident Ward nurse Medicine consultant Surgical resident UM EM faculty facilitator
Problem Definition	Hospital admissions process identified as a problem in current system. Team members defined process characteristics (Figure 1).
	Key metrics identified to define the admissions process: Lead time = time physician decision for admit to arrival on ward Average lead time = 13 hours – data collected in small project during week 1 of Lean project Number of patients remaining in the ED at shift change after an admission order was completed
	Lean team defined institutional standard for the lead time: Patients should be transferred to an available bed within 1 hour of the decision to admit to an inpatient ward
	Project goal defined to move closer to institutional standard: Decrease the number of patients waiting longer than 1 hour by 50% within the next 12 months
Defining the Scope	Use of SIPOC tool (Figure 2) to define the scope of the Lean analysis of the admissions process and identify any additional team members to add to the current team.
Value Stream Mapping	Current state of process extensively mapped by team Physical flow of patients within institution Information flow among staff within institution “Gemba Waste Walks” performed to observe current process and help identify wasted steps Team identified waste (Table 2) within process and labeled the waste on the Value Stream Map (Figure 3)
Root Cause Analysis	“Forced prioritization matrix” was used to determine complex problems within the process that should be examined in detail by root cause analysis Root cause analysis using standard Lean tools (Figure 4): “Five Whys” questions asking method “Ishikawa Fishbone Diagrams”
Future State Planning	Brainstorming sessions used to develop solutions New future state developed with goal of creating a single flow system that addressed root causes of problems and eliminated wasted steps (Figure 5)
A3 Summary Document and Implementation Plan	Team summarized all aspects of the process visually Detailed implementation plan was constructed to guide each step of the transition phase Team members were assigned tasks to ensure completion of transition to future state Final report submitted to CEO/Medical Director

CEO = chief executive officer; SIPOC = supplies-inputs-process-outputs-customers; ICU = intensive care unit; UM = University of Michigan