• Hospital medicine
• Quality improvement methodologies
• Quality improvement
• Lean management
• Medical education

My pager goes off. It’s the nurse worried about my sick patient in room 143 who spiked another fever overnight and is becoming more tachycardic. I ask my intern to evaluate and consider broadening the antibiotic coverage. Looking over our list, I notice there are still 12 patients to see: 4 potential discharges, 3 overnight admissions and 5 others. My pager beeps again and it's the emergency department (ED) calling for another admission. I look at the clock and notice its 8:05. Attending rounds begin in 55 min. Just under 11 h left in the call day.

I run to the ED to triage the new admission, passing by our quality improvement board for inpatient medicine. It's packed with information: charts and graphs depicting length of stay, hand washing, patient satisfaction and infection control. Our progress interests me greatly, but I seldom have a moment to look at the board given the time pressures of my daily work. Downstairs in the ED, I interview and examine the patient, diagnosing decompensated heart failure. I enter admission orders quickly, starting a diuretic so we don’t waste time. It has been the new standard work to place orders for an inpatient admission within 1 h of an ED call in an effort to improve the patient experience and expedite movement from the ED to the medicine ward. I know this target well because I was the resident representative during our recent quality improvement workshop on decreasing patient wait times in the ED.

During this activity, we were educated in the use of Lean, one of many powerful tools for process improvement.1 Lean starts with understanding the ‘current state’ of a system and outlining an ideal ‘future state’ followed by transitioning towards that ideal through a series of stepwise experiments using the scientific method. Lean has …