Mountain Vista Hospital (MVH) is a 200-bed community hospital located in a region of a state that has approximately 200,000 people in a four-county service area. It is a non-profit organization with a local board of directors. There is on large academic hospital (University Health System) with 400 beds located in a county to the north, and two similar-sized community hospitals (Hamilton County Hospital and Park Regional Hospital) located approximately 25 miles in either direction from Mountain Vista. MVH used to command the market share for general services (orthopedic, general surgery, cardio-vascular, pulmonary medical, medical-surgical, OB/GYN and peds). The university system is the tertiary center but has recently made aggressive moves in purchasing or controlling many smaller regional hospitals. Hamilton County Hospital has launched many initiatives and is perceived in a favorable light by consumers in the region mostly on the strength of their marketing and branding via social media.

Park Regional is currently evaluating merger with University and this will enable additional specialized services to be provided. Hamilton County recently opened a state-of-the-art emergency department that is highly publicized. MVH has invested in new off-site locations (e.g., radiology/imaging services, therapy, outpatient primary care, etc.), but the main campus renovations were limited to inpatient rooms. The ED was built in the late 1970s and functionality is poor due to cramped location and lack of treatment rooms. Parking is also a problem. The hospital's financial performance has suffered over the past five years.

The Mountain Vista Hospital System's board of directors is concerned about declining performance. The board requires an annual strategic plan including initiatives designed to help the organization get back on track. Competition from two area hospitals that are consolidating with a major university-based system has been affecting their market share. A year's worth of patient perception data from surveys indicates that while inpatient services are positive, emergency department services are perceived negatively in several areas. The ED volume has decreased over the past three year from a high of 12,800 visits annually in 2017 to 9850 in the last fiscal year (2019). The hospital's benchmark on satisfaction is 80% but many areas lack meeting this goal based on patient surveys.

The ED Data indicates that the number of patients who leave without being seen after being registered is above 10 percent. When patients leave, not only are direct ED revenue lost (average $500 or more per left without being seen (LWBS), but hospital inpatient revenues are as well ($10,000 or more per LWBS) for approximately 5 percent of those LWBS patients had reasons for the visit that that might have been admitted. Furthermore, the impact on patient safety and a hospital's reputation can be equally significant. Delayed access to care can be a trigger for malpractice litigation, just as prolonged wait times are tied to low patient satisfaction scores and negative online reviews. All this can damage an ED's reputation and impact its bottom line. A health care organization may face additional liability if a patient's condition worsens during his or her ED stay, or if the ED fails to reassess patients who have experienced excessive wait times, leading to premature discharge.

Over recent years, the leadership team has not focused on the ED, as other projects have included renovation and expansion of outpatient services. The board hired a new CEO who reinvigorated the leadership team. When discussing the downturn in admissions, the new CEO says that the national average of hospital admissions through the ED is 17 percent. Thus, part of the attrition in admissions is lower volume in the ED and lost revenue from those who leave without being seen. The new CEO wants to introduce reform through a Lean environment.

The CEO wants to create a culture change as it is evident that management and staff are more inclined to tolerate adverse circumstances (loss of ED revenue; decrease in satisfaction; shift of market) than to put forth effort and experience discomfort involved in changing those circumstances. The CEO introduces a graduate student from Fairmont State's Masters Degree in Healthcare Management. The student is doing an independent research project. The CEO says the student will do the following and present a plan for a lean approach to the ED. This would be a framework for moving forward.

1. analyze the data, spot trends, etc. The hospital's goal is a benchmark of 80 percent satisfaction on patient surveys. What does the data tell? Highlight key areas that indicate further analysis is needed. Summarize this and use tables to present data in this section of the report. In this section, why does the problem exists. Narrow to one area as an example of how the Executive Leadership can identify a Lean project.

2. Overview for a potential Lean project. You are not solving all the problems; only recommending a Lean approach to better outcomes in one area as an example. You can be creative in how you approach this (e.g., a short summary and then a table with data). This will generally identify components in relation to the ED: Defining the project and objectiveswhy is it important? (pick key points in scenario) Identifying what needs to be measured (analysis of the process; create a table) Why is it important to improve outcomes (and to assure improvements will be sustained)?

Describe/define a plan for strategically directed action Include a rationale for a culture-creating path

Develop strategy for a properly planned launch Identify at least one value stream as an example (include at least one map) Design a strategy deployment overview that would manage the process (timeline).

Describe why senior leadership must cultivate a blameless environment to sustain results, achieve strategic goals, and avoid a quick-fix path to failure through a Lean approach.