Plenary: Using Toyota Production System Tools to Reengineer an Academic Medical Service

1Denver Health Hospital Authority, Denver, CO

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 1007


Most responses to Accreditation Council for Graduate Medical Education (ACGME) regulations such as floats, nonteaching services, and midlevel providers have sought to preserve the traditional call system. As a result, hand‐offs have increased, compromising continuity and raising patient safety concerns.


To use Toyota Production System (TPS) Lean principles and tools to completely redesign our medicine ward system to comply with ACGME regulations while improving continuity of care.


Single piece flow and standard work are cornerstones of Lean systems. In the traditional call system with 5 teams, 1 team admits the majority of patients every fifth night, with the 4 other teams having smaller patient loads after spending 2–4 days “diuresing” their service. In addition, staffing patterns vary as teams determine days off by preference, sometimes leaving only 1 resident to round on a large service on the first day postcall. Using the TPS tools and principles, we replaced the traditional call system, which was supplemented with floats, moonlighters, and jeopardized residents, with a shift system comprising 2 firms of 6 interns and 3 residents. Each firm contains 2‐day teams of 1 resident and 2 interns. In the evening, 1 intern from each firm starts a long shift, which we have termed the “continuity shift,” at 6:00 PM, admitting until 6:00 AM and continuing until 4:00 PM the next day. Interns work a cycle of 1 continuity shift followed by 4 consecutive day shifts, then a full day off, returning to work the following 6:00 PM after 47 hours off‐duty. To standardize work, every day of the year each day team has 2 interns and 1 attending. Residents have 1 weekend day off each week, when intensity of care is lower and educational sessions are fewer. Using administrative data, we projected that 89% of patients admitted on the continuity shift would be discharged by the end of the intern's 5 consecutive shifts. To compare continuity before and after the shift system, we reviewed 120 random charts, determining continuity by recording the number of notes written by the same intern on admit, hospital day 1, and all hospital days. Chi‐square analysis was used to compare the 2 cohorts. Continuity was improved, as shown in Figure 1. By dividing admissions among 2 teams postcall, the “bolus” effect was halved in a substantial move toward single piece flow.



By implementing TPS principles and tools, we were able to redesign our medicine services to function without floats, moonlighters, jeopardized residents, or midlevel providers while complying with ACGME regulations and improving continuity of care.


D. Mancini ‐ none; R. Albert ‐ none; E. Sarcone ‐ none; R. Westergaard ‐ none; E. Havranek ‐ none; E. Chu ‐ none

To cite this abstract:

Mancini D, Albert R, Sarcone E, Westergaard R, Havranek E, Chu E. Plenary: Using Toyota Production System Tools to Reengineer an Academic Medical Service. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 1007. Journal of Hospital Medicine. 2011; 6 (suppl 2). Accessed April 10, 2020.

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