Upon creating the current state value stream map, the multi-discplinary team learned more about Lean in healthcare, and considered the following improvements. The team brainstormed and determined the following kaizen events: (Kaizen Event) 1. Work load balancing and cross-training would be used between the Triage nurse and the Emergency Room (ER) nurse. In the current state, the Triage nurse performed vitals, recorded Chief Complaint (CC), performed brief initial evaluation, and dispensed pain medications. In the future state, they decided to eliminate the wait time between Triage and the first ER encounter. This was accomplished by taking the patient directly from the Triage to the ER suite due to the obvious need for treatment. The vitals, assessment, etc. would not be repeated at this time. This eliminated many steps of the initial ER room visit. Both the Triage nurse and ER nurse would be cross-trained and qualified. This had required the Triage nurse to be trained in ER nursing. Also, the initial wait time at registration was to be eliminated by creating a placard for the patient to begin filling in initial information. (Work Load Balancing and Standard Work) 2. Kanban for supplies would be used in the ER medication room. This would create a pull system for the supplies. The current state had the nurse searching for a 3 cc syringe, along with the ordered medications. This caused a delay in patient care delivery. The future state would implement kanbans which ensured the supplies were well stocked and available when needed. (Pull System and Kanbans for Supplies) 3. Visual controls would be used to notify the nurse of patient room availability and location of the healthcare provider. In the current state the ER nurse searched for the healthcare provider while also looking for an available room, which caused additional delay. The future state eliminated this searching for the healthcare provider and room by installing a multi-color light system. This eliminated the queue time between Triage and the initial ER encounter. (Visual Controls) 4. Each ER suite had supplies missing at various locations in each area. This caused the nurse to be frustrated and time delays in caring for patients from one suite to another. The future state incorporated the SS process to eliminate this problem. (55) 5. The current state had a delay of 30 minutes from the second ER encounter to the Casting Room. The future state has the Triage nurse notifying the Casting Room technician via a visual control (i.e., pager code number) that a patient will be requiring, his or her services within 30 minutes. Previously the Casting Room Technician would be notified at the time the cast was to be applied which resulted in a wait time of 30 minutes. The Casting Room staff used 5S to better organize their room. By the early notification and a better organized room, they could be prepared to receive a patient within 15 minutes. (Visual Controls) 6. The current state has the physical layout utilizing the Radiology department for the majority of cases requiring X-rays. This had caused a delay of 20 minutes. In the future state a portable radiology unit and technician (runner) were utilized in the ER suite. This eliminated the transport to and from Radiology and the respective wait times. (Physical Layout and Runner) 7. Once the future state was fully implemented, everyone was trained in the new processes. This resulted in a change for many staff. Subsequently, a "lunch and learn" was conducted to educate the staff on the changes being made. (Resistance to Change) Instructions: A. Create a future state value stream map. The patient will be the customer as well as the supplier. The first process box should be Registration. B. At the bottom of the value stream map, create a step graph displaying the cycle times (value added times) as well as create a step graph displaying the cycle times (value-added times) and wait times. C. At some location on the map, create a small box displaying overall cycle time and lead times of this event. D. At various locations on the value stream map identify the various kaizen events required to attain the future state..