This is the first in a series of articles describing the application of Lean management systems to Laboratory Medicine. Lean is the term used to describe a principle-based continuous quality improvement (CQI) management system based on the Toyota production system (TPS) that has been evolving for over 70 years. Its origins go back much further and are heavily influenced by the work of W Edwards Deming and the scientific method that forms the basis of most quality management systems. Lean has two fundamental elements--a systematic approach to process improvement by removing waste in order to maximise value for the end-user of the service and a commitment to respect, challenge and develop the people who work within the service to create a culture of continuous improvement. Lean principles have been applied to a growing number of Healthcare systems throughout the world to improve the quality and cost-effectiveness of services for patients and a number of laboratories from all the pathology disciplines have used Lean to shorten turnaround times, improve quality (reduce errors) and improve productivity. Increasingly, models used to plan and implement large scale change in healthcare systems, including the National Health Service (NHS) change model, have evidence-based improvement methodologies (such as Lean CQI) as a core component. Consequently, a working knowledge of improvement methodology will be a core skill for Pathologists involved in leadership and management.

redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources.

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-Bed availability remains the main operational focus for managers and clinicians on a day-to-day basis within the NHS. There is now published research that establishes a lack of bed stock is too simplistic an explanation of the situation. Other reasons for bed shortage include the daily and weekly lack of synchronisation of admissions and discharges, the large variation in bed occupancy over time, the downtime during weekends and holiday periods, wasted time during inpatient stays and the variation in patient length of stay. So far most of what little work has been done has focused on the front end of the process, to 'buffer' unplanned admissions through the use of short-stay facilities, such as medical assessment units, as a short-term solution. This paper reviews the evidence for the hypothesis that bed availability problems can be solved by actions other than the addition of more beds to the system. KEY WORDS: accident and emergency flow, admissions and discharges, bed management, synchronisation, systems planning, variation

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Proper capacity planning is vital, but is often poorly done. Planning using aggregated data will lead to inadequate capacity. Understanding demand, and particularly the variation in that demand, is critical to success. Analysis of emergency department demand and capacity is the first step towards effective workforce planning and process redesign.

Recommends process control measures as a way of creating an organization memory of how decisions affect performance--something that is currently lacking.

-The challenge of generating bed availability is constant in most NHS acute trusts. Building on previous work applying queue theory, this paper now takes operational data from one NHS trust, collected over a period of more than a year, to provide an evidence base and to establish the practical challenges associated with demand variation and managing length of stay. The problem is split into three separate parts. Daily bed shortages are mostly influenced by the timing of arrival and discharge of patients with a short length of stay. Patients who stay for longer than one to two days contribute most significantly to the observed weekly bed availability problem. The problems associated with bed shortages around Christmas time and into the New Year are not simply issues of increased demand. A reduction in discharge capacity is a major contributory factor that results in unnecessary increases in length of stay.