Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis

Andria L. Ford, Jennifer A. Williams, Mary Spencer, Craig McCammon, Naim Khoury, Tomoko R. Sampson, Peter Panagos, Jin Moo Lee

Research output: Contribution to journalArticlepeer-review

108 Scopus citations


Background and Purpose: Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke increases efficacy, prompting national efforts to reduce door-to-needle times. We used lean process improvement methodology to develop a streamlined intravenous tPA protocol. Methods: In early 2011, a multidisciplinary team analyzed the steps required to treat patients with acute ischemic stroke with intravenous tPA using value stream analysis (VSA). We directly compared the tPA-treated patients in the "pre-VSA" epoch with the "post-VSA" epoch with regard to baseline characteristics, protocol metrics, and clinical outcomes. Results: The VSA revealed several tPA protocol inefficiencies: routing of patients to room, then to CT, then back to the room; serial processing of workflow; and delays in waiting for laboratory results. On March 1, 2011, a new protocol incorporated changes to minimize delays: routing patients directly to head CT before the patient room, using parallel process workflow, and implementing point-of-care laboratories. In the pre-and post-VSA epochs, 132 and 87 patients were treated with intravenous tPA, respectively. Compared with pre-VSA, door-to-needle times and percent of patients treated ≤60 minutes from hospital arrival were improved in the post-VSA epoch: 60 minutes versus 39 minutes (P<0.0001) and 52% versus 78% (P<0.0001), respectively, with no change in symptomatic hemorrhage rate. Conclusions: Lean process improvement methodology can expedite time-dependent stroke care without compromising safety.

Original languageEnglish
Pages (from-to)3395-3398
Number of pages4
Issue number12
StatePublished - Dec 2012


  • Acute stroke protocol
  • Door-to-needle time
  • Lean manufacturing
  • TPA
  • Thrombolytic
  • Value stream analysis


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