This study aims to describe the challenges and adaptive strategies involved in implementing a manual chronoanalysis instrument at the entrance of a medium-sized public emergency department in a nondigital context, from a Lean in Emergency Care perspective.
A descriptive observational study with a qualitative and operational focus was conducted using the Lean methodology in a medium-sized public hospital in Brazil. A manual chronoanalysis instrument, the Time and Length of Stay Card, was developed to standardize the measurement of patient flow times at the emergency department entrance. The instrument made temporal milestones along the care flow visible and functioned as a data sensitization and data literacy device for teams operating in a predominantly analog environment. The card followed patients throughout the care pathway, recording key milestones to estimate Lead Time (total length of stay) and identify Waiting points (waste due to waiting) between stages such as risk classification, medical assessment and diagnostic testing. Data collection was conducted through managerial rounds across reception, triage, medical care, laboratory, diagnostic imaging and observation areas, following the Gemba Walk principle. Nonconformities were discussed in real time using the five Whys methodology, and implementation barriers were addressed through nonpunitive communication, rapid feedback and incremental adjustments to the instrument and work routines.
Implementation revealed operational, organizational and behavioral challenges associated with high cognitive workload, initial resistance to perceived bureaucratic demands, and dependence on leadership presence to ensure record completeness. Addressing these challenges promoted organizational learning and strengthened situational awareness, shared responsibility and flow governance across macro, meso and micro levels.
The study demonstrates that Lean transformation in public emergency departments depends less on digitalization and more on real-time institutional learning. Manual chronoanalysis emerges as a feasible, low-cost and effective Lean management strategy to initiate data-driven flow governance and sustain continuous improvement in resource-constrained settings.
