This month JC is going to close out the academic year with a topic of interest that I thought would be of interest to a broad audience of clinicians including our graduating residents who will soon be joining the “real world”. One of the realities of EM practice is the broad adoption by hospital administrators, ED Directors and other policymakers of Lean Design principles and their application in the busy ED environment. It is interesting that although Lean principles have been around for many years, Kiichiro Toyoda is credited with being among the first to innovate car manufacturing which ultimately evolved to what is described as The Toyota Way. Many Lean principles can be applied across the broad sector of service industries and in fact, the Institute for Healthcare Improvement published a white paper entitled “Going Lean in Health Care” that describes healthcare applications. This year, one of our EPT facilities (Sentara Leigh) decided to adopt lean methodology practices designed by Karen Murrell from Kaiser Permanente South Sacramento hospital where they designed a “no wait” ED. Early reviews are mostly positive with major decreases in waiting, LWBS and throughput times. That stated, is the model applicable to all ED settings? Are there necessary adjustments in a teaching environment, trauma or tertiary care setting? How dependent is the model on a fully staffed ED and in-patient nursing units? What are the financial costs to ED physician groups? Are there patient outcomes data beyond throughput that support the model?