Improving patient flow and hospital capacity through governance-oriented Lean bed management: an action research study

Abstract Background Emergency department overcrowding and prolonged boarding times are widely recognised as manifestations of systemic failures in hospital flow governance rather than physical capacity constraints. Despite growing evidence supporting Lean-based approaches, most published interventions focus on isolated processes, with limited attention to governance redesign at a system level. This study examines a governance-oriented intervention aimed at improving patient flow through the redesign of bed management structures. Methods A single-centre action research study with a before-and-after design was conducted in a public Portuguese hospital between March and October 2025. The intervention focused on redesigning bed management processes and governance structures through four interconnected domains: structured diagnosis, standardisation of critical pathways, active bed management, and organisational governance redesign. Operational indicators were analysed using routinely collected monthly data, comparing pre-intervention (March–April 2025) and post-intervention (September–October 2025) periods. Results The intervention was associated with directionally consistent improvements in hospital flow across all eight monitored indicators, although the short monthly time series (eight observations) did not meet formal criteria for statistical significance or run chart signal. Time to admission decreased from 808.5 to 652 min (− 19.4%), boarding time from 348 to 188 min (− 46.0%), and bed turnover interval from 515 to 429 min (− 16.7%), while discharges completed by 12:00 increased from 10% to 15% (+ 50.0%). These improvements occurred without bed capacity expansion, despite rising emergency department demand (+ 4.3%). Secondary indicators, including overall length of stay and emergency department length of stay for non-admitted patients, remained stable, suggesting genuine improvements in flow coordination rather than changes in case mix or premature discharge. Conclusions Lean-based interventions structured around governance redesign may be associated with improvements in hospital flow performance without expansion of physical capacity, even in the face of increasing demand, although the short observation window precludes firm causal attribution. Positioning bed management as a strategic organisational function, supported by formal governance structures, real-time coordination, and cross-functional accountability, represents an underutilised lever for improving hospital performance and patient safety. These findings suggest that governance redesign may represent an important and underexplored strategy, alongside traditional capacity-expansion approaches, in efforts to address hospital flow dysfunction.