The emergency department (ED) at Lynchburg General Hospital (LGH) was operating at well over its capacity, and too many patients were leaving without being seen by a doctor. Chris Thomson, chairman and medical director of the LGH-ED, was charged with bringing the numbers back on track, and he began by ramping up the ED's Lean program. Thomson and the ED's new process engineer, Jennifer Stowers, set out to enhance quality, service, and efficiency while standardizing and streamlining all processes to make the ED more efficient in every way. They also felt strongly that creating a new pediatric ED would be beneficial. But would the hospital as a whole be receptive to the changes Thomson and Stowers were proposing? This case has been used in Darden's course elective "Management of Service Operations."