Fix Patient Flow Bottlenecks – Forever

Patient flow seems impossible to fix in most hospitals.

Nearly every step in a patient’s journey can stop flow.  Even the most LEAN-ed processes require fanatical vigilance to guarantee patients don’t get stopped as they move through our hospitals.

Water Pouring from Bottle

Eli Goldratt popularized ‘bottleneck’ in his classic ‘The Goal‘ – a long narrative presentation of the Theory of Constraints.  A worthy read.

Bottlenecks decrease flow.

They cause havoc by showing up unplanned.  In industry, bottlenecks turn up as critical processing steps whose maximum speed determines the maximum speed of a whole production line.

In healthcare, bottlenecks change all the time.  In fact, a dozen different things could be the bottleneck – the rate limiting step – over 1 day in the ED.  During the morning, it’s lack of staff; during the afternoon, it’s lack of beds.  Despite this, most folks like to blame their favourite bottleneck:

 “If we only had more beds. If only we didn’t have admitted patients!”

“If only we didn’t have such slow docs!”

“If only we had more nurses (or faster nurses…)!”

“If only we had more space!”

If only…

Picking one bottleneck – usually out of our control – removes responsibility to address all the bottlenecks within our control.

In recent posts, we’ve been talking about closing the waiting room, bringing patients straight into the ED and cycling them from chairs to exam tables.  These steps bypass the ‘bed block’ excuse most EDs use for making patients wait for hours in the waiting room.  Once patients get ushered straight in, dozens of new bottlenecks show up: nursing shift change, waiting for porters, DI/Lab back-up, not enough MDs, patient reassessment delays…running out of patient gowns…

There’s only one way to guarantee a bottleneck will never slow flow in your ED.

Parallel processing

Like putting together an IKEA cabinet, some things need to be done in order.  Sequential processing means doing things one after the other – like a long train of boxcars.  However, insisting on sequential processing creates hundreds of potential bottlenecks.  Parallel processing unhitches the boxcars and lets them all run on separate tracks at the same time.  That way, if any process stops, all the others can continue.

Simple enough…

But, medicine loves process.  Many of the sacred cows in emergency medicine are core to sequential processing:

Triage followed by

Secondary Assessment followed by

MD assessments followed by

Lab and DI followed by




Most providers fight to keep care in a general order.  It’s what they’re used to.

A parallel approach looks like this:

Triage (sorting only…more in another post) followed by

Everything else

Easy, right?  It’s not.

If you truly adopt this thinking, you might have MDs assess and discharge a patient before the patient even sees an RN.  Or, you might have Lab/DI and discharge planning involved before an MD gets to a patient.  This requires huge flexibility for providers who’ve been bound by historical process.

But…but…what happens first?

After triage, everything else gets done ‘as soon as possible’.  Whoever can get to the patient first, gets started on their part of the process even if it means they can’t complete it before another provider arrives.  Get it done, now!  Sequential steps can never be tolerated as an excuse for making patients wait.

What bottlenecks are holding you back?  What’s holding you back from adopting a fully parallel approach?  Share your thoughts by clicking on ‘leave a reply’ or # replies below.

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Are Patients Always Right?


At one time, patients decided whether their problem was worth a visit to the doctor.

Patients were welcomed.  Minor concerns gave providers a chance to relax in an otherwise stressful day.

But, attitudes change.

Instead of welcoming all patients & all complaints, nurses and doctors get taught to judge whether patient complaints are deserving.

They learn that caring for patients with problems unsuited to their highly specialized skills should be done by someone else.

Anyone else.

Over time, providers develop strong opinions about who really needs their care.

Only the truly sick patients ‘deserve’ to be in the ED….except the very sickest of all….dying patients.  They shouldn’t have come to the ED in the first place.

Here are some of the flags nurses and doctors use to identify undeserving patients.

Undeserving patients –

1. Seek help for minor complaints that should have been handled at home.

2. Take poor care of themselves.

3. Attend the ED/clinic out of convenience.

4. Demand repeat investigations.

5. Should be seen by their family doc, or public health nurse, or not at all.

Otherwise really nice nurses and doctors adopt these attitudes.   They reason it’s all part of being a good steward of public funds and common sense.  They confuse a reasonable expectation to educate patients about options to access care – best done at discharge – with turning patients away.

 “Let’s face it: most patients don’t need to be seen.”

‘Undeserving’ patients don’t get great care.  EVER.

We need a new attitude.

We need –

to always let patients define whether their concern is legitimate.

to welcome all patients no matter how ‘minor’ their complaint.

to treat all patients as privileged – like family.

Nothing less than a new attitude, ideal and service standard will do.

If we want to change the way patients access care, we need to provide attractive options for patients.  We cannot provide few, inconvenient options for access and then train providers to hold a ‘send them away’ attitude.  This never promotes great service or care.

Changing minds will require changing incentives in our present system.  We need redesign at the highest level.  In the meantime, how are you going to change attitudes in your ED or clinic?

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ED Stretchers Boarding & Flow

Racing a patient through the emergency department on a stretcher makes exciting TV.

Physician and Nurse Pushing Gurney

But for most EDs, stretchers are the enemy, because stretchers crush patient flow.

Most patients walk into the emerg and walk home – less than 15% get admitted in Canada. There’s no need to force patients to lie on a stretcher unless absolutely necessary.

Patients sit for hours with serious or potentially life-threatening conditions in most waiting rooms.  It’s much safer to get them in and examine them on an exam table inside the ED even if it means they have to sit in chairs during investigation and treatment.

Sure, some patients need stretchers for the duration of their ED visit.  But for most patients, if they can walk, they can sit.  If they can sit, they do not need a stretcher.

Stretchers enable dysfunctional behaviour that makes patients wait.

Stretchers –

1. Attract admitted patients boarding them for days.

2. Act like real estate for ED patients.  Providers assign one ‘lot’ for each patient.

3. Make patients immobile even if they walked into the ED.

4. Allow providers to ‘tuck patients in’, rails up, safe and sound.

Exam tables increase flow by –

1. Removing a spot for admitted patients.  Exam tables are like OR tables:  OR tables are for surgery, not admission.

2. Providing a shared resource for all, not an assignment for one.

3. Getting patients to move, which fosters flow.  Exam tables don’t have wheels.

4. Keeping providers moving with patients.  Exam tables are unsafe without a provider present.  Patients spend minutes on an exam table instead of hours on a stretcher.

Dozens of patients cycle on and off one exam table, whereas one stretcher serves only a few patients per day.  If the average patient spends 6 hours in the ED, each stretcher can serve, at most, up to 4 patients per day and usually far less.

If you haven’t done so already, replace as many stretchers as possible with exam tables.  If exam tables are only found in the minor treatment area, you don’t have enough!

Like any change in historic process, providers realize how attached they are to stretchers when you start asking them to use exam tables instead.  But without building EDs twice the size, we cannot continue insisting that all patients, except the lowest acuity, get seen on stretchers.   Staff support exam tables once they see how much  flow improves; it’s the best way to get patients seen and treated promptly in today’s over-crowded EDs.

Stretchers ruin patient flow, function as a reservoir and promote dysfunctional behaviours. Get rid of them where ever you can!


Do admitted patients block your ED stretchers?  Do all your ED patients currently in stretchers actually need to be in one?  Are they blocking flow making other patients wait for care?  Why not replace some stretchers with exam tables?


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