Physician Scheduling Extreme – Interview with Dr. Marko Duic

Imagine a schedule where you could work any day you wanted, see as many (or few) patients as you wanted, and take as many holidays as you wanted.

Sound unbelievable?

Dr. Marko Duic has honed a physician scheduling system that delivers MD choice, MD control and a perfect fit between physician speed and patient volumes.  He shares how he does it:

Welcome, Marko.  You’ve figured out a way to give physicians choice, control and as many holidays as they want.  Is that true?

For individual physicians, it’s true.  The only restriction is that a few physicians need to stick around to keep the emerg going–so not everyone can take off at the same time.  This might be an issue if everyone in the department wants to go to the same conference. But if an individual physician wants to go off for 3-6 months, to, say, cycle from Cairo to Capetown, it’s not a problem.

How long have you been doing this for?  

Since 2001

How do the physicians like it?  

They state that it’s a major reason why they’d never go to another ED to work.

How do patients like it – what results do you achieve?

The most important patient satisfaction correlate is their time to see the doctor (Physician Initial Assessment time).  Well, the two hospitals in Ontario that use this system are often number 1 and number 2 in PIA times, and one of them is definitely a leader in satisfaction among peers.

What do the nurses think of this system?

At first, not that pleased that we could muster up ANY number of physicians ANY time, and they would get stuck with a pile of orders.  They had to see that a pile of orders is better than a pile of unseen patients.  At least with the patients having been seen by MDs, nurses could be asked to do the most urgent orders first.   What the nurses like about his system is that there are always enough doctors to see the patients, so they never have to get abused by impatient patients.  There’s never a day when three slow physicians work back to back and the place explodes.

Could this system work anywhere; do you think you could teach others to do it?

Of course it could work anywhere.  It’s how patients would schedule doctors, if patients were allowed to schedule us. 

Most emergency departments schedule a fixed number of shifts every single day, but you don’t.  Why?

Each physician has a number of patients per shift that he’s most comfortable seeing.  It could be 15, could be 30, could be 45, could be 60.  And each emergency department has a number of patients that they see any given day.  So for example, in one of our departments, we see 300 on Sundays and Mondays and 270 the other five days.  So I have to schedule enough physicians that their combined capacity to see patients adds up to the number of patients I’m expecting.  So if all the fast guys go on a conference together, the slow remaining guys have to be scheduled in larger numbers–maybe 9 or 10 of them in a given day to see that many patients.  If the slow guys go on a conference, I might only need five or six of the remaining fast guys to see the patients.  If everyone’s in town, and I alternate fast and slow guys, I might need 7 or 8 physicians.  If the physicians are different speeds, how can you expect to have the same number of them per day?

So, how do you determine exactly how fast each MD works?  

I have stats, but they don’t really work that well.  So I do it by trial & error repetition and intuition.

But what if more patients arrive on a particular day?  

Shifts start when patient waits get up to a certain level.  Physicians call each other to figure out when the next one needs to show up.  If the day’s busier, it becomes evident in the conversations.  Physicians come in early, and stay late, and if needed, call an extra physician.

And what if you need another physician to help?

We use our on-call funds to pay one of them to show up.  We call in turn, alphabetically, and change the order by one physician each time, so everyone gets a chance.

Who decides if more MDs are needed on any given day?

The physicians who are working in the department at the time.  If they risk running over the target patient waiting time, they call extra help in.

What if the physicians working that day do NOT call for extra help?

Then the times go over, this is a disaster, and they need to explain why they don’t.

What are your thoughts on the provincial Hospital On-Call funding system?

It’s good to have money to pay physicians to come in to serve patients.  Especially in the ED, where volumes and acuities are unpredictable, and where timely access to care is what’s held out to the public in the name EMERGENCY DEPARTMENT that’s posted on the door.

Are there times when you have scheduled too many MDs on one day?  What happens then?

They either shorten all the shifts, or cancel one of them, or both.  They come to an agreement that suits them all.

Okay, let’s focus on the mechanics of schedule creation.  How do physicians ‘pick their shifts’?

They submit a selection form that shows me when they want to work, when they can work, when they would prefer not to work, and when they can’t work.  I use all the physicians’ forms to give everyone a schedule that’s almost entirely made up of shifts they want or can do.

Is it completely different every month?

Basically, yes.  Some patterns repeat–some guys like nights; other guys like Wednesday mornings; some people can never work Friday evenings.  But overall, it’s different every month.

What happens if there are too many shifts requested by the group?

Everyone gets a bit less than they asked for.

What happens if you can’t provide enough coverage to meet the expected volumes on a day?

Short term, everyone works a bit more than they would like.  Long term, hire more people.  But if it’s one day, and no one wants to work then, then there’s a lottery.

Can MDs take holidays?

Yes, any time, for any length of time.  We’ve had people take full-year sabbaticals or 4 to 6 months LOAs and come back to a full shift roster.  This system is totally flexible.  20 guys can cover the absence of 1-2 guys with minimal disruption for a long time.

What if everyone wants to take holidays at the same time?

Then we close the department.  No, seriously, there’s a max of about 1/3 of the department that can be on holidays for a longer period, or 1/2 the department for a few days, or 2/3 for a day or two, and it can still have full staffing.

What about Christmas, New Years and summer vacation – how do you handle those holiday requests?

In whatever way EPs want, but overall, some people always want to work them, and if there are not enough, then there’s always the record of who did it last year and the year before–those people get first dibs on taking them off this year.

Wow – this seems too good to be true, but it looks like the results prove it works.  Do you have any final comments?

Try it, you’ll like it.  More importantly, the physicians will love it and insist on always doing it this way.  Patients will love it too.

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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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Patient Safety Requires Abundance

How much more can you work?

Finger Pressing Button on Calculator


Do you work too much already?


Emergencies demand MORE.


You risk patients’ health if you cannnot respond to increased demand.



Most departments run on a poverty mentality: serve as many patients as possible doing as little as possible for each.  Parsimony appears wise, even frugal, but it’s backward and unsafe.

A poverty mentality fosters a dysfunctional system with no resilience – nothing extra, no reserve for disaster, no teaching, no service excellence, no follow-up, only the bare minimum.

Abundance turns poverty on its head.  Why not do as much as you can for every patient?  Instead of sprinting through diagnosis and discharge, why not provide over-the-top care and service?  Why not welcome patients back if they can’t get great follow-up that works for them?

Abundance means treating all patients like they were privileged.  Privileged patients get all the extras without extending their stay.

Abundance provides outstanding patient experience AND builds resilience – the ability to flex; to increase services on demand – necessary to guarantee safe, quality care for the next wave of patients.  Poverty delivers second-rate care and jeopardizes emergency services for the whole community.


1.  “But great service will just increase volumes!”

2.  “Can’t most of the patients be seen in a clinic?”

3.  “Won’t abundance increase costs?”

Objection #1  This has to be the dumbest reason to not improve service.  If volumes increase because your service is great, so be it.  Hopefully, other EDs will improve, too.

Objection #2  True, emergency departments exist to care for the acutely sick and severely injured.  Emergency services require

I. Capacity to care for the acutely sick and severely injured,


II.  A dependable method to sort out patients who aren’t sick or injured.

I. Patient resuscitation for the acutely sick requires 3-4 nurses, at least one MD and a horde of other staff to attend immediately.  Ask ED staff:

Have you had 2 resuscitations at the same time?

How about 3?

Have you ever had 4 resus patients at the same time?

These scenarios are NOT rare.  While the answers depend on your annual visits, guaranteeing immediate care might demand up to 16 nurses, a team of allied health providers and a group of MDs.

II. No method can guarantee that patients sent away from an ED won’t come to harm.  All EM staff have seen patients triaged to a minor treatment area only to be admitted to the ICU or sent for emergency surgery.  Sore throats and back pain can turn out to be life-threatening epiglottitis or aortic dissection.  Why not see them in the ED?

Objection #3 “ED care costs too much.”

So, why don’t we send patients straight to a clinic where they’d be seen immediately?  A clinic could assess patients, perform routine investigations, get urgent access to x-rays and even provide IV treatment.”

Indeed.  And how would the costs differ?

Fixed costs for EDs are huge, but it costs very little to see one more low acuity patient – far less than a separate clinic.  And, low acuity patients NEVER block up the ED.


In Canada, EDs back up everything else – doctors’ offices, post-op clinics, imagining, consultant services, etc.  An abundance mentality guarantees that no matter what happens, patients will receive immediate, high-quality care.  EDs must create their own resilience with an abundance approach to service or risk emergency preparedness for their whole community.


How much more can you do – today – for patients in your ED?  Are you risking your community by fostering a poverty mentality?





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Saving time. Saving Lives

Guest post by Dr. Marko Duic MD

At a recent high-school career-night talk where I was invited to discuss medicine as an option, I asked the 11th and 12th grade students why they were possibly considering medicine.

“To save lives” came the unsurprising response.  What else would they say?

Later, when I described that my job is not only as an emergency physician but also a department chief—an administrator—they determined that I made less, not more money than I would if I were only an emergency physician, so they asked me why I do it.  My answer surprised even me, so I would like to share it.

When the students first told me they wanted to do medicine to “save lives”, I pointed out that we don’t do that in medicine.

Instead, we delay death. 

Everyone ends up dying anyway, which would not be the case if we really saved lives.  However, by doing our physician work well, we have a chance of giving patients useful time between whatever life-threatening emergency they presented with, and their inevitable later demise.

They asked for an example.

I pointed out that most potentially life-threatening causes of chest pain (MI, PE) are treated with “blood thinners”. But once in a blue moon, and only a few times in the average emergency physician’s career, the parade of usual chest pains for which we give life-prolonging blood thinners, is punctuated by a patient with a very similar but not identical chest pain for which blood thinners could be life-ending:  the aortic dissection. It is easy to miss such a patient if one is not paying attention, and if one did miss such a patient, the results could be grim.

So the story I told was of a 48 year old man I had seen six months previously who had had a 55 minute stay in our emergency—including triage, being examined, scanned and transferred to vascular surgery in another hospital.  His wife reported that he was discharged a week after surgery, which repaired his dissection that extended from the aortic root to the ileac bifurcation.  He was now doing well at home.

Had I saved his life?  No, he will die at some point.  But maybe he has 10 years until some other grievous atherosclerotic event does end his life.

10 years, 16 useful hours in a day:  about 60,000 hours of useful time for this patient, as a result of an excellent team, a great emergency department, and very fast and very careful doctoring.

WOW, the high school students said with admiration.  That’s really cool.  Or maybe the term was “wicked”.

At my hospital, by engaging the team to come up with a leaner flow process, we cut down the average wait for patients by about two hours.  The change was planned for months, then put into place overnight on 6 June 2011.  On 5 June, patients waited 4 hours at the 90th percentile, and on 6 June and thereafter, they waited 2 hours (posted on this site earlier).

Thus every patient (I told them to keep things simple, although the details are messier) saved 2 hours of useful time.

250 patients/day, 500 hours saved per day.  120 days—one quarter—60,000 hours of useful time have been saved.

Administration for physicians is not as dramatic as “saving a life” as a physician, and filled with much recrimination from all kinds of people with aversion to change, even though it’s clearly an improvement for patients.  Yet it’s deeply rewarding when one can “save lives” administratively—allow people who could go live in the community to stop wasting their lives in the waiting room.

As a physician, I can “save a life” once in a while.  As an administrator, I can save some life for each patient.


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Schedule 4 Patient Flow AND Efficiency

Schedulers think in LEGO blocks.  They guess how much work an average staff member can do, and then schedule enough staff to meet the average amount of work each day.

To build a schedule, they plug staff into a grid, like identical LEGO blocks, to meet the demands of an average day.

4 problems with LEGO block scheduling:

1. Nobody is average.

2. No day is average.

3. Under-staffing makes patients wait.

4. Over-staffing makes costs go up.

Average doesn’t exist in clinical medicine.

Treatment protocols can be standardized, but the core of clinical medicine – history taking and physical examination – remains messy, relational and often intuitive.  Ask any emergency nurse: every doctor works at a different speed – same goes for the nurses.

Discussing speed makes most providers squirm. Slow providers say fast ones are slipshod and careless; fast providers say slow ones are lazy or talk too much.

Schedulers run from this time bomb.  It’s safer to assume average work speed, and hope that patients won’t wait, and costs won’t soar.

But patients wait… and costs soar.

How can this be resolved?

Let’s look at physician schedules.  First, we must re-frame provider ‘speed’ – defuse the time bomb. Dr. Marko Duic put it something like this:

“Every physician has a number stamped on his forehead that states the number of patients he can safely see per hour. Everyone can see the number, but no one can see his own number. Ask any nurse how many patients a physician sees in an hour, and they will tell you as accurately as reading a number off the doctor’s forehead.”

We can’t change the speed people work, and we must welcome every worker onto the schedule regardless of how fast or slow they work.

How can we build a schedule that minimizes patient waits AND maximizes staff efficiency?  Furthermore, how can you get staff to want such a schedule?

If you want to schedule for waits AND efficiency:

1. You must match demand with productivity.  You should know how many patients attend your ED per hour.  You know how fast your docs work.  Schedule enough MDs, based on their individual work speeds, to meet the average patient volumes by hour.  Some days you may need twice as many doctors, if they all happen to be slower on one day.

2. You need hour to hour flexibility.  Physicians must stay late, arrive early, go home early or call in more MDs for help when patient volumes warrant.  Let the physicians on duty control these decisions, and keep them accountable for the outcomes.

3.  You should let physicians chose whatever shifts they want.  Choice makes doctors happy.  Collect their shift preferences and have them indicate 50% more shifts than they want for whatever time frame you are scheduling (e.g., 1 month).  Juggle the MD lineup each day based on #1 above.

We will interview the provincial guru on MD scheduling, Dr. Marko Duic, in one of the next posts to bring out the details.


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Patient Waits Drop if Waiting Room Closed

See what happened to our wait times from the first day we closed our waiting room, without spending a penny:

On June 6th, 2011, patient waits plummeted from over 4 hours at the 90th percentile to just over 2 hours when we closed our waiting room.  90th percentile = how long 9 of 10 patients have to wait; it presents the worst case scenario.  Today, patients wait less than 60 minutes on average to see a physician – one of the shortest in Ontario.  

Physician Initial Assessment includes a complete history and physical examination; not just shaking hands in the corridor or having an alternate care provider see patients.

From day one, the left-without-being-seen rate crashed from 3-4% down to 0.4%.

Hoarding patients in the waiting room – like boarding admitted patients in the ED – prevents patients from receiving the care and treatment they need.  If you remove the waiting room reservoir and bring patients straight into the ED, they get seen, diagnosed and treated.

6 keys to success:

1. You need an outstanding team of nurses, physicians, allied health and administrative staff willing to try something new.  This can’t be overstated!

2. You need nurses willing to accept working differently.  Sometimes there will be crowds of patients; other times there will be none.  RNs will need to work together to move patients through when volumes surge instead of moving patients through when the nursing schedule allows.  Schedules must match patient volumes by time of day; not the time of day when stretchers open up.

3. Physicians must be willing and able to increase staffing to meet surges in patient volume.  MDs must arrive early, stay late or call in their peers for help if patient waiting threatens to exceed targets.

4. Wherever possible, replace stretchers with exam tables.  Ambulatory patients can be seen on exam tables and wait in chairs.  Stretchers attract admitted patients; stretchers kill patient flow.

5. You need an unlimited capacity mindset.  Every patient needs to come inside.

6. Physicians have to get comfortable moving/directing patients into exam rooms and back out into chairs.

We’ll dig into all these points in later posts.

For now, what’s holding you back?  Why wouldn’t you want to decrease patient waiting by closing your waiting room?


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Reservoirs Kill Patient Flow

Reservoirs often show up as extra capacity, and who wouldn’t welcome that?  Shiny new clinical space gets first place on hospital tours, center stage in photo shoots and prominent mention in ad covers.

We find reservoirs all over healthcare: special inpatient wards, waiting rooms, bigger clinics, bigger emergency departments…extra capacity.

But, mindlessly expanding capacity decreases patient flow – increases patient waiting – if we don’t guard against forming reservoirs.


5 features of reservoirs in healthcare:


 1. Reservoirs slow patient flow.  Like giant, hydro-electric dams, they convert high flow, hard-to-manage situations into low flow, contained events.


2. Reservoirs allow us to meter out patients – for example,
we trickle them in from the waiting room into the ED, or trickle them up to the inpatient wards – when we are ready to see them.


3. We find reservoirs familiar; a common solution to high flow demands. They’re socially acceptable.  In fact, most institutions pride themselves on the size of their reservoirs.


4. Reservoirs decrease chaos and make us feel safe, but patients feel just as scared and unsafe while parked in a reservoir.


5. Reservoirs fill easily.  They attract contents.  Reservoirs might empty now and then, but they tend to promote filling and storage (waiting).


Waiting rooms, gigantic emergency departments or even special inpatient wards are reservoirs, and patients do not benefit from them if they exist only to slow patient flow.

These fat areas in the stream of patient flow end up grinding flow to a halt without extreme vigilance to keep patients moving.

We have to match patient volumes with flow; not capacity.  Sure, we always need more beds, but we need increased flow more.   Flow doesn’t just mean flow out of the hospital; it means flow in, too.  We often blame long term care or families for not taking patients home, as though there’d be no waiting if there were no alternate level of care patients (ALC; patients who need long term care) in the hospital. Or, we blame the inpatient wards for not taking patients out of our EDs sooner.

Truth is: we didn’t have an ALC problem years ago, but we still had admitted patients in the ED.  ALC represents one (major) factor impeding flow, but it’s not the only issue.

In the same way, patients crowded ED waiting rooms long before holding admitted patients in the ED became such a problem.


Until we develop a culture of taking every patient in – in to the ED and up to the wards – when they present, and not just when we are ready for them, we will never get rid of reservoirs and crush patient waiting.


How can we balance maximal patient flow and institutional capacity?  Is bigger better?  How can we avoid building reservoirs?



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Why build waiting rooms? For patients or providers?

Every emergency department has a waiting room that probably gets used more than any other room in the ED.

Did a patient group meet and declare they wanted waiting rooms?

Of course not.  Patients come to the ED to get help; not sit in a waiting room.

“Well, patients need to be able to wait somewhere before they get inside the ED.”


Why can’t we bring all the patients straight inside the ED?


Only someone painfully unaware of modern ED struggles could ask such a silly question.

“We don’t bring patients inside the ED because we don’t have enough resources to care for them.”

It’s all about stretchers and ratios.  We decide the ED is full when all our stretchers are full.  We decide the number of stretchers by how many nurses we have working based on a ratio of 4 stretchers to 1 nurse.

Stretchers and ratios keep everything neat and orderly inside the ED.

So, to maintain order inside the ED, we build waiting rooms to house all the patients that we don’t feel ready or able to help.  No matter how many patients pile up in the waiting room, we stick to our stretchers and ratios.

Providers want waiting rooms; waiting rooms benefit providers not patients.  Patients want to come straight inside the ED.

Why don’t we bring all patients inside?  What could be worse for patients than leaving them for hours in the waiting room?


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