See What We’re Trying Next to Improve ED Patient Satisfaction, Quality and Flow

So far, we’ve posted what works.  In two days, we will try something that (almost) never works.



Does repeated failure mean something is impossible?


Hundreds of teams of really smart people have failed to improve outcomes and efficiency by putting physicians at triage.   In some cases, flow did not change.  In others, costs were too high.  We want to try it anyways.



Why would we bother?


It’s what we want for our families.  

When nurses and physicians need a medical opinion, they go straight to the nearest MD they trust.  Direct access.  All the non-value added steps removed.

Time equals quality in emergency medicine.  

The sooner we diagnose and treat patients, the higher quality of care we can guarantee.


The chance to radically improve flow and efficiency is just too attractive to ignore.  Imagine being able to see and treat even 10% of your patients out front – a chunk of patients would never enter the ED.  30 fewer patients and family members packed into the bowels of the ED seems reason enough to try it.

Fewer steps = lower cost.  

If we could exam and begin treatment without a lengthy pre-screen, triage and registration process, we would decrease the number of providers involved and decrease patient length of stay.  Staffing costs and length of stay directly impact efficiency.

Parallel processing beats sequential processing.  

Modern ED Triage is sequential.  It’s guaranteed to become a bottleneck unless an oversupply of staff continually support it.  A parallel RN-MD clinical stream right at the front door seems destined to succeed.


“If it ain’t broke…”  

We’ve ranked with the top 3 EDs in Ontario for time to physician initial assessment (PIA) for 18 months.  Our average PIA hovers just under 1 hour.  However, Voltaire said, “The good is enemy of the best” (approximately).  Unless we continually improve, we will slip back.

Everyone failed – why won’t you?  

Failed attempts don’t mean something is impossible.  As Thomas Edison said, “I have not failed.  I’ve just found 10,000 ways that won’t work.”  If a concept seems logical and irresistible, it’s worth trying again.  Also, St. Joe’s Hamilton seems to enjoy early success with their recent attempt at putting a physician at triage which inspires us to try it for ourselves.

We’ll let you know how it turns out when we try it in 48 hrs.  Please share your thoughts below – tell us what we need to know.  There’s still time to change what we’re about to attempt!

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Emegency Departments That Lag

Time to treatment equals quality for much of emergency medicine.  It’s also the easiest way to decide whether an ED is any good.  Missed diagnoses, errors of judgment, and clinical mistakes can be hard to spot by comparison.

Emergency Departments That Lag

1.  Long Line up at triage –

The most at-risk patients stand in the line-up for triage.  Every day, patients walk in with a deadly process inside of them.  Until they have been seen, they are unsafe.  A line up to be seen is indefensible.

2.  Long triage process –

Triage should be sorting; not a primary nursing assessment.  Patients need a diagnosis and treatment.  In most cases, this means getting patients and physicians together as fast as possible.  A long triage process does not add value for patients.

3.  Long Line up at registration and long registration process –

Registration – getting a chart made – does not add value for patients; it only delays care.  It must be short!

4.  Packed waiting room –

There is no reason for patients to EVER wait in the waiting room.  Please argue in the comment section below if you disagree.

5.  Patients must repeat their story over and over and over.

Providers should quickly check what others have recorded, verify the facts and ask additional questions.  Starting over with every provider drives patients nuts.

6.  No discharge excellence

Patients should leave the ED with copies of lab and radiology reports, written discharge instructions (if necessary), and clear instructions for follow-up and return visits to the ED.

7.  Dismissive attitude

Patients should be welcomed to the ED for ANY complaint.  No complaint is trivial for a patient.  We – healthcare providers, media, government, all of society – seem to think healthcare would be just fine if it weren’t for all the patients.  Besides being unwelcoming non-verbally, there’s a big difference between “Why are you hear today?” and “How can I help you?”

Rules in case you get sick:

Don’t go to your family doc unless you’ve tried something yourself first.

Don’t go to your specialist unless you go to your family doc first.

Don’t go to the ED unless you’ve gone anywhere else first.

Don’t go to the ED unless you are nearly dying.

If you are dying, you shouldn’t go to the ED because we can’t do anything for you…



But all our beds are full of admitted patients!

Definitely the most popular excuse, admitted patients definitely make it almost impossible to provide emergency care some of the time.  But, even with admitted patients blocking beds, patients should still be brought into the ED and seen on exam tables.  If they can wait on chairs in the waiting room, they can wait on chairs inside after they’ve been assessed.

Thankfully, Ontario has started to hold hospitals accountable for getting admitted patients out of the ED, and up to the wards.

Who owns morale?

Management owns operations; staff owns morale.  Sure, you can crush morale in even the most engaged staff, but blaming management for staff attitudes will mire an ED in under-performance.  Staff control their own morale, and it must be part of performance management.

How does your ED stack up?  As a patient, have you researched your local EDs to see which ones to avoid?  

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What You Need to Know to Improve Patient Flow at Triage

Modern triage = patient sorting + a boat-load of protocols and ‘value added’ steps.

Napoleon’s surgeon seems to be the first provider to try a sorting process for crowds of patients.  He wanted to quickly sort which wounded soldiers were most likely to return to battle, so he could provide care for them first.  Historical triage got soldiers back into action while seriously wounded soldiers were left to die.


In the olden days of emergency medicine (30 years ago), patients could usually be seen soon after registration.  They were brought straight in, seen by a nurse and a physician soon after.  In the 1990s in Ontario, the ED became a favourite spot to park admitted patients when the inpatient wards became ‘full’ as defined by staff working on the wards.

Around this time, triage turned into primary care nursing for new arrivals and the crowd of patients warehoused in the waiting room.

This was never meant to be.

Triage must be rapid sorting or it’s not triage at all.

Long interviews, multiple forms, medication reconciliation, past medical history, allergy lists, infection control screening, extensive sets of vital signs, patient examination, wound inspection, and answering questions about waits, parking, directions and vending machine locations – modern triage redefined the term ‘triage’.

Maybe that’s a good thing?  Surely, all the added work being done by modern triage was started for a reason?  Maybe patients want to come to the ED to get a really thorough triage?


Patients come to the ED to get a diagnosis and treatment.  Anything that stands in the way of diagnosis and treatment does not add value for patients.

Triage should add value by getting patients to the care they need as quickly as possible.  We should resist anything that stands in the way of patient care.  Quality care depends on timely assessment and treatment.  Triage adds value only if it facilitates timely care.  Triage should never bottleneck flow; there should never be a line-up to see the triage nurse.

We must unload all the duties we’ve piled onto triage, if we are serious about improving patient flow.

If hospitals insist on running waiting rooms like a clinical areas, patients would be better served by assigning nurses to care for the patients in the waiting room instead of shackling triage nurses with non-value-added work.

Does triage add value in your hospital or does it delay care?  Is there a patient line-up for triage?  

Please click Leave a Reply or # replies below.

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The Secret of Great Hospital Performance

MP900386070When you pull out to pass a car on the highway, what do you care about?
Do you care about speed or…
do you care about your gas pedal? 
We press on the gas pedal (input) in order to pass (output).
We focus on the job at hand, what we need to get done. We do not care about the gas pedal. We care about passing safely.

Healthcare focuses on the gas pedal.

  • How much will this cost?
  • How big is our budget deficit?
  • Where can we trim costs?
  • Why are costs going up so fast?

It’s understandable. Money grabs our time and attention in hospital leadership.  But, like the gas pedal, inputs should be secondary. Our biggest concern should be outputs, are we delivering great care?

Block funding for hospitals died years ago in most countries.  Unfortunately, block funding still thrives in many Canadian hospitals.

Block funding = stretch one pile of cash out for a whole year of hospital services.

  • No funding for growth.
  • No funding for acuity.
  • No incentives to deliver more care.
  • Focus on the budget; don’t spend a penny more…keep the gas pedal in focus.

Fortunately, most jurisdictions are starting to admit that block funding doesn’t make sense.

Focus on Outputs

The secret to great hospital performance = focus on outputs.  Focus on great service and outcomes for patients, first.

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7 Common Patient Waits & How to Fix Them

After supper, a friend told me healthcare gave terrible service.

Men Sitting at Table Drinking Espresso

As a senior management consultant for a well-known multi-national corporation, he spends his time helping companies run well.  In his opinion, healthcare runs poorly.

While full of wonderful, caring people, healthcare is inconvenient and inefficient.


7 Waits and How to Fix Them

1. Waiting for appointments with Family Practice – All family docs could offer same day visits.  Some physicians have been doing it for decades.  Their patients love it, and their practices remain profitable.  Some patients want appointments booked days in advance and that should continue.  Other patients want to be seen the same day and could be accommodated with on-site urgent-care clinics or advanced access booking.

Patients should never have to wait to see their family doc (or a physician in the practice group).

 2. Waiting in the waiting room for your physician This should be very rare.  When it happens every visit, it represents terrible practice management.  Physicians run 2-3 exam rooms to prevent patient waiting.  If physicians are double-booking because of patient no-shows, then they should collect no-show fines or consider firing patients  from their practice who continue to not attend for booked appointments.  If physicians are booking too many patients to see them promptly, they need to stop booking so heavily and spread out appointments.  They should stop fooling themselves and book a longer day at the office.  They are staying late anyways; they might as well do the courtesy of allowing their patients to arrive later instead of making them sit in the waiting room for hours.

Either way, it’s up to physicians to keep their own waiting rooms empty.

3. Waiting for blood-tests and X-Rays –  Lab tests can be processed in minutes to hours, but we make patients book separate visits to get blood-work and imagining, then we make them book another visit to discuss the results!  Basic blood-work and x-rays should be available same day for all patients.  This can be done by allowing advanced access at labs and imaging suites.  Digital images can be read off-site.

Patients could receive basic tests and results in the community just as they do in the ED without extra cost to labs and with great savings for patients.

4. Waiting to see specialists.  Ostensibly, wait times to see specialists are long because there aren’t enough specialists.  However, there’s a glut of unemployed specialists in many fields (e.g., orthopedic surgery, cardiac surgery, etc).  Most of the specialists are ‘unemployed’ because they can’t get operating room time.  If there really are too few specialists, why don’t they leverage family docs (or unemployed surgeons) in their clinics to screen through their consults and follow-ups?

I worked for a few years as an associate with our local vascular surgeon to churn through his office visits and minor procedures so he could focus on patients needing surgery.

5. Waiting in an ED waiting room –  We discuss how to close your waiting room in other posts.  It’s the right thing to do – get patients inside, get them seen, get them treated.

6. Waiting for an inpatient bed inside the hospital –  There is no reason to warehouse patients in emergency departments.  Unless hospitals make a conscious decision to get patients up to the wards, nurses and physicians will not change their behaviour and get patients upstairs.  Dozens of papers show that quality and patient satisfaction improve when patients wait in the halls on inpatient wards instead of waiting in the ED.  Furthermore, hospitals that send admitted patients up to the wards, when there are ‘no beds available’ on the ward, somehow find a way to put patients into rooms.  Staff find a way to discharge other patients to open up space.

Admitted patients should never be left in the ED to wait for an inpatient bed.

7. Waiting for surgery –  Patients wait because OR time is limited by OR closures or cancellation of surgery.  ORs need to be kept open – after hours if necessary – to treat patients.  Surgery must not be canceled because surgical beds are full of medical patients.

Let surgeons manage surgical beds; do not let medical flow issues shut down surgical flow.


1. If we remove waits, won’t demand go up? Won’t utilization increase?  Anxious patients who demand ‘unnecessary’ investigations receive those investigations in the current system.  Most average patients don’t want to give blood or get X-Rays and then wait around for results unless they really have to.  Average patients would continue to pursue investigations only on advice from their physicians.

2. Wouldn’t MDs start ordering too many tests if they knew they could get same-day results?  Sure, more family docs might order blood-work and X-Rays for patients that they presently send to the ED preventing a few ED visits.  Same day service would still require hours of waiting for patients; hardly a convenience all patients would want.  The current technology for blood-work and x-rays still dissuades frivolous testing because of the time and effort required. Until investigations become as quick and convenient as a medical scan on Star Trek, we won’t see a giant spike in investigations.

Canadians wait politely, and they should not.  There’s no need for most of it.

We need to challenge the old way of doing things: waiting for appointments, waiting in waiting rooms, waiting for labs, waiting for x-rays, waiting to discuss results, etc, etc…

We need to adopt a ‘get it done now’ approach all across healthcare.

If you agree, feel free to leave a comment by clicking on leave a reply or # of replies.


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112 Patient Flow Solutions for Emergency Departments

This list should get us started…  Please add your ideas in the comment section at the end!

  1. Close your waiting room – bring patients straight inside to chairs if no beds open
  2. Use triage to enhance flow: triage = sorting and nothing else
  3. Limit the number of nurses at triage – 1 nurse can SORT 200 patients per day easily
  4. Have patients self triage
  5. Use on-line triage
  6. Use Bedside registration
  7. “Quick Reg” – limited registration; just enough to create a chart
  8. Have patients use self registration
  9. Offer pre-registration on line
  10. Post live wait times on-line to smooth patient volumes
  11. Use patient passports – patient education hand-outs at front door
  12. Educate the community to arrive in ‘slow’ hours (e.g., before 11am Tues – Fri)
  13. Educate community to avoid the surges on Sunday evening/all day Monday
  14. Limit 1 visitor per patient
  15. Encourage patients to bring med lists with them
  16. Encourage community MDs to send in referral notes
  17. Have on-call MDs
  18. Have flexible start and stop times for MDs
  19. Get MDs to take responsibility for flow in real time
  20. Have on call RNs
  21. Shorten nursing documentation (1-2 pages max)
  22. Use combined triage & nursing secondary assessment form
  23. Use physician scribes/navigators
  24. De-zone – move staff to where need is greatest; don’t leave a zone overstaffed
  25. Use advanced directives
  26. Use pre printed orders
  27. Measure and reward MD performance
  28. Measure consultant response times
  29. Insist on in-house consultant coverage for internal medicine, anesthesia, pediatrics…
  30. De-unionize – flow will improve
  31. Have nurses only do nursing tasks (carry out orders, give medications), not clerical work
  32. Track RN break times – insist on accountability
  33. Reward RN extra effort (staying late, skipping breaks, going the extra mile)
  34. Match RN staffing to patient volumes by hour
  35. Match MD staffing to patient volumes by hour
  36. Never allow MDs to go home if waits are long
  37. Staff extra MD and RN shifts on known high volume days (Mondays, holidays)
  38. Encourage MDs/RNs to work in teams and hand over readily
  39. Stagger RN shift changes
  40. Have dedicated ED X-Ray
  41. Have U/S (and tech) in the ED
  42. Use techs for lab draws and ECGs
  43. Stat labs
  44. Prioritize ED lab and DI
  45. Don’t batch
  46. Dedicated porters (RN/tech should porter if porters overwhelmed)
  47. Track DI and lab turn-around times
  48. Get a great EDIS (ED information system)
  49. Create meaningful alerts on EDIS to identify LOS, reassessments, etc
  50. Have a modern EMR linked to the EDIS
  51. Retire outdated EMRs – an old, slow EMR might be worse than none at all
  52. Consider a real time locating system (e.g., RFID)
  53. Consider EMR on tablets for each MD
  54. Computer terminal in each room
  55. Link ED EMRs with community EHRs
  56. Have forms available on-line
  57. Bypass ED for STEMI identified by EMS (straight to PCI)
  58. Eliminate phone calls for CT, etc
  59. Extend CT hours of operation
  60. Encourage the hospital to work on a 24-7 service model (at least a 7 day service model!)
  61. Do not schedule big surgical cases on Monday
  62. Track admits and discharges by time of day and day of week
  63. Eliminate day-day variations of admits/discharges
  64. Perform nurse handover on the ward; not by phone from the ED
  65. Get admitted patients straight up to the ward before a bed becomes available
  66. Use a visual bed management system for inpatient flow admitted patients leave promptly
  67. Use patient flow navigators
  68. Create robust medicine clinic follow-up clinics (next day)
  69. Do not allow consultants to ‘send patients to the ED’ and see them there
  70. Teach residents about quality and efficiency as paramount in their education
  71. Use PO instead of IM, and IM instead of IV treatments if possible
  72. Position EMS off-load in-front of the main nursing station – not hidden away where patients can languish
  73. Form psychiatric patients promptly as needed
  74. Do not perform an internal medicine ‘ward’ work-up in the ED
  75. Order all tests and treatments on the first touch
  76. Plan on disposition from the first encounter
  77. Have Multi-use rooms (eliminate bottle-necks)
  78. Establish procedures to sedate patients in any room
  79. Partner with volunteers – they can help a ton!
  80. Establish CDUs on in-patient wards – do consultations there
  81. Give every MD, RT and Consultants a phone to carry
  82. Do not scale down services over holidays when demand always goes up!
  83. Encourage same day, out-patient cardiac diagnostics and consultation
  84. Establish direct referrals to cardiology (not internal med, NP, cardiology, etc)
  85. Have everything needed for work in every area (don’t make staff walk to the ‘tube system’)
  86. Use pre-printed prescriptions
  87. Have the chief call in 2-3 times per day to monitor flow
  88. Create an internal, real-time ED surge plan
  89. Create a hospital wide surge plan and link it to the ED surge plan
  90. Give admin on call authority to move admitted patients out the ED
  91. Have back on-call to support internal medicine consults
  92. Do not allow surgeons to be on-call to the ED on their OR day
  93. Teach all nurses to apply splints and/or casts
  94. Use ‘just in time’ approach to patient movement – don’t stock-pile patients by loading rooms
  95. Avoid batching
  96. Assign patients to areas; not rooms
  97. Use overhead paging liberally – don’t walk around looking for patients
  98. Improve patient signage
  99. Use patient instruction sheets
  100. Use a re-assessment check-list so MDs aren’t called to reassess prematurely
  101. Build a minor treatment area (aka fast track)
  102. Get rid of as many stretchers as possible (limits holding admitted patients)
  103. Use exam tables where-ever possible
  104. Use some chairs instead of stretchers in the acute area for telemetry patients
  105. Get rid of walls – use curtains to divide most rooms
  106. Eliminate sequential processing
  107. Insist on parallel processing
  108. Look for bottlenecks – theory of constraints
  109. Learn queuing theory and how it applies to your department
  110. Learn and love LEAN
  111. Employ an unlimited capacity mindset – don’t limit flow for lack of ‘rooms’
  112. Adopt a ‘get it done NOW‘ attitude across the organization!

More ideas?  Questions?  Feedback?  Click on leave a reply or # replies below:

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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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