10 Commandments for Great Patient Flow

Follow these rules to improve patient flow, quality, and efficiency. We made most of the list in a recent ED meeting, but it applies anywhere patients present.

1. Add value for patients first, always, and without compromise.

2. Never make patients wait unless it adds value for them.

3. Triage means sorting, not primary nursing assessment (see 1 and 2 above).

4. Time is Quality for most care.

5. Nurses and physicians must pull in the same direction at the same speed: ED team = 2-horse chariot.

6. Professionals must do what they do best: RNs do RN work, not clerical work.

7. Remove or unload bottlenecks.

8. Always design parallel processes, not sequential.

9. Design for unlimited capacity; you cannot turn people away.

10. Patients need humanity with every encounter, especially when ‘there’s nothing wrong’.

Do you have any to add? Please share them in the comment section. Thanks!

(image credit: http://blog.cachinko.com/)

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?

Pros

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.

Irresistible.

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.

Cons

“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!

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.

Nice.

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?

NO!

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?

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