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- Retire outdated EMRs – an old, slow EMR might be worse than none at all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