Slash door-to-doc time, boost patient satisfaction with staff-driven improvement effort

Streamlined triage process sets the tone for further improvements

Sumner Regional Medical Center in Gallatin, TN, offers good evidence that quick-turnarounds are indeed possible when you have motivated staff. Within just four months, Sumner went from the 5th percentile to the 98th percentile, according to patient reviews of their experience in the ED. Mary Jo Lewis, FACHE, the chief executive officer (CEO) at Sumner Regional since September 2010, emphasizes that the dramatic transformation is the result of a staff-driven improvement effort that is ongoing to this day; however, it is nonetheless clear that her own visit to the ED late last year served as a healthy catalyst for change.

It was hardly an undercover operation. Lewis had been cleaning her house on a Saturday morning when she began to experience chest pains. She wasn't dressed in her usual CEO garb at the time, so when she entered the ED, no one picked up on the fact that she was the boss. "Whenever someone walks in and says they're having mild chest pains, [ED personnel] don't ask you any more questions. They take you straight back and start hooking things up," says Lewis. "So, for the first 20 minutes of my visit, I was a totally anonymous patient."

While Lewis is quick to emphasize that the care she received was first rate, she noticed that people kept asking her the same questions over and over, and there were inexplicable delays. So, while her health turned out to be fine, the experience led to a top-to-bottom review of ED operations to see where processes could be tightened up.

Put every task under scrutiny

Lewis brought in an efficiency expert from the health system's corporate office to help, but the improvement process was really driven by the ED personnel themselves. "We got staff nurses, emergency physicians, and other key players in the ED to spend two days looking at the process we use," explains Donna Mason, RN, MS, CEN, SAEN, director of the emergency department. "You get graded on door-to-doc time, so we first documented every step that takes place from the time people enter the ED to when they see a doctor."

The process was eye-opening, says Mason, recalling that staff tallied as many as 44 steps that patients and ED personnel would go through before a physician even entered the picture. These included social questionnaires, such as domestic-violence screening and suicide screening, finding out what medications patients were taking, and documenting whether patients had received various preventive vaccinations, adds Mason. "These were all things that were very important to patients, but we looked at whether they were being done in the right place," she says.

Ultimately, ED personnel drastically reduced the number of tasks involved with the triage process so that patients now only go through four steps before seeing a physician:

  • they are immediately taken to a triage station as soon as they enter the ED;
  • a triage nurse collects "quick-admit" information, including the patient's name, birth date, social security number, and primary complaint;
  • the patient receives an arm band with identification information; and
  • the triage nurse takes the patient to a bed.

Now, most of the screenings and documentation tasks that used to take place during triage are being carried out by the primary nurse, who takes care of the patient at the bedside. "This does add work for the bedside nurses, but they're collecting information that they need to take better care of the patient," says Mason.

Such changes have slashed the average door-to-doc time from 67 minutes to just 18 minutes, and this all occurred while volume actually increased, explains Lewis. "In October of 2010, we had 2,649 ED visits, and in March of 2011, we had 2,946 ED visits, reflecting a 10.5% increase in volume in a community where the population did not change," she says. "Some of this increase is attributable to flu season, but ED personnel were able to accomplish these efficiencies at a time when ED volume was very high."

Include hospital's IT staff in the loop

Whenever you revamp patient flow, you need to make sure your information technology (IT) is working with the system, stresses Mason. In this case, IT people were part of the team, so they were on hand to make adjustments as needed. "We had to completely revamp the documentation system on the front end from quick registration to how we did triage," she says. "Our IT people were making changes every day to make the process work with the care of the patient instead of making the care of the patient work with the process of the computer."

However, there were plenty of low-tech changes as well, says Lewis. For example, when reviewing the patient-flow process, it came to light that whenever the person manning the switchboard went to lunch, incoming calls were then diverted to the ED registration clerk, overwhelming her with unnecessary tasks when she really needed to be focused on incoming patients. "That wasn't smart, so we fixed that, and now when someone comes in, she can give them her full attention," adds Lewis. "It wasn't rocket science. It was just identifying little things like that, and now the registration clerks are a lot happier."

With patient satisfaction way up, there are still more improvements yet to be made. For example, the next process to go under the microscope will be staffing, says Mason. She doesn't anticipate any changes in terms of adding or subtracting personnel, but she expects there will be adjustments in shift schedules. "Typical ED [volume] peaks are at 9 a.m., 11 a.m., and 1 p.m., but here we have a pretty significant peak at 8 a.m.," says Mason. "We have a 9 a.m. to 9 p.m. shift for nurses, so we may look to move that shift to 8 a.m. to 8 p.m."

There may also be adjustments made to later shift schedules to accommodate changing volume patterns. "Emergency department traffic used to slow down by 11 p.m.," observes Mason. "That doesn't happen anymore. Now the ED census doesn't drop off until about 1 a.m., so we may look at having our 1pm to 1am shifts moved to 2 p.m. to 2 a.m. We are really just adjusting our staffing to meet the needs of patients."


Donna Mason, RN, MS, CEN, SAEN, Director, Emergency Department, Sumner Regional Medical Center. E-mail: