Patient Flow Solutions

Lean-driven solutions slash ED wait times, LOS

Next target for ED improvement effort is the hospital admissions process

You know there is a problem when the average wait time to see a provider is in the four-to-five-hour range, and 3% to 7% of incoming patients are routinely leaving the ED without being seen (LWBS). And when confronted with these dismal statistics roughly two years ago, administrators at The Aroostook Medical Center (TAMC) in Presque Isle, ME, certainly understood that big changes were in order. "Our wait times and length-of-stay [figures] were terrible compared to national numbers," acknowledges Daryl Boucher, MS, the director of Emergency Services at TAMC.

To right the ship, administrators brought in a lean expert and spent more than a year identifying inefficiencies and reengineering patient flow processes. Then they shifted to implementation mode, where over a period of four to five months, a number of parallel processes were put to the test and refined, explains Boucher.

In fact, the lean-driven improvement process continues to this day, but the effort has already produced dramatic results. Boucher notes that the LWBS rate is now under 1%, and wait times typically hover around the five-minute range.

How did they do it? There were literally dozens of changes, ranging from redesigned registration and triage processes to strengthened responsibilities for charge nurses and more point-of-care testing. None of it came easy, stresses Boucher, noting that almost any change goes along with a fair amount of employee pushback. However, he observes that ED clinicians and staff are now eager to see the monthly performance metrics. "Continuing to see the results is a motivator these days," he says.

First, highlight inefficiencies

Tim Doak, PE, the project manager and facilities engineer at TAMC, has managed the improvement effort from the start, providing outside perspective to personnel who are consumed with ED processes on a daily basis. "People are so involved in their own piece of the care delivery system that sometimes no one really takes the time to take a step back and look at the end-to-end process," he explains. "We had a very clunky registration and triage process that required the patient to bounce back between the waiting room and triage and the registrar numerous times. It made great sense for the people doing the work and their piece of it, but when you looked at it from the patient's standpoint, it was very frustrating."

To turn things around, a workgroup consisting of a select group of ED personnel, as well as representatives from all the departments that interact with the ED on a daily basis, was assembled to consider how ED processes could be streamlined and improved, explains Doak. "We continued having project meetings, and step-by-step we rolled out new process changes, made new observations, and determined whether the changes were having the effect we had hoped or not. If they were, we continued them, and if they were not, we tweaked them a little bit and went in a different direction."

For example, what became clear early on in the improvement effort was that a majority of the patient complaints the ED was receiving came from the lower triage levels, says Boucher. This made sense because patients with acute problems were typically seen right away while patients with sore throats or ear aches typically had to wait.

To resolve this problem, the first thing the improvement team did was implement a fast-track system during the peak hours between 9 a.m. and 11 p.m. "Now, any lower triage patients go through fast track," says Boucher. "We do direct bedding with them and direct bedside triage, so essentially for those people who come in with something minor, we just take them to a room, a physician assistant (PA) or nurse practitioner (NP) sees them, and then discharge typically occurs in less than 20 minutes."

To implement this change, one room was set aside for the fast-track patients, and the ED hired two mid-level providers to provide care along with a tech or LPN. While this may sound like a straight-forward solution, Boucher explains that getting all the staff on board proved challenging. "It was a huge shift in culture for us because the motivation has always been to treat our sickest patients first. That is the point of triage. You come in with something bad and you are treated first," explains Boucher. "But what we discovered was if we could get those quick in-and-outs taken care of, our rooms were available for those sicker patients, so it has really flip-flopped how we treat patients."

Coupled with the new fast-track system, the workgroup redesigned the responsibilities of charge nurses, essentially giving them new powers to monitor and facilitate the flow of patients to providers. Under this new approach, if three patients with minor problems arrive in the ED at the same time, the charge nurse is able to assign at least one of these patients to an ED physician, rather than the mid-level provider manning the fast track.

The idea is to minimize wait times and move patients through the system, but it is a major culture change because the ED physicians only want to take care of the sicker patients, explains Boucher. "This is an ongoing challenge," he says. "It is a team approach. Instead of playing man-to-man, we are playing zone, and everybody is responsible for something."

Consider point-of-care testing

When pouring over the ED's data, the workgroup observed that patients with relatively minor problems were often experiencing a long LOS because they were waiting for the results of routine lab tests. "One of the things we discovered is that for some routine, in-and-out, triage level four and five patient exams, our lab transport times and result times were significant primarily because the lab didn't see some of these tests as critical," explains Boucher. "If they received a request for a urinalysis and a troponin, they were going to run the troponin because that involves a cardiac patient."

To get around this problem, ED administrators decided to bolster the number of point-of-care tests done right at the bedside in the ED, especially for patients who were likely to be discharged from the ED. "We didn't get much resistance to this because the nurses were frequently frustrated waiting on lab results, so this was a way to do the tests themselves and get the results quickly," says Boucher.

The point-of-care testing program is still being ramped up, with the nurses and techs being trained to perform the tests. Further, the lab is overseeing the program, so lab administrators are developing the policies and procedures as well as a quality assurance program, explains Boucher. Most of the point-of-care tests cost about the same as the lab-based versions, and there is no added cost to the patient, he adds.

Fix processes before renovating

With positive press about the reductions in wait times in the ED at TAMC, volume is on the increase, but, thus far, the increase has not adversely impacted wait times or LOS. Currently, the ED sees about 50 patients a day and 17,000 patients per year, says Boucher. What's more, he stresses that additional changes are on the way that will further streamline care delivery.

For example, the ED is in the midst of completing renovations that have been designed with the new process in mind. "We wanted to fix the process before we fixed bricks and mortar," notes Boucher. "We are not even increasing the rooms dramatically. We are renovating for the sole purpose of increasing flow and movement within the ED."

In the revamped ED it will be easier to block rooms that are assigned to nurses so that they don't have to go from one end of the hall to the other, and the nurse's station will be redesigned so that the charge nurse is centrally located and accessible, observes Boucher.

In addition, following a trend in many redesigned EDs, specialty rooms that are now set aside for orthopedics, OB/GYN issues, or other disease-specific procedures will be turned into all-purpose rooms. "What we have done is taken all the supplies and equipment out of the disease-specific rooms and put them on carts that can then be moved to any room," says Boucher. "Instead of a patient waiting for a particular room to be available, they will be able to go to any room and we can then bring the equipment needed to that room."

Boucher adds that the renovations were a tough sell because they will not be increasing the number of beds in the ED. "It is all ease and efficiency," he says.

Also on the agenda for 2013 is a new focus on the hospital's admissions process. Boucher notes that it is the next logical step in TAMC's performance improvement effort. "We have gotten very efficient at getting people into rooms quickly. We have wait times under five minutes at this point," he says. "The problem is when we have no inpatient beds or we can't move people out of our beds because we are waiting for a hospitalist or a consultant to come do an admission when we are stuck, so the goal is to really look at outflow: how we can improve efficiency in getting patients out of the ED and into each of the units."

Get buy-in from core personnel

Under a lean approach to performance improvement, it is true that selected frontline staff members devise solutions and drive the process, acknowledges Boucher. However, he stresses that administrators need to understand that this does not eliminate resistance to change. "Once you roll out [the solutions] so that everybody is impacted, suddenly new perspectives come out," he says. This is where leadership can makes the key difference.

"Lean doesn't really provide a mechanism for managing the culture change that is going to have to occur. It just identifies what your end point is and the steps you are going to have to take to get there," explains Boucher. "You will get to a point where there is some disagreement, and leadership really needs to play a role in making sure you are making the right decisions."

Doak agrees, emphasizing that leadership needs to stay engaged. "This is something that needs to be supported from the top down," he says. "Although the process changes happen from the bottom up, the sustainability piece is really a top-down function, so administrators need to understand what they are looking for, and they need to be on the floor frequently making observations for themselves."

Doak adds that administrators should not expect meaningful changes to take hold overnight; you have to be very patient, he stresses. "We have had a lot of instances where we would roll something out, and then over time staff would kind of digress a bit, and then we would have to go back and refresh what we were doing and get everyone focused on it," observes Doak. "The sustainability piece is often the toughest piece of this. It can be easy to change something. It is tougher to be very rigorous about it and continue on down that road."

Boucher advises colleagues who are embarking on a lean-driven performance improvement initiative to establish a clear goal of what they want to accomplish, and to stay focused on that goal even when potential solutions fall short. "Some of the processes that we thought would work didn't work at all, so then we regrouped and tried something else, but we never lost sight of what our goal was," he says. "A goal focus is really important because there will be lots of approaches that fail and lots of barriers that will be encountered."

Secondly, consider how you will deal with naysayers, because some people will inevitably leave or threaten to leave, adds Boucher. "My personal view is that cave dwellers always exist, so I just minimize what they contribute," he says. "Buy-in is important as long as you have buy-in from the core."


  • Daryl Boucher, MS, Director of Emergency Services, The Aroostook Medical Center, Presque Isle, ME. Phone: 207-768-4741.
  • Tim Doak, PE, Project Manager and Facilities Engineer, The Aroostook Medical Center, Presque Isle, ME. E-mail: