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Emergency Department “Door to Doc” Time

Submitted By: Bob Sproull

Beginning January 7th I will be leading a team of hospital employees working on a problem in the Emergency Department (ED) of their hospital.  There is a metric that is tracked which measures the length of time from when the patient enters the Emergency Department until the medical screening exam begins by the physician known as “Door to Doc” time.  The problem is that under the new Healthcare “rules,” if the wait times are too long, then patient satisfaction scores will be negatively impacted.  If patient satisfaction scores are too low, then Medicare, Medicaid and private payers like Blue Cross and Aetna will reimburse for services at a much reduced rate.  Door to Doc time is but one facet of patient satisfaction, but it’s important from a patient satisfaction perspective.

Since 1986, with the passage of the Emergency Medical Treatment and Active Labor Act (EMTALA), patient volumes in emergency departments have increased significantly.  Several different studies have estimated the increase to be on the order of 40%.  Because of this increase, overcrowding and excessive wait times have forced EDs to look at their processes to improve flow and reduce wait time.  They’ve also been forced to provide more complex and prolonged care to the point where sometimes ED patient’s health is at risk. Because this new higher level of ED patients is straining the ED staff’s ability to handle them in a timely manner and to provide timely and quality care.  As a result, even more delays are being experienced by the incoming patients.

In anticipation of our improvement event, the team leaders are busy collecting and analyzing pertinent baseline data to be used by the full team to make improvements to patient flow and satisfaction.  The problem to be studied is correlated with the actual throughput rate of patients passing through the Emergency Department.  It should be clear now to all of my regular readers that the path this team will take will be to first, understand the boundaries of our improvement effort and performance metrics we are trying to improve.  This will be accomplished by reviewing the project charter that was created by the project champion.  Once this is completed, the two Green Belts and I will deliver “just in time training” to the full team so that the concepts of things like process, constraints management, waste categories and the improvement tools we will use during our improvement initiative will be clearly understood.

The team will then “walk the Gemba” so they have the information needed to create a SIPOC diagram and a current state process map (or Value Stream Map).  The team will observe things like patient flow, estimated processing times, where apparent waste exists, key hand-offs within this process, paper work, wait times, patient queues, etc..  They will use all of this information to correctly identify the constraint within the Emergency Department’s process from point of entry to the beginning of the examination by the ED physician.

The team’s next step will be to decide how to exploit the constraint by looking for ways to reduce waste and variation within it by employing the principles of Lean and Six Sigma.  The key to improving patient flow will be to identify and focus the team’s improvement efforts primarily on the system constraint, but will also look for ways to reduce things like the number of handoffs, improve current communication mechanisms, waiting room times, etc. during our effort.

There is an inherent danger in isolating our improvement effort to only this specific part of this process  (i.e. Door to Doc).  By limiting our “field of view” to this single part of the patient value stream, we could create downstream problems. Improving one part of a process will most surely improve the flow through the current constraint, but a new constraint will arise as an effect of the improvement effort.  For example, when the team is successful in reducing the Door to Doc time, the velocity of patients moving to the next step in the process will be higher and could cause a queue of patients waiting for things like test results to come back or even the physician’s decision on whether or not to admit the patient.  If the decision is made to admit the patient, then the new constraint could even be the discharge process that frees up beds in the various hospital units.  In the world of TOC, improving a singular part of the process without considering the overall impact on the total system is known as a localized improvement.

Once the Gemba Walk has been completed we will develop a SIPOC to get a 10,000 foot view of our process.  When we are satisfied with our SIPOC we will then create a Current State Process Map with swim lanes listing all of the activities used to move a patient through this process.  The team will then perform a value stream analysis by color coding each activity in the process as either value-added (Green), non-value-added but necessary (yellow) or non-value-added (red).  We will then create an ideal state map by removing all of the non-value-added activities.  Finally, we will create a future state map that will lie somewhere in between the current state and the ideal state maps.  The future state map will identify all of the needed changes to the current process and should significantly improve the flow through the door to doc process.

The final stage of our improvement effort will be to develop an improvement plan, based upon how we see our future state process.  The plan will consist of Just Do Its, potential Rapid Improvement Workshopsthat might be needed as a result of this new process, potential additionalValue Stream Analyses recommendations and possible DMAIC opportunities needed to reduce variation.  The Just Do Its will typically be tied directly to the creation of the team’s recommended Future State Process Map.  The team will then present their findings and recommendations to the executive staff and process owner(s) to gain their buy-in.

It should be a “fun” week and when it’s completed I will report the team’s findings and recommendations here on my blog.

To read more about how to dramatically improve healthcare processes and reduce costs, download the first chapter of Performance Improvement for Healthcare: Leading Change with Lean, Six Sigma and Constraints Management.

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