SummaryBanner Health introduced a new model to redesign patient flow processes in emergency departments. Under this model, a clinical team rapidly triages each patient, allowing accelerated treatment of less sick patients and faster admission for those who are very ill and require inpatient care. Eight emergency departments in the Banner Health system that adapted this two-track patient flow model reduced the patient leave-without-treatment rate from 7.1 to 1.7 percent, average emergency department length of stay by 14 percent, and "Door-to-Doc" waiting times by 58 percent.Moderate: The evidence consists primarily of pre- and post-implementation comparisons of waiting times, patients leaving without treatment, and ED length of stay, which show clear improvements in access to ED care. However, there was no control group to determine whether the new model alone was responsible for the increased ED efficiency.
Developing OrganizationsBanner Health
Date First Implemented2006
Problem AddressedNationwide, there has been a steady increase in the volume of patients visiting emergency departments (EDs), and many hospitals have failed to adequately provide the services and reorganization needed to meet the health care needs of these patients on a timely basis.
- Longer waiting times: As patient volumes in EDs increase, waiting times to see an ED physician are getting longer, even for heart attack patients and others in need of immediate attention. African Americans, Hispanics, women, and patients seen in urban EDs wait longer than do other patients.1 The increase in ED wait times has been attributed to rapidly growing patient populations, shortages of primary care providers, inadequate health care insurance coverage that results in patients seeking safety net treatment in EDs, and overcrowding "upstream" within hospitals.2
- More patients leaving without treatment: Many ED patients do not have life-threatening, emergency medical conditions,3 and long waiting periods often result in these patients leaving without treatment. A study at one public hospital found that 46 percent of those who left without treatment were judged to need immediate medical attention, and 11 percent of those who left were hospitalized within the next week.4
- A problem for Banner Health as well: Banner Health EDs in the metro Phoenix area have experienced an increase in inpatient and ED visits as the region's population has grown dramatically. ED patients often spent hours in crowded waiting rooms before seeing a doctor, and the leave-without-treatment rate in some Banner hospitals exceeded 13 percent during peak periods.1
Description of the Innovative ActivityBanner Health implemented a model known as "Door-to-Doc," which reorganizes the ED patient flow process by splitting patients into "less sick" and "sicker" subgroups based on a "quick look" rather than a full triage. Each hospital customizes the Door-to-Doc model to its unique patient flow processes and physical space. Key elements of the general program are described below:
- "Quick look" at arriving patient: When a patient arrives in the ED, he or she gets a quick, preliminary registration and is quickly assessed by a registered nurse (RN). Less sick patients are escorted to an intake space where they await assessment by an RN and physician team and complete the registration process and make the copayment. Sicker patients are escorted to an ED bed.
- Rapid treatment for less sick patients: An RN and physician together assess the patient and review once more if an ED bed is required, and order any needed diagnostic tests. The patient remains dressed and seated in the designated waiting area and is treated as if he or she was in a clinic. After tests are performed, the patient is moved to a results-pending waiting room. After the lab results come in, the medical team makes a decision, and the patient is either admitted to the hospital and placed in a bed in a special holding unit, discharged, or transferred to another facility.
- Acute care for sicker patients: Sicker patients are escorted to an ED bed where a team made up of a nurse, technician, and physician conduct an evaluation and order diagnostic tests and/or treatment as needed. While the patient is in the bed, a full registration is performed and copayment collected. The patient is moved to a results waiting area, if needed. After results are reviewed by the medical team, the patient is admitted to a holding unit until an inpatient bed is available, discharged, or transferred to another facility.
- Capacity for holding patients: Banner EDs, like many other EDs throughout the country, struggles at time with getting admitted patients moved out of the ED in a timely fashion. This problem stems from high inpatient occupancy levels and late discharges. To help EDs deal with this, the toolkit specifically helps determine bed and staff allocation for the holding population, given facility specific arrival rates, acuities, and patient care times.
References/Related ArticlesAmerican Academy of Pediatrics Committee on Pediatric Emergency Medicine. Overcrowding crisis in our nation's emergency departments: is our safety net unraveling? Pediatrics. 2004;114(3):878-88. [PubMed] Available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/3/878
Wilper AP, Woolhandler S, Lasser KE, et al. Waits to see an emergency department physician: U.S. trends and predictors, 1997–2004. Health Aff (Millwood). 2008;27(2):w84-w95. [PubMed] Epub 2008 Jan 15. Available at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.2.w84
Banner Health. About the Door-to-Doc Patient Safety Toolkit [Web site]. 2008. Available at: http://www.bannerhealthinnovations.org/DoortoDoc.
ERs Move to Speed Care; Not Everyone Needs a Bed. Wall Street Journal. 2011. Available at: http://online.wsj.com/article/SB10001424053111904888304576476242374040506.html
Eitel D. Grocery Store Math for the Emergency Department. Hospitals and Health Networks. Available at: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/07JUL2008/080715HHN_Online_Eitel&domain=HHNMAG
Zilm F, Crane J, and Roche K. New Directions in Emergency Service Operations and Planning. J Ambulatory Care Manage. 2010; 33(4): 296-306. Available at: http://www.zilm.com/New_Directions.pdf
Contact the InnovatorKevin Roche, PhD
Phone (Banner Gateway): (480) 543-2293
Phone (Corporate): (602) 747-7287
Innovator DisclosuresDr. Roche has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsUse of the redesigned ED model in eight Banner Health EDs resulted in a significant decline in waiting times, the percentage of leave-without-treatment patients, and ED lengths of stay. The increased capacity that resulted from the two-tier patient flow process allowed the eight EDs to care for more ED patients each year, which increased system revenues. Below are the mean results from the eight Banner hospital EDs, comparing results before the program with 2 years after implementation.
Ochsner Health System in New Orleans and Memorial Hermann Healthcare System in Texas have implemented the program and are seeing similar results.Moderate: The evidence consists primarily of pre- and post-implementation comparisons of waiting times, patients leaving without treatment, and ED length of stay, which show clear improvements in access to ED care. However, there was no control group to determine whether the new model alone was responsible for the increased ED efficiency.
- Faster time to treatment: The average time from patient arrival to being seen by a doctor fell by 58 percent, from 117 to 49 minutes.
- Fewer patients leave without treatment: The percentage of ED patients who left without being treated fell by 76 percent, from 7.1 to 1.7 percent.
- Reduced ED length of stay: The average amount of time a patient spent in the ED fell by 14 percent, from 310 to 268 minutes.
- Enhanced capacity to serve ED patients: The number of ED patients seen increased from 110,400 to 111,503, an increase of 1 percent.
Context of the InnovationBanner Health, headquartered in Phoenix, AZ, is one of the largest nonprofit health care systems in the United States with 20 hospitals in seven western states. Nationally, Banner hospitals care for 1 in every 200 inpatient admissions, and its EDs handle approximately 680,000 visits annually. Due to rapid population growth in the Phoenix region, Banner's six Arizona hospitals faced overcrowding in their inpatient and ED settings. Many ED patients spent hours in waiting rooms or in beds stationed in hallways before seeing a doctor or gaining admission, and many left without receiving treatment.
To address this issue, the leadership of one Banner Hospital, Banner Mesa Medical Center in Mesa, AZ, agreed to pilot test the Door-to-Doc model in its ED, which had 34,380 visits in 2006. After the pilot test, Banner Health enhanced the model and implemented it throughout its five hospital EDs in Arizona, some of which had leave-without-treatment rates exceeding 14 percent. The model was also implemented in two Banner hospitals in Colorado that had low leave-without-treatment rates. Because of the wide diversity in these hospitals' EDs (which varied significantly in physical layout, size, staffing, patient demographics, and patient acuity), these hospitals provided a unique "living laboratory" for testing the efficacy of Door-to-Doc.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Consulting with an industrial engineer: Banner enlisted the help of an industrial engineer at Arizona State University who was an expert in through-system modeling in nonhealth, industrial settings; this individual helped Banner to consider reorganization concepts that were not inherent to health care methodology.
- Model development: The industrial engineer worked with a team of ED staff and physicians, using a rapid-cycle approach to develop a unique flow process—the Door-to-Doc model—as a generic approach to ED patient flow reorganization that could be implemented in any of Banner's EDs. What differentiated this approach was that it was engineered as a throughput flow model, without the encumbrances of cultural legacy issues or entrenched personnel issues that often plague health care facility reorganizations.
- Management incentives: To win the commitment of hospital and ED management, management compensation plans included incentive compensation tied to improved ED patient flow.
- Determining physical configuration and staffing: Physical configuration and staffing for the Door-to-Doc model was determined by applying queuing theory to hospital-specific data related to patient arrival rates, acuities, and patient care times. A toolkit developed by Banner guides the process analysis to evaluate each ED facility's patient flow to determine appropriate staffing and process reconfigurations. Key questions considered during this analysis include the following:
- Does the ED have a leave-without-treatment problem? An analysis can be made comparing the number of patients leaving without treatment to total patient volume.
- Does patient volume merit a two-tier treatment system? The toolkit helps to identify the facility's busiest times to determine whether patient volume is sufficient to merit a split flow process.
- How should patient flow be calculated? The toolkit includes materials to help determine the anticipated arrival rates to each area of the split ED; the result is based on patient acuity, volume, and number of patients admitted to inpatient units.
- What is the typical patient's experience in the ED? The kit helps to summarize the ED patient's typical length of stay, waiting time, and test turnaround time by level of urgency.
- How much capacity is needed? The tool helps to determine how much space is required in each area, based on a provider's physical patient capacity. The appropriate amount of space depends on patient acuity, arrival rates, service times, and target performance objectives.
- What is the appropriate staffing for the ED? The tool helps to determine staff requirements in each area of the proposed split ED by hour of day, based on arrivals per hour to each area, productivity in each area, and a generic time-of-day arrival pattern.
- How well is the program performing? A scorecard helps evaluate the impact of the realigned ED on safety (including leave-without-treatment rates), throughput within the ED, patient and staff satisfaction, and business loss (leave without treatment and diversion hours).
- Implementation support: Organizational structures were created to support implementation and to coordinate with other activities that affect the ED. The process design modules were developed by teams of ED staff and physicians, using a rapid cycle approach. Key elements of this process include the following:
- Care process: This component explores how each facility's ED care process would need to change to implement the Door-to-Doc process.
- Assessing readiness to change: This component assesses the readiness of the organization to change and provides tips for improving acceptance based on a survey of key stakeholders within the ED. This step is key to gauging the degree of success or amount of resistance that will be encountered.
- Organizing for change: This component describes team structures as well as roles and responsibilities for successful implementation.
- Managing the implementation: This component identifies key activities for managing Door-to-Doc implementation, including involving stakeholders in identifying implementation steps and assuring successful completion. Organizational structures can also be created to allow employees to participate in the implementation and coordinate the various activities affecting ED patient flow.
- Gap analysis: This component addresses process control issues after implementation.
Resources Used and Skills Needed
- Staffing: With respect to ongoing operations, ED staffing did not change as a result of adopting the Door-to-Doc model in six of the eight Banner hospitals. Two of the eight EDs that implemented the model added staff because they were understaffed before the process change. Because the model is based on peaks and hourly arrival patterns, the staffing model has the flexibility to absorb increased volume without increasing staffing levels. With respect to initial implementation, the existing health system, hospital, and ED staff should be able to follow the step-by-step processes spelled out in the Door-to-Doc toolkit. Either an internal engineer or external expert may be needed, however, to provide the "number crunching" statistical analysis necessary to assess patient flow data. Such experts may be available through regional academic institutions.
- Costs: Hospitals designated internal teams to apply the Door-to-Doc toolkit. Costs are not available.
Funding SourcesAgency for Healthcare Research and Quality; Banner Health
The project was initially funded internally. Banner Health secured a grant from the Agency for Healthcare Research and Quality (U18 HS 15921) to further develop and refine the Door-to-Doc model and apply it to other Banner EDs in Arizona and Colorado.
Tools and Other ResourcesDoor-to-Doc Patient Safety Toolkit—Manual and explanation. Available at: http://www.bannerhealthinnovations.org/DoortoDoc.
Door-to-Doc Patient Safety Toolkit download. Available at: http://www.bannerhealthinnovations.org/DoortoDoc.
Getting Started with This Innovation
- Appoint a committee made up of hospital and ED staff, physicians, and internal engineers to spearhead the Door-to-Doc initiative.
- Designate sufficient resources and make the initiative an institutional priority. Possible options include linking ED patient flow improvements and patient satisfaction to executive benefit packages to assure commitment to the initiative.
- Assemble ED usage statistics, conduct patient satisfaction surveys, and perform other data-gathering tasks as outlined in the Door-to-Doc toolkit process analysis components.
- Reconfigure the ED and provide staffing as specified by the toolkit findings.
Sustaining This Innovation
- Continuously perform analysis to see if the model is working: Measure "Door-to-Doc" times; leave-without-treatment rates; throughput as measured by arrivals, admissions, and length of stay of different patient tiers and during different times of day; patient and staff satisfaction; and business loss, as measured by leave-without-treatment and diversion hours.
- Prepare for and develop strategies to overcome staff resistance: The reconfiguration promoted by the Door-to-Doc model produces major changes in patient flows and the jobs that ED staff perform. Be prepared for major cultural changes and some resistance within the department. Involving staff in the implementation process can help to facilitate the change. One facility had to put the reconfiguration on hold because the interim ED director lacked the department's confidence to carry out the changes.
- Pay attention and respond to the data: One facility implemented the model but continued to have long waiting times and a substantial number of leave-without-treatment patients. The facility conducted a process audit of the ED and found that staffing had not increased during peak volume times as had been recommended by the Door-to-Doc's patient flow assessment. The Door-to-Doc model forces ED managers to continuously think about and manage flow processes, a task that many had not been regularly involved in before.
Additional Considerations and Lessons
- Although Banner EDs have seen tremendous improvement in door-to-doc and throughput times, the EDs still struggle with capacity. This is due primarily to population growth outpacing Phoenix-area emergency care capacity, delays in getting patients admitted to inpatient units or transferred out of the hospital, and an increased behavioral health population with very constrained resources. Electronic medical record adoption has also been a challenge and can impede the joint provider–nurse patient assessment at some facilities.
Use By Other OrganizationsAs noted, a diverse set of 10 Banner Health hospitals have implemented the model:
In addition, the Ochsner Health system in New Orleans, LA and Memorial Hermann Healthcare System in Texas have implemented the model.
- Banner Baywood Medical Center in Mesa, AZ, a community hospital with 318 licensed hospital beds. Its ED also serves Banner Heart Hospital, an 111-bed facility on the same campus. In 2006, the ED had 59,987 visits. In 2010, the ED had 51,997 visits.
- Banner Desert Medical Center in Mesa, AZ, the largest hospital in the metro-Phoenix area's East Valley with 549 licensed hospital beds. In 2006, it had 83,012 ED visits. In 2010, the ED had 98,512 visits.
- Banner Estrella Medical Center in Phoenix, AZ, which has 214 licensed hospital beds. In 2006, it had 65,455 ED visits. In 2010, the ED had 88,291 visits.
- Banner Good Samaritan Medical Center, a teaching facility in downtown Phoenix, AZ, with 575 licensed hospital beds and 85 licensed rehabilitation/behavioral health beds. In 2006, it had 53,024 ED visits. In 2010, the ED had 57,736 visits.
- Banner Gateway Medical center in Gilbert, AZ, which has 176 licensed hospital beds. In 2010, the ED had 49,271 visits.
- McKee Medical Center, in Loveland, CO, which has 115 licensed hospital beds. In 2006, it had 26,352 ED visits. In 2010, the ED had 26,913 visits.
- North Colorado Medical Center in Greeley, CO, a tertiary care facility with 336 licensed hospital beds and 62 licensed long-term/rehabilitation/behavioral health beds. In 2006, the hospital had 46,750 ED visits. In 2010, the ED had 52,614 visits.
- Banner Thunderbird Medical Center in Glendale, AZ, with 332 licensed hospital beds and 62 licensed behavioral health beds. In 2006, its ED had 71,626 visits. In 2010, the ED had 81,095 visits.
- Banner Del E. Webb Medical Center in Sun City, AZ, which has 404 licensed hospital beds. In 2010, the ED had 55,822 visits.
- Banner Boswell Medical Center in Sun City, AZ, which has 430 licensed hospital beds. In 2010, the ED had 44,262 visits.
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Service Delivery Innovation Profile
Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: April 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 11, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.