Can a Service Industry Model Improve Emergency Department Throughput?


One of the most common issues in emergency departments (EDs) across the country is the management of patient flow. Despite methods such as fast-tracking, split flow or diverting low-acuity patients elsewhere, sustained performance improvement continues to be a challenge.

That was one of the primary findings of a benchmarking study conducted by Vizient. The study comprised data collected by 84 members ranging from ambulatory care centers, freestanding emergency departments, AMCs, integrated delivery networks and community hospitals. The study’s results were the catalyst for the Emergency Department Throughput Performance Improvement Collaborative which had more than 70 participating organizations.

“In the typical emergency department, we found a common pain point: the need to better manage the flow of patients at peak times of the day with the resources they have,” said Marty Lucenti, MD, PhD, senior principal at Vizient. “We see the same pattern of influx of patients everywhere, but what organizations haven’t been able to do is efficiently manage those peak times and eliminate the delays in treatment and care.”

This pattern can be described as low volume during the early morning hours, trending upward and peaking around noon, then trending back down close to midnight. This means a typical ED has plenty of resources in the early morning hours and then, at some point, there are no longer the necessary resources to meet the demand of the patients coming in at that high peak point. Finally, it takes time for the ED to catch up to demand as the volumes start shifting back down.

Get into the queue

With the problems clearly identified, Lucenti presented a customer flow management concept to the members in the collaborative that is proven in other industries, but novel in health care: queuing systems.

“An example of this is can be found in your typical grocery store. Most grocery stores have a policy that once there are more than three people in line, they open another cash register to handle the overflow of shoppers,” Lucenti said. “That approach to managing patient flow has not historically been done in the ED.”

In a queuing system approach in the ED, the leadership thinks about what resources are available and determines which resource will become the limiting factor for effectively delivering patient care.

“That’s what the queuing system concept brings to the table—identifying what resources are in place, what are the constraints and does the organization have the resources to manage such constraints,” explained Lucenti.

In addition to queuing systems, organizations also need to strive to define the scope of their care.

“We essentially asked the members in the study, ‘What kind of patient care responsibilities are asked of your ED?’,” Lucenti said. “'Is your patient volume dominated by high, medium or low-acuity patients? Does your ED provide a significant amount of inpatient bed boarding? Are you used as the single setting of timely complex diagnostic evaluations?' So, understand all different patient care responsibilities your ED is asked to provide and then work to ensure you reliably have the necessary resources in place to provide those services.”

Understand your demand

Emergency department leadership should gain an early understanding of the scope of patient services they are actually providing.

“A typical ED provides many different services that clog up the system,” said Marilyn Sherrill, Vizient performance improvement collaborative advisor. “Often it is supplemental work that has been put on ED staff, such as patient boarding, transfer functions, etc. Awareness sets the stage for a realization of what has the potential to get in the way of performance improvement strategies.”

Understanding the scope of needed care is just the tip of the spear. Next comes the follow through.

Synchronization of resources

After the analysis and planning, the next step is execution. Lucenti advises that an ED should synchronize its resources.

“That’s the secret sauce,” Lucenti said. “Stop building your system around triage and build your system the same way places like Wal-Mart, AT&T and Kroger do it. They commit to a substantial amount of study and analysis, which helps an organization understand demand, workload patterns and resource requirements to adequately meet their patients' needs.”

While the ED throughput collaborative is underway, plans are in motion for a new ED-focused collaborative for the third quarter that will focus on defining the scope of the ED. For more information on how to join that collaborative, please contact Marilyn Sherrill at

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