Case Study #7: Improving Space Efficiency While Lowering Wait Times


  • Suburban hospital in a large Texas city
  • 23,000 annual ED visits
  • 9 ED beds and 3 minor care beds


  • Overall satisfaction had been increasing from 70% to more than 90% through previous process improvement work
  • However, wait time satisfaction had been decreasing and was near 50%
  • Problems included rising volume and limited space
  • Number of patients who Left Without Being Seen (LWBS) was increasing
  • Rising LWBS created lost revenue, decreased patient loyalty, and raised patient safety concerns


Recipe for Change in the ED:

  • Ingredients: The Team
    • Administrative leader with vision
    • Physician leader willing to seek new approaches
    • Nursing leader with will to implement
  • Directions: The Process
    • Engage team with a vision
    • Provide time for team members to participate
    • Capture data and evaluate
    • Run small tests of change to arrive at the solution
    • Celebrate success

Goals and approach

  • Get patients to a physician quickly
  • Use limited space efficiently
  • Maintain patient safety and improve experience
  • Rapid Medical Evaluation (RME) system implemented
  • Utilized lean mantra (create more value with less work)
  • Collected and analyzed data
  • Measured value by patient feedback


Reduce wasted space

  • Kept vertical patients vertical
  • RME: ESI Level 4-5 (occasional 3), ENT, Respiratory, Dermatological
  • Main ED: ESI Level 1-3, Cardio, Abdominal, Gyn
  • Recognized “triage is a process, not a place”

Make haste to doctor

  • Minimized up front registration/triage time
  • Full registration moved to back area/RME area
  • All nurses trained to do quick reg/bedside triage (for triage surges)
  • Eased triage bottle neck
  • Triage info shortened
  • Other nurses trained to do triage in parallel in the treatment area
  • Improved physician utilization — Work RME or regular ED (e.g., place professional resources at nodes of demand)

Tools for change

  • Daily sheets
  • Charts
  • Efficiency measures
  • Safety measures
  • Financial measures
  • Patient experience measures
  • Example measure: physician scorecards triage to doc, door to door, and trends
  • Followed weekly with PI team meetings. Discussed at monthly ED physician and nurse staff meetings. Updates also given periodically at Medical
  • Executive Committee meetings and forwarded up the administrative chain.


  • Average door-to-doc time decreased from 52 to 34 minutes
  • Wait time satisfaction increased from 50% to more than 80%
  • Left Without Physician Contact (LWPC) dropped to less than 1%
  • Left Without Being Seen (LWBS) dropped to less than 1%
  • Significant gross revenue generation from capturing LWBS
  • Staff buy-in


Figure 1. Faster Door-to Doc by Improved Use of Staff (moved to bedside registration & triage)

Figure 1. Faster Door-to Doc by Improved Use of Staff