Door-to-Doc Toolkit

The challenges faced by hospital emergency departments (EDs) throughout the United States are well documented. A number of reports have described overcrowding that puts ED patients at risk.   Regardless of whether this overcrowding is related to rapidly growing patient populations, shortages of primary care providers, inadequate healthcare insurance coverage, or overcrowding “up stream” within hospitals, there is no question that emergency departments need to improve patient flow processes with a focus on improving patient safety.

Banner Health is a large regional health care system headquartered in Phoenix, Arizona consisting of 29 hospitals in 7 western states with bed sizes ranging from 18 to more than 600.  Its hospitals in the Phoenix-metro area account for nearly 40 percent of all hospital admissions. Nationally, Banner hospitals care for one in every 200 inpatient admissions.  Banner EDs have 500,000 or more visits annually.  In its largest facilities, it became clear that ED patients were often spending hours in crowded waiting rooms before seeing a doctor. An increasing number of those patients were choosing to leave without treatment (LWOTs), taking the risk of worsening their condition; at some facilities the rate had grown to more than 13%.  Improving patient safety for emergency department patients became a priority for the organization.

From this focus, an innovative change in process flow called  Door-to-Doc (D2D) emerged at one facility, Banner Mesa (which now houses the Banner Simulation Medical Center).  It was successful in reducing the time for patients to be seen by a physician and the rate of LWOTs, thereby improving patient safety.

A Living Laboratory

Because of their size and diversity, Banner hospitals provided a unique “living laboratory” for testing the efficacy of D2D. The eight Banner hospitals involved in this project have EDs varying in physical layout, staff size, patient population, acuity (injury or illness severity) and business. The proportion of ED patients who are treated and released to those admitted as inpatients varies with seasonal demand patterns (time-of-day, day-of-week, and month-of-year) within each hospital as well as from hospital to hospital. Implementing this safety practice in diverse settings was facilitated by the partnership with Jeffery K. Cochran, PhD, Professor, Department of Industrial Engineering in the Ira A. Fulton School of Engineering at Arizona State University (ASU), a nationally recognized research university.

The method for implementing the Door-to-Doc process flow in diverse Emergency Departments was based on a change model that recognizes the need for robust technical solutions along with acceptance of the change by those affected. It involved two important aspects:

  • Process: analyzing the process for adaptation to unique patient acuities and volumes
  • People: facilitating acceptance of the changes among the individuals affected

The “people” aspect was addressed through creating organizational structures to support the implementation work and coordinating with other activities that would affect EDs. The process design was developed by Design Teams of ED staff and physicians, using a rapid cycle approach.

The intervention consists of a patient flow process change.  A main feature is that patient flow is split into “less sick” and “sicker” patient subgroups based on a “quick look” rather than a full triage.  This has the advantage of keeping less sick patients, which is the vast majority, flowing (rather than waiting in the lobby) during busy times. Less sick patients do not own a bed, rather they move among treatment areas as they would in a clinic setting.  Additionally, they are not undressed, remain vertical as much as possible, and wait for their lab and other test results outside of the flow of other patients. Other key features that reduce delays in seeing a physician include, a joint medical assessment by the nurse and physician together which reduces the time of patient in front of the clinical team, freeing them up to see more patients, and staffing of “hold” beds by inpatient staff (rather than by ED staff as is the current practice), containing patients who have been admitted to inpatient units but are delayed in moving.

Sizing and staffing of the D2D model is accomplished by applying queuing theory to hospital specific data regarding patient arrival rates, acuities, and patient care times.


Using the D2D Toolkit

The ED Door to Doc Toolkit includes embedded tools that are not active in the web presentation mode.  To activate these tools, the toolkit files below must be downloaded.  Please follow the steps in the order listed below:

  1. Download the entire toolkit folder to your computer
  2. View the “ToolkitCover” presentation.
  3. View the “AHRQ_Toolkit_Summary” document
  4. Proceed through the rest of the tools in the order listed on the flow chart displayed on page 1 of the "AHRQ_Toolkit_Summary”. Open each tool from your computer by double-clicking the spreadsheet.


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