Decreasing Door-to-Floor Emergency Department Length of Stay through Applied Lean Principles

Improving Patient Experience By Reducing Door-to-Floor Length Of Stay

It’s no surprise that reducing “Door-to-Floor” length of stay (LOS) for admitted patients is a top priority for most emergency departments. The time that elapses between a patient first coming in, getting seen by an ED provider, and being either discharged or transferred to another hospital department all counts. But most crucially, the LOS metric impacts a key goal of any hospital: creating a high-quality patient experience.

But most crucially, the LOS metric impacts a key goal of any hospital: creating a high-quality patient experience.

A short bed turnover is important. In the words of one physician, “[Patients] need to be treated by clinicians at the appropriate level of care as soon as possible, and hospitals depend on operational efficiency for their financial wellbeing.” [1] Which principal elements can be explored and improved upon to lessen door-to-floor length of stay? One of Aligned Provider Wyoming’s emergency medicine physicians, Jessica Hughes, MD, ED, explored this very topic in a case study published in the British Journal of Medicine.

Applying Lean Principles for Improving Emergency Department Processes

In the article, 25 Applied Lean Principles Decreased Door-to-Floor Length of Stay, Dr. Hughes and her fellow researchers focused on these primary areas for optimizing processes throughout the door-to-floor value stream:

  • Directly observing patients, operations, and provider processes
  • Shadowing frontline staff to identify opportunities for process improvement.
  • Holding Rapid Process Improvement Workshops (RPIW) with frontline staff.

What Dr. Hughes and her fellow researchers found was intriguing. Door-to-Floor length of stay (LOS) times could be delayed for a multitude of reasons. These ranged from practice variations among personnel to a lack of open, clean, and staffed beds, to high patient volume in the ED.[2]

By conducting “Waste Walks” with frontline staff, the research team was able to identify areas where excess waste could be eliminated. The team then conducted rapid process improvement workshops (RPIW), helping staff to identify and prioritize solutions associated with their observations. Through these interviews, the research team was also able to identify longer term improvement projects with medical staff, starting with the implementation of Plan-Do-Study-Act cycles.

These PDSA cycles involved having staff plan the goals they wanted to achieve, try a new intervention, observe its effectiveness, and then iterate as needed. Through these, Dr. Hughes and her team found ways to shorten and optimize processes by looking the time effectively needed for discharge, as well as for moving patients from the ED into their new placements within other departments (“right patient, right floor.”) Additionally, they helped create a more seamless “patient pull” system. Finally, they sought to standardize the ED Handoff Report, to properly equip receiving providers with the correct information to continue with a patient’s follow-up treatment.

Over the course of the study, the efforts had these positive effects:

  • A sustainable reduction in length of stay (LOS) for admitted patients, from 310 minutes to 251 minutes, i.e. saving 1 hour.
  • A 40% increase in patients being discharged in under 5 minutes.
  • A decrease in bed-requested to bed-assigned times, starting with 37 minutes at the outset and going down to 13 minutes. This was done by implementing a Microsoft OneNote “pull system” for charge nurses that helped them standardize the way they matched patient types to the appropriate units.
  • Though it didn’t result in savings to time, there was a notable improvement in the quality and consistency of patient information being transferred, due to implementing a standardized ED handoff report for care transitions.

Helping Emergency Department Leaders Optimize Workflows to Reduce LOS

As an emergency medicine staffing and management provider, Aligned Providers understands the delicate balance that ED leadership (including medical and nursing directors) continuously must strike in staffing properly and designing good workflows. While there are many things that are out of individual providers’ control, we are excited to present Dr. Hughes’ research as an opportunity for hospitals to implement some of these Lean principles for reducing these LOS metrics, including optimizing the way resources are used. As any person in these positions will agree, being able to reduce door-to-floor time by an hour is significant.

As any person in these positions will agree, being able to reduce door-to-floor time by an hour is significant.

It is our hope that this case study– with information about using Lean applications of observation, eliminating waste, standardizing workflows, and identifying process improvements– could be implemented into more EDs across the country. And as always, we are here to help your hospital improve their average door-to-floor length of stay so that you can see similar metric improvements, which will no doubt benefit patient experience, care quality, and ED efficiency.