Best Practice Submission
North Central Baptist Hospital Adult Emergency Department Split Flow Operations
Points of Contact:
Heather Anderson, (210) 297-1000, HKANDERS@baptisthealthsystem.com
Tammy Holland, (210) 297-4652, TSHOLLAN@baptisthealthsystem.com
Group Involved with the Project. The North Central Baptist Hospital Adult Emergency
Department
Submitted by Major Jennifer L. Rodriguez
11 May 2012
Executive Summary: The Baptist Health System (BHS) takes pride in providing exceptional
care and service to patients and their families. As part of its commitment to high quality care
and patient satisfaction, the BHS implemented split-flow operations in all emergency
departments in 2009. Split flow operations improves efficiency of care, decreases door-to-doc
times, shortens length of stay (LOS), decreases the number of patients leaving without being
seen (LWBS) and improves patient satisfaction. North Central Baptist Hospital (NCBH)
launched split flow operations in November 2009 and realized a 79% decrease in LWBS within
one month.
Objective of the Best Practice: Utilization of split-flow operations improves efficiency of
throughput of patients in the emergency department (ED). Improved flow of patients results in
fewer patients waiting to be seen, fewer patients leaving without being seen (LWBS), shorter
length of stay (LOS) and improved patient satisfaction scores.
Background: Prior to 2009, the emergency departments in all BHS hospitals experienced
excessive wait times, high numbers of patients LWBS, greater than one hour door-to-doc times,
countless diversion hours and significantly low patient satisfaction scores.
In an effort to
improve these issues, BHS initiated operational studies of all five hospitals emergency
departments and discovered significant variation in ED flow. In 2009, BHS implemented the
“Split-Flow” patient flow model. Developed through a partnership between the Banner Health
System in Arizona and Dr. Jeffery K. Cochran of Arizona State University, this model is based
on the queuing theory and significantly decreased patient waiting times and LWBS rates in each
hospital ED (Banner Health, 2012). In FY 2009, prior to implementation of split-flow, NCBH
ED experienced an average 3.6% LWBS rate, 75 minute door-to-doctor time and patient
satisfaction scores in the 83rd percentile.
Literature Review: Extensive evaluation of ED patient flow in order to decrease waiting time
and improve patient satisfaction is well documented. The use of lean processes to evaluate
patient flows is extremely beneficial when attempting to improve ED patient experiences and
overcrowding (King, Ben-Tolvim, & Bassham, 2006). The authors redesigned patient flows
similar to split-flow by focusing on patients likely to be admitted and patients likely to be
discharged from the ED. In addition, this process utilized specific triage criteria to assist nurses
with determining where to place patients in the queue. Eitel, Rudkin, Malvehy, Killeen, & Pines
(2010) discussed methods to improve ED quality and flow. These methods included the use of
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the Emergency Severity Index (ESI) triage, Lean Six Sigma (LSS) management methods and
queuing systems, all of which encompass the split-flow process. Wiler, Griffey, & Olsen (2011)
reviewed various modeling approaches related to ED patient flow and identified strengths and
weaknesses associated with each model. These various models are valuable when utilized as
part of a complete analysis of ED operations. Research by Cochran and Roche (2009) supports
the use of a queuing model and split patient flow in order to increase ED access and reduce the
number of patients LWBS. Incorporating these techniques produced significant improvements in
door-to-doc times and decreased the number of patients LWBS. This research is the foundation
for which the BHS implemented split-flow operations.
Implementation Methods: A BHS Master Black Belt (MBB) conducted an initial baseline
analysis of ED flow to identify patient arrival rates, acuity levels, length of stay and staffing
models. Utilizing the door-to-doc toolkit (Banner Health, 2012), the MBB determined targets for
length of stay, staffing and required rooms. A multi-disciplinary core team consisting of the ED
Director, staff, physicians, admissions, ancillary departments and inpatient nursing developed a
project charter identifying specific problem areas and goals. Education of all stakeholders
included a detailed split-flow process, layout, function of areas and appropriate documentation.
Results: Monthly averages for LOS, door-to-doc time, LWBS and overall patient satisfaction
data were compiled for fiscal year (FY) 2009 prior to implementation of split-flow and for FY
2010 following implementation. Significant results included a decrease in average door-to-doc
time from 75 minutes to 35 minutes, and a decrease in LWBS rate from 3.6% to 0.6%. See
Table 1 for a comparison of before and after results.
Conclusion: Overcrowded emergency departments and long wait times directly impact patient
satisfaction. As evidenced by the significant results gained following implementation of splitflow at NCBH, analysis of ED flow and utilization of queuing methods can significantly impact
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the quality of care provided. Improved patient throughput in the ED can decrease the numbers of
patients LWBS and potentially increase patient satisfaction scores. Military health care facilities
experience high volumes of patients within the ED regularly. Improvement in processes and
patient flow as identified with this best practice can potentially enhance the patient’s experience
and improve overall military health care.
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Table 1.
North Central Baptist Hospital Split Flow Results
Average LOS
for discharged
patients (min)
208
Average
Door-to-Doc
Time (min)
75
Average
LWBS %
FY 2009
Average LOS
for admitted
patients (min)
350
3.6
Average Patient
Satisfaction
Overall %
34
FY 2010
274
153
35
0.6
95
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References
Banner Health. (2012). ED door-to-doc toolkit. Retrieved from
http://www.bannerhealthinnovations.org/DoortoDoc/About+D2D.htm
Cochran, J.K., & Roche, K.T. (2009). A multi-class queuing network analysis methodology for
improving hospital emergency department performance. Computers & Operations Research,
36, 1497-1512.
Eitel, D.R., Rudkin, S.E., Malvehy, M.A., Killeen, J.P., & Pines, J.M. (2010). Improving
service quality by understanding emergency department flow: a white paper and position
statement prepared for the american academy of emergency medicine. The Journal of
Emergency Medicine, 38 (1), 70-79.
King, D.L., Ben-Tovim, D.I., & Bassham, J. (2006). Redesigning emergency department
patient flows: application of lean thinking to health care. Emergency Medicine Australasia,
18, 391-397.
Wiler, J.L., Griffey, R.T., & Olsen, T. (2011). Review of modeling approaches for emergency
department patient flow and crowding research. Academic Emergency Medicine, 18 (12),
1371-1379.
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