Decrease and Smooth Variation to Improve Flow

Variation is part of every process. Some variation is random and inherent in every process. Random (or natural) variation cannot be eliminated, but it can be optimally managed. Understanding and distinguishing between natural and artificial variation is the key to improving flow. Many quality and cost problems in a process or product are due to variation. The process that produces 95 percent on-time delivery or good product is the same process that produces the other 5 percent late deliveries or bad product. Reducing variation in such cases improves the predictability of outcomes (and may actually exceed customer expectations) and helps reduce the frequency of poor results. Use of protocols, changes in the triage process, and scheduling of elective surgeries based on historical demand for beds can help hospitals decrease and smooth variation.


Changes for Improvement


Establish an Emergency Department Fast Track

Establishing a "fast-track" process for patients with urgent conditions that can be treated relatively quickly can reduce extensive waits and improve overall flow of patients through the emergency department. A physician often can treat a fast-track patient while waiting for test results for a more seriously ill or injured patient. A separate process can also be established for patients who require additional observation, such as patients with chest pain or asthma. Implementing a fast track can reduce the overall length of a patient’s stay in the emergency department and increase patient and staff satisfaction.



  • Create a separate area or designate separate beds — and ideally separate staff — to segregate fast-track patients from the main ED, a process that may also prevent unnecessary admissions.
  • Define criteria to identify patients that can be moved directly from triage to fast track.
  • Commit to consistent hours and staff in the ED fast track to eliminate confusion and streamline patient flow on an ongoing basis.
  • Use a specific satellite area to handle registration, x-rays, and labs for fast-track patients.



Establish Emergency Department Protocols for Triage, Tests, and Treatment

Protocols are a set of steps that clinical staff agree to take in the diagnosis and treatment of particular types of patients. Identifying the top 10 patient diagnoses that staff see in the ED and developing protocols for the diagnosis, testing, and treatment of patients with these diagnoses can streamline patient handoff from one step in the treatment process to another. This greatly reduces delays and improves overall patient flow through the ED.



  • Use established protocols to move patients with the top 10 diagnoses through the steps of the protocol immediately, eliminating the delays that often occur in ordering appropriate tests. For example, move a person with an extremity injury directly to x-ray rather than having them wait to be seen by a physician.
  • Use protocols to determine necessary tests at the outset to reduce unnecessary delays in getting the needed information to a consulting physician.
  • Protocols can also be an effective method for identifying steps in the treatment process that other health care professionals, rather than physicians, can provide.



Dedicate Operating Room(s) for Unscheduled Surgeries

When unscheduled (emergent, urgent, etc.) surgical demand is significant, it creates a major obstacle in smoothing elective admissions since such demand cannot be controlled. Scheduled and unscheduled surgical demands compete for the same operating room (OR) resources. An attempt to increase OR utilization rate will result in diminishing quality of care by increasing patient waiting times for unscheduled surgeries. An attempt to reduce waiting times for unscheduled surgeries will inevitably reduce OR utilization rate. Therefore, according to the variability methodology, when demand for unscheduled surgeries is significant, these surgeries should take place in operating room(s) designated for this purpose.



  • Collect accurate data on demand for scheduled and unscheduled surgery.
  • Collect accurate data on the volume and arrival patterns of patients representing different components of unscheduled surgical demand: emergent, urgent, semi-urgent, and non-urgent surgeries.
  • Determine the average waiting times that would be tolerated for each type of unscheduled surgical demand (e.g., average waiting time for emergent surgeries should not exceed 20 minutes).
  • Apply queuing theory to determine the number of ORs needed for unscheduled demand, based on the average waiting times for different levels of urgency (emergent, urgent, etc.).
  • Use information about scheduled case demand, duration, turnover times, and the prime time to estimate the number of ORs needed for scheduled surgeries



Limit Elective Surgical Admissions

Limiting or capping elective surgical admissions within a defined unit provides useful data about the occurrence of high and low demand for operating rooms. This data can then be used to work with surgeons to adjust the scheduling of surgical patients, which leads to smoothing the system-wide flow of elective surgical admissions.



  • Select one unit to test this change for one day.
  • Identify the average daily number of elective surgical admissions for the selected unit.
  • Limit (cap) admissions for the day to the average daily number of elective surgical admissions (the unit may take less than, but not more than, the number agreed upon).
  • Analyze the results of the test and use the data to work with surgeons to adjust the scheduling of surgical patients accordingly.



Synchronize Surgical Case Start Time

Synchronize surgical case start time to a consistent, agreed upon point. For instance, use incision time to synchronize all of the processes leading up to the actual surgery, including patient registration, pre-anesthesia preparation, room set-up, and anesthesia. Once the synchronization point is defined and agreed upon, all processes can be timed with reference to that point.



  • Get people to see themselves as part of the same system in order to make the use of synchronization successful.
  • Use incision time as the synchronization point because: (1) all preparatory tasks must be completed at this time; and (2) after that time, synchronization is made easier because all providers are nearby.
  • Define tasks and lead times for each member of the surgical team relative to the incision time. For example, if incision time is scheduled to occur 90 minutes after arrival, nurse assessment is complete at 60 minutes before incision; anesthesiologist assessment is complete at 45 minutes before incision; the patient is brought to the operating room 30 minutes before incision; and incision occurs at "time zero."
  • Ensure that all staff use a common time reference. GPS or NTP network controlled clocks and count-down/count-up timers allow all time devices to be synchronized to the second thereby reducing the likelihood or inaccurate time notations of events. [Submitted by: John Edwards, Surrey, BC, Canada]



Use Facsimile Reports to Transfer Information to Receiving Units

Medical staff can use facsimile (fax) reports to facilitate the movement of patients from one point of care in the hospital to the next. Delays often occur in transferring patients when the nurse on the receiving floor is not available to take the patient report. Faxing reports from the emergency department (ED) to the receiving units reduces delays in admissions and improves the ability of the ED to accept additional patients. The use of faxed reports can be expanded beyond the ED to notify nurses on the receiving units in any area of the hospital that a patient is being transferred.




  • Establish a standard process for receiving nurses to get the faxed report and know that the patient is on the way.
  • Request input from staff on the floors in developing a fax tool that provides the necessary information.
  • The process of faxing reports from the ED can be expedited by printing the nursing units and their fax numbers on the back of the faxed report form. It can also be helpful to list the room numbers that make up each ward as the ED nurses often do not know if "Room 428" is located in 4 West or 4 East. [Submitted by: Scott Keech, Clinical Consulting Manager, Kaiser Permanente-Northern California Regional Office]


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