Reducing ED Door-to-Doctor Time by Implementing Lean Process and Tools

Florida Hospital
Orlando, Florida, USA


The Florida Hospital Orlando team began working with IHI’s Emergency Department Learning and Innovation Community in 2006. We looked at processes and flow. The team members participating in the Community were:

Dena Mikkonen – ED Administrative Support
Diana Vetterick – Clinical Process Improvement Specialist for ED (Key contact, data reporter)
Brenda Hutson – ED Nurse Manager
Katie Phelps – ED Assistant Nurse Manager
Scott Harris – OPI representative
Dr. Brad Bowls – ED Medical Director
Patricia Price – ED Nurse Manager
Ron Nieves – Lean Assistant Nurse Manager
Kathy Tiedeken – Executive Sponsor
Connie Hamilton – Executive Sponsor



To decrease emergency department (ED) door-to-doctor time by 25 percent by December 2008.

To accomplish this aim we will:
  • Decrease door-to-discharge time (length of stay for discharged ED patients) from present level to 210 minutes by December 2008
  • Decrease length of stay of admitted patients from present level to 390 minutes by December 2008
  • Decrease the percentage of patients who check in at the ED triage desk but who leave without seeing the doctor (LWSD) by 50 percent by December 2008



  • Length of Stay for Discharged ED Patients: Time in minutes from the arrival in the ED to the discharge
  • Door-to-Doctor Time
  • Length of Stay for Lean Track Patients: Time in minutes from arrival in the ED to discharge for the subset of patients in the Lean Track program
  • Length of Stay of Admitted Patients: Time in minutes from arrival in the ED to departure to the floor
  • Number and Percent of Walkaways: Percent of the total number of patients who check in at the ED triage desk and who leave before being treated or seen by a physician (LWSD)


  • Implemented the predictive model in the ED and staffed accordingly. We looked at the previous four weeks of volume, key metrics, and admissions. We then determined the average daily demand for that day of the week. We staff up on our busier days and reduce staff on the average days to meet demand. Presently many more of the departments in the hospital are using the same model for lab, radiology, housekeeping, etc.
  • Reduced the lab turnaround time (TAT) to 60 minutes or less from order to result. We broke that metric up further so the ED has 30 minutes to get the specimen to the lab, and lab has 30 minutes to have the result posted. Each day we know which half of the equation either met or did not meet the goal.
  • Looked for and decreased waste or non-value-added steps. We observed and videotaped processes. We redesigned the staff work areas to be closer to the patients. We redesigned our stocking process so the need items were easy for the staff to access. We designated physician exam rooms so the physician is not traveling across a large ED many times a day.
  • Incorporated lean tools into our daily process. Some of the tools are: single patient flow, 5S (Sort, Simplify, Sweep, Standardize, Self-Discipline), demand and capacity, parallel processing, and managing by metrics.
  • Developed a monthly process council. Each department is represented at the council, including someone from each of the nursing units. We review metrics and discuss an action plan from each department or unit not meeting the goal. Senior leadership is present. The following month, we review progress on the action plan and revise the plan if we are still not meeting the goal.



Summary of Results / Lessons Learned / Next Steps
Implementing lean principles and using the predictive model have had significant effects on our measured metrics, and we have adopted this approach as part of our culture at Florida Hospital. We needed the support of the physicians, staff, and administration to make this successful. The process must be monitored constantly or we tend to go back to our old habits.
  • Choose the right people for your team; they need to be committed to the process and strong enough to stand by the process when their co-workers do not believe in or understand the process.
  • Monitor your results frequently and make small changes instead of multiple changes when you get way off course. It is easier for the staff to accept small changes.
  • Share the results, good or bad, with the staff and senior leadership.
  • Don’t be afraid to try a suggestion because no one has all of the right answers.
  • Don’t be afraid to take the leap of faith.
  • Learn from other people or, in our case, from our other campuses.
  • Insist on support from the senior leadership group; this will not be successful without their support. Sing your praises. Do not keep your good progress to yourself; it’s all about what is best for the patient. Tell your story.

Contact Information
Diana Vetterick, RN, BS
Clinical Process Improvement Specialist 
Florida Hospital

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