C3: Efficient Emergency Department Patient Intake and ...€¦ · Segmenting ED Patient Flow Minor Urgent Care Peds/Med/Surg Dx/Rx Complicated medical pts Critical Care Urgent Care

C3: Efficient Emergency Department Patient Intake and

Timely Inpatient Admissions

© 2009 Kirk Jensen, MD, MBA, Jody Crane, MD, MBA, Kevin Nolan, MA

Kirk Jensen, MD, MBA, FACEPJody Crane, MD, MBA, FACEP

Kevin Nolan, MA

Objectives for the Session

• Describe methods for efficient patient intakeDescribe methods for efficient patient intake• Identify ideas on how the ED can assist with

timely admissions to inpatient units

© 2009 Kirk Jensen, MD, MBA, Jody Crane, MD, MBA, Kevin Nolan, MA 22

Thinking About Flow

Optimizing Patient Intake and Throughput:Segmenting Patient Flow Into Incoming

Patient Streams…

© 2009 Kirk Jensen, MD, MBA, Jody Crane, MD, MBA, Kevin Nolan, MA3

The view from the gurney up:“Vertical” vs. “Horizontal” Patients

• Horizontal Patients─ Stretcher bound

• Vertical Patients─ Ambulatory

─ Ambulance Arrival─ Sick─ Older─ Perceived serious or life-

threatening Condition─ Value (Traditional

Healthcare)

─ Arrive by Triage─ Well─ Younger─ Perceived urgency or

convenience factor─ Value (Starbucks or

McDonalds)


SpeedSafety Preservation of Life/Limb

SpeedConvenienceFinancialOther non-medical factors

4

Segmenting ED Patient Flow

Minor Urgent Care

Peds/Med/Surg

Dx/Rx

Complicated medical pts Critical Care

d TUrgent Care Dx/Rx

Probable discharge

Dx/Rx

Possible admission

and Trauma


Fast Track Main ED Main ED/CDU

Critical Care Unit

5

Patient Segmentation by Acuity

ESI 5-Level TriageESI 5 Level Triage System:

• Easy• Highly Reliable• Allows for quick

patient


psegmentation

6

Emergency Severity Index (ESI) and Patient Acuity

Degree of Acuity Level of Acuity Patient Condition/Description

High LEVEL 1 EMERGENT Patients in this category require immediate attention with maximal utilization of resources to prevent loss of life, limb, or eyesight.

LEVEL 2 URGENT Patients in this category should be seen by a physician because of high risk for rapid deterioration, loss of life, limb, or eyesight if treatment or interventions are delayed.

Medium LEVEL 3 ACUTE Patients who develop a sudden illness or injury within 24-48 hours. Symptoms and risk factors for serious disease do not indicate a likelihood of rapid deterioration in the near future.

Low LEVEL 4 ROUTINE Patients with chronic complaints, medical maintenance, or medical conditions posing no threat to loss of life, limb, or eyesight..

LEVEL 5 ROUTINE Patients in this category are currently stable and require no resources such as labs or x-ray.

7

Triage

Segmenting Your ED’s Patient Flow into Incoming Patient Streams

Brief RN Assessment:ESI Evaluation / Evaluation of Acuity


Low AcuityPathway

ESI Levels 5, 4,+ some 3s

Moderate AcuityPathway

Most ESI Level 3s

High AcuityPathway

ESI Levels 1 + 2

8

Keep Your Vertical Patients Vertical and Moving

Treat andRelease

Patients enterintake area

Patient IntakeArea

Release

ResultsWaiting

Area

-Results Back-TreatmentComplete

-Discharge-Focused -Triage Orders


FocusedEvaluation and

Treatment-Move to results

waiting area.

g-Dx/Rx Protocols-MLP in Triage-MD in Triage-Super-Track -Fast-Track-Team Triage

9

Alaska Airlines-Reengineering Flow


Optimizing your Fast Track

The role of the Fast Track is to segment and serve those patients that are uncomplicated or relatively easy to treat. The Fast Track is not a casual add-on or an overflow unit.


Optimizing your Fast Track

• Many inefficient Fast Tracks have multiple handoffsresulting in queues and too sick patients in FT tying up bedsresulting in queues and too sick patients in FT tying up beds

• Key tactics:─ Optimize and maximize patient selection─ Match hours of operation to patient demand─ Optimize space and capacity


─ The right clinical mix of providers and productivity

12

Super Track

A “Super” Fast Entrance/Exit1 MD/PATrack located in or

near triage for the purpose of promptly treating patients who require very low resource utilization

Treatment Room 1

Treatment Room 2

1 MD/PA1 Nurse1 Tech


Room 1 Room 2

Procedure Chair

Results Waiting

13 Courtesy of Jody Crane, MD, MBA

Projected Hourly VolumesHour Average Patient Arrivals by Hour based on Annual Volumes

10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 110,000 120,0000:00 0.32 0.65 0.97 1.29 1.61 1.94 2.26 2.58 2.91 3.23 3.55 3.871:00 0.24 0.48 0.71 0.95 1.19 1.43 1.66 1.90 2.14 2.38 2.62 2.852:00 0.18 0.35 0.53 0.70 0.88 1.05 1.23 1.40 1.58 1.75 1.93 2.103:00 0.17 0.34 0.50 0.67 0.84 1.01 1.18 1.34 1.51 1.68 1.85 2.024:00 0.18 0.35 0.53 0.70 0.88 1.06 1.23 1.41 1.58 1.76 1.93 2.115:00 0.12 0.24 0.36 0.48 0.60 0.73 0.85 0.97 1.09 1.21 1.33 1.456:00 0.17 0.34 0.50 0.67 0.84 1.01 1.18 1.34 1.51 1.68 1.85 2.027:00 0.22 0.44 0.65 0.87 1.09 1.31 1.53 1.74 1.96 2.18 2.40 2.628 00 0 35 0 70 1 05 1 40 1 74 2 09 2 44 2 79 3 14 3 49 3 84 4 198:00 0.35 0.70 1.05 1.40 1.74 2.09 2.44 2.79 3.14 3.49 3.84 4.199:00 0.49 0.98 1.48 1.97 2.46 2.95 3.45 3.94 4.43 4.92 5.42 5.9110:00 0.61 1.21 1.82 2.43 3.03 3.64 4.25 4.86 5.46 6.07 6.68 7.2811:00 0.61 1.23 1.84 2.46 3.07 3.68 4.30 4.91 5.53 6.14 6.75 7.3712:00 0.67 1.34 2.01 2.68 3.35 4.03 4.70 5.37 6.04 6.71 7.38 8.0513:00 0.72 1.44 2.16 2.88 3.60 4.33 5.05 5.77 6.49 7.21 7.93 8.6514:00 0.60 1.19 1.79 2.38 2.98 3.57 4.17 4.76 5.36 5.95 6.55 7.1415:00 0.60 1.19 1.79 2.39 2.99 3.58 4.18 4.78 5.37 5.97 6.57 7.1716:00 0.51 1.02 1.53 2.04 2.55 3.06 3.57 4.08 4.59 5.10 5.61 6.1217:00 0.56 1.12 1.69 2.25 2.81 3.37 3.93 4.50 5.06 5.62 6.18 6.7418:00 0.67 1.33 2.00 2.66 3.33 3.99 4.66 5.32 5.99 6.65 7.32 7.9819:00 0.68 1.35 2.03 2.70 3.38 4.06 4.73 5.41 6.08 6.76 7.44 8.1120:00 0.73 1.47 2.20 2.93 3.67 4.40 5.14 5.87 6.60 7.34 8.07 8.8021:00 0.62 1.24 1.86 2.48 3.11 3.73 4.35 4.97 5.59 6.21 6.83 7.4522:00 0 52 1 04 1 56 2 08 2 61 3 13 3 65 4 17 4 69 5 21 5 73 6 25

© 2007, Jody Crane, MD, MBA14

22:00 0.52 1.04 1.56 2.08 2.61 3.13 3.65 4.17 4.69 5.21 5.73 6.2523:00 0.44 0.87 1.31 1.75 2.18 2.62 3.06 3.49 3.93 4.37 4.80 5.24

= 1 provider 3 bed Super Track seeing between 1.32 and 2.00 pts/hr= 2 provider 6 bed Super Track seeing between 2.00 and 4.00 pts/hr= 3 provider 9 bed Super Track seeing between 4.00 and 6.00 pts/hr= 4 provider 12 bed Super Track seeing between 6.00 and 8.00 pts/hr= 5 provider 15 bed Super Track seeing between 8.00 and 10.00 pts/hr

ESI DistributionChange on this

page onlyLevel I 0%Level 2 10%Level 3 50%Level 4 35%Level 5 5%

Level 3 pot FT 5%© Jody Crane, MD, MBA 2007

Please enter the target MD/PA/NP productivity

2.00 pts/hr

Projecting Utilization: SUPER TRACK14

“Team Triage”*

Team of providers utilizing an “intake team” mentality for

Quick Look Quick Reg

Quickteam mentality for promptly assessing, treating, and discharging level 3 patients

2 Providers (MD/PA),2 RN,1 Paramedic2 Scribes, 1PSR/HUC

Quick Triage

*Mary Washington Hospital design TreatmentArea

5 Rooms

Results Waiting

15 Courtesy of Jody Crane, MD, MBA

Patient Intake

Virtual Beds

Patient Intake

Treatment

Teams 1,2,4


, ,

Final Patient Segmentation Step

16

Projected Hourly VolumesHour Average Patient Arrivals by Hour based on Annual Volumes

10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 110,000 120,0000:00 0.73 1.45 2.18 2.91 3.63 4.36 5.08 5.81 6.54 7.26 7.99 8.721:00 0.53 1.07 1.60 2.14 2.67 3.21 3.74 4.28 4.81 5.35 5.88 6.422:00 0.39 0.79 1.18 1.58 1.97 2.36 2.76 3.15 3.55 3.94 4.33 4.733:00 0.38 0.76 1.13 1.51 1.89 2.27 2.65 3.03 3.40 3.78 4.16 4.544:00 0.40 0.79 1.19 1.58 1.98 2.37 2.77 3.17 3.56 3.96 4.35 4.755:00 0.27 0.54 0.82 1.09 1.36 1.63 1.91 2.18 2.45 2.72 2.99 3.276:00 0.38 0.76 1.13 1.51 1.89 2.27 2.65 3.03 3.40 3.78 4.16 4.547:00 0.49 0.98 1.47 1.96 2.45 2.94 3.43 3.92 4.42 4.91 5.40 5.898:00 0.78 1.57 2.35 3.14 3.92 4.71 5.49 6.28 7.06 7.85 8.63 9.429:00 1 11 2 22 3 32 4 43 5 54 6 65 7 75 8 86 9 97 11 08 12 19 13 299:00 1.11 2.22 3.32 4.43 5.54 6.65 7.75 8.86 9.97 11.08 12.19 13.2910:00 1.37 2.73 4.10 5.46 6.83 8.19 9.56 10.93 12.29 13.66 15.02 16.3911:00 1.38 2.76 4.14 5.53 6.91 8.29 9.67 11.05 12.43 13.82 15.20 16.5812:00 1.51 3.02 4.53 6.04 7.55 9.06 10.57 12.08 13.59 15.10 16.61 18.1213:00 1.62 3.24 4.87 6.49 8.11 9.73 11.35 12.98 14.60 16.22 17.84 19.4714:00 1.34 2.68 4.02 5.36 6.69 8.03 9.37 10.71 12.05 13.39 14.73 16.0715:00 1.34 2.69 4.03 5.37 6.72 8.06 9.41 10.75 12.09 13.44 14.78 16.1216:00 1.15 2.29 3.44 4.59 5.74 6.88 8.03 9.18 10.33 11.47 12.62 13.7717:00 1.26 2.53 3.79 5.06 6.32 7.59 8.85 10.12 11.38 12.64 13.91 15.1718:00 1.50 2.99 4.49 5.99 7.49 8.98 10.48 11.98 13.47 14.97 16.47 17.9619:00 1.52 3.04 4.56 6.08 7.60 9.12 10.65 12.17 13.69 15.21 16.73 18.2520:00 1.65 3.30 4.95 6.60 8.25 9.90 11.55 13.20 14.86 16.51 18.16 19.8121:00 1.40 2.79 4.19 5.59 6.99 8.38 9.78 11.18 12.58 13.97 15.37 16.7722:00 1.17 2.35 3.52 4.69 5.86 7.04 8.21 9.38 10.55 11.73 12.90 14.0723:00 0.98 1.97 2.95 3.93 4.91 5.90 6.88 7.86 8.84 9.83 10.81 11.79

17

ESI Distribution

Change on this

page onlyLevel I 0%Level 2 10%Level 3 50%Level 4 35%Level 5 5%

Level 3 pot FT 5%

Please enter the target team 1 MD, 1 MLP, 2RN, + Support

6.00 pts/hr

= 1/2 Team*1MD,1RN ED Volume Between 3.96 and 6.00 pts/hr= 1 team ED Volume Between 6.00 and 12.00 pts/hr= 2 teams ED Volume Between 12.00 and 18.00 pts/hr= 3 teams ED Volume Between 18.00 and 24.00 pts/hr= 4 teams ED Volume Between 24.00 and 30.00 pts/hr*Team = 1 MD, 1 MLP, 2 RN, 1 Paramedic or tech, 1 Unit coordinator, 1 Patient Liasion, 2 Scribes*Team = 5 intake beds, 7-8 treatment beds

© 2007, Jody Crane, MD, MBA17

Projecting Utilization: INTAKE TEAM

MediCorp Health System ED Improvement Journey


Mary Washington Hospital

• Working on advanced methods of patient i t k i 2002intake since 2002

• Using and pioneering approaches employing Lean in the ED

• Have learned a lot about what drives ED throughput


throughput• Lead by a team of front-line workers

engaged in problem solving

6'-3/8"

42 43 46

Lab -Phlebotomy

Waiting Room

TriageReception

RME 2004 -2006Results Waiting

-8 7

/8"

6'-5 5/8"

2'-8

7/8

"

6'-5 5/8"

2'-8

7/8

"

6'-5 5/8"

2'-8

7/8

"

6'-5 5/8"

2'-8

7/8

"

6'-5 5/8"

13'-3

"

42 43 44 4645

49

48

47

23

24

2526

OR 1

50

OR 2OR 3

OR 4

TR 8

TR 7

TR 5

TR 6

27

39

38

37

36

35

41

40Peds WR

Rainbow

Rad Room RME Team

PA Team

Main ED


2'-8

7/8

"

6'-5 5/8"

2'

TR 9

16 15 14

13

12

10

11

18

19

20

21

22

28

29

31 30 17

32

33

35

34

Rainbow Room

(Internal Waiting)

MD Team

Results Waiting

Super TrackPivot

Mini Triage

Intake Teams 2007- Current

Patient IntakeTreatment

Main ED

Mini Triage


Emergency Streaming

RN

15-20%Super Track

ESI 4-5

50 60%


20-30%Main EDESI 1-3

50-60%Intake/PODs

ESI 3


Super Track Process Flow


Today….


Intake Process Flow


RATED Implementation• “Leaned” the

process─Visual Management

with color coding─Point of use supplies─Rapid Changeover─Reduced Staff


Movement─Reduced Variation─Designed to meet

takt time

1Results Waiting

6

3

2

4

5


4

Lab

9


9

PODs

• Implemented 02/09 ti i t d 10%anticipated 10%

volume drop w/ SHC opening─Dropped 1MD and 2

PA shifts per Day

/8"

2'-8

7/8

"2'

-8 7

/8"

2'-8

7/8

"2'

-8 7

/8"

2'-8

7/8

"

13'-3

"


(28 hours)─Decreased RN Staff

by 15%─Closed 10% of

Rooms

2'-8

7/



Waiting

Peds Waiting

TreatBays

Lab

Stafford Medical

Center ED(Feb 2009)

Area

WaitingArea

Triage(4)

Intake

RWArea

Main ED

y(4)

Rad/CT

Area

© 2009 Kirk Jensen, MD, MBA, Jody Crane, MD, MBA, Kevin Nolan, MA© 2009, Jody Crane, MD, MBA

Rec/Quick

Security

14 beds 1 Trauma bay

EntranceWalk-in

SquadEntrance

33

Waiting

Peds Waiting

TreatBays

Lab

STARS

Stafford Medical

Center ED(Feb 2009)

Area

WaitingArea

Triage(4)

Intake

RWArea

Main ED

y(4)

Rad/CT

Area

STARSStrategic Triage, Assessment and Rapid Service


Rec/Quick

Security

14 beds 1 Trauma bay

EntranceWalk-in

SquadEntrance

34

Triage(4)

Intake

RWArea

TreatBays(4)

ESI 4,5

Stafford Medical

Center ED(Feb 2009)

Intake

ESI 2,3

ESI 1,2

Admit

DischargeESI 2-5


EntranceRec/

Quick

Discharge

35


© 2009 Kirk Jensen, MD, MBA, Jody Crane, MD, MBA, Kevin Nolan, MA© 2009, Jody 37

Admissions from the Emergency Department


You are not the only one interestedin this subject - JCAHO

Leadership Standard (LD 3.15)p ( )“The leaders develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital.”


JCAHO Scott Altman, MD, MBA

EDs, Admissions and Hospital Wide Patient Flow

Patient StreamsDirectAdmit

Admissions

Inpatient

Discharges


What we would like to see…

T i

Admission


Triage

41

ED

- ED MD and Admitting MD

Timing

- D/C paperwork not signed or

Physical Bed Issues

- No Physical bedsAncillary

T t

Bed Availability

The Admission Value Stream Analysis:Trouble begins where trouble begins…

ED MD and Admitting MD Communication

- ED Shift Change

- ED Treatment not yet complete

D/C paperwork not signed or completed by MD

- Lack of inpatient unit staffing

- Multiple admissions

- Inpatient unit shift change

No Physical beds

- Room Availability

- Nurse busy and did not communicate to housekeeping

- Bed not clean

Results

- Test Results

- Waiting lab work started in ED

D/C Delays

- Waiting patient RN writes D/C instructions

- Pt not left inpatient unit bed

C ll d i ll f /C

- Transport

Other

-Calls to and from ED and Inpatient units

- MD & House Supervisor Communication


- Call admin on-call for D/C

-Complete ED Treatment -Lab work -Transport -Staff change -Doc Dictate -Staffing (RN to bed ratio) -Rm Availability (pt not left, no bed to put in, bed not clean) -Bad timing for multiple admissions

ED to Nursing Unit Delays

42

Accelerating ED Admissions

There isn’t oneThere isn t one magic bullet…


There is a portfolio of effective strategies…

43

A Robust Portfolio of High Leverage Admission Strategies and Tactics

• “Connect” the ED to the rest of the Hospital

• A Hospitalist ProgramAn Engaged Medical Staffp

• A “Lean” Admission Process• Staffing to Demand• A Demand/Capacity Prediction

and Management Process• A Bed Czar/Patient Flow

CoordinatorA B d T ki S t

• An Engaged Medical Staff• Service Line Optimization• Specialized Units or Services• Flexible Units/Flexible Staff• A Diversion Plan• A Saturation Plan• Effective Case Management


• A Bed Tracking System• Bed Board Rounds/Huddles• Multidisciplinary Rounds

Effective Case Management • Adopt a Boarder• Smoothing Surgical Flow• Coordinating

Admissions/Discharges

44

Emergency Department Admissions:Emergency Department Admissions:

Focusing on actions within the control and influence of your

Emergency Department Team…


g y p

45

ED Admissions - Some Initial Activities

1. Define the magnitude of your admission problem/opportunity

2. Flow Chart the ED admission process

3. Collect data on the reasons for admission delays

4 Understand historical admissions from the ED


4. Understand historical admissions from the ED on average by day of week, time period of the day (e.g. before 1pm) and unit (e.g. ICU)

46

ICU Tele M/S Units

Mon Before 1PM

After 1PM

Tues Before 1PM

Admissions from the ED

Tues Before 1PM

After 1PM

Wed Before 1PM

After 1PM

Thurs Before 1PM

After 1PM

Fri Before 1PM

After 1PM

.

.

Real Time Identification and Communication of Potential Admissions from the ED

1. Have up-to-date information on ED patient status visible on a white board or electronic system in the ED

2. Establish ED board rounds (when, who) to review patient status

3. Based on ED board rounds, predict admissions for the next 4 hours


4. Communicate to patient placement when a decision is made in the ED to admit a patient

5. Communicate ED admission predictions to patient placement

48

Critical Tactical Initiatives to Optimize ED Patient Flow

Improving ED Patient Flow Priority Start DateOptimize and maximize Patient Intake

OOptimize your Fast track

ED Bed capacity and utilization

Leverage your clinical talent and time

Maximize your bed turns

Teamwork and Culture

Minimize your boarding burden

Accelerate your Admissions Process

49

You and your Emergency Department

are the ultimate reality show


ultimate reality show…

50

Take a look at your ED:


Take a look at your ED:-Get passionate…-Get serious…-Get it done…

51

You can do this…


Courtesy Mike Williams, The ABARIS Group

52

References


Resources: Improving Patient Flow in the Emergency Department-A nice overview-easy to read and comprehend


References• Fitzsimmons J., and M. Fitzsimmons. 2006. Service Management: Operations, Strategy, Information

Technology. 5th ed. Boston: McGraw-Hill.• Goldratt, E. 1986. The Goal. Great Barrington: North River Press.• Institute for Healthcare Improvement (IHI). Optimizing Patient Flow: Moving Patients SmoothlyInstitute for Healthcare Improvement (IHI). Optimizing Patient Flow: Moving Patients Smoothly

Through Acute Care Settings. Innovation Series 2003. “Bursting at the Seams: 2004. Improving Patient Flow to Help America’s Emergency Departments.” Urgent Matters Learning Network Whitepaper. www.gwhealthpolicy.org accessed September 17, 2005.

• Building the Clockwork ED: Best Practices for Eliminating Bottlenecks and Delays in the ED. HWorks. An Advisory Board Company. Washington D.C. 2000.

• Bazarian J. J., and S. M. Schneider, et al. Do Admitted Patients Held in the Emergency Department Impair Throughput of Treat and Release Patients? Acad Emerg Med. 1996; 3(12): 1113-1118.

• Full Capacity Protocol. www.viccellio.com/overcrowding.htm• Kelley, M.A. The Hospitalist: A New Medical Specialty. Ann Intern Med. 1999; 130:373-375.• Holland L L Smith et al 2005 “Reducing Laboratory Turnaround Time Outliers Can Reduce


• Holland, L., L. Smith, et al. 2005. Reducing Laboratory Turnaround Time Outliers Can Reduce Emergency Department Patient Length of Stay.” Am J Clin Pathol 125 (5): 672-674.

• Husk, G., and D. Waxman. 2004. “Using Data from Hospital Information Systems to Improve Emergency Department Care.” SAEM 11(11): 1237-1244.

• Christensen, Grossman, and Hwang,-The Innovator’s Prescription, 2009

55

References

Emergency Department Contributors to Ambulance Diversion: a Quantitative Analysis

Schull et elAnnals of Emergency Medicine 41:4 April 2003; 467-476

The Access Block Effect: Relationship between Delay to Reaching an Inpatient Bed and Inpatient Length of Stay

Richardson, DB Med J Australia 2002; 177:492


The Effect of Hospital Occupancy on Emergency Department Length of Stay and Patient Disposition

Acad Emerg Med 2003; 10: 127-133

References

• Derlet R, et al: Expectations of Patients Arriving in an Emergency Department.” Society for Academic Emergency Medicine Annual Meeting. Chi IL M 1998Chicago, IL, May, 1998.

• Thompson, et al. “How Accurate are Waiting Time Perceptions of Patient in the Emergency Department?” Ann Emerg Med, 1996(12).

• Hollingsworth J, et al. “How do Physicians and Nurses Spend Their Time in the Emergency Department?” Ann Emerg Med 1998(1):97-91.

• MacLean SL, Fong M, Desy P, et al:”2001 ENA National Benchmark Guide: Emergency Departments” Emergency Nurses Association: 2002.

• Manos et al. Inter-observer agreement using the Canadian Emergency


g g g yDepartment Triage and Acuity Scale. CJEM; 2002:16-22.

• Worster A, Gilboy N, Fernandes CM, Eitel D, Eva K, Geisler R, Tanabe P. Assessment of inter-observer reliability of two five -level triage and acuity randomized controlled trial. Can J Emerg Med 2004;6(4):240-5.

57

References:The Psychology of Waiting

• Maister, D. (1985). The Psychology of Waiting Lines. In J. A. Czepiel, M. R. Solomon & C. F. Surprenant (Eds.), The Service encounter: managing employee/customer interaction in service businesses. Lexington, MA: D. C. Heath and Company, g p yLexington Books.

• Norman, D. A. (2008) -- The Psychology of Waiting Lines The PDF version is an excerpt from a draft chapter entitled "Sociable Design" for a new book-www.jnd.org/dn.mss/the_psychology_of_waiting_lines

• Norman, D. A. (2009). Designing waits that work. MIT Sloan Management Review, 50(4), 23-28.


• Christine M. Meade, PHD, Julie Kennedy, RN, BSN, TNS, and Jay Kaplan, MD, FACEP-The Studer Group- JEM 2008

• Fitzsimmons J., and M. Fitzsimmons. 2006. Service Management: Operations, Strategy, Information Technology. 5th ed. Boston: McGraw-Hill.

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Documents

C3: Efficient Emergency Department Patient Intake and ...€¦ · Segmenting ED Patient Flow Minor Urgent Care Peds/Med/Surg Dx/Rx Complicated medical pts Critical Care Urgent Care