• E-mail
• Print
• RSS

Push and Pull in the ED

Patient Safety Quality Monthly, October 26, 2010

Want to receive articles like this one in your inbox? Subscribe to Patient Safety Quality Monthly!

If your organization is working on improving patient flow—and who isn't?—it is likely you have run into a problem where the ED is pushing people from the emergency room to the nursing floor, and the nursing floor or ICU is complaining that they were "not ready" or the patient was just "sent up". Sometimes you hear similar things when a patient is "pushed" out to the discharge team or to any other unit.

Our goal in any situation where we are moving patients is to have a smooth and well-managed flow. Anytime there is poor synchronization, we know we will have process problems, staff frustration, and potentially safety issues.

Managing flow is a classic problem and is a great place for us to apply one of the powerful LEAN concepts. That's the concept of PUSH and PULL.

In a simplified fashion, PUSH says that when we are done with our tasks we push the patient (or product) on to the next step in the process based on our needs—not the patient's. The opposite of this is to PULL. As soon as we are ready in our process, we reach out and get the next patient or product and PULL them into our process. Obviously, we would all prefer to be able to PULL things into our process when we are good and ready, and we may get a little upset if people are constantly pushing. Generally, processes that PULL are more easily synchronized.

So let's go back to the issue of coordination of flow between the ED and the floors. Why does the ED have a tendency to PUSH to get people moved out of their area? Typically it's because they are trying to balance their flow—as more people come in, the folks who are already there have to go somewhere. So they get pushed out to the floor or back to "the street."

So why don't we have the same problems in other areas like endoscopy or outpatient surgery? The primary difference is the amount of control that those processes have on the incoming stream of patients. We use that time-honored approach of "the appointment" to control the incoming flow. If we don't have a slot in the schedule, we move the patient to next week. This really is just reaching out to our patient population and PULLING them in when we are ready.

The ED doesn't have that luxury. We can't schedule motor vehicle accidents and strokes to fit the convenience of our processes. And because the ED can't schedule when people arrive, it starts a whole chain of events that ripples through the organization. A surge in the ED causes a surge in ICU and med-surg, and everyone gets out of synchronization.

Does that mean that this will never change? Not really. There are some great process flow activities being done to improve the flow in the ED—and they are really helping. But perhaps one of the most interesting changes on the horizon isn't even coming from process improvement projects in the ED; it is coming from marketing!

A key satisfaction differentiator for people who use the ED—and have a choice—is the wait time. When the marketing folks recognized this, it became a key advertising focus: "We guarantee we will see you in the ED within 30 minutes." Now, by itself, that didn't really change our flow, it just put a lot more pressure on the ED staff!

The real change came when the marketing people took it to the next level—displaying the actual wait time on billboards or on the Internet. "The present wait time at our ED is 12 minutes." This results in a fascinating change in the whole process dynamic. In the past there was no control over the incoming flow to the ED (except for diversion). Now the incoming flow is being balanced by market forces. If the wait time is long at one ED, people will check the Internet and go to another ED with a shorter wait time. Without a lot of prior process thinking, we are now doing what might be called "load leveling" out in the community.

This will change the whole PUSH-PULL dynamic. Now when an ED is ready for more patients from the community, it reduces its wait time on the Internet, and in the larger markets, this will result in PULLING patients from the community to the ED—something that in the past we could never control as directly.

Of course, this is not happening everywhere or that quickly, but it is an interesting example of how we can use tools like PUSH-PULL to better understand and communicate the process world we deal with every day.

Ken Rohde, Senior Consultant, October 2010

Want to receive articles like this one in your inbox? Subscribe to Patient Safety Quality Monthly!

• E-mail to a Colleague
• Print
• RSS
• Archive