D2D Care Process Tool

Flow
Chart A Care Process

Mary Ellen Bucco, MBA

Twila Burdick, MBA
Chris Modena, RN, MBA/HCM
 Acceptance Goals
• With this tool, the user will be able to
answer the question: “How would our
current Emergency Department (ED) care
process need to change to implement the
Door to Doc (D2D) Care Process?”
• This acceptance assessment is based on
two exercises: a walkthrough and a
flowchart comparison of current ED
processes to the D2D Care Process.
 D2D in the Front of the ED
The D2D Care Process reduces the time it takes for the patient to
see a physician in the ED. It changes the patient flow to eliminate
waiting in the initial care process steps.

Typical ED Process D2D ED Process

Arrive at ED Arrive at ED
wait in waiting room Quick Look/Quick Registration
Triage Go to patient care area
wait in waiting room See doctor and nurse
Register
wait in waiting room
Back to bed Quick Look (not
wait in treatment room triage) identifies
See nurse patients as “less sick”
wait in treatment room and “sicker” and
See doctor determines the D2D
process in the back.
 D2D in the Back
for “Less Sick” Patients
After the patient has been seen by a physician, the Door to
Doc (D2D) Care Process changes the way “less sick”
patients are treated.
– “Less sick” patients are treated like patients seen in a clinic
• Not lying down in an ED bed unless needed
• Not being undressed unless necessary
• Not waiting in patient care areas
• Not occupying an ED bed for tests and treatments, but
moving to other areas
– When ED volume is sufficient, less sick patients are seen in a
separate intake area
• Not sized like Acute ED room
• Not equipped like Acute ED room
– Informed Discharge conducted
• Not necessarily with the original caregiver
 D2D in the Back
for “Sicker” Patients
For “sicker” patients, the D2D Care Process is similar to
current Acute ED Care Processes.

– Regularly sized and equipped ED rooms

• Patient undressed
• Patient in ED bed for tests and treatments and waiting for
decision-making

For “sicker” patients who are admitted, the D2D Care

Process is different in capacity-constrained EDs.

– When an inpatient bed is not available, patient care is

assumed by inpatient caregivers (nursing, physicians)
• May be in space within the ED or separate from the ED
 Process Flow Diagram
• A flow diagram is a graphic representation of the
sequence of steps in a process.[1]
– Boxes or rectangles show process steps
– Diamonds show decision points
– Arrows show the direction of flow
– Circles with letters show connectors
• Flow diagrams of your actual process compared
to the D2D process can help identify process
changes that must be made.
– The Door to Doc Care Process Flow follows
 Door to Doc Care Process[2] 7. Specimen
Collection
3. Patient
4. MSE/focused
escorted to
assessment, Orders 5. ED Bed 6. Diagnostic 8. Medical
Intake Space No B
& Documentation Required? Testing Required? Imaging
(RN and Physician)
(RN or Tech)
9. Procedure/
Yes Treatment
“Less Sick” Patients A

Intake (ESI 3- 5*)

No No 19.
Patient to
Discharge
Room for
Informed
Discharge

1. Quick 10. 12. 20.

Reg (PFS 11. Patient
Patient 2. Sicker? Move patient Medical Patient to IP
Rep) and B Review of leaves the
Arrives (ESI 1 or 2) to Results Decision Unit/IP Holding
Quick Look Results ED
Waiting Area Making Unit
(RN)
21.
Transfer to
18.
another facility
Patient
Remains in ED
“Sicker” Patients Yes Bed

Acute (ESI 1- 2*) 14. No

MSE/Focused Assessment,
Orders, Specimen Collection,
13. 17.
Procedure and
Patient 15. 16. Patient meets
A Documentation Yes B
escorted to ED Testing Treatment Results Waiting
(RN, Tech, Physician)
Bed Criteria
Full Registration & Co-Pay
Collection
(PFS Rep)

*ESI-Emergency Severity Index [3]

 Your Current ED Process Flow
To be sure you know how your current ED process
operates, do a “Walk-Through”
Tips for Your Walk-Through
• Start with patient entry into the ED and end with the patient leaving the ED
• Include two to three people, if possible, with each viewing the process through the
eyes of a nurse and physician, patient and physician, etc.
• Conduct walk-through at different times of the day, days of the week
• Make a point of noting the paper trail of charts, lab reports, referrals, transfers,
medications, etc along that accompany the process steps
• At different steps ask the staff to tell you about the process step
Questions to Ask
• Is this a busy or slow time?
• How long on average does it take to complete a process?
• Is the current process working well for patients and the staff?
• Is the staffing level the same 24/7?

Use this information to construct a “high-level” flow

diagram of the current process
• Use ‘sticky notes” on a large surface in a group setting to identify and arrange the
steps before drawing it on paper
Patient Arrival Process
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the change.
Start with the first steps as the patient arrives
at the ED.
Check the box that best describes the
magnitude of the change.

Step Description Possible Changes Staff Affected BIG Medium Small/No

Change Change Change

1a. Quick Registration -Patient Accounting system accommodation for Patient Registration or
‘Quick Registration Business
-Arrangements to complete registration later in care Representatives
process
-Patient Registration co-located with Quick Look

1b. Quick Look -Eliminate triage Nursing staff,

-Co-location with Quick Registration particularly Triage
Staff

2. Sicker? -Adopt “quick look” methodology (such as Nursing staff,

Emergency Severity Index) for identifying sicker and particularly Triage
less sick patients Staff

3. Patient Escorted to -Not all patients taken to an ED Bed Techs

Intake Space
Caring for “Less Sick” Patients
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the change.
Continue with the process for “less sick”
patients.
Check the box that best describes the
magnitude of the change.

Step Description Possible Changes Staff BIG Medium Small/No

Affected Change Change Change
4. MSE/focused assessment, -Jointly performed medical screening, rather than nursing Physicians,
orders and documentation and physician separate Nurses,
-Patient focused documentation (rather than separated by Techs
provider)
-Eliminates mix of sicker and less sick patients increasing
the number of patients that can be seen by a physician

5. ED Bed Required? -Handoff by physicians of patients who are determined to Physicians

be “sicker” after medical screening exam
6. Diagnostic Tests Required? n/a n/a

7. Specimen Collected -Less sick patients move to these areas as directed on Ancillary
their own staff
8. Medical Imaging Performed -Less sick patients move to these areas as directed on Ancillary
their own staff
9. Procedure/Treatment -Less sick patients move to these areas as directed on Ancillary
Performed their own staff
Caring for “Sicker” Patients
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the change.
Continue with the process for “sicker”
patients.
Check the box that best describes the
magnitude of the change.

Step Description Possible Changes Staff Affected BIG Medium Small/No

Change Change Change
13. Patient Escorted to ED Bed n/a n/a

14a. MSE/focused assessment,

orders, specimen collection,
procedure and documentation
14b. Full Registration and Co-Pay -Complete registration at bedside Patient Registration
Collection or Business
Representatives
15 Testing n/a n/a
16 Treatment
17 Patient ok for results waiting? -Patients not requiring a bed moved out of Physicians, Nurses,
acute bed to results waiting Techs
18. Patient Remains in ED Bed
Decision Making and Leaving
Review the flow diagram of your current
process compared to the D2D process to
identify the estimated scope of the
change.
Continue with the decision making
process and leaving the ED.
Check the box that best describes the
magnitude of the change.

Step Description Possible Changes Staff Affected BIG Medium Small/No

Change Change Change
10. Move Patient to -Less sick patients don’t own a bed Physicians, Nurses,
Results Waiting Area Techs
11. Review Test Results -May involve handoff from original caregiver Physicians, Nurses,
Techs
12 Medical Decision
Making
19. Patient to Discharge -Utilize standardized approach for discharge and Physicians, Nurses,
Room for Informed completion of registration and co-pays as needed Patient Registration
Discharge -Separate location for discharge process or Business
-May involve handoff of care Representatives
20 Patient to IP Unit/IP -Admitted patient care assumed by inpatient care Inpatient and ED
Holding providers nurses, physicians
21. Transfer to another n/a n/a
facility
 Next Step
• Review the results of the comparison of your
current process with the D2D Care Process.
• Now that you have identified the magnitude of
the changes that will be required to implement
D2D in your Emergency Department, the next
step is to determine whether the critical
success factors for acceptance of these
changes are in place.
• Proceed to the next tool: Survey
Ready to
Change?
B
 References
[1] Brassard M. The Six Sigma Memory Jogger II. Salem, NH:
Goal/QPC. 2002.

[2] Burdick TL, Cochran JK, Kisiel S, Modena C. Banner

Health / Arizona State University Partnership in
Redesigning Emergency Department Care Delivery
Focusing on Patient Safety. 19th Annual IIE Society for
Health Systems Conference. 8 pages on CD-ROM. New
Orleans, LA; 2007.

[3] Eitel D, Wuerz RC. The ESI Implementation Handbook.

Emergency Nurses Association Ed. 1997-2003.