Door to Doc
Slide Presentation from the AHRQ 2010 Annual Conference
On September 27, 2010, Joseph Guarisco, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (4.47 MB). Free PowerPoint® Viewer (Plugin Software Help).
September 26-29, 2010
Ochsner Medical Center
Door-to-Doc (D2D) Patient Safety Toolkit
Banner Health and Arizona State University
AHRQ Grant #: HS015921-01
An image of the Door-to-Doc (D2D) Patient Safety Toolkit is shown.
- Hurricane Katrina's crossroads
An image of the New Orleans area with a hurricane swell is shown.
- Hurricane Katrina's crossroads
An image of the New Orleans Time Picayune newspaper with the headline "Clear Out or Else" is shown.
- Hurricane Katrina's submerged crossroads
Two images of street signs on the South Louisiana Submerged Roads Program are shown.
An image of an article from the Times Picayune is shown. The title of the article is "Maryland is hungry for Louisiana crabs, but Louisiana can't deliver."
An image of an article from the Times Picayune
is shown. The title of the article is "Crab-crazy Maryland finds itself a victim of BP's Gulf oil spill."
A graph comparing LWBS% between Post Katrina and Pre Katrina is shown.
A graph comparing the Wait Times between Post Katrina and Pre Katrina is shown.
An image of an article titled "Two Years Later, Every Day is Monday in New Orleans Emergency Departments." is shown.
Sign on a restaurant door titled "Why a Restaurant Customer Quits"
3% Move Away
14% Unclean Dining Area
14% Bad Food
68% Indifferent Attitude About Service
911 Call: Ignored Woman Dies On ER Floor
Chief Medical Officer Ousted In MLK Emergency Room Death Aftermath
An image of Edith Rodriguez is shown.
- ED Crowding
- Output (admission delays)
- Throughput (non-lean workflow)
- Input (poorly engineered demand management)
An image of a cartoon is shown. The caption reads "Martha, I am not feeling too well. Maybe we should go over to the ER and get triaged!!"
Solve this problem
An image of a cartoon character thinking is shown.
- Cracking the code
- Implement lean workflow
- Lean registration
- Lean triage
- Create virtual capacity
- processing protects the most precious resource...the bed
- Rules based process
- Match resources to demand
- Queuing Theory
- Grocery Store Math© for EDs
An image of a qTrack (design schematic) is shown.
An image of qTrack (overview) is shown.
An image of qTrack (workflow simple) is shown.
Door to Doctor 2010
A chart showing Door to Doctor 2010, Minutes vs Hours of the Day is shown.
System Door to Doctor
A chart showing System Door to Doctor (target 20 min) is shown.
A chart showing System LWBS (target 1%) is shown.
Door to Doc
Image of three different bar charts. Each chart shows the time span of March 2010 through August 2010. One chart is on LWBS, the second chart is on D2D (min); and the third chart is on Volume.
Cost Analysis of LWBS
- Net revenue (for real current LWBS payor mix)
- Outpatient facility net revenue @ $300/visit discharge (90% of visits)
- Inpatient facility net revenue @ $5,000/visit admission (10% of visits)
- Professional provider net revenue @ $125/visit all (100% of visits)
- 1% LWBS @ 50,000 visits = 500 visits
- Lost opportunity net dollars for every 500 visits that LWBS
- $135,000 facility outpatient revenue (450 pts x $300)
- $250,000 facility inpatient revenue (50 pts x $5,000)
- $62,500 professional revenue (500 pts x $125)
- Cost of 1% LWBS at 50,000 volume = $447,500
||$ Budget Variance
||% Budget Variance
||$ Prior Variance
||% Prior Variance
|Emergency Medical Systems Nom
|Total Gross Patient Revenue
|Total Gross Revenue
- Requires a leap of faith (1)
- Unlocking old behaviors
- No registration up front and no deep dive triage
- Dramatically different workflow for staff
- Reduce scarce real beds to create more virtual beds??????
- Patient perspectives
- " I never got a bed!"
- Privacy concerns
- Physician issues
- No compensation benchmarks for this kind of work. and it is uniquely different
- EM MDs become internal customers.not comfortable position for them
- Not every MD suitable for D2D, requires great risk stratification skills
- Requires a leap of faith (2)
- New roles to manage with odd job descriptions
- Flow techs and flow nurses
- Administrative issues
- "Only the uninsured leave"...not so
- Its not about the expense, its about the return (ROI)
- Staffing paradigm shift
- MLPs and LPNs...may be perceived as threatening
- Forget FTE hrs/visit...think cost/visit
- Lean processing at registration and quick look
- Intake beds must be protected at all cost...almost.
- Accountability for the WR
- Internal queuing always...not in the WR
Joe Guarisco MD FACEP
Current as of November 2010
Door to Doc. Slide Presentation from the AHRQ 2010 Annual Conference (Text Version). November 2010.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf10/guarisco_margulies_mchugh/guarisco.htm