Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department.

Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitations, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.