"Not so fast!" the complexity of attempting to decrease door-to-floor time for emergency department admissions.

Article-at-a-Glance Background Successful quality improvement is fundamental to high-performing health care systems, but becomes increasingly difficult as systems become more complex. Previous attempts at the University of California, San Francisco (UCSF) Medical Center to reduce door-to-floor (D2F) time —the time required to move an ill patient through the emergency department (ED) to an appropriate inpatient bed—had not resulted in meaningful improvement. An analysis of why attempts at decreasing D2F times in the ED had failed, with attention to contextual factors, yields recommendations on how to decrease D2F time. Methods A team of 11 internal medicine residents, in partnership with the Patient Flow Executive Steering Committee, performed a literature review, process mapping, and analysis of the admissions process. The team conducted interviews with medical center staff across disciplines, members of high-performing patient care units, and leaders of peer institutions who had undertaken similar efforts. Findings and Recommendations Each of the following three domains—(1) Improving Work Flow, (2) Changing Culture, and (3) Understanding Incentives—is independently an important source of resistance and opportunity. However, the improvement work and understanding of complexity science suggest that all three domains must be addressed simultaneously to effect meaningful change. Recommendations include eliminating redundant and frustrating processes; encouraging multidisciplinary collaboration; fostering trust between departments; providing feedback on individual performance; enhancing provider buy-in; and, ultimately, uniting staff behind a common goal. Conclusion By conceptualizing the hospital as a complex adaptive system, multiple interrelated groups can be encouraged to work together and accomplish a common goal.