Improving emergency department patient flow at  St. Mary Medical Center

Contact information

* This field is mandatory

Contact details


Company details


ED process improvement consulting and interim leadership helps implement a middle- trac process, improving flow

The ED at St. Mary Medical Center (SMMC) in Apple Valley, CA was challenged with significant volume growth, recurring gaps in ED leadership, prolonged lengths of stay, and high LWBS rates. SMMC asked Philips to provide interim ED leadership and performance improvement in the ED.

Philips provided an Interim ED Manager, Interim ED Director, and led an intensive multidisciplinary Performance Improvement Consulting initiative which identified several opportunities to increase process efficiency and patient flow.

smmc results
smmc results
smmc results

An innovative approach to ED performance improvement


Strong interim leadership


Philips consultants joined SMMC as Interim ED Manager and ED Director, focused on day-to-day operational and staff management. Leadership responsibilities included staff communications/relationships/support, hiring vacant staff positions and resource planning, staff development and training, assisting with conflict resolution, team mentoring, and more. They quickly became valuable leaders of the team.

A comprehensive assessment of key operational metrics was completed and a performance improvement (PI) engagement was recommended. Adding the PI program allowed the interim leaders to focus on team management while supporting the operational efficiency process changes.

A third consultant joined to focus on leading teams towards improving key performance indicators. The third consultant supported SMMC during these improvement initiatives and the two other consultants were asked to continue in the interim roles for the long-term.

ED Performance Improvement

The performance assessment included a thorough analysis of data collected for volume, arrival patterns, staffing patterns, ESI level distribution, ED billing visit level distribution, disposition breakdown, and length of stay. The consultants conducted interviews with administrators, departmental leaders, and staff, and spent considerable time observing ED patient flow, staff workflow, departmental processes, and communication.

Several areas were identified as needing improvement, including actions to:

  • Revise front-end processes to include the intake and triage processes
  • Re-educate staff on the ESI 5-level triage system
  • Examine utilization of existing space to optimize workflow
  • Implement standard work processes to addresses the frequent capacity issues in the ED

A PI work team was organized, led by Philips consultants and included SMMC physicians, administrative leaders, ED staff, and ancillary staff. The task was to collaboratively agree to an action plan to improve the ED walkout and length of stay rates.

The work team completed a deep dive review into each area identified in the assessment and leveraged the data analysis and stakeholder input gathered earlier. They developed recommendations for process change, prioritizing change initiatives which could make the greatest impact.

Middle-Trac patient flow process 

Key to supporting the PI recommendations was development of a new process solution termed ‘Middle-Trac’. Derivative of a split-flow process where patients are triaged quickly into parallel care streams, Middle-Trac focuses on patients in the middle (ESI level 3) who do not require immediate treatment. It keeps these patients vertical and moving through the department, not occupying valuable treatment spaces until a disposition decision is made.

Similar to an assembly-line, elements of the Middle-Trac process work cohesively. A triage nurse classifies arriving patients into one of three categories: immediate bed needed, fast track appropriate, and remaining Middle-Trac patient population. A detailed process flow maximizes continuity of care, manages essential resources, and minimizes provider hand-offs.

SMMC Middle-Trac process flow

"The Philips consultants provided exceptional leadership and became part of our team. They helped identify, develop, and implement process change which has had a significant impact on our patient throughput as well as patient and staff satisfaction."

Marilyn Drone, MSN, RN

Executive Vice President, Chief Operating Officer, and Chief Nursing Officer, St. Mary Medical Center


The Philips-SMMC team was successful in implementing process changes that significantly improved door-to-provider times, ED length of stay, and the left without being seen rate for Middle-Trac patients. Two Philips consultants were asked to remain in the interim leadership roles long-term.

As a result of the engagement, SMMC was able to achieve the below results*:


  • 34.3% reduction in ED discharge patient length of stay, 361 to 237 minutes
  • 66.2% reduction in arrival-to-provider, 74 to 25 minutes
  • 85.3% reduction in left without being seen (LWBS), 7.5% to 1.1%

smmc results
smmc results
smmc results

 * Results from case studies are not predictive of results in other cases. Results in other cases may vary.

St. Mary Medical Center (SMMC) logo

Meet our team

Nicholas Chmielewski

Dan Hannan, MBA, BSN, BS, RN 

Senior Consultant

Dan brings 30+ years of clinical care and leadership experience focused on ED and hospital-wide operations, informatics, throughput, and patient experience. He has helped providers reduce left without being seen, arrival-to-room, and ED length of stay.

You are about to visit a Philips global content page

JoAnn Lazarus

JoAnn Lazarus, MSN, RN, CEN, FAEN

Principal and Practice Operations Lead, Retired

JoAnn was a leader for the emergency services team, providing interim leadership and leading process improvement projects. Among her accomplishments include establishing a fast track, a middle track, implementing a SWAT team for the waiting room, and decreasing the walk out rate by 25% in a 100,000-visit level 1 academic trauma center.

You are about to visit a Philips global content page


Customer story

Related practice area

You are about to visit a Philips global content page


You are about to visit a Philips global content page


Our site can best be viewed with the latest version of Microsoft Edge, Google Chrome or Firefox.