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The chapters in this section deal with various aspects of throughput in a system, or “flow,” and this chapter presents an overview of flow in the emergency department. Flow is an important concept because it addresses making processes, people, and performance in the ED more efficient and effective, thus resulting in greater satisfaction for both patients and staff. The chapter briefly introduces the key concepts involved in flow, which other chapters will then examine in more detail. Most importantly, it presents a vocabulary or taxonomy of flow, which will be essential in understanding the more detailed concepts presented in other chapters.

What Is Flow?

The concept of flow can be found in a number of different industries and is particularly important in service operations such as restaurants and hotels. The concept of “flow” plays a critical role in the “Lean” approach to healthcare operations and services. Theories, methodology, and applications of flow have been refined increasingly over the years. Those theories have been adapted for use in medicine; specifically in emergency medicine. Flow is defined as the efficient movement of patients through the network of services that constitute emergency department operations (from arrival to evaluation, diagnosis, treatment, and discharge or admission to the hospital) while adding value and eliminating waste.1

The essence of flow as it pertains to healthcare service operations is that all of the steps in the process are highly coordinated and orchestrated in such a manner that patients consistently progress (flow) through the continuum of care. Like water flowing in a river, patients should continuously move through healthcare processes toward wellness. Delays caused by inefficient or uncoordinated processes impede flow or patient movement through the system similar to way rocks and other obstacles impede water flow in rivers.

Flow is easy to misunderstand. For instance, many ED managers map their processes and declare, “Here is our flow.” Having a process is not synonymous with having flow, and a great deal of work and effort must go into obtaining smooth flow. Because it concerns movement of patients and information through a system and flow initiatives emphasize efficiency, it is tempting to think flow simply means cutting time off all processes. Taking steps to improve flow often does involve making processes more efficient so that they take less time—but only if doing so results in increasing effectiveness of those processes and thus better care of patients. Simply stated, this adds value and decreases waste. For some conditions, improving flow means taking more time to diagnose and treat properly. Doing so results in more effective care and more efficient flow.

Another perspective, and an important one, is the psychological concept of flow, which can be found in studies originated by the psychologist Mihaly Csikszentmihalyi in the mid-1970s. Csikszentmihalyi described flow as being deeply and constructively engaged or immersed in a task or action, with a resultant sense of clarity, where ...

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