title: "Not so fast!" the complexity of attempting to decrease door-to-floor time for emergency department admissions.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  By conceptualizing the hospital as a complex adaptive system, multiple interrelated groups can be encouraged to work together and accomplish a common goal.
authors.forename: Gene R
authors.initials: GR
authors.lastname: Quinn
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Le
authors.forename: Krishan
authors.initials: K
authors.lastname: Soni
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Berger
authors.forename: Y Erica
authors.initials: YE
authors.lastname: Mak
authors.forename: Read
authors.initials: R
authors.lastname: Pierce
mesh_terms: D003142:Communication; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007400:Interprofessional Relations; D009042:Motivation; D015279:Organizational Culture; D010343:Patient Admission; D010348:Patient Care Team / Q000458:organization & administration; D058996:Quality Improvement / Q000458:organization & administration*; D013997:Time Factors; D035502:Trust; D057188:Workflow