Flow and wait times at the DMV vs. the ER appeared in Culture, Hospitals, Patient-Centered Care by Dr. Paul Rosen.  In the article, he compares the traffic flow of the DMV and how it has improved, to the ER waits which are still floundering.  Read on


A couple of weeks ago, I received the dreaded letter from the Department of Motor Vehicles. Visions of long lines, sitting on hard plastic chairs, and hours of wasted time went through my mind. It was a reminder to go to the DMV to renew my soon-to-expire Delaware driver license.

The bottom of the letter suggested I go to their website for more information. I assumed the website would offer nothing helpful. But I was wrong. On my iPhone, I could see there were currently 43 customers in the cue at the New Castle County DMV, and the wait time was 13 minutes.

Wow, perhaps the DMV had changed since my previous license renewal experiences. I brought my 13-year-old-son with me to check it out.

When we arrived, we approached the greeter’s desk and encountered a smiling lady who asked us three scripted questions. In a friendly tone she offered us the option of the standard process or the kiosk. The standard process appeared to be moving briskly, but since I had my tech-savvy son with me, I went for the kiosk.

After that, I was shocked to realize that I was walking out of the DMV with my newly printed license—just 8 minutes later. My son asked, “What was so bad about that?” Will he never experience the waiting lines and wasted time of the dreaded DMV?

Are those days gone forever?

In 2013, the hospital patient flow guru Eugene Litvak published Don’t get your operation on a Thursday in the Wall Street Journal. In it, he proposes how long lines in the ER can be fixed. The solution is the OR schedule.

There are two kinds of variability, he explains: natural variability and artificial variability. Natural variability is the volume of patients who arrive at the ER front door and get admitted; a flow that cannot be controlled.

Artificial variability is the patients admitted based on the surgery schedule. If the operations are booked heavily early in the week, and lightly later in the week, then the ER will be backed up early in the week due to fewer available beds. Beds are reserved to receive patients from the operating room.

Litvak argues that if the surgeries are evenly spaced throughout the week, patients will flow better through the ER, and the admission process will not be backed up. There is no need to build larger hospitals or hire more staff.

Another supporter of high volume flow and standardization of practice is Dr. Jody Crane who wrote the book: The Definitive Guide to Emergency Department Operational Improvement: Employing Lean Principles with Current ED Best Practices to Create the “No Wait” Department. He espouses using metrics, setting timed targets, and constant process improvement work to deliver a patient experience that is reliable and efficient.

Directors of Emergency Rooms are in a tenuous position, caught between inefficiencies in the hospital “upstairs spill-over” and “ER impact-flow” downstairs. ER directors are not only saving lives and providing high quality clinical care, but expectations have grown to the point where flow, wait times and speedy service are being demanded by patients and by hospital CEOs.

The ER is the front door to the hospital and the health system. Executives want to ensure that patients have a good first impression when they arrive to the ER. Long wait times hurt the overall patient experience, even when the medical care is excellent.

I don’t mean to be facetious when I compare the DMV experience to the ER experience. The point is, however, if the DMV can employ lean processes and high-touch customer service, then I think that those of us in healthcare can work to implement the recommendations of Litvak and Crane.

Maybe, one day, my 13-year-old will not be able to remember a time when a visit to the ER meant long waiting times.

Paul Rosen, MD

Response To Dr. Rosen:

An additional demand on ER time also stems from physicians themselves. Patients who could be treated in medical offices are being told to “go to the emergency room- the doctor cannot see you”. I have witnessed this many times, where patients need simple treatment and medication. They would be better served outside the emergency room but have been instructed by health professionals to seek care there (i.e. evenings and weekends)

Fortunately, many “mini clinics” have sprung up at neighborhood pharmacies to see these individuals.

It will not be a surprise when patients seek care there of their own volition instead of going to their physician. If you want to keep these patients as your own, it may be time to analyze your practice. That way, it will not be a shock if you start to see your patient load dwindle!

By the same token, if you are the doctor that is responsive to your patient needs, not only is it correct ethically, but a great medical marketing point.

Share your thoughts about it in the comment box below.  Let’s hear your opinions!