An interdisciplinary team of front-line physicians, nurses, medical assistants, and executives assembled and used value stream mapping to assess the entire ED care process, from patient arrival to admission or discharge. Value stream mapping uses visual documentation to analyze all repeatable steps in a care delivery process.5 The team closely observed each step of care (eg, registration through discharge) from the patient perspective and built a schematic representation of each step, including any waits or delays. Variability in the evaluation and treatment processes for patients was identified as a root cause of delays in care. For patients with low-acuity suspected simple fractures, there was no standard process to determine if x-ray imaging would be ordered in triage or only after clinician assessment; what type of clinician (nurse practitioner, trainee, or physician) would initiate care; or if the patient should follow up in an outpatient orthopedics clinic or receive definitive care with an in-person consultation in the ED.

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