1. One-on-one meetings with each physician
2. “At-the-elbow” coaching of all key roles in the new model
3. Shift huddles
4. Online training modules
5. In-service presentations
6. Information binders with one-page visual displays outlining the flow model, inclusion and exclusion criteria for each area, swim lane diagrams for the choreography of work in each area, high-flow processes (described below), and standard work for each role in each zone

The development of these one-page documents helped the team to formally standardize the work in the department for the first time in 10 years.

The Tennity ED implemented several other strategies:

• High-flow rescue: “High flow” refers to the surge state in the emergency department. The Tennity ED leaders and staff have hard-wired triggers for when a geographic area in the department is overwhelmed (particularly PIT and RTU, where patient turnover needs to be fast). In this model, the middle- and low-acuity patients are siphoned off to the RTU so the acuity and admission rate are higher in the acute care areas. They developed a system that brings another worker to an area experiencing high flow so it doesn’t get permanently overwhelmed and backlogged with patients. The front patient flow coordinators and back flow coordinator are trained to recognize and “turn on” the high-flow rescue. 
• PIT to NIT: For emergency departments practicing PIT models, there is often a falloff in efficiency at night when the model closes down. The night shift, with its pared-back staffing, is vulnerable to surges, and the intake of middle- and lower-acuity patients can suffer. The Tennity ED frontline staff liked the abbreviated intake process so much, they did not want to shut it down completely at night. Instead of reverting to the old traditional nurse triage model, they run a nurse in triage (NIT) model. The nurse does the abbreviated intake and uses an established chief complaint–driven order set to quickly send labs in the PIT area before rapidly sending patients to the appropriate zone. As a result, the night shift not only comes into to an empty waiting room, all patients have been seen, have had labs drawn, and usually are roomed quickly.
• Epic support for workflows: Essential to these strategies was working with the Epic technology team at Eisenhower Health—Johnna Young and Susan Breshears—to modify the tracking board and create a PIT narrator to streamline the process. In this way, the IT system supported the new patient flow and workflow.

The results of the new process are in Table 1.

Nothing tells the story of the fantastic change implemented by the Tennity ED better the picture of an empty waiting room.