Award-Winning Triage Redesign Improves Emergency Care at Zuckerberg San Francisco General Hospital and Trauma Center

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In December 2025, the California Association of Public Hospitals and Health Systems and the California Health Care Safety Net Institute presented the 2025 Innovation Award to the San Francisco Health Network and the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) for their project, Sustaining Change at the Front Door: A Multidisciplinary Approach to Emergency Department Triage Design. 

The award recognizes an extraordinary three-year effort that has dramatically reduced the emergency department's (ED's) left without being seen (LWBS) rate – the percentage of patients who leave the ED before a doctor or advanced practice provider sees them – to levels below the national benchmark, reduced care disparities, and pioneered new ways to engage staff and patients in improving care.

ED triage, especially when boarding is high, is among the hardest places to work in a hospital, says Christopher Peabody, MD, MPH, ZSFG's associate chief medical officer for Performance Excellence, who led the effort (pictured, right).

'“It took – and continues to take – an enormous amount of persistence and dedication to make this effort a success, but we are very proud of what we’ve been able to accomplish.”

Pandemic Drives Up LWBS Rates

Three years earlier, as the country emerged from the COVID-19 pandemic, the LWBS rate at ZSFG's ED climbed to levels well above the national target of two percent. The Center for Medicare and Medicaid Services (CMS) uses LWBS rates to measure EDs' efficiency because when patients leave, often out of frustration with long wait times, it can put them at significant risk.

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"In the face of steadily increasing volumes, high left without being seen rates are especially concerning because, at times, those leaving are among our most vulnerable patients," says Christopher Colwell, MD, chief of Emergency Medicine at ZSFG (pictured, left).

"Those rates not only jeopardize patient safety but also the department's mission to provide health care and trauma services with compassion and respect," says Peabody.

In response, the department planned and launched a triage redesign initiative through its Kaizen Promotion Office (see the tile below), rooted in improvement science, psychological safety, and staff and patient engagement. The multidisciplinary Triage Improvement Task Force comprised nurses, physicians, advanced practice providers, quality improvement specialists, and executive sponsors, including the hospital's CEO, its chief nursing officer, and its chief of performance excellence. The team met weekly for more than a year.

During this time, the task force mapped the triage process, analyzed electronic health record throughput data, and reviewed more than 4,000 patient experience surveys.

"We then paired our data analysis with empathy-driven exercises, staff surveys across all shifts, and role simulations," says Peabody.

That effort led to several high-impact interventions. They created a nursing triage team lead role responsible for triage across the entire ED. A Patient Experience Specialist oversees ED visitor management. The task force also standardized triage functions, refined staffing models, and made capital improvements, including interpreter phones and phone chargers for patients.

Consistent, transparent communication centered on daily huddles that included patient input, as well as weekly updates. The team relied on iterative Plan-Do-Study-Act cycles to test and refine the various initiatives.

Measurable Improvements in Patient Care, Staff Morale

All that work over a three-year period led to significant successes:

• By 2025, the LWBS rate had dropped dramatically, including remaining under two percent for the final eight consecutive months of 2025, below the national benchmark for quality EDs and a number ZSFG had never achieved previously.
• The redesign also enabled the ZSFG ED to care for more than 550 additional patients per month — a 12 percent increase.
• There was a 63 percent reduction in LWBS rates for Black patients, significantly narrowing a persistent disparity.
• Patient experience scores improved by seven percent, as measured by the net promoter score (a widely used metric for patient satisfaction).
• Daily discharges from triage increased and, in November 2025, diversions dipped below 25 percent — one of the lowest rates ever for ZSFG, according to Colwell.
• Staff satisfaction rose. Frontline nurses reported that the nursing triage team lead dramatically improved coordination among nurses, nurse practitioners, physicians, and patient experience staff, making every shift feel safer and more coordinated.

Implications for Hospital-Wide Quality Improvement 

As important as those improvements are, it's equally meaningful that the initiative forged new relationships throughout the hospital and new models for sustainable quality improvements.

For one, says Peabody, "It deepened our department's relationships with urgent care, social medicine, addiction care teams, behavioral emergency response teams, psychiatric emergency services, and consulting services, which now partner with the triage team to improve flow and efficiency and enhance care coordination system wide."

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The team also developed a post-pandemic quality improvement blueprint that emphasizes psychological safety and staff voices to maximize engagement, build consensus, and integrate patient perspectives and data science into any new initiative. For example, they instituted several asynchronous methods for collecting and prioritizing ideas so every participant in the effort – including patients and frontline staff – has a genuine opportunity to have their voices heard.

"This project set a new standard for how to do improvement," says Hemal Kanzaria, MD, MSc, ZSFG chief of Performance Excellence and leader of the Kaizen Promotion Office (pictured, right). "We've always believed in patient and staff engagement, but this is an example of ushering that engagement to a new level."

"It's become the new model for improvement (Kaizen) events at ZSFG and is spreading to the inpatient and care coordination departments," says Peabody. "We believe this level of engagement is the key to sustaining improvements."