Scholarship Recipient: Strategies to Enhance Patient Flow
Polina Gorodinsky, University of Michigan
Strategies to Enhance Patient Flow
Polina Gorodinsky, Healthcare Innovators Scholarship Recipient
I recently sat down with the Process Excellence team at a nearby hospital to discuss their patient flow challenges in the Emergency Department (ED). Two classmates and I stared bewilderingly at a complex value stream map sprawled on a conference room white board as we discussed how to decipher multiple excel files of patient data from the past year. Needless to say, we felt woefully underprepared for our assignment: to analyze the flow of patients from the ED to an inpatient room and identify bottlenecks in the process. Still, I began to appreciate the importance of patient flow. Bottlenecks, sometimes lasting several hours, mean that patients and families spend unnecessary time waiting, while that space in the ED is unavailable to other patients. Improving patient flow not only reduces delays and wait times, an efficient flow of patients through the care process ensures that patients receive safe and timely care while preserving the effective use of staff time and hospital resources. Ultimately, this translates to better care, better business, and better patient satisfaction.
Successful hospitals have recognized that patient flow is a system-wide priority, as all flows in the hospital are interconnected. Executive leadership support is essential to successful improvement initiatives and a patient flow champion can advocate adoption of improvement strategies and garner support from early adopters. Multi-disciplinary, hospital-wide teams are necessary to oversee and implement patient flow changes. This requires comprehensive coordination and communication between teams and across departments.
Lean Six Sigma methodologies have been utilized to redesign patient flow processes. The lean process involves first mapping the current patient flow process and distinguishing value-added steps from non value-added steps, so every step adds value to the process.2 Cycle times are measured, including times within each activity and waiting times, to analyze bottlenecks in the process. Following a root cause analysis, changes to the process can be tested, with the goal of developing a standardized, value-driven process.
Rapid Cycle Changes, specifically the Plan-Do-Study-Act (PDSA) cycle, have been an effective tool for patient flow improvement.3 PDSA cycles involve small tests of change, analysis of results, adjustments, and spread of success. Improving patient flow is a large, complex project, so it is helpful to break it up into smaller, manageable components and measure frequent, small tests of change.4 Learning from experience allows teams to build quickly on successful results, and these changes can then be evaluated and modified as needed for dissemination to the larger organization.5
A central component of process improvement is performance measurement; without meaningful measures, it is impossible to assess the impact of new strategies. A core group of hospitals have, for example, identified a standardized set of performance measures for the ED, and collect and report these measures on a consistent basis.3 This allows hospitals to create dashboards and evaluate performance against both internal and external benchmarks. Sharing outcomes widely throughout the organization can build ownership and accountability for change.
Transfer and Admit
The first component of patient flow, admitting and transferring patients, is one area hospitals target for improvements. Transfer centers, for example, are a new function and appear to be growing.6 Transfer centers are nurse-staffed call centers that serve as a single point of reference for incoming referrals, admission decisions, routing, bed placement and OR requests.6 Innovative facilities are transitioning the transfer center model into a patient flow center model by integrating transport, bed management, case management, and discharge.7 For example, the patient flow center can act as a communication hub between referring and receiving physicians, ensuring seamless patient transfer.7
The ED plays an important role in patient admittance at hospitals as roughly half of all patients who are admitted go through the ED.6 Hospitals have pursued multiple strategies to improve ED processes, such as a “fast track” (accelerated triage and registration for low acuity patients), combined triage and registration, bedside triage, and clinical decision units.8 Some hospitals have designated a patient flow manager, responsible for the timely transfer of patients.8 Communication between the ED and the rest of the hospital is critical. In fact, some hospitals have replaced the traditional “push system” with a “pull system” in which the inpatient floors play an active role in pulling ED patients into available beds.8
Bed and capacity management, the second component of patient flow improvement, hinges on matching demand and capacity. Unit level bed huddles are one such strategy, in which teams discuss patients recently admitted, patients to be discharged that day, and patients to be discharged the following day.9 Then, hospital-wide multidisciplinary bed meetings can address that day’s capacity and demand issues.9 Forecasting demand involves measuring flow variation and using data to predict patterns. Hospitals have then scheduled staff to meet demand, and used other strategies such as staggering shift schedules, lunches, and breaks, especially for transport staff.10 Matching demand to capacity on a real-time, continuous basis can be accomplished through bed and capacity management systems. Real time demand capacity management systems can predict demand and capacity, document a specific plan if demand exceeds capacity, and evaluate the plan.9
Tracking systems have also been implemented to improve patient flow, as well as to improve efficiency and patient safety.6 Tracking systems use a tag on patients that is picked up by sensors and shown on an “electronic whiteboard” for a snapshot view of all admissions, transports, and discharges.6 Such systems allow for detailed reporting on time spent moving through the system, and can provide notifications if patients have been waiting too long, based on a set standard.6 One hospital used patient tracking systems to alert other departments when a unit is near capacity and needs to borrow staff from other units.10 Tracking systems can also communicate with other systems, such as capacity management, discharge planning, and potentially EHR systems.6
The OR is not typically the first place hospitals look for improving patient flow, yet, peaks and valleys in the elective OR schedule have downstream effects on inpatient units and the ED.9 IHI has compiled multiple successful strategies, including designating separate ORs for scheduled and unscheduled surgeries, smoothing the flow of elective admissions based on utilization and post-op destination, and assuring optimal surgical start times, turnover times, case durations, and procedure scheduling.1
The final step of patient flow, discharge, can have a significant impact on overall flow, as newly admitted patients cannot move into a bed until one is available. IHI recommends that hospitals begin discharge planning at the time of admission, as this allows for early initiation of discharge processes.4 Additionally, hospitals have scheduled the date and time patients will be discharged at least one day in advance, and have distributed discharges in a planned manner throughout the day, putting greater emphasis on discharging patients earlier in the day.6 To address the gap between discharge and transportation, some hospitals have created a “discharge lounge”.3 Hospitals can also synchronize other movements to the discharge schedule, such as through integration with capacity management and tracking systems.6 Finally, coordinating care transitions with outside physicians and long term care facilities can extend the chain of flow improvements.2
Integrated Patient Flow
A complicated system such as hospital-wide patient flow requires information integration. Multiple components of patient flow—transfer, transport, bed management, tracking, discharge planning—can be combined into one patient flow communication center. Such systems provide real-time visual indicators of patient flow status, and importantly, capture all data in one central location.12 Data obtained from these systems can be used to target improvements in problem areas. Thus, integrated patient flow technology, coupled with formal process improvement methods, shows the most promise for improving patient flow.
Many strategies have been proposed and have resulted in measurable improvements in patient flow, but hospitals have been most successful by engaging key stakeholders in the change process and focusing on comprehensive strategies that best address their unique challenges. To achieve lasting changes, hospitals should prioritize patient flow system-wide by emphasizing the care, safety, and experience of the patient.
1. Institute for Healthcare Improvement. Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series. 2003. Available at: www.IHI.org
2. Institute for Healthcare Improvement. Going Lean in Health Care. IHI Innovation Series. 2005. Available at: www.IHI.org
3. Wilson MJ, Nguyen K. Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments. Urgent Matters ⁄ George Washington University Medical Center. Available at https://urgentmatters.org/media/file/reports_UM_WhitePaper_BurstingAtTheSeams.pdf.
4. Johnson M, Capasso V. Improving Patient Flow Through a Better Discharge Process. Journal of Healthcare Management. 2012;57(2):89-93.
5. McClelland MS et al. The Past, Present, and Future of Urgent Matters: Lessons Learned from a Decade of Emergency Department Flow Improvement. Academic Emergency Medicine. 2011; 18:1392-1399.
6. California Healthcare Foundation. Using Tracking Tools to Improve Patient Flow in Hospitals. 2011; April.
7. Dempsey C. Optimizing Patient Flow and Satisfaction: It’s Time to Look at OR Scheduling. The Patient Flow Journal. 2012. Available at: https://www.centrallogic.com/resources/patient-flow-journal/optimizing-patient-flow-and-satisfaction-its-time-to-look-at-or-scheduling?page=1
8. Urgent Matters Toolkit. Available at: https://urgentmatters.org/toolkit
9. Kaczynski D. Perfecting Patient Flow Through Real-Time Demand Capacity Management. The Patient Flow Journal. 2013. Available at: https://www.centrallogic.com/resources/patient-flow-journal/perfecting-patient-flow-through-real-time-demand-capacity-management
10. Edwards JN, Silow-Carroll S, Lashbrook A. Achieving Efficiency: Lessons from Four Top-Performing Hospitals. The Commonwealth Fund. 2011; July(15).
11. Kurtz T. Integrating Patient Transport and Transfer Center Services. The Patient Flow Journal. 2012. Available at: https://www.centrallogic.com/resources/patient-flow-journal/integrating-patient-transport-and-transfer-center-servicesDownload File