Scholarship Winner: Optimize Patient Flow to Use Scarce Resources Efficiently

Sean Reiter, University of Colorado Denver


Sean Reiter Patient Flow Essay PhotoSean Reiter (University of Colorado Denver, Healthcare Administration, MBA) is the winner of the “Healthcare Innovators” Patient Flow Scholarship. Reiter was selected based on academic excellence and innovative perspectives. 

“The days of solving patient flow issues by simply adding bed capacity are history,” said Reiter. “If lasting improvements in patient throughput are to be achieved, improving communication across interdisciplinary care teams is paramount.”

The following is a copy of the patient flow research submitted as part of Reiter’s application.

Optimizing Patient Flow to Use Scarce Healthcare Resources Efficiently

Sean Reiter, Healthcare Innovators Scholarship Winner

The idea of meeting the increasingly complex needs of a growing patient population while improving financial and patient health outcomes is not a new concept.  For years, healthcare organizations (HCOs) have responded to increased demand for medical services by adding capacity in both space and staff.  However, in today’s ultra-competitive, complex environment, the need for effective patient flow management has never been greater.

Following an overview of the basics of patient flow management, the goal of this paper is to discuss some of the most effective strategies to date that have been implemented by HCOs.  Finally, additional thoughts on how the patient flow process can be further improved will be discussed.

Patient Flow Management 101

Healthcare costs continue to increase dramatically.  The combination of fiscal, demographic, and social characteristics are forcing HCOs across the nation to address the critical and immediate challenge of meeting patient needs through methods previously thought unnecessary.   HCOs can’t afford to simply continue to add space and staff to alleviate patient flow issues resulting from increased patient volume.  To truly alleviate bottlenecks, HCOs need to increase patient throughput, which is primarily done by increasing bed turns and minimizing care delays (Haraden, 2007).

In order for HCOs to increase patient throughput, it is vital for these organizations to first realize that no individual hospital department works in isolation or is designed for maximum patient flow (Haraden & Resar, 2004).  Rather, each department is part of a tightly knit system that patients progress through.

Another critical concept for HCOs to be cognizant of is the different types of variation that exist within the patient throughput management process.   Variation is inherent in all processes; variation in patient throughput management processes exists in the form of clinical, flow, and professional variability.  For these types, it is critical for HCOs to manage random variation and eliminate nonrandom variation (Dempsey, 2009).

With the basics of patient flow in mind, several solutions to help solve the patient throughput problem have been developed.  Successful solutions have focused on areas such as care team member composition, hospital department design, and patient care process models.  Discussed below are some of the most successful patient throughput process design strategies.

Patient Care Process Redesigned and Operationalized

Surgery Scheduling

One strategy to improve the efficiency of patient throughput is to adjust the surgery schedule for elective procedures.  Patients generally access the hospital via two primary routes:  through planned elective procedures and unplanned admission through the ED (see Figure 1).  Pines, Mutter, and Zocchi (2012) have shown that ED admission rates have remained relatively stable over the past 20 years.  Conversely, and somewhat counter intuitively, planned surgery schedules include significantly more variability.

Figure1-Patient Flow Paths in Hospital

figure1reiter

Surgery schedules are often created to meet individual provider preferences such as day of week or time of day.  However, these preferences can lead to an artificially high number of surgical cases on one day, which can increase the stress placed on limited health resources (Litvak, 2005).  The end result is that on days with overuse of elective surgery, fewer resources are available for fairly predictable ED admissions, leading to delays in care and decreased care outcomes.

Changes in surgical scheduling methods have been shown to produce significant improvement when used in conjunction with supporting strategies such as designating separate operating rooms (ORs) for elective and emergent surgeries.  For example, Boston Medical Center reduced step-down unit variability by 55% and cut the number of delayed or cancelled surgeries from 334 to 3 over an 18 month period (Litvak, 2005).

Electronic Inpatient Whiteboard

The electronic inpatient whiteboard is a method of tracking and communicating key patient information to all care staff within a care department such as the ED.  The goal of the whiteboard is to improve communication among multi-disciplinary care teams and improve care coordination; these goals are accomplished by providing a single, highly visible location that displays time-stamped relevant patient status information (Wong, Caesar, Bundali, Agnew & Abrams, 2009).

Toronto General Hospital (TGH) has used the whiteboard with positive results.  After implementing the whiteboard, TGH administered an open-ended questionnaire to employees to rate their performance of the board.  71% of respondents believed that the whiteboard improved and standardized the care communication process (Wong et al., 2009).

Electronic Bed Management Systems

One of the most successful strategies has been to implement the use of an electronic bed management system (EBMS).  An EBMS expands upon the electronic whiteboard idea by creating a comprehensive system that notifies pertinent care members in all departments of patient discharge status.  The approach used at the University of Texas MD Anderson Cancer Center exemplifies this strategy.

Similar to many other HCOs, the crucial initial step towards improving patient throughput at MD Anderson was timely and accurate patient discharge information shared with all relevant care team members (Tortorella, Ukanowicz, Douglas-Ntagha, Ray & Triller, 2013).  In the case of patient discharges, nursing, patient transport, housekeeping, and admission staffs all need to be aware of patient discharge status (See Figure 2).  Without one system that allowed all involved care staff to be aware of patient discharge status, delays inevitably occurred.

Figure 2 – Patient Throughput Process

figure2reiter

To alleviate this problem, MD Anderson implemented an EBMS that provided real-time patient discharge status information to all parties involved in the discharge process.  Key attributes of the EBMS included ease of use by all care team personnel, accessibility from several electronic devices such as smartphones and mobile devices, and the ability to timestamp each step in the bed turnover process (Tortorella et al., 2013).

Addressing these attributes successfully not only allowed comprehensive use of the system by all clinicians regardless of position from anywhere in the hospital, but also provided the capability to pinpoint trouble spots in the process for further improvement.  The results that MD Anderson experienced were significant.  Over a three year time period, MD Anderson was able to lower average overall bed turnover time from 111 minutes to 49 minutes (Tortorella et al., 2013).

When designed and implemented properly, an EBMS can offer additional patient throughput improvements capabilities as well.  For instance, a comprehensive EBMS has the capability to monitor patient throughput performance at both the departmental and organizational levels.  At the departmental level, an EBMS could be used to monitor patient discharge levels by each nursing unit (Medical/Surgical, ICU, Oncology, etc.).  Likewise, at the organizational level, an EBMS could be utilized to analyze the patient throughput process as a whole (Tortorella et al., 2013).

In addition, a properly designed EBMS has the ability to improve the tracking of pending discharges.  Improved management of pending discharges can be helpful for all care staff personnel involved in the patient throughput process (Tortorella et al., 2013).  For instance, advanced notification of pending discharges can be useful during periods when the number of patients attempting to enter the HCO is greater than the amount of resources available.

Additional Thoughts

The strategies discussed here have been shown to improve patient throughput in several HCOs and should be strongly considered for adoption by others.  However, for continued improvement moving forward, additional changes to how care is coordinated within the community need to be made.

Partner With Community Organizations

Currently, HCOs have responsibility over managing patient flow internally, but have no control over outside forces.  A patient who requires additional care outside of the HCO might be ready to be discharged, but the receiving HCO might not be ready for that patient; this lack of coordination results in a delay and prevents the primary HCO from turning over that bed to begin a new admission.  Haraden and Resar (2004) suggest creating mutually beneficial partnership with appropriate community organizations to extend the chain of care.  Examples of community HCOs to partner with could include nursing homes, hospice centers, home health agencies, and rehabilitation facilities.

Improve Access to Care

Augmented access to primary care could also help improve patient throughput.  Presently, many individuals do not have basic health insurance and use the ED for primary health consultation.  If additional individuals were insured and the elective surgery schedule were better coordinated among inpatient departments and linked to planned discharges, HCOs could stand to improve patient throughput.

Conclusion

It’s clear that patient flow management is critical for HCOs to succeed in meeting the fiscal, demographic, and social needs of the modern healthcare environment.  In particular, the importance of improving total patient throughput with the use of a comprehensive communication system can’t be understated.  It is to the benefit of HCOs to implement these proven strategies in conjunction with a plan to meet the patient flow challenges of the future.

REFERENCES:

Dempsey, C.J.  (2009).  Managing Variability in Perioperative Services.  Association of Perioperative Registered Nurses Journal.  Vol. 90, No. 5, 677-682.  DOI: 10.1016/j.aorn.2009.05.023

Haraden, C.  (2007).  Getting Started on Flow:  Work of the IHI Innovation Community.  [PowerPoint slides].  Retrieved from IHI website.

Litvak, E.  (2005).  Optimizing Patient Flow by Managing Its Variability.  In From Front Office to Front Line:  Essential Issues for Health Care Leaders. 92-111.  Oakbrook Terrace, IL:  Joint Commission Resources.

Pines, J.M., Mutter, R.L., & Zocchi, M.S.  (2012).  Variation in Emergency Department Admission Rates Across the United States.  Medical Care Research and Review, Vol. 70, No. 2, 218-231.  DOI: 10.1177/1077558712470565

Tortorella, F., Ukanowicz, D., Douglas-Ntagha, P., Ray, R., & Triller, M.  (2013).  Improving Bed Turnover Time with a Bed Management System.  Journal of Nursing Administration.  Vol. 43, No. 1, 37-43.  DOI:  10.1097/NNA.0b013e3182785fe7

Wong, H.J., Caesar, M., Bundali, S., Agnew, J., & Abrams, H.  (2009).  Electronic Inpatient Whiteboards:  Improving Multi-Disciplinary Communication and Coordination of Care.  International Journal of Medical Informatics.  Vol. 78, No. 4, 239-247.  DOI:  10.1016/j.ijmedinf.2008.07.012

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