The Key to Improving Patient Throughput

Healthcare needs a transformation--hospitals can no longer afford to take a business-as-usual approach. Substantial dollars are at stake, whether it's absorbing the cost of poor efficiency or foregoing revenue opportunities because of poor capacity management. Consider the movement and experience of a typical patient in today's hospital. The average patient will be in the hospital for about five and a half days. During that stay, he/she will encounter a multitude of providers, staff and departments. How this hospital stay is managed and how the patient is moved between hospital areas dictates the "experience," and has a significant impact on the hospital's performance. While the clinical outcome of the patient stay is the most critical component of a patent's experience, the other is the process by which the patient moves through the hospital. Regardless of how capable the clinician or advanced the medical technology, patients will perceive their care to be substandard when delays and awkward interdepartmental handoffs occur. For a patient and their family, inefficient handoffs are sometimes the most visible aspect of a patient's hospital stay. Patient care is the business of the hospital, and when care processes are inefficient, the business is inefficient. In short, a hospital's ability to optimize capacity and maximize profitability is largely determined by how efficiently their processes, and ultimately their operations, are managed. In order to address these challenges, the following five approaches are required:

1. System-wide process improvement and integration of the separate departments--not isolated silos.


2. Process visibility and accountability through metrics.


3. Communication with all the stakeholders; the patient, their family, the physician(s) and hospital employees.


4. Identification of key patient indicators to assist patient throughput and enhance communication to deliver accurate, real-time information to all in the patient care process.


5. Application of a technology solution used for bed tracking and real-time patient flow logistics for workflow intelligence, and capacity management for sustainable improvement.

Hospitals have certainly attempted to improve patient flow. For the most part, however, these solutions have fallen short because they a) address only part of the problem or address it as a departmental issue; b) lack any reliable mechanism for measuring or sustaining performance improvements, and c) lack any IT tools to support the process. And of course, let's not forget lack of communication. Consider some of the key performance symptoms and their impact:

• Patient admission-- delays in getting patients into critical care beds, delayed access to step-down or medical/surgical beds, extensive wait times for patients, extensive bed turnovers, unacceptable number of critical care denials and unpaid days.


• Compromised Emergency Department (ED) Throughput-- diversions, waiting for an impatient bed, increased ED length of stay due to lack of inpatient beds, declining patient satisfaction.


• OR bottlenecks--problematic throughout due to delayed or cancelled surgeries.


• Delayed discharges--unnecessary delays, incomplete patient education and higher than expected readmission rates.


• Intra-stay challenges--lack of care coordination and communication among the various departments and providers.


• Patient dissatisfaction --poor survey scores surrounding delays and lack of communication between providers, caregivers and family members.


• Staff dissatisfaction--inefficiencies, waits, delays, excessive phone calls and manual processes.


• Physician dissatisfaction--complaints about turnaround times, efficiency issues, communication disconnect and poor performance perceptions.


• Measurement/metrics--lack of transparency, clear responsibilities and defined metrics.

There are solutions that can help organizations maximize performance, as well as patient satisfaction. Consider a dashboard to provide real-time summary of bed and patient status indicators such as:

• LOS by unit


• Accuracy of discharge predictions (percent of time that actual discharge times meet expected.)


• Projected occupancy by unit in the short term (next three hours)


• Bed placement time from the ED disposition to arrival on the unit


• Number of hours that the ED is on diversion and ED boarders


• Average dead bed time--the time gap between one patient being discharged and another occupying the bed


• Test results required for a patient to progress through their hospital stay


• Patient safety issues (i.e.. fall risk, oxygen status)


• Expected discharge time

Benefits of utilizing IT across the Continuum of Care Capacity Management. Although often tied to the need to turn around patients, patient throughput does not exist in a vacuum. Only through a holistic approach can desired outcomes be achieved. In 2006, an American Hospital Association survey showed 62 percent of hospitals operating either at or above the capacity of their ED. As a result, one-third of hospitals experienced ED diversion, with more than half of the urban hospitals reporting some diversion. Diversion problems are not caused by capacity challenges across the organization that trickle down and clog the ED--a phenomenon common in many hospitals, according to the U.S. General Accounting Office (GAO). According to a recent GAO report, the factor most commonly associated with overcrowding was the inability to transfer existing ED patients to hospital inpatient beds. Ninety percent of the hospitals surveyed reported such "boarding" of admitted patients in their ED, with nearly 50 percent indicating an average waiting time of 2 hours or longer. Through real-time communication and workflow tools, desired outcomes can be achieved. Patient Hand-offs. Whether due to a shift change, patient transfer, patient discharge or another reason, a hand-off requires the "coordination of a race car pit crew." The "pit crew" has great clarity about the role of each person. There is a refueling team, the tire team, a cleaning crew, and one senior mechanic assigned to signal the driver all under the control of the pit "boss." The team is broken down even further: there is a jack man, a tire man, the guy with the air hose (to tighten and loose the tire bolts) for each tire. The refueling team has at least two people one to support the hose, one to ensure the tight connection so there is no spill and generally a back-up crew in case there is a problem. This approach has been used successfully by a surgery team in the UK to reduce errors from the OR to the ICU. Some handoffs are more complicated, but the principles are the same; there is a need for facility to have protocols around medication orders, general orders, responsibilities, communication, patient safety and comfort. Smooth handoffs also result in less frustration, improved quality, and greater staff satisfaction among patients and staff. It will also reduce errors, decrease costs and increase throughput. Consolidation of information. It is rare that a patient is not progressing due to just one missing test result or one outstanding data point. Lack of results, whether in laboratory, radiology or other tests, all add to the need for patient-specific information, including around-the-clock, real time information about patient location, test results, patient safety issues (i.e. fall risk, oxygen status) and expected discharge time. This also allows clinicians and support staff to see patients in the pipeline and anticipate service needs. Simultaneous visibility of patient throughput status and location available to all stakeholders in real time is essential. Operational Efficiency. It is important to utilize the most efficient workflows, enhanced communication, IT support and transparency. The benefits of this integration continue as both patients' and providers alike utilize real-time data and systems that are transferable across the entire patient care process.