How can hospitals increase efficiency by assuring greater throughput to avoid building more beds? And how can they do so while improving safety, quality, and patient and staff satisfaction and finances?
These were the questions at Yale-New Haven Hospital, where discharges were slowed by a backlog of patients resulting, in part, from physician recruitment and program development that had temporarily outpaced facilities development.
Because discharge is one of the hospital measures for its performance incentive program, common for all employees and managers and representing 80% of the annual performance bonus, YNHH was motivated to facilitate speedier discharges.
Framing the Process Properly
Richard D'Aquila, YNHH COO, actively led the new initiative. A multi-disciplinary steering committee was appointed as the ultimate decision-makers. Nursing leadership conducted weekly meetings prior to steering committee meetings. Safety was the first priority.
A second priority was "actively managing" organizational resources. Active management includes setting clear expectations, assigning work, and identifying variance and performance issues in real time. Frontline leaders and employees met daily to review schedules ("huddles") and daily operating reports. Accountability was data-driven relative to targets and time frames.
Pre-engagement, a consulting firm, Carpedia, carried out an "opportunity analysis" to identify areas of particular gain, in terms of quantifiable financial results. This took five consultants up to three weeks to complete. Outcomes were set for each functional and support area, for example: room turnover time (for Environmental Services) and turnover time (for Patient Transportation). The consultants identified the main database indicator as average length of stay (ALOS) reduction from 5.23 to 5.02 days—primarily for adult medical and surgical patients.
Nurse directors quantified reasons for variances. Unit huddles were conducted three times a day for 10 minutes to review which patients were going home and which could go home if barriers were overcome, such as nursing home transfer or organizing rides home.
Here are the results achieved during a two-year period starting in July 2008:
- ALOS decreased from an average 5.23 to 5.02 days YTD through June 2009.
- LOS in ED for patients being admitted was decreased by 25 minutes, despite significant increases in ED volume
- Percentage of discharges by 11:00 AM were increased 50% from 12% to 18% on average
- Median time of discharge was decreased by 45 minutes
- Post-Anesthesia Care Unit length of stay decreased by approximately 25 minutes and showed further improvement in the last nine months
- Bed turnaround time was decreased by 35 minutes on average for priority 1 bed assignments
- Patient transport time remained within 30 minutes despite the addition of a new Cancer Hospital Pavilion
Proper Staff Support and System
The opportunity analysis set up targets and time frames relating to performance gaps in current processes. The seven-person Operations Support (OS) Department provided consulting, behavior audit, support, and coaching. Execution controls were established to allow managers to monitor and prioritize assignments for both clinical and non-clinical managers. Daily operational supports gave a balanced set of key performance indicators, comparing actual to planned performance.
YNHH augmented the consultant team (which lacked physicians and nurses) with a team of two physicians, one nurse, one pharmacist, and one financial analyst). Different service lines wanted to "own" their own beds. Centralized bed placement was more effective in reducing wait for the Post-Anesthesia Care Unit (PACU) and for the ED.
For the first year, the Associate Chief of Staff was Chair of the Steering Committee. He explained to physicians the basic premise to reduce crowding of the PACU and the ED by discharging patients earlier in the day. When patients were admitted later in the day house staff could not treat these patients promptly. There was a poor match of resources, as house staff was needed for discharge summaries, prescription orders and counsel on post discharge care. The early discharge initiative conflicted with the scheduled teaching program.
Under the SPF initiative, the discharge process now begins the evening before the scheduled discharge. Residents huddle together and identify patients likely to leave and put together elements to facilitate earlier discharge, such as notifying the family.
Green, yellow, and red indicators are used the day before discharge to predict likely readiness for discharge the next day.
- Green indicates very likely to be discharged the next day
- Yellow indicates clinically ready the next day but this readiness will be contingent upon, for example, the ability to tolerate a diet or pending laboratory results.
- Red indicates not likely to be clinically ready for discharge the next day and/or an appropriate disposition is not available
The disposition requires that the interdisciplinary team be in close communication regarding both clinical status and appropriate disposition resources. Success in reducing waiting times generated cascading support for the SPF initiative.
Accountability and Transparency
The consultants met with YNHH leadership team on a weekly basis. The Steering Committee navigated much of the work. The consultants presented what had been done last week and what was going to be done in the next two weeks. Teams used dashboards, targets, and reviewed variances for identified performance measures. (See Exhibit 1 for excerpts from the YNHH Executive Throughput Scorecard. This scorecard tracks throughput for the week ending 11/06/2010).
Units and departments reported to the Steering Committee followed templates, and set desired outcomes. For example, 11:00 AM was set as the target hour because this was a time when the OR, the PACU, and the ED got congested with patients were waiting for treatment on the floors. The goal was to increase the percentage of patients being discharged earlier rather than to change the hour of discharge for all patients.
The median patient discharge time was moved from 3:00 PM to 1:30 PM.
YNHH has achieved significant results in increasing throughput without adding staff positions. Patients benefit by being in the right bed at the right time.
The Steering Committee was chaired by a respected physician and half of the members were physicians, ensuring buy-in. Data shows that patients were waiting less for needed treatment on the floors as a result of new schedules and targeting. And success in reducing wait times built support for changes in physician schedules. Transparency and accountability was accomplished largely through the formation of a strong Steering Committee with ultimate decision-making authority for the initiative.
Extra resources, both externally from the consultants and internally key staff temporarily reassigned were essential in implementing new methods which spanned many departments and involved major changes in schedules and work flow. Sustainability was assured and implemented before the external and internal consulting services were withdrawn (although they are still available as needed).
To ensure continuity of the SPF initiative, senior leadership has instituted regular meetings with accountability for results going forward as YNHH tackles new areas for improvement. One such area is a transforming patient care initiative. YNHH nurses familiar now with the safe patient flow methodology, trust that the new initiative will not primarily focus on cost cutting.
Richard D'Aquila is Chief Operating Officer, Yale-New Haven Hospital; Peter Follows is President, and Michael Zaccagnino is Managing Director, Carpedia Healthcare; Anthony R. Kovner, Ph.D. is Professor, NYU Wagner. The authors would like to acknowledge the contribution of Sandra Bacon, Director Operations Support, Yale-New Haven Hospital, for her contributions to the authors regarding the content.