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Reducing the Patient Flow Bottleneck
Nearly all hospitals struggle with patient flow challenges. Whether you are constantly on diversion or there just never seem to be enough available beds to ccommodate new patients, there are some very basic steps that must be taken before progress can be made.
Sizing Up the Problem
A 2003 whitepaper by the Institute for Healthcare Improvement entitled "Optimizing Patient Flow" outlines a quick test:
- Do you "park" more than 2 percent of your admitted patients at some time during the day at least 50 percent of the time?
- Does your hospital have a midnight census of 90 percent or more of your bed capacity more than 50 percent of the time?
The answers to these simple questions indicate whether patients are efficiently moving through the hospital to get timely care and whether a hospital is so crowded at the beginning of the day that handling an influx of new patients is hopeless.
Must Haves
Many hospitals have already come to the realization that they have a serious patient flow problem. Initial attempts to address bottlenecks have failed. A common result is an expanded Emergency Department with the capacity to hold a much larger number of patients (who still have to wait, albeit in a more attractive waiting room). Since the systemic problems causing the bottleneck have not been addressed, a new strategy must be developed. Convinced that they need help to address the problem, hospitals have reached out to consultants to evaluate their systems. This approach can be very effective, but may cost millions of dollars. And while consultants can make recommendations, they cannot actually implement the proposed solutions. There are a few pieces that must be in place for any patient flow initiative to be successful. Without these "must haves," patient flow challenges will continue to be a major problem.
- Buy-in from administration: Starting with the CEO, hospital administrators must be committed to making necessary (sometimes unpopular) changes to solve patient flow challenges.
- Focus on system: Patient flow needs to be viewed as a single system with multiple processes that are interdependent. Traditionally, many separate departments operate independently, any one of which can cause a bottleneck and may get "blamed."
- Measurement: You can't improve what you don't measure. There must be a system to track performance metrics. These include ED wait times, length of stay, discharge clean response time, and turnaround for lab results, among many others.
- Anticipate discharges: There must be some means for knowing ahead of time when discharges will occur, so staff can plan accordingly, rather than reacting to urgent requests. This includes arranging for the patient's transportation home.
- Prioritize discharges: Lab results, prescription fills, blood work, etc. need to be prioritized and expedited for patients awaiting discharge.
- Nursing cooperation: A healthy relationship with Nursing is essential to make sure discharges are prioritized and expedited. They have to be reassured that improved patient flow leads to better patient care and fewer headaches.
- Coordination of support services: Communication between Environmental Services and Patient Transportation is essential, as these departments must handle key discharge tasks. Increased information leads to optimized staffing and processes.
Creative Solutions
Many of Crothall’s client hospitals have implemented their own solutions to enhance patient flow. Here is a sample of some creative approaches:
| Solutions | Outcomes |
| Patient Flow Coordinator (Virginia Mason Medical Center – Seattle, WA) A supervisor, focused on expediting discharges, walks the floors looking for empty beds or planned discharges. He is empowered to initiate discharge tasks instead of waiting for another department to make a request. |
Turnaround times are down from 55 to 41 minutes. Discharge volume has increased by an average of 10% during this time. |
| Flexible Staffing Model (The Children’s Hospital – Denver, CO) A tiered overflow staffing model was implemented to handle peaks in discharge demand in an organized way by planning how temp labor is utilized. Staggered discharge teams have shifts designed around discharge demand as opposed to traditional staffing models. Peaks in demand are anticipated via a morning report that lists all scheduled discharges for the day. |
Turnaround times are down from 62 to 44 minutes. Discharge volume has increase |
| Self-Dispatching (Allegheny General Hospital – Pittsburgh, PA) A hospital initiative called “Code Green” gives precedence to discharges. Nursing is cooperative and gives better notification. Housekeepers are empowered to “self-dispatch,” beginning discharge cleans before a request has even been entered into the bed tracking system. |
In only two months, discharge volume is up 5%, while turnaround times are down from 69 to 62 minutes. 73% of discharge cleans are now self-dispatched by housekeepers. Since the advent of “Code Green,” this Level I Trauma facility has never been on diversion. |
| Throughput Committee (Presbyterian Healthcare System – Charlotte, NC) Representatives from all departments impacting patient flow have regular meetings in which they list throughput challenges, which become projects that must be addressed. A scorecard containing vital patient flow and capacity metrics is constantly updated and departments are held accountable. |
Turnaround times are down from 83 to 61 minutes. Discharge volume has increased by an average of 55% during this time. |
Click here for more information on the successful Patient Flow initiatives at Presbyterian Health System.