An often overlooked but crucial element to quality is patient flow: The more predictable it is, the better the staffing and the better the care.
|Christy Dempsey||Susan L. Madden|
Improving patient safety and quality of care are among the most important challenges facing hospital executives, not the least because of recent changes in hospital reimbursement. The usual tactic is to reduce medical errors and health care-associated infections, ensure proper drug dosage, and develop and enforce standards of care. While these efforts are important, we should also consider one of the less obvious but critical operational issues: variation in patient flow.
Variation in patient flow occurs throughout a hospital and contributes to such problems as diversions, extended waiting times, overcrowding and boarding in the emergency department (ED) and post-anesthesia care units (PACUs), bumped and late surgeries, lack of available routine and ICU beds, overburdened nurses, and exasperated physicians. Not only does this threaten patient safety and quality of care, but it also causes enormous stress in the institution, making it increasingly difficult for hospitals to recruit and retain physicians and nurses. These workforce shortages in turn threaten patient care and cause stress to the remaining staff. It’s a vicious cycle that must be addressed.
A hospital can reduce variation with an innovative, multiphase strategy that uses operations management science and rigorous data analysis, combined with collaboration among hospitals and their physician partners. This strategy includes eliminating artificial variability by pacing the elective surgeries and right-sizing nursing units.
The Problem with Variable Patient Flow
Peaks and valleys in inpatient census are a large source of stress, leading to problems with hospital capacity, nurse-to-patient ratios, inpatient bed availability and boarding times, and impacting the ability of the hospital to recruit and retain staff and maintain quality of care. In an article in the September/October 2005 issue of Nursing Economics, Dr. Peter Buerhaus and colleagues found that more than 75 percent of RNs believe the shortage of nurses presents a major problem for the quality of their work life, the quality of patient care, and the amount of time nurses can spend with patients (Nursing Economics 23: 214-221).
In addition, with our rapidly declining lengths of stay, beds often turn over more than once a day, meaning that nurses on an acute inpatient unit may take care of two or more patients in each bed every day. Thus, the nurse-to-patient ratio is actually much less than the nurse-to-bed ratio because the nurse is caring for more patients than there are beds on any given shift. According to a study published in the Journal of the American Medical Association (JAMA) in 2002, nurses who were responsible for more patients than they could safely care for reported greater job dissatisfaction and emotional exhaustion; the study concluded that “failure to retain nurses contributes to avoidable patient deaths” (JAMA 288: 1987-1993).
Quality-of-life issues are also of increasing concern to physicians. As Dr. Ken Larson, a trauma and general surgeon in Springfield, Mo., states, “No one wants to do it anymore. Doctors are on call all the time; the insurance companies dictate their practice. The money isn’t what it used to be and the medico-legal aspects further complicate the issues. It’s a lifestyle issue, and the returns just aren’t as good as they used to be.”
Surgeons must balance the clinic office, hospital rounds, surgery and any teaching or research activities every day. Variability in patient load adds to the stress physicians experience by contributing to late and overtime surgeries, rounding on patients throughout the hospital because of lack of beds on the appropriate unit, patient dissatisfaction with waiting times, and threats to the quality of patient care.
Two Types of Variability
The OR schedule in most hospitals is a mix of elective and nonelective cases. Separating the two types of cases improves the flows of each because there is no longer competition for the same resources.
The variability from unscheduled surgeries is a natural variability, meaning that patients arrive randomly as illness or injury occurs. The way to manage this random demand is to use tools developed in industry such as queuing theory, along with good data on emergent/urgent case volume and arrival rates.
The variability we encounter in the OR for elective surgeries is artificial. Patients do not arrive randomly, but are scheduled according to a block schedule or the physician’s preference. This type of variability should be eliminated because it is the primary source of the peaks and valleys in demand. Elective surgical admissions, contrary to popular belief, are more variable in most hospitals than admissions through the ED.
When peaks occur in the elective surgical schedule, there is increased demand for staff, equipment and space throughout the organization—expensive resources that then sit idle during the valleys. Patients are often held in the PACU or worse, in the OR and ED, awaiting beds. The surgeon must decide if she should send the patient to the most appropriate unit where the nurses are trained and skilled in caring for this type of patient, or send the patient to the first available bed, where the nursing staff may not be appropriately trained to provide the type of care needed.
In the first situation, the patient may have to be boarded in the PACU or the OR, causing the surgeon’s next case to be delayed. In the second, not being on the correct unit may increase the patient’s length of stay and subject him to increased risk of error or infection. Surgeons must then round in multiple areas of the hospital, potentially delaying later surgeries or their office hours, and further compounding the lifestyle issues already at play.
If the elective surgical schedule can occur with no bumping or delays, the utilization of the elective operating rooms can be substantially improved and approach 90 percent and higher with fewer overtime hours or late rooms. Physicians can increase their case volumes and be assured that elective cases will start on time, eliminating a large source of stress in their lives and improving revenue for the hospital. In addition, when capacity is set aside for the urgent/emergent cases, a hospital can achieve better access for these patients and significantly reduce waiting times, leading to improved quality of care.
Creating a Better Elective Schedule
Pacing the elective schedule to ensure steady patient volumes in the hospital’s nursing units is tricky and requires a collaborative approach with the physicians. Physicians have block time on particular days in the OR because they want access to the OR, easier scheduling for their offices and some predictability in an unpredictable career. Pacing the schedule means that some surgeons will need to change their block days/times, and they may not like the change.
When working with physicians, it’s paramount to base the new block on solid data and a scientific approach, along with a foundation of trust developed between physicians and hospital administrators. It helps to review data on variability, mortality, patient safety and quality. Also, surgeons should understand that the new schedule will improve the flow of patients to certain destination units and reduce duplication of staff and equipment, providing additional capacity for the OR and the entire hospital without the addition of new beds or ORs.
Hospital leaders can design a new, smoother, elective surgery schedule by referring to past use—by service and by surgeons—juxtaposed with patient destination unit information.
Once you have removed the artificial variability from the elective surgical schedule and applied operations management techniques to manage the natural variability, the final step is to determine the true bed capacity and staffing needs for the organization and reduce wait times, while strategically planning for hospital and physician growth. This ensures that patients will continue to be placed in the most appropriate bed. Future growth can more easily be accommodated within the existing physical plant, and when the time comes, the administration will be able to accurately assess the need for additional capacity.
At St. John’s Regional Health Center in Springfield, Mo., elective surgeries on the schedule were bumped daily because of urgent/emergent cases, overtaxing the nursing staff and physicians. In 2002, the hospital introduced the operational methods described in this article to eliminate artificial variability and pace the elective demand.
Surgeons expressed concern about the new schedule at first, since many were already used to negotiating with anesthesiologists over start times and blaming each other for delays. Critical to the success and sustainability of this kind of process improvement is communication with hospital leaders, surgeons and staff, along with data analysis. By fostering this collaboration, the hospital staff reaped benefits over and above patient flow advancements.
By the end of first quarter 2003, surgeons’ late starts dropped from 16 percent to less than 5 percent and are now less than 1 percent. But the most important result of this process is that the hospital enjoyed a 59 percent increase in med-surg admissions from the ED (excluding those going to the ICU) after pacing the elective surgery schedule, without adding physical beds or increasing wait times in the ED. Overall, St. John’s has witnessed significant increases in surgical volume, inpatient capacity and efficiency, access to care, revenues, and patient and staff satisfaction, as well as improved quality of post-operative care.
Benefits of a Less Variable Patient Flow
By applying operations management techniques based on rigorous data analysis, along with a collaborative approach to solving operational issues, hospitals can substantially improve their patient flow. Better patient flow and the collaborative culture that it engenders will not only improve patient safety and quality of care, but also the work lives of the hospital staff, and increase the hospital’s ability to recruit and retain physicians and nurses.
Smoothing out patient flow has other benefits as well. By eliminating the peaks and valleys of patient census, the hospital can enlarge its functional capacity to increase patient volume without physical expansion, costly capital requirements and labor increases. It is a return on investment that hospitals can’t afford to pass up.
Christy Dempsey, B.S.N., M.B.A., C.N.O.R., is senior vice president for clinical operations at PatientFlow Technology Inc. in Springfield, Mo. Susan L. Madden, M.S., is project director at PatientFlow Technology Inc. in Boston.
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