Quality Update

Improving Patient Flow, Patient Satisfaction and Patient Safety

Hospitals have been challenged to optimize patient flow for years. As early as 2003, the Institute for Healthcare Improvement stressed that "the key … lies in reducing process variation that impacts flow."

Improving patient throughput has a ripple effect: Patients get in and out of the emergency department faster, patient satisfaction goes up, patient safety improves and revenues increase.

Satisfied Patients

The number of patients coming to the emergency department is steadily climbing and so are hospital admissions through the ED. Currently, EDs generate 30 percent to 45 percent of total admissions and revenue, according the QHR, a hospital consulting and management company.

However, satisfaction plummets when patients have to wait for several hours to get transferred out of the ED. Press Ganey's 2006 “Hospital Pulse Report: Patient Perspectives on American Health Care," shows that patient satisfaction is lower (82.6 percent) when patients are admitted from the emergency department than from other points (85.1 percent).

Typically hospitals with crowded EDs board patients either in a hallway or other areas until a bed opens. Now, technology can ease ED boarding by using real-time data to identify when a unit lacks capacity to accept additional patients. "Since we are now able to measure specific intervals of care in the emergency department, we can better direct system performance improvement efforts," says Linda Laskowski-Jones, R.N., vice president of emergency, trauma and aeromedical service at Christiana Care Health System in Newark, Del.

Once a bottleneck is identified, hospital administrators can examine the entire system and streamline the process. "Patient flow is not about improving wait times in the ED," says Stephen Mayfield, senior vice president for quality and performance improvement at the American Hospital Association and director of the AHA Quality Center. "Rather, it's an enterprisewide approach that reduces process deviations. Once this occurs, hospital executives can expect a certain number of patients and design processes that can handle that expected number, yet remain flexible enough to handle random variation."

Patient Safety

Providers can predict a day in advance and with 80 percent accuracy when a patient will be discharged. By beginning discharge planning early in the patient's care plan, inefficient discharges can be reduced. Discharge planning means coordinating several different caregivers in order to smooth the process. Case managers should be involved up front. By partnering with long-term care organizations, nursing homes and hospice, the discharge team can streamline transfers. The integrated approach to discharge ensures better outcomes, reduces length of stay and results in fewer readmissions.

Increasing Revenue

Cancellations on the day of surgery hurt hospital revenue, as well as physician and patient satisfaction. Cancellations can often be avoided by ensuring that all laboratory testing, EKGs and X-rays are completed and results are available to caregivers by the day of the surgery.

Exacerbating the situation is the fact that surgical schedules are based on physicians’ preferences. The result can be an unbalanced week, with operating rooms filled to capacity on Tuesday and Wednesday, but virtually unused on Friday and Saturday. Serious bottlenecks on busy OR days occur when patients show up in the ED and need surgery. Information technology allows hospitals to balance elective cases, better coordinate surgical hours and designate operating rooms for unscheduled surgeries.

Hospitals lose potential revenue streams if patients get frustrated by long waits and leave the ED without being seen. Many times, hospitals fail to effectively measure this wait time. Long Beach (Calif.) Memorial Medical Center administrators set a goal for ED patients to wait no more than 15 minutes to be seen by a clinician. In observing the process, they found that ED patients actually waited an average of one hour and 20 minutes. The hospital redesigned the triage system and added an extra triage nurse during busy times. It also developed a "fast track" system, allowing patients with easily handled problems to leave the emergency department within two hours.

Mary Longe, director of patient flow for AHA Solutions Inc., identifies five critical areas in which technologies can significantly improve patient flow: scheduling; bed management; patient, staff and asset tracking; interactive patient care; and nurse communications.

For best results, Longe says, hospitals should employ enterprisewide solutions.

Improve Scheduling

Scheduling software provides comprehensive appointment, event and task management for patients, staff and clinicians. Overbooking and satisfaction-zapping wait times can be eased or eliminated. Reminders and alerts can be generated to minimize no-shows—patients who fail to arrive for treatment.

Simplify Bed Management

The goal of bed management is to accurately place the patient in the right unit with the right level of staff and right level of care the first time. A successful electronic bed management system helps assign or transfer patients from the ED and other clinical units, while reducing the use of phone calls and paper processes.

By using an electronic bed management system, hospitals can optimize the use of monitored and other special beds, and provide real-time capacity information. An electronic system can show which rooms are occupied by an acute patient, an observation patient or a swing-bed patient. It also details which rooms are waiting to be cleaned and how long an observation patient has been in the room. This enables hospital personnel to accurately monitor current and short-term bed flow, potentially avoiding going on bypass and then having empty beds.

Patient, staff and Asset Tracking

Several technologies exist that provide real-time tracking of patients, staff and equipment to greatly improve workflow and efficiency. They reduce staff wait time, overhead paging and playing phone tag, enabling caregivers to spend more time with patients. Automated patient flow systems provide standard processes throughout an enterprise.

For example, tracking technology at Memorial Healthcare System, Hollywood, Fla., updates ED patients' location and status and tracks equipment such as EKG machines, IV pumps and mobile carts. Since implementing the system, emergency department length of stay decreased by an average of 18.5 percent for adults while the ED length of stay for admitted patients (time from triage to exiting ED) decreased by 36 percent. Automated tracking of patient milestones and discharge protocols helped increase cash collections as much as 60 percent. Other systems automatically notify nursing units before they run out of critical supplies.

Interactive Patient Care

Hospitals are under pressure to improve patient perceptions. In 2008, the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality will begin to publish online results of their Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.

Inova Fair Oaks Hospital, Fairfax, Va., uses IT to improve nurse communication and nurse responsiveness. Patients actively participate in their own care by entering information about pain and learning about treatment processes and procedures. By reducing the time spent on non-nursing activities, nurses were able to increase direct patient care. After using the technology for one year, nurse responsiveness increased more than 23 percent and patients received 4 percent more education and 11.5 percent more explanation about treatments and tests.

"While hospitals can't control the variability of illness or patients' arrival times, patient flow technologies exist to efficiently and effectively manage patient throughput," Longe says. "They help hospitals respond, not just react. The result is more efficient use of assets and staff with increased patient satisfaction and patient safety."

The AHA Quality Center is a resource of the American Hospital Association designed to help hospitals accelerate their quality improvement processes to achieve better outcomes for patients and improve organizational performance. Visit www.ahaqualitycenter.org.

This article 1st appeared in the November 2007 issue of HHN Magazine.

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