frontiers - capacity management
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Volume 20
Number 4
Summer
2004
FRONTIERSO F H E A L T H S E R V I C E S M A N A G E M E N T
Carol Haraden and Roger Resar
Suzanne S. Horton
Diana Henderson, Christy Dempsey, an
Debra Appleby
Richard S. Zimmerman
Matthew Lambert III
Leo P. Brideau
Capacity Managemen
BreakthroughStrategies for
Improving Patient
Flow
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Editorial
Audrey Kaufman
Lead Articles
3 Patient Flow in Hospitals: Understanding and Controlling It Better
Potential benefits of improved flow include better clinical outcomes, improved patientsafety, greater patient and staff satisfaction, and improved financial performance.Carol Haraden, Ph.D., and Roger Resar, M.D.
17 Increasing Capacity While Improving the Bottom Line
Overcrowding of the ED is not all about the ED but is a symptom of a broken system.
It is linked to the admission, discharge, and transition processes throughout the orga-
nization.Suzanne S. Horton, R.N.
25 A Case Study of Successful Patient Flow Methods: St. Johns Hospital
St. Johns keys to success for patient flow include having strong senior leadership sup-
port involving key stakeholders and multidisciplinary members on teams, having
teams meet weekly to discuss successes and challenges, having a physician cham-pion(s) leading each team, and good communication to all staff.Diana Henderson, Christy Dempsey, and Debra Appleby
Commentaries
31 The Commentaries: A Summary
33 Hospital Capacity, Productivity, and Patient SafetyIt All Flows Together
Creating successful change is more apt to occur and be sustained when there is align-
ment of goals linking healthcare institution and practitioner for the benefit of the pa-
tient.Richard S. Zimmerman, M.D.
39 Improvement and Innovation in Hospital Operations: A Key to Organizational Health
For an organization to be successful it has to do more than just improve operations;
substantial innovation must also take place.Matthew Lambert III , M.D., FACHE
47 Flow: Why Does It Matter?
IHI can convene, support, cajole, and lead. But in the end, real improvement requires
hard work on the front lines. Senior leaders must cause severe discomfort with the
status quo and give frontline caregivers the time, tools, permission, and support to
create improvement.Leo P. Brideau, FACHE
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Volume 20
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FRONTIERSO F H E A L T H S E R V I C E S M A N A G E M E N TFrontiers of Health Services Management is committed to providing our readers with compelling,
in-depth features and commentaries that are of current importance to the practice of health services
management by drawing on the expertise of the best practitioners and scholars.
1
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Laurence M. Merlis, FACHE, ChairPresident and CEO, Greater Baltimore MedicalCenter, Baltimore, MD
Barbara A. Arrington, Ph.D., FACHEAssociate Professor, St. Louis University,St. Louis, MO
Raymond G. Brazier, FACHECEO, Mesa View Regional Hospital,Mesquite, NV
Joseph F. Damore, FACHEPresident and CEO, Sparrow Health System,Lansing, MI
Annette V. DrennanPresident, The Specialty Hospital,Meridian, MS
Cathy E. Duquette, Ph.D.Senior Vice President, Hospital Association of
Rhode Island, Providence, RI
Vivian A. EchavarriaDirector, Ancillary Support Services, AlaskaNative Medical Center, Anchorage, AK
Elizabeth J. Freeman, FACHEDirector, VAPAHCS, Palo Alto, CA
Earl G. Greenia, FACHEAssistant Administrator, Irvine RegionalMedical Center, Irvine, CA
MAJ Heather A. Kness, CHEOperations Officer, Pacific Regional MedicalCommand, Tamc, HI
Brenda Stevenson Marshall, Ph.D.Associate Professor, Cleveland State University,Cleveland, OH
Frederic P. Skinner, J.D.Watertown, NY
Rick L. StevensExecutive Director, Support Services, CARITASHealth Services, Louisville, KY
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Frontiers of Health Services ManagementMaureen C. Glass, CHE, CAE
Publisher, American College of
Healthcare Executives
Chicago, IL
Joyce A. Sherman
Managing Editor
Health Administration Press
Chicago, IL
Audrey Kaufman, Editor
Janet Davis, Associate Editor
Health Administration Press
Chicago, IL
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audrey kaufman 1
Editorial
editorial
What comes to mind when you have to go to a hospital emergency room, either as
the patient or as a companion to the patient? Other than the immediate illness,
most people think of crowded rooms and hours of waiting. Overcrowded and bot-
tlenecked emergency departments are a chronic problem that has now reached cri-
sis proportions. Emergency departments are so overcrowded that patients are
being parked in hallways for hours waiting for a hospital bed or are turned away
altogether and sent to another institution. This is not just frustrating for patients
and their companions, it is also unsafe, non-patient-centered care.
With the advent of an uninsured and underinsured middle class, and other
such trends, the number of patients coming into the hospital through the emer-
gency department has increased dramatically and continues to increase. Somehospitals are tackling this problem by building more spaceenlarging the emer-
gency department, adding more beds on the floors, building another wing. But is
this really a long-term solution?
This issue of Frontiers takes a look at the patient flow/capacity management
problem from a systems perspective. We have asked Carol Haraden, Ph.D., vice
president at the Institute for Healthcare Improvement (IHI) in Boston, and Roger
Resar, M.D., IHI fellow at the Mayo Health System in Eau Claire, Wisconsin, to
draw from their work with more than 60 hospitals, where they evaluated what fac-
tors are involved in achieving the smooth, timely flow of patients through hospital
departments and helped develop methods for improving flow. These authors sug-gest that reducing delays and bottlenecks in the emergency department depends
on assessing and improving flow between and among departments. Hospitals
must view the problem in terms of an interdependent system rather than indi-
vidual departments. Improving the flow in one area alone, increasing nurse
staffing ratios, and placing patients off service (in the hallways) have not solved
the bottleneck problem and could significantly increase the risk of harm to the pa-
tient. However, they argue, by managing the flow of elective surgeries, achieving
timely and efficient transfer of patients from the intensive care units to
medical/surgical units, and improving the flow of inpatients to long-term-care fa-
cilities, the emergency department will be able to more efficiently move patientsonto floors and into beds where they can get appropriate care.
Complementing the article by Haraden and Resar are two case studies. The
first is written by Suzanne S. Horton, R.N., director of nursing at Baptist Memorial
audrey kaufman, assistant director and acquisitions manager
at health administration press in chicago, has worked in
healthcare publishing for more than 25 years.
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Hospital in Memphis, Tennessee. The second comes from Diana Henderson, ex-
ecutive director for quality; Christy Dempsy, director of perioperative services; and
Debra Appleby, supervisor of quality resources at St. Johns Hospital in
Springfield, Missouri. Both hospitals sought to solve their patient flow problems
by joining IHIs IMPACT collaborative to improve patient flow and care delivery.Each case study describes the particular issues that these institutions were facing
and the specific strategies used to reduce delays and increase patient flow.
Quality and patient-focused care are at the heart of the initiatives described in
this issue of Frontiers. Keeping patients in the emergency department or its corri-
dors for hours, keeping patients in the intensive care unit longer than necessary,
and keeping surgical patients waiting for an unoccupied surgery suite is no longer
acceptablein each case the patient is put at risk. Furthermore, these are not sep-
arate problems: departments in the hospitals cannot be viewed as single units.
Each is an interdependent part of the system as a whole. The authors emphasize
this fundamental idea throughout their discussions.
ON A PERSONAL NOTE
This is the first issue of Frontiers that will be managed in-house at Health
Administration Press. For the past 20 years, the journal has had an academic edi-
tor, most recently Leonard Friedman, Ph.D., who leaves very big shoes to fill. As
the new editor from within, I and my colleague, Janet Davis, will do our best to
maintain the high standards for which this journal has become known and to de-
velop issues that are both thought provoking and useful to the busy executive.
Audrey Kaufman
E R R A T U M In the Spring 2004 issue of Frontiers, the amount that Caterpillar Inc. spent on
healthcare costs for employees, retirees, and their dependents in 2003 was incorrectly
stated in the Editorial as $500 billion. The correct amount spent was $500 million.
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Patient Flow in Hospitals:
Understanding and Controlling It Better
C A R O L H A R A D E N , P H . D . , A N D
R O G E R R E S A R , M . D .
Summary Because waits, delays, and cancellations are so common in
healthcare, patients and providers assume that waiting is an inevitable,
but regrettable, part of the care process. For years, hospitals responded
to delays by adding resourcesmore beds and buildings or more staff
as the only way to deal with an increasingly needy population.
Furthermore, as long as payment for services covered the costs, more
construction and more staff allowed for continued inefficiencies in the
system. Today, few organizations can afford this solution. Moreover, re-
cent work on assessing the reasons for delays suggests that adding re-
sources is not the answer. In many cases, delays are not a resource prob-
lem; they are a flow problem. The Institute for Healthcare Improvement
has worked with more than 60 hospitals in the United States and the
United Kingdom to evaluate what influences the smooth and timely flow
of patients through hospital departments and to develop and implementmethods for improving flow. Specific areas of focus include smoothing
the flow of elective surgery, reducing waits for inpatient admission
through emergency departments, achieving timely and efficient transfer
of patients from the intensive care unit to medical/surgical units, and
improving flow from the inpatient setting to long-term-care facilities.
leadarticle
carol haraden, ph.d., is vice president at the institute for
healthcare improvement (ihi) in boston, and roger resar, m.d., is
an ihi fellow at luther midelfort, mayo health system, in eau
claire, wisconsin.
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Patients and providers regard
waits, delays, and cancellations as an
inevitable consequence of receiving
care. That the hospital is a complex or-
ganization often serves as an easy ex-planation, but one that results in de-
layed and unstructured improvements
regarding flow. With more hospitals
unable to take care of their commu-
nity healthcare needs, problems with
flow in particular have taken center
stage in boardrooms and newsrooms.
Although no individual hospital area
(now sometimes known as a mi-
crosystem) is designed to achieve op-
timal flow of patients, the emergencydepartment, intensive care unit, and
operating rooms and their related pre-
and postcare areas tend to be major
bottlenecks because they are noninter-
changeable resources and conduits for
much of care received in the hospital.
The Institute for Healthcare Im-
provement (IHI) has worked with
more than 60 hospitals in the United
States and the United Kingdom to
evaluate what influences the smoothand timely flow of patients through
hospital departments and to develop
and implement methods for improv-
ing flow. Reducing delays and unclog-
ging bottlenecks depend on assessing
and improving flow between and
among these departments. To im-
prove flow, hospitals must view the
problem in terms of an interdepen-
dent system rather than individual de-
partments. Any individual depart-ment that improves flow in its area
alone often in fact exacerbates the
problem for other dependent depart-
ments. For example, consider the
emergency department (ED) that tries
to improve flow through the ED by
moving patients into a hallway or
lounge while they wait for a bed on a
medical or surgical unit to become
available. Although this might seem
like a good solution, it ultimatelyworsens the situation for both the pa-
tient and the receiving floor. Studies
have shown that increased nurse
staffing ratios (Aiken et al. 2002) and
placing patients off service (D. Brailer,
CareScience, personal communica-
tion) have significantly added to the
risk for mortality and morbidity.
THE KEY TO UNDERSTANDING
FLOWOne of the first steps necessary for un-
derstanding flow is to accept that flow
depends on the inherent variation
found in the healthcare delivery sys-
tem. It is a common but an incorrect
assumption that healthcare flow is a
result of what appears to be the ran-
domness and complexity of disease
presentation: Who could possibly pre-
dict broken legs, heart attacks, or
strokes and then always have the rightresources ready for quick, timely, and
safe care? Providers and consumers
alike believe that waits, delays, and
cancellations are to be expected be-
cause of the presumed and logical in-
ability to predict and manage unsched-
uled and emergent demand. This
belief has been challenged by studies
on the effects of variability on the
healthcare delivery system. When ana-
lyzed, the variation introduced by thevery structure of the delivery system it-
self far outweighs the variation caused
by the randomness of patient arrivals
in the ED as well as the disease state
with which they present. Variation
from the randomness of disease,
Reducing delaysand unclogging
bottlenecks
depend on
assessing and
improving flow
between and
among
departments.
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termed natural variation, can be ac-
commodated by managing demand
based on historical data and queuing
methods. Similarly, the natural varia-
tion introduced by differing levels ofstaff competency and clinical abilities
can and must also be managed. All or-
ganizations strive to maintain the
competency of staff to minimize this
type of variation. Generally, this varia-
tion is handled reasonably well by
state and federal regulatory agencies
or by processes within a hospital to re-
view the competency of staff and to
provide training. Natural variation can
affect flow but commonly plays asmaller role and tends to become rela-
tively constant in the system.
Variation introduced into the care
system from personal preferences
and beliefs of individual clinicians,
called artificial variation, cannot be
similarly managed and needs to be
eliminated. The population of surgi-
cal schedules or basis of decisions
made about when to admit or dis-
charge a patient is largely dependenton a wide variety of human partici-
pants, with many unknown inputs.
The effect of artificial variation on
flow far exceeds the effect of variation
resulting from random, highly com-
plex disease presentations. For this
reason, emphasis needs to be placed
on change concepts related to reduc-
ing the artificial variation in health-
care delivery. Litvak and colleagues
found that typically 50 percent of theadmissions to a hospital are from the
ED and 30 percent are for elective
surgery (McManus et al. 2003). The
elective surgical admissions have
more effect on flow than the random
admissions from the ED. How is it
possible that an elective set of admis-
sions can have more effect than auto-
mobile accidents or heart attacks? The
answer is related to the exceedingly
arbitrary nature of elective schedulingdecisions.
If a surgical schedule is viewed
several weeks ahead, the placement of
patients in the schedule has little rela-
tionship to the resources that might
be demanded when the patients are
actually admitted. Surgeons with no
information about the impact of ad-
missions, projected intensive care
unit (ICU) use, or other resource de-
mands tend to schedule cases by theslots available. When the slots are
filled, the hospital responds three
weeks hence in a reactive mode,
rather than predict and try to smooth
the demand on the resources.
One vital key to improving flow
lies in reducing variation in processes
related to flow. While some variability,
such as the types of patients coming
into the ED, is normal and expected,
other types of variation should not beexpected or tolerated; they require
elimination before additional beds are
built and staffed. Hospitals in partner-
ship with IHI have tested a broad
range of changes to reduce process
variation and improve flow. These
changes and measurements as well as
eventual goals are discussed in this ar-
ticle.
THE ED ONLY LOOKS LIKETHE PROBLEM
The emergency department increas-
ingly has faced waits for care, with
consequent delays in treatment, to a
point where diversions have become a
common part of ED language. Patients
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who are increasingly frustrated with
the length of these delays and waits
are leaving EDs untreated. In the
United States, EDs experienced a 20
percent increase in patient visits overthe past decade (CDC 2003). Not sur-
prisingly, ED waiting times have also
increased. According to the Centers
for Disease Control and Prevention,
the average wait time for nonurgent
visits increased between 1997 and
2000 by 33 percent, from 51 minutes
to 68 minutes (CDC 2002).
Of those individuals who leave the
ED because of the lengthy wait times,
how many return to the hospital evensicker and in need of additional re-
sources is unknown and of concern.
Increasingly, hospitals are realizing
the community obligations of their
EDs and have decreed a no-diversion
status policy. Although this policy is
commendable, it does not solve the
problem; it only forces the problem
downstream in the hospital. Patient
safety and patient-centered care con-
tinue to be illusions.Diverting ambulances away from
hospitals that are at capacity does still
happen and is, in fact, on the rise in
most areas, although some communi-
ties have banded together to make
this practice a thing of the past. An
October 2001 U.S. government study
shows that ambulance diversions
have impeded access to emergency
services in metropolitan areas in at
least 22 states since January 1, 2000.More than 75 million Americans re-
side in the areas affected by these am-
bulance diversions (U.S. House of
Representatives 2001, i).
Examples abound, according to the
study.
In Tucson, Arizona, so many hospitals
diverted ambulances that paramedics
had to struggle to find any place to
bring patients. In the Boston area, am-
bulance diversions last year ran asmuch as ten times higher than in pre-
vious years. On some days in Atlanta,
eight to ten hospitals diverted ambu-
lances at the same time. In Los Ange-
les, two dozen emergency rooms at the
heart of the areas emergency system
were closed to ambulances almost one-
third of the time in June 2001. (U.S.
House of Representatives 2001, i)
The so-called ED problem, how-ever, is actually a systemwide prob-
lem. EDs do not exist in isolation, but
are part of a system of care through
which patients flow. Increasing capac-
ity in the ED to accommodate more
patients, a solution chosen by many
hospitals, is like broadening the large
end of a funnel without increasing the
capacity at the neck or constriction
point.
In a recent report on ED crowding,the U.S. General Accounting Office
(GAO 2003, 1) noted the connection
between the ED and the rest of the
hospital system:
While no single factor stands out as
the reason why crowding occurs, GAO
found the factor most commonly as-
sociated with crowding was the inabil-
ity to transfer emergency patients to
inpatient beds once a decision hadbeen made to admit them as hospital
patients rather than to treat and re-
lease them. When patients board in
the emergency department due to the
inability to transfer them elsewhere,
the space, staff, and other resources
Flow problemscannot be solved
simply by working
harder or by
adding beds and
staff.
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available to treat new emergency pa-
tients are diminished.
Another recent study of ED over-
crowding also showed that the pri-mary reason hospitals go on diversion
is the lack of available critical care
beds (The Lewin Group 2002). An in-
teresting way to look at the dimin-
ished capacity is to measure for a
week the number of patients waiting
to transfer to a hospital bed. The aver-
age number of patients waiting repre-
sents the percentage of ED capacity
that is taken away by waiting.
Poor ED flow is not a trivial prob-lem; at a minimum, it has the follow-
ing costs:
Patient safety. The ED becomes an
inappropriate and expensive hold-
ing area when patients are not
transferred to an inpatient unit in a
timely manner. The patients can
best be described as off service and
parked (i.e., keeping or placing
admitted patients in a holding loca-tionsometimes in the ED, some-
times simply in a hallwaywhen
they cannot be moved immediately
to their intended bed or location).
The safety level of ventilated pa-
tients in an ED is without question
more tenuous than in an ICU; the
ED just is not the best place for this
type of care. Solving the ED prob-
lem by parking patients in hallways
on the receiving unit to await trans-fer to a bed in that unit is de-
plorable, but in todays world, park-
ing is part of the plan in many
hospitals. Who among us, espe-
cially when sick or vulnerable,
would like to be placed in a hallway?
Care not given. When the ED is
overcrowded because patients can-
not be transferred quickly to care
units or operating rooms, incoming
patients can experience harmful de-lays in receiving care, and many
leave without being treated. One
hospital described those patients as
only 1.3 percent of all patients regis-
tered. When the math was done in
terms of number of patients, how-
ever, such elopements involved
more than 1,000 patients. What
more complicated diseases did the
ED treat in the long run because of
the failure to treat initially? Reduced institutional revenues. Any
patient waiting for an inpatient bed
in the ED basically robs the hospi-
tal of ED capacity and, subse-
quently, robs the community of
service. The ED is a source of rev-
enue and an important care site for
patients; when it is not accessible
and patients are diverted, both the
patients future care and potential
revenue are lost.
Waits and delays, bottlenecks, and
backlogs are not the result of lack of
effort or commitment on the part of
staff. Their source lies in what
Berwick (1996) calls the first law of
improvement: ...[E]very system is
perfectly designed to achieve the re-
sults it achieves. The answer to im-
proving flow of patients lies in re-
designing the overall systemwidework processes that create the flow
problems. These problems cannot be
solved simply by working harder or
by adding beds and staff.
Optimal care can only be delivered
when the right patient is in the right
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place with the right provider and the
right information at the right time.
Improvement efforts by hospitals in
the United States are showing that it
is possible to reduce waits and delaysin the hospital environment by en-
hancing the flow of patients and in-
formation throughout the care sys-
tem. Better flow will increase access;
reduce waiting times; lower costs;
and, ultimately, improve outcomes in
safety, throughput, and financial sta-
tus. The section that follows describes
one such program.
THE CHALLENGE FOR
HOSPITALS
The Institute for Healthcare Improve-
ment has developed a process and
methodology for hospitals to use in
evaluating and improving patient flow
in acute care settings. As part of its ef-
fort to foster improvements through-
out the healthcare system, IHI invites
hospitals to engage in this process,
using the methods described in the
following sections.
1. Evaluate Flow: How Much of the
Time Do You Get It Right?
The first step in evaluating the flow
of patients through your acute care
setting(s) is to find out, on average,
how much of the time your hospital
gets it right in moving patients
through the system in a timely and
efficient manner. In considering thisquestion, your hospital needs to look
at both the frequency of parking pa-
tients and hospital occupancy as key
indicators.
Two key questions help bring these
issues into focus:
1. Do you park more than 2 percent
of your admitted patients at some
time during the day at least 50 per-
cent of the time?
Example: In a hospital with amidnight census of 500 pa-
tients, 10 patients (2 percent)
were parked during the day,
waiting for admission to the
final destination bed. This oc-
curs more than half the time
during the sample period.
2. Does your hospital have a mid-
night census of 90 percent or
more of your bed capacity more
than 50 percent of the time?Example: A 500-bed hospital
had more than 450 patients in
the hospital at midnight (90
percent of capacity) more
than half the time during the
sample period.
If you answer yes to one or both
of these questions, your hospital is
likely struggling with flow problems
on a regular basis. Parking patients isa clear indication that the system is
inhibiting the smooth forward move-
ment of patients to their appropriate
destination. And if your midnight
census typically is high, you probably
experience capacity problems be-
cause your hospital is virtually full at
the start of the day, leaving little ca-
pacity for new admissions. To ad-
dress these issues, you will have two
tasks: (1) work to reduce flow varia-tion and (2) extend the chainthat
is, work with others along the contin-
uum of care, including those outside
your hospital, to smooth the flow of
patients into and out of your organi-
zation.
To addresscapacity issues,
you will have two
tasks: (1) work to
reduce flow
variation and (2)
extend the
chain.
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Even if you answer no to both of
these questions but still feel that pa-
tients do not consistently move
smoothly through the system, this
may indicate a need to reduce flowvariation.
2. Measure and Understand Flow
Variation
Variation is intrinsic in healthcare. It
is the result of clinical variability(number of patients presenting with
certain clinical conditions),flow vari-
ability(the ebb and flow of patients ar-
riving throughout the day), andprofes-
sional variability(the variation in skilllevels and techniques among pro-
viders). Eugene Litvak (IHI 2003a)
suggests that only the following sce-
nario would (in theory) eliminate vari-
ability entirely:
1. All patients have the same disease
with the same severity.
2. Patients arrive at the same rate
every hour.
3. All providers (physicians andnurses) are equal in their ability to
provide quality care.
Some kinds of variability (so-called
random variability) cannot be elimi-
nated, or even reduced; they must be
managed. This is true of patient vari-
ability. We cannot eliminate the many
types of problems from which pa-
tients suffer, nor can we control when
they arrive in the ED.Nonrandom variability, on the
other hand, is often driven by individ-
ual priorities, resulting, for example,
in surgical schedules that are heavy on
Wednesdays but light on Fridays be-
cause of surgeons preferences rather
than actual demand. Nonrandom vari-
ability should not be managed; it
should be eliminated.
Volume, census, or occupancy
rates are often calculated and dis-played as means or averages. How-
ever, it is the variation in these metrics
that causes most of the flow problems
in our hospital systems. Consider this
example: The mean elective surgical
volume for two hospitals for one week
is 125 patient cases each. Hospital A
has a steady flow of surgical cases
throughout the week, allowing for op-
timal scheduling and predictable de-
mand for staffing and patient beds.Hospital B, which also has a mean of
125 cases, schedules 50 percent of its
cases on Mondays and Wednesdays
and 50 percent on the remaining days.
Because the caseload is so high on
Mondays and Wednesdays, there is no
room for the seemingly random but
historically predictable surgical com-
plications and added cases. The de-
mand for staff, beds, and equipment
is at a maximum. Any added volumeor decrease in capacity is felt quickly
as waits, delays, and cancellations.
A helpful exercise is to look at the
variation in census between each day
of the week and the variation in cen-
sus within each day. These measures
can point to different problems and
solutions. To assess within-day varia-
tion, an organization can measure the
midnight census and the midday cen-
sus. The difference between these twomeasurements gives an idea of the
variation within that day. A common
way to express this is the standard de-
viation between the midnight census
and the midday census for two weeks
(count only on weekdays). The cause
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for the within-day variation is mostly
related to a lack of synchronization
between admissions and discharges.
For between-day variation, an orga-
nization can measure the variationbetween elective surgical admissions
and ED admissions expressed either
as a standard deviation or as residual
differences between days. The cause
for this variation is commonly due to
wide variations in elective surgical ad-
missions.
3. Test Changes to Improve Flow
Hospitals that want to improve flow
should consider testing two maingroups of changes:
1. Changes that can be made within
the hospital
2. Changes that result in cooperative
relationships with other healthcare
providers outside of the hospital
Changes Within the Hospital
Smooth the surgical schedule. The
elective surgical schedule is the majorsource of artificial variation in flow.
Several concepts, such as the follow-
ing, are being tested by several of the
60 hospitals working in the flow do-
main of the IMPACT collaborative1
and show early promise in smoothing
the elective surgical schedule by re-
ducing the demands on hospital re-
sources:
Smooth the number of elective sched-
uled cases. Scheduling the maximumnumber of elective surgeries without
regard to eventual downstream use of
resourceswhether it is a surgical-
bed or an ICU-bed caseleaves little
flexibility for the demands from a
fairly predictable ED admission
schedule or emergency surgical de-
mand. By smoothing the number of
elective surgical admissions, the de-
mands on downstream resources will
be known and predictable.Separate emergent surgery from elec-
tive surgery. Because the vast majority
of surgery is scheduled, most of the
operating room space should be as-
signed as such. Utilization of the
scheduled rooms then becomes pre-
dictable and controllable, and wait
times for unscheduled surgery be-
come manageable. Setting aside
rooms for emergent surgery as a sepa-
rate flow stream then does not resultin cancellations of elective surgery.
Additional benefits can be achieved by
designating a specific surgeon to do
the emergent cases if the volume will
warrant this approach. In most cases,
the separation of emergent and ur-
gent cases within the current call sys-
tem will be the first significant and
helpful step in improving flow.
Schedule the discharge. Admissionbottlenecks are often created because
discharges are not managed effi-
ciently. Creating a more consistent
and predictable discharge schedule by
taking the following steps can help
improve flow:
Provide a process for scheduling the
time that patients will be discharged. Al-
though the date and time of discharge
may be known a day in advance for
some patients, hospitals have histori-cally tried to build all discharge strate-
gies on predicting discharges. Data
suggest that discharges from surgical
floors can be predicted with consider-
able accuracy because of the pre-
dictability of the surgical procedures
In most cases, theseparation of
emergent and
urgent surgery
cases within the
current call
system will be the
first significant
and helpful step
in improving flow.
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themselves. In fact, early data indicate
that nurses, doctors, and other health-
care providers can usually predict one
day in advance, with more than 80
percent accuracy, which patients on asurgical unit will be discharged the
following day. A process to schedule
discharge times and dates with these
patients is therefore relatively easy.
The opposite is true on medical
units. Frequently, the discharge is de-
pendent on tests to be run that day. In
those units the ability to schedule the
time for discharge depends less on
predicting the day before and more
on the ability of the unit to respond toa discharge order and give a patient a
reasonable discharge time. Regard-
less of whether discharge time is pre-
dicted the day before or the same day,
scheduling the discharge time should
lead to optimizing and planning the
discharge, and, eventually, the dis-
charge times for transferred or admit-
ted patients from other parts of the
hospital will also be synchronized to
that schedule. This work will mostlikely require a centralized planning
and scheduling function. Planners
can record data about the ability of
the system to comply with the sched-
ule and document reasons for non-
compliance to identify bottlenecks
and processes that need improve-
ment.
Orchestrate the discharge. A series of
tasks must be performed in a specific
order prior to discharging a patient.The ancillary services (e.g., lab, phar-
macy, physical therapy), however,
work best without rigid schedules.
Staff who perform these services can
self-organize and schedule the work
to achieve a common goal: setting the
prearranged discharge time, whether
it is known the day before or the same
day. Orchestrating the discharge al-
lows all care providers to schedule
their work accordingly so that a con-tinuous flow of patients can be dis-
charged throughout the day and into
the early evening.
Provide a process and a team for dis-
charging patients with more complex is-
sues, using data from discharge coordina-
tors. Not all patients can be easily
discharged. Because of the complexity
of their disease, lack of support at
home, or psychosocial problems,
some patients are difficult to place inappropriate settings after discharge.
Although the time and date of dis-
charge should be scheduled for these
patients as for others, the orchestra-
tion of the discharge may need to be
handled separately and differently.
This may require a special person or
team capable of crafting customized
solutions to meet the discharge needs
of these patients. The complexity of
the patient should not allow regres-sion to a chaotic and unplanned dis-
charge.
Synchronize other movements to the
discharge schedule. Once an organized,
preplanned set of discharge times is
in place on each hospital unit, internal
transfers of patients from an ICU to a
step-down unit, admissions from the
ED, or transfers from other hospitals
can be synchronized to that schedule.
Individual units can create schedulesbased on their own resources and de-
mands but coordinate on a larger sys-
tem level. This synchronization allows
local, unit-level control and sys-
temwide optimization to occur simul-
taneously.
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12 frontiers of health services management 20 :4
Decrease demand within the hospital.
Use a rapid-response team. The assump-
tion that all demand for hospital ser-
vices originates outside of the hospital
must be challenged. Recent work inboth the United States and Australia
has shown the effect of rapid-response
teams in decreasing demand for ICU
beds. For example, a study published
recently shows a reduction of cardiac
arrests and a marked decrease in the
use of ICU beds if symptoms are rec-
ognized before the actual code occurs.
The time of maximal impact from a
rapid-response team is during the pe-
riod of time commonly known asfail-ure to rescue. This is a term used to
connote an approximately four-hour
period that often precedes a patients
cardiac arrest, respiratory arrest, or
stroke. In the failure-to-rescue period,
there is a change in the patients
symptoms, which, although continu-
ous, is often subtle. While the care-
giver is concerned and often attempts
to communicate the changes, the
signs and symptoms are often seen assoft signs, such as decreased ap-
petite, decreased respiratory rate, or
increased tiredness, and more moni-
toring is ordered. The patient contin-
ues to deteriorate until an event oc-
curs, such as an arrest, a stroke, or
other failure, that raises the alarm in
the system. The implementation of ap-
propriate rescue care has shown a re-
duction of up to 90 percent in patient
days that result from return to theICU after a cardiac arrest. Avoiding
placement in or a return to the ICU of
hospitalized patients can have a large
impact on ICU flow (GAO 2003).
Decrease length of stay in the ICU.
Capacity in the intensive care unit is
directly dependent on the length of
stay in the ICU. Teams in IHIs ICU
IMPACT collaborative who have been
working with ventilated patients have
recently demonstrated marked de-creases in ventilator hours and, con-
sequently, decreases in ICU lengths
of stay. Using a process whereby all
evidence-based care that is necessary
and sufficient for ventilator-depen-
dent patients is combined, or bun-
dled, patients have a shorter stay on
the ventilator and, in some cases, sig-
nificant decreases in ventilator-associ-
ated pneumonias. The effect of an 8-
to 12-hour decrease in average lengthof stay for a given ICU is equivalent
to the addition of three ICU beds.
Changes Involving Providers Outside of
the Hospital
The issues affecting patient flow in
the hospital do not all occur within
the walls of the hospital. The raw
facts suggest that unless hospitals ex-
pand their partnerships with other
providers in the communitycreat-ing working relationships with new
partners and developing creative new
care systems with existing partners
the problems that the community
brings to the hospital will never be
solved. It is crucial for hospitals to
work with the community to find so-
lutions to the flow problem. The hos-
pitals participating in IHIs collabora-
tive project on flow call this
extending the chain.Responsibility driven by geogra-
phythat is, addressing only those
problems in ones own areais the
source of much variation in hospi-
tals. Particularly for hospitals with
patient flow problems, working more
The effect of an 8-to 12-hour
decrease in
average length of
stay for a given
ICU is equivalent
to the addition of
three ICU beds.
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carol haraden an d roger resar 13
intensively with physicians and long-
term-care facilities in the commu-
nitythose with the power to affect
both admissions and dischargesis
an effective strategy to improve flow.
Set up specialized units outside of the
hospital. A common and particularly
frustrating bottleneck in the ICU or a
step-down unit, for example, is the in-
ability to transfer chronic ventilator
patients off the unit because of a lack
of chronic ventilator beds in other set-
tings. Multiple examples of hospitals
using their own resources to help de-
velop chronic ventilator beds areknown. One such example is paying a
knowledgeable physician to set up a
unit in a nursing home. If a hospital
feels that this type of financial assis-
tance for an unaffiliated nursing
home is not appropriate, it does not
understand the overall effect that a
few chronic ventilator patients can
have on the throughput of the hospi-
tal. In addition to helping with flow in
the hospital, such ventilator units,when set up properly, can and will
lead to better patient outcomes at
lower cost. Similar principles have
been used in creating neurology and
cardiac rehabilitation units outsourced
to long-term-care facilities. In all of
these examples, the business case is
easily demonstrated.
Make the nursing home reservation.
Most hospitals use a push system todischarge a patient to a nursing home
facility. Once a patient is determined
to need a nursing home bed, a search
is started by the hospitals social ser-
vices staff. A better, more efficient sys-
tem might be to synchronize hospital
and nursing home needs by establish-
ing a reservation system whereby
hospitals can reserve beds in nursing
homes once a patient in need is iden-
tified, and vice versa. The nursinghome or the hospital still receives pay-
ment if the reservation is not can-
celled and the bed goes unused, much
like the system used in the hotel in-
dustry.
Extend the chain on the front end of
the hospital. Use midlevel providers to
decrease demand for hospital services.
Acute changes that occur in patients
in nursing homes or at home com-monly cause these patients to seek
care in the emergency department.
Using on-site, midlevel providers such
as nurse practitioners and physician
assistants to give tests and treatments
in these settings can avoid ED visits
and, in many cases, admissions to the
hospital. An extension of this idea has
been used in the San Diego school
system with excellent results in treat-
ing asthma patients. Here, the hospi-tal partnered with the schools to pro-
vide treatment to patients at their
school, thus improving their care and
health and reducing ED visits and in-
patient admissions.
SUMMARY
The frontline units (microsystems)
that actually deliver care in hospitals
are tightly linked. Understanding pa-
tient flow therefore requires looking atthe whole system of care, not just the
isolated units. A key element in this
understanding is the concept of nat-
ural and artificial variation, from
sources both inside and outside the
hospital. Variation can and should be
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14 frontiers of health services management 20 :4
measured as a first step to dealing
with the problems of patient flow in
hospitals.
Interventions that can smooth flow
include rethinking the scheduling ofelective surgical procedures; creating
a system for planned patient dis-
charge; and extending the chain of
care, both prior to and following dis-
charge. Potential benefits of better
flow include better clinical outcomes,
improved patient safety, greater pa-
tient and staff satisfaction, and im-
proved financial performance.
NOTE
1. The Institute for Healthcare Im-
provement has been working for the
last two years with more than 60 hos-
pitals in the United States and the
United Kingdom in a collaborative
project to improve flow through acute
care settings. This work is becoming
embedded in a group of more than
100 hospitals that are addressing the
issue of healthcare improvement as
part of IHIs IMPACT network. TheIMPACT network is a group of
change-oriented healthcare organiza-
tions committed to ambitious levels of
improvement on a broad scale. Seven
hospitals participating in IMPACT
have agreed to become true innova-
tion sites and test the new flow-
change concepts in almost a Skunk
Workssm
type environment (IHI
2003b). Leadership commitment, in-
tense faculty involvement, and heavilyfocused resources contribute to a
rapid growth of knowledge in how to
improve flow.
Through IMPACT and the work in
the innovation sites, hospitals have
been testing the theory that the key to
improving flow throughout the acute
care setting lies in understanding the
variability throughout the hospital
system, as discussed in this article
(IHI 2003b).
REFERENCES
Aiken, L. H., S. P. Clarke, D. M. Sloane, J.
Sochalski, and J. H. Silber. 2002. Hospital
Nurse Staffing and Patient Mortality, Nurse
Burnout, and Job Dissatisfaction.Journal
of the American Medical Association 288
(16): 198793.
Berwick, D. M. 1996. A Primer on Leading
the Improvement of Systems. British Med-
ical Journal 312 (March 9): 61922.
Centers for Disease Control and Prevention
(CDC), National Center for Health Statis-
tics. 2003. More Americans Seek Medical
Care in Hospital Emergency Rooms: In-
juries Cause One in Three Visits. National
Hospital Ambulatory Medical Care Survey:
2001 Emergency Department Summary. Ad-
vance Data No. 335. (PHS) 2003-1250. [On-
line report; retrieved 3/11/04.] www.cdc.gov
/nchs/releases/03news/ervisits.htm.
. 2002. Visits to the Emergency De-
partment Increase Nationwide. National
Hospital Ambulatory Medical Care Survey:
2000 Emergency Department Summary. Ad-
vance Data No. 326. (PHS) 2002-1250.
[Online press release; retrieved 3/11/04.]
http://www.cdc.gov/nchs/releases/02news
/emergency.htm.
Institute for Healthcare Improvement (IHI).
2003a. Maximizing Hospital Flow for Effi-
cient and Effective Care: Manifestations of
Variability Within the ED and OR. Slide
presentation, March 11.
. 2003b. Optimizing Patient Flow,
Moving Patients Smoothly Through Acute
Care Settings. Innovation Series 2003
paper. [Online article; retrieved 2/18/04.]http://www.ihi.org/newsandpublications
/whitepapers/flowfinal.pdf.
The Lewin Group. 2002. Analysis of AHA ED
and Hospital Capacity Survey. [Online re-
port; retrieved 2/2/04.] www
.hospitalconnect/aha/press_room-info.
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Mandell, D. M. Berwick, M. Pagano, and E.
Litvak. 2003. Variability in Surgical Case-
load and Access to Intensive Care Ser-
vices. Anesthesiology98 (6): 149196.
U.S. General Accounting Office (GAO). 2003.
Hospital Emergency Departments: CrowdedConditions Vary Among Hospitals and Com-
munities. Report No. GAO-03-460. Wash-
ington, DC: U.S. GAO.
U.S. House of Representatives, Committee on
Government Reform, Special Investiga-
tions Division. 2001. National Preparedness:
Ambulance Diversions Impede Access to
Emergency Rooms. Report prepared for Rep.
Henry A. Waxman. October 16, p. i. [On-line report; retrieved 3/11/04.] www.house
.gov/reform/min/pdfs/pdf_com/pdf
_terrorism_diversions_rep.pdf.
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Increasing Capacity While Improving
the Bottom Line
S U Z A N N E S . H O R T O N , R . N .
Summary Baptist Memorial HospitalMemphis had a capacity prob-
lem, or so we thought. After examining a situation that we considered
virtually unfixable, we implemented high-leverage process changes re-
sulting in significant improvements in patient flow. We learned that we
did, after all, have the capacity we needed without adding any beds or hir-
ing additional staff.
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suzanne s. horton, r.n., is director of nursing administration at
baptist memorial hospital in memphis, tennessee.
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BACKGROUND AND
ENVIRONMENT
Baptist Memorial HospitalMemphis
(BMH-M), a 736-bed tertiary care hos-
pital, has routinely exceeded 90 per-cent occupancy. Process mapping for
patient flow and bed turnaround has
been in continual flux, and the hospi-
tal, the busiest in Tennessee, has pur-
sued flow initiatives for more than
five years. Early process-improvement
efforts included centralization of bed
assignments and the addition of a
bed-tracking system to provide bed in-
formation in real time. These efforts
resulted in improvements in turn-around time (TAT) for bed assign-
ments; however, demand continued to
exceed capacity. The emergency de-
partment (ED) implemented best
practices for bedside registration,
triage criteria, initiation of protocols
at triage, and the opening of a fast-
track area. However, the results were
disappointing. In addition, the
tremendous amount of time and en-
ergy expended without visible resultsbecame a drain on the entire team.
Our ED was always in crisis; the ED-
centered process approach was inef-
fective.
In March 2002, Memphis hospi-
tals were diverting ambulances an av-
erage of 70 percent of the time. Am-
bulance services were exhausted daily,
and ambulance crews waited at the
local EDs for as long as 90 minutes.
The crisis prompted both negativepress and frequent regulatory inspec-
tions.
Memphiss hospital leadership and
the Emergency Medical Service Coun-
cil joined together to test eliminating
diversion. Administrative and clinical
personnel were able to redirect their
energies from diversion decision-mak-
ing issues to patient care excellence.
As a result, patients went to their pre-
ferred hospital, ambulance serviceswere no longer exhausted, and the
community TAT for ambulances de-
creased to 60 minutes overall (6 min-
utes at BMH-M).
Upon elimination of diversion, the
ambulance crisis was solved, but the
larger crisis related to patient flow had
now shifted to the ED. We had a deci-
sion to make as to how we would en-
sure care to all patients seeking it in
our ED. From that effort, the BMHmission of preaching, teaching, and
healing that was established in 1912
came alive in 2002.
HOW WE MOVED FORWARD
Administration, nurses, and physi-
cians adopted a zero-tolerance philos-
ophy for barriers to flow and vowed to
find a cure. BMH-M became involved
with the Institute for Healthcare Im-
provement (IHI) in fall 2002, joiningthe following four IHI IMPACT col-
laborative domains:1
1. Improving critical care
2. Achieving workforce excellence
3. Improving flow through acute care
settings
4. Improving patient safety
Strategies and Their Implementation
Our first initiative. The express admis-sion unit (EAU) (Advisory Board
2001) opened in fall 2001, with no
additional labor being used to staff it.
The EAU is a 21-bed dedicated area
that processes direct and emergency
department admissions, relieving
By eliminatingdiversions,
administrative
and clinical
personnel were
able to redirect
their energies
from diversion
decision-making
issues to patient
care excellence.
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unit nurses of work associated with
admission assessments and initial
admission orders while removing re-
sponsibility for particularly time-
intensive activity from busy unitnurses.
At the start of the initiative, the
unit was open Monday through Friday
from 7 a.m. to 11 p.m. All initial pa-
perwork and diagnostics were com-
pleted in the EAU with a projected
TAT of 60 to 70 minutes. The EAU
provided some relief, but we realized
in the winter crunch 2002 that 16-
hour access to it was an impediment
to overall flow. During the wintercrunch, which saw high volume and
higher acuity, we noticed that to close
the EAU by 11 p.m., no beds could go
to the ED patients for approximately
four to five hours to ensure that all 21
EAU patients had rooms. This stand-
still occurred in the busiest part of the
day for the ED. When we began oper-
ating the EAU 24 hours a day, the flow
became smooth.
Since expanding the hours, theEAUs volume has increased to 35 to
50 patients per day. An unexpected
benefit was that physicians no longer
sent patients to get their workup in
the ED. Patients initial workup oc-
curred expeditiously in the EAU,
which resulted in a 50 percent reduc-
tion in ED holding hours for admitted
patients. The EDs winter crunch of
2002 dissipated, and unit staff nurses
turned their energies from admissionduties to patient care with fewer inter-
ruptions.
The emergency department. As a
member of IHIs IMPACT collabora-
tive on flow, our first area of focus,
after establishing the EAU, was the
ED. We committed to the following
collaborative measures:
Patients were to be placed from the
ED to an inpatient bed within onehour of the decision to admit.
Patients were to be moved from the
post-anesthesia care unit (PACU)
to an inpatient bed within one
hour from the time the patient is
deemed ready to move.
Patients were to be placed from the
intensive care unit (ICU) to an in-
patient bed within four hours from
the time the patient is deemed
ready to move. Patients were to be physically
transferred from the inpatient facil-
ity to a long-term-care facility
within 24 hours after the patient is
deemed ready to transfer.
After the first IHI learning ses-
sion, we began rapid process improve-
ment, a technique of testing ideas for
change on a small scale, altering
processes to improve them, and ex-panding or spreading the processes to
other areas when they are successful.
Little did we know that it would revo-
lutionize and energize every aspect of
everything we did. Our first test of
change involved faxing reports from
the ED to the receiving unit, which
eliminated time spent holding and re-
turning calls. We began with one unit
and eventually spread this process to
the entire facility within threemonths. We then worked through a
package of ED high-leverage changes
(changes that give the organization
the most return in terms of outcome)
provided by IHI faculty. The ED staff,
nursing leadership, and ED medical
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director met weekly to initiate
changes and modify them as needed.
Changes included the following:
Enhancing triage staff (added para-medic and triage nurse during
peak time)
Enhancing triage criteria
Beginning lab and x-ray diagnostic
procedures at triage per protocol
when the ED was at capacity
Taking patients directly to a room
when one is available with bedside
registration
Matching both physician and nurs-
ing labor to peak times Providing e-mail access to staff to
improve communication
One of the highest-leverage
changes was segmenting the urgent
care population within the ED and de-
veloping a fast-track area, essentially
providing a minor medical unit within
the ED. Patients with nonemergent
needs typically wait the longest and re-
quire the least amount of time fortreatment, leading to great dissatisfac-
tion. It is important to note that fast
tracking patients was not new to this
team, but a commitmentto this group
of patients was. Previously, this area
was only open seemingly when
staffing allowed, and the stars in the
heavens were aligned just right. The
ED medical director and the nursing
management team agreed that a suc-
cessful fast-track process was criticalto improving performance. Time was
invested daily to coach and mentor
staff and provide positive feedback to
those who made it happen. Tough
decisions had to be made when staff
were not successful.
Changes that enhanced this
process were as follows:
An area adjacent to, but not in, the
main ED was dedicated to fasttrack.
A nurse practitioner or physician
assistant, nurse, and emergency
medical technician were dedicated
to fast track.
Criteria for fast tracking were re-
vised and included in the triage cri-
teria.
Departments (e.g., x-ray and lab)
partnered for optimal TAT.
Data micromanagement and prob-lem solving occurred on a daily
basis.
Access case management. Access
case management is a process change
we began in the ED, but our plan is to
spread to all access (entry) points of
the hospital. The process uses case
managers to ensure that the patients
are admitted to the right level of care,
evidence-based protocols are initiatedby diagnosis, and appropriate hospital
and social needs are identified and
acted on at the entry point. At BMH-
M, a case manager and social worker
were assigned to the ED to ensure our
patients received timely and appropri-
ate services, and evidence-based pro-
tocols were initiated with the help of
the case manager in the ED for treat-
ing congestive heart failure and pneu-
monia. This team assisted in access-ing community resources to those in
need. It also mobilized internal re-
sources on complex cases that re-
quired a multidisciplinary approach
to discharge planning. Having the
team in the ED connected them to the
Huddle meetingsimprove bed-flow
planning and
provide more
information to all
stakeholders.
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family at the soonest possible point to
participate in identifying any dis-
charge concerns.
The critical care unit. Parallel to the
flow changes were changes initiatedin critical care. In January 2003, an
intensivist program was implemented
on nights and weekends in our 38
general critical care units. Multidisci-
plinary rounds were held every night
by core staff as well as three days a
week with an expanded team. These
rounds stressed compliance with evi-
dence-based practices such as reduc-
tion in ventilator-acquired pneumonia
and other common complications incritical care. Such practices included
elevating the head of the bed at 30 de-
grees, interrupting continuous seda-
tion at least once every 24 hours, and
preventing deep-venous thrombosis
and upper-gastrointestinal bleeding.
In addition, because the intensivists
were now present, patients who would
normally wait until the next day for
extubation were weaned from the ven-
tilator during the night.Huddle meetings. Huddle meetings
were initiated to improve bed-flow
planning and provide more informa-
tion to all stakeholders. In these meet-
ings, the house supervisor, bed-
assignment nurse, housekeeping su-
pervisor, and key charge nurses came
together three times a day to plan for
surgeries, patients coming from outly-
ing facilities, other admissions, and
transfers to higher and lower levels ofcare. This process has facilitated an
enduring team effort to provide pa-
tient-centered bed flow.
The discharge process. Orchestration
of discharges is another breakthrough
practice. A patient-centered approach
to care, orchestrated discharge is a col-
laboration with the physician that an-
ticipates when the patient will be dis-
charged. Once the physician agrees
that the patient is ready for planneddischarge, an appointment time is
agreed on with the patient and family
for the discharge date (usually the
next day, but it can be the same day).
All disciplines, including the physi-
cian and physician consultants, are
alerted to the discharge appointment
time. All actions required for dis-
charge are completed prior to the ap-
pointed time to allow the patient to
leave within 30 minutes of that time.This process allows the patient, fam-
ily, and staff to be much more proac-
tive in the discharge process. Even the
ambulance service, our new partner in
the no-diversion world, appreciates
the importance of an orchestrated dis-
charge and assists us in meeting the
goal. In terms of capacity, the process
allows the centralized bed-assignment
area to plan on beds that will be va-
cated at specific times during the dayto slot admissions, transfers, and sur-
gical patients who are in the queue.
RESULTS
After one year, the following outcomes
were achieved in overall IHI measures
and in the ED, the PACU, and the
ICU.
IHI Measures
The following results were achievedafter implementing several IHI mea-
sures:
1. Patients placed from the ED to an
inpatient bed within one hour of
the decision to admit increased
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22 frontiers of health services management 20 :4
from a baseline of 52 percent to 73.1
percent.
2. Patients placed from the PACU to an
inpatient bed within one hour from
the time they are deemed ready tomove increased from a baseline of
76 percent to 78.3 percent.
3. Patients placed from the ICU to an
inpatient bed within four hours
from the time they are deemed
ready to move increased from a
baseline of 45 percent to 62.7 per-
cent.
4. Patients transferred from the inpa-
tient facility to a long-term-care fa-
cility within 24 hours after they aredeemed ready to transfer increased
from a baseline of 68 percent to
80.1 percent.
Additional ED Results
The emergency department saw the
following results after implementing
the new policies:
TAT for overall ED was reduced by
9 percent, while ED volume in-creased by 6 percent.
Fast-track volume increased from
12 percent to 20 percent of the
adult volume in the ED.
TAT for the fast-track area de-
creased from 2.21 hours to approxi-
mately 1.5 hours.
Patients who left without being
seen by a physician decreased from
5 percent to 1.4 percent.
Holding hours for admitted pa-tients were reduced by 50 percent.
Patient satisfaction improved from
the 10th percentile to the 85th per-
centile, according to a survey con-
ducted by the Gallup Organization
(2003).
Employee satisfaction improved 30
percent in the highest 2 points (6
and 7) of a 7-point scale.
TAT for ambulances averaged 7
minutes, as compared to the com-munitys average of 60 minutes.
PACU Results
Holding hours were reduced by 36
percent.
ICU Results
The results achieved in the ICU are as
follows:
Length of stay was reduced by 2daysthe equivalent of building 12
ICU bedswith no construction or
additional staff.
Mortality rate decreased 40 per-
cent.
Volume increased 20 percent from
fiscal year 20022003.
Ventilator-acquired pneumonia de-
creased 80 percent.
Readmission rate did not change.
WHAT NEXT?
Future plans include expanding the
access case management initiative to
all points of entry, implementing mul-
tidisciplinary rounds on all units, and
providing 80 percent of those patients
with an orchestrated discharge with
their appointment time met at least
80 percent of the time. In addition,
we plan to smooth surgical flow by
capping elective cases to decreasedaily variability.
LESSONS LEARNED
Improving flow is not about building
more beds or hiring more staff. It is
about developing and improving
Improving flow isnot about
building more
beds or hiring
more staff. It is
about developing
and improving
processes to
decrease
variability and
smooth flow.
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processes to decrease variability and
smooth flow. For BMH-M, it required
a culture change of leadership and
staff that moved us from Were doing
the best we can to Sorry, that is notgood enough. Our mantra became,
What is the barrier, and how do we
eliminate it? Overcrowding of the ED
is not all about the ED but is a
symptom of a broken system. It is
linked to the admission, discharge,
and transition processes throughout
the organization. The added payoff is
that improved processes result in im-
proved quality of care as well as pa-
tient and employee satisfaction.
NOTE
1. Please see Note 1 of Patient Flow in
Hospitals: Understanding and Con-
trolling It Better, by Carol Haraden
and Roger Resar, in this issue of Fron-tiers for a discussion of the IHI IM-
PACT collaborative project.
REFERENCE
Advisory Board Company. 2001. Heart of the
Enterprise: Optimizing Nursing Productiv-
ity in an Era of Deepening Shortage.
Washington, DC: Advisory Board Com-
pany.
Gallup Organization. 2003. Emergency Pa-
tient Loyalty Results. Washington, DC:
Gallup Organization.
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A Case Study of Successful Patient
Flow Methods: St. Johns Hospital
D I A N A H E N D E R S O N , C H R I S T Y
D E M P S E Y , A N D D E B R A A P P L E B Y
Summary Participating in the Institute for Healthcare Improvement
(IHI) IMPACT collaborative has given St. Johns Hospital the opportu-
nity to improve patient flow and the delivery of patient care. This part-
nership has allowed us to experience a wealth of information shared by
a collaborative network of hospitals. IHI has introduced rapid-cycle im-
provement methodologies, variability-reduction strategies, and strate-
gies to aid in planning for the expected as methods that have enhanced
our already established performance-improvement program. St Johns
has achieved breakthrough improvement with patient flow.
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diana henderson is executive director for quality; christy
dempsey is director of perioperative services; and debra appleby
is supervisor of quality resources at st. johns hospital in
springfield, missouri.
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26 frontiers of health services management 20:4
BACKGROUND
St. Johns Hospital is a tertiary hospi-
tal located in Springfield, Missouri,
serving 32 counties that cover 22,000
square miles in southwest Missouriand northwest Arkansas. The hospital
has more than 30,000 admissions a
year and an average length of stay
(LOS) of 4.53 days for all patients.
St. Johns senior leadership formed
an alliance with the Institute for
Healthcare Improvement (IHI) in May
2002 to assist our organization in
achieving a superior level of perfor-
mance. IHI measures of improvement
include improved health status, betterclinical outcomes, lower cost, greater
access, greater ease of use, and im-
proved satisfaction for individuals and
their communities.
St. Johns leadership team, includ-
ing representatives from St. Johns
Hospital senior leaders and medical
management services, selected im-
proving patient flow through the acute
care setting from the five domains of-
fered by IHI. Perioperative serviceswas identified as the initial focus of
the project. St. Johns perioperative
services consists of 26 operating
rooms in the hospital and 6 ambula-
tory surgery center rooms. An average
of 25,000 cases are performed annu-
ally in these rooms. All specialties are
represented, with the exception of
organ transplantation. The rationale
for selecting perioperative services was
that it is a high-volume, high-risk,multifaceted area and displays strong
leadership support. Issues with on-
time starts, turnover times, and pa-
tient flow through the various areas of
perioperative services are significant in
terms of patient, staff, and physician
satisfaction; cost and revenue; and
quality of care.
Variability in caseloads, patient
acuity, and specialty needs has a direct
impact on not only perioperative ser-vices but also the hospital as a whole.
This variability leads to the down-
stream effect of hospital bed capacity
constraints, LOS issues, and intensive
care unit (ICU) bed availability as well
as the upstream effect of excessive
emergency department (ED) waiting
times. Therefore, to accelerate im-
provements in perioperative services,
teams involving the ED (upstream ef-
fect) and the surgical ICU (down-stream effect) were commissioned
concurrently.
St. Johns overall aim for this pro-
ject is to ensure that patients receive
timely access to appropriate care and
move safely and efficiently through
the system without unnecessary and
unproductive delays. As discussed
below, each team has established
goals that contribute to achieving the
overall aim.
METHODOLOGY
Project teams were formed, and a
physician champion and team leader
were identified for each team. St.
Johns leadership team collaborated
with the physician champion and
team leader to determine what disci-
plines or stakeholders should be rep-
resented on the team. Team members
were selected from each area affectedby the improvement process. A walk-
through of each teams area was con-
ducted to identify opportunities for
improvement. Frontline staff not in-
volved in the teams also played a cru-
cial role in identifying opportunities
The PDSAimprovement
model helps to
build the
organizations
capacity for
change by
focusing on
foundational
issues.
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for improvement by participating in
individual department surveys. Per-
formance-improvement tools were
used to identify delays or bottlenecks
in the process. Decisions were madescientifically, based on data rather
than hunches. Once data were ana-
lyzed, changes were developed and
tested.
St. Johns uses the Plan-Do-Study-
Act improvement model devised by
Langley, Nolan, and Nolan (Berwick
1996). The Plan-Do-Study-Act
(PDSA) cycle describes inductive
learningthe growth of knowledge
through making changes and the re-flecting on the consequences of those
changes. Nolans model intends that
the enterprise of testing change in in-
formative cycles should be part of nor-
mal daily activity throughout an orga-
nization (Berwick 1996, 620).
The PDSA improvement model
helps to build the organizations ca-
pacity for change by focusing on foun-
dational issues such as the following:
Creating a change culture
Developing an infrastructure to
support improvement
Building the business case for
quality
Implementing strategies for
rapidly spreading innovation
St. Johns uses the rapid-cycle im-
provement methodology by including
the key stakeholders on each team,conducting tests of change (trying a
change on a small scalee.g., one pa-
tient, one doctor, one room) to see
what works and what does not, under-
standing that a failed test is an oppor-
tunity to learn, accelerating successes
by holding weekly team meetings to
evaluate effectiveness and to plan next
steps to spread improvements, remov-
ing barriers, and communicating
strategies and outcomes throughoutthe organization.
OUTCOMES
The key to improving flow lies in re-
ducing process variation that impedes
flow. While some variability is normal,
other variation is not and should be
eliminated (IHI 2003, 1). Litvak sug-
gests that variability could be de-
creased by providing an operating
room dedicated to unscheduled oradd-on cases (McManus et al. 2003).
By doing so, overall efficiency would
be increased and the variability in sur-
gical case flow would actually be re-
duced.
Operating Room Use
The concept of dedicating an operat-
ing room to unscheduled cases,
thereby limiting its use for scheduled
procedures or block time, is not one tobe considered lightly in an era of in-
creasing surgical case volumes, lim-
ited capacity both in terms of physical
space and staff availability, and com-
petition for managed care covered
lives. However, St. Johns, in collabo-
ration with its surgeons, set aside an
operating room as a trial project in
November 2002. Prior to this time,
the operating room had been blocked
for a general/trauma surgeon groupfor elective cases. By agreeing to re-
lease this room from use for their
elective cases, the general/trauma sur-
geons actual elective weekly block
time was reduced. The trauma sur-
geons were agreeable to this test of
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28 frontiers of health services management 20:4
change because potential existed to
improve overall efficiency (Henderson
et al. 2003).1
After approximately three months
of segmenting this room as an add-on room, the data were reassessed.
The following improvements were
achieved (Henderson et al. 2003):
During the hours of 7:30 a.m. to
1:30 p.m. on weekdays, the num-
ber of surgical cases increased by
5.1 percent.
The number of operating rooms
needed for surgical cases at 3 p.m.,
5 p.m., 7 p.m., and 11 p.m. onweekdays decreased by 45 percent.
A 2 percent overall reduction in
overtime was achieved.
The general/trauma surgeon
group involved in the project real-
ized a greater than 4.6 percent in-
crease in revenue.
The nursing floors are able to pre-
dict more accurately their evening
and night-shift staffing require-
ments.
ED Patient Flow
St. Johns is a Level I trauma center
with 64,000+ visits annually. To re-
duce prolonged waiting times in the
ED, we chose to focus on delays in
admitting ED patients. Admission de-
lays tie up ED beds for up to an hour
or more after the ED has completed
its work with the patient and he or
she is simply awaiting a bed. Wefound that a key process step that ac-
counted for much of the delay in-
volved communication between the
ED nurse and the accepting nurse on
the floor. The communication
process between the two departments
sometimes required multiple phone
calls to connect with the staff mem-
ber needing to receive the patient sta-
tus details.
In an effort to expedite this com-munication process, a standardized
fax report form was tested for admit-
ting patients to an intermediate car-
diac floor. The fax report form was de-
veloped collaboratively by the ED and
cardiac staff and evaluated by both
staff each time a fax was sent. The fax
reporting procedure provided great
staff satisfaction, because it elimi-
nated waiting time on the phone for
the ED nurse and the floor nurse ex-perienced less interruption from pa-
tient care activity. Multiple phone calls
from both units were eliminated,
which was a great time saver (Hender-
son et al. 2003).
After the initial trial, the use of this
form was implemented as routine
practice for this floor and on an addi-
tional intermediate cardiac floor, with
similar success. The ED faxed report
is now a standard part of the processthroughout the hospital. In December
2003, the median time from the deci-
sion to admit to physical placement in
an inpatient bed was 61 minutes. This
is a 67 percent decrease, compared to
baseline data. The implementation of
the faxed report clearly has had a posi-
tive impact on this measure (Hender-
son et al. 2003).
Additional successes in the ED in-
clude the following:
ED acute care center (fast track)
hours have been expanded from 12
to 16 hours per day. Visits have in-
creased from an average of 38 to
60 visits per day.
A key step thataccounted for
much of the delay
involved
communication
between the ED
nurse and the
accepting nurse
on the floor.
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ED internal patient-satisfaction