Complex adaptive strategy to produce capacity-driven financial improvement.

EXECUTIVE SUMMARY

Managing capacity in hospitals and emergency departments (EDs) is a global problem. This article demonstrates an efficiency model applied to an acute care hospital facing a budget shortfall as a result of capacity constraints that negatively affected admissions and increased ED diversions. Operating on the hypothesis that reducing inpatient length of stay would allow patients access through all service points and would return the admissions growth rate to budget, a turnaround team was quickly assembled and charged by the chief executive officer to fix the primary cause of financial underperformance--the creeping length of stay--within 60 days.

This case study is generalizable to all organizations, regardless of size. Deploying an efficiency model based on the complex adaptive systems approach of "swarmware," the hospital's rapid turnaround efforts produced the results necessary to achieve two established goals: (1) length of stay was decreased to 0.1 days below budget in the 60-day time flame, and (2) all admissions and potential admissions were accepted (saying

"yes" to patients) through key points of access in the hospital. Transfer Center denials were reduced to 0 in 19 days, and monthly ED diversions decreased from 110 hours to 20 hours in 60 days. By using a swarmware approach, the hospital created additional bed capacity, allowing for community demand to be accommodated, budgeted admissions target to be exceeded, and market share to be stabilized. This article describes this project's processes and outcomes and the lessons learned and applied, which will assist healthcare leaders who are facing capacity issues in their own organization.

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Managing capacity in hospitals and emergency departments (EDs) is a global problem, reaching well beyond the U.S. healthcare system (Bayley et al. 2005; Emergency Nurses Association 2006; Feldman 2002; Kelly 1994; MacKenzie et al. 2008). The escalation of healthcare demand continues to exceed population growth trends (Richardson, Asplin, and Lowe 2002). Although construction of new physical space continues, it does not relieve the ubiquitous capacity problems in hospitals. As institutions find that their capacity lags behind their construction, their ability to handle increasing demands until the additional "bricks and mortar" are in place is limited. Consequently, efforts to maximize efficiency and eliminate all forms of waste have taken precedence in healthcare management.

Don Berwick (1996) defines the central law of improvement as follows: "Every system is perfectly designed to achieve the results it achieves." At the main hospital of Lehigh Valley Health Network, the processes and systems implemented during a two-year (2002-2004) capacity improvement initiative were found to be functional. However, new internal and external capacity pressures emerged that, once again, challenged the hospital's operational efficiency. In addition, by fall of 2006, the inpatient units began experiencing gradual increases in length of stay (LOS), resulting in higher occupancy, lower bed turnover, and, consequently, reduced inpatient capacity. The ultimate result of this inefficiency was financial underperformance. This situation heralded the potential for a significant financial shortfall for the fiscal year ending in June 2007 and thus required rapid intervention.

Although the intervention applied to prior improvement endeavors was successful, it was too time consuming and slow for the current mandate to turn around financial performance within 60 days. This article shows how the main hospital within the Lehigh Valley Health Network effectively used a complex adaptive strategy to make a dramatic capacity-driven financial improvement in a short time.

BACKGROUND AND CONTEXT

Lehigh Valley Health Network provides care in eastern Pennsylvania and includes the state's busiest Level I trauma center; pediatric and neonatal intensive care units; and regional centers for cardiac, stroke, burns, and cancer care. Its main inpatient hospital, Lehigh Valley Hospital-Cedar Crest (LVH), is the focus of this case study.

In 2002, demand for inpatient beds at LVH exceeded capacity. Construction of additional bed capacity would not be complete until 2007. As a learning organization (Senge 1990), LVH is committed to developing internal talent to overcome challenges. Combining this talent with internal resources, LVH launched a two-year initiative called "Growing Organizational Capacity (GOC)" to meet demand and improve access (MacKenzie et al. 2008). The GOC was powered by a coordinated series of well-programmed, data-driven projects, which significantly improved access and capacity and transformed LVH's way of doing business. Considerable time and effort was spent on building relationships, developing an understanding of total system flow, removing waste, implementing system changes, and establishing metrics to track capacity and throughput issues.

Management at LVH wanted to capitalize on the GOC's success. Budget for fiscal year 2007 was aggressively set and was based on the performance improvement achieved through the GOC. For 2007, the budget was built on a 7 percent admissions growth above the 8 percent increase in admissions attained in 2006. Even though the admissions in early 2007 exceeded those in 2006, by late fall, budget projections were not being met.

Length of stay (LOS) was creeping up, exceeding the budget target by 0.35 days. For a 500-bed hospital like LVH, a 0.1-day LOS higher than expected means a loss of the equivalent of 11 beds. This dramatic effect was experienced at LVH in November and December 2007, with a shortfall of approximately 250 patients. Ultimately, the hospital could not meet community demand, as evidenced by increases in ED diversions and loss of market share. The local controller's report demonstrated that LVH's market would bear a 3 percent growth, but the hospital was underperforming. All internal and external performance indicators signaled that capacity was the constraint.

The budget shortfall in early fiscal year 2007 demanded an efficient and fast 60-day turnaround. With the GOC initiative, management used a complex adaptive systems approach called "clockware" (Zimmerman, Lindberg, and Plsek 2001), a time-consuming, data-driven method. This time, the urgency of the situation required a converse approach to clockware--known as "swarmware" (Burns 2001; Zimmerman, Lindberg, and Plsek 2001). Swarmware projects are idea-driven, short cycle, and limited-resourced, and several may be deployed at the same time. As originally developed by Kevin Kelly (1994), these projects are management processes that explore new possibilities through experimentation, trials, autonomy, and work at the edge of knowledge and experience.

Informed by the lessons from the GOC initiative, management quickly responded, assembling a turnaround team (TAT) to fix the primary cause of financial underperformance--the gradual increase in LOS. The hypothesis was that reducing the LOS would allow patients access through key service points and would return admissions growth rate to budget levels.

METHODS

The chief executive officer set the short-term turnaround expectations and distributed control of the process to the chief medical officer and the chief operating officer, who sponsored TAT (Miro et al. 2003). In turn, they assigned the senior vice president of Clinical Services, chairman of the Emergency Department, and senior vice president of Physician and Hospital Network Development the responsibility for leading the turnaround within 60 days. These three leaders represented both the demand and capacity sides of the complex capacity equation. As supported by Burns (2001), the focus was on actions rather than on plans or designs. The swarmware process was as much about "going to gemba" (going to where the work is done) (1) (Liker 2004) and experimentation as it was about leveraging relationships and processes established in the GOC. It was also about knowing when the goal was "good enough," when the experiment was "good enough," and when the outcome was "good enough."

Structure and Process

The TAT leaders selected a 24-member team representing senior management, physicians, clinical services, and operations from across LVH. The team was supported by the talents of internal resources from Quality and Patient Safety, Finance, Public Affairs, Research, Management Engineering, Information Services, Organizational Development, and Physician and Hospital Network Development (Figure 1).

Each participant in TAT reprioritized his or her workload to accommodate formal meetings weekly and ad hoc project work daily. Also, the most senior leadership group of the organization-clinical chairs, senior vice presidents, and the C-suite--dedicated significant time in its weekly meetings to monitor TAT's progress. The engagement and focus of the entire organization were major contributors to the team's success.

TAT, with approval from the sponsors, resisted the temptation to design overly complicated objectives and instead stayed with two simple and direct goals:

1. Reduce average length of stay to at or below budget.

2. Say "yes" to all patients through key points of access.

The team knew that if these two goals were achieved, the monthly admissions targets would also be met and thus the ultimate aim of turning around the 2007 budget would be attained.

Swarmware includes the notions of autonomy and working at the edge of a knowledge area, such as door-to-balloon time (Feldman 2002). The work of TAT was much more fluid than the work of the GOC, but it had a firm structure:

* The consistent leadership message to the team instilled urgency, not panic. Consideration of how to say the message was as important as the message itself. The message was clear: TAT had to lead the efforts to address the supply and demand problem.

* TAT's structure was both formal (in terms of membership and meeting design) and informal (in terms of group discussion and task processes).

* The actual tasks were performed at the site of the processes and outside of the meeting room.

* TAT members met weekly for 90 minutes. Attendance was mandatory, and a written progress report was required.

* TAT's three leaders maintained the team's focus. They clearly communicated that the meetings were designed for soliciting input and advice and discussing scope creep.

* Timely visual data/goal feedback was provided, including the posting and review of goal progress at the weekly senior leadership meeting. This step was critical to the tone of the work.

Weekly TAT Metrics Development

Because of the short project life cycle of 60 days, measuring and monitoring progress toward the goals became the first major challenge for TAT. Access to weekly, rather than monthly, information was crucial. A data subgroup was commissioned to develop, track, and present pertinent weekly metrics in graphic form so that progress and arising issues would remain visible and current (Figure 2). These weekly metrics were not intended to replace standard hospital operating calculations; rather, they were designed to allow for measurement and monitoring in this experimental process.

[FIGURE 1 OMITTED]

Sponsored by the TAT coleader (chair of the Emergency Department), the data subgroup included representatives from Information Services, Quality and Patient Safety, Finance, and Management Engineering. The subgroup determined how to collect and display actionable, timely information so that the entire team could quickly see results of any implemented changes. The subgroup had to redefine and clarify existing data so that weekly information would be meaningful.

Admissions

Before the formation of TAT, the admissions budget was spread monthly. To track admissions weekly, Finance spread the budget to the weekly level using a Friday-through-Thursday format to accommodate the need for the most current information at the Tuesday weekly meetings.

Average Length of Stay

The normal clinical calculation for average length of stay (ALOS) is based on individual encounters, excluding observation days, reported monthly. This formula was inappropriate for calculating weekly measures, as it would have indicated that ALOS was getting worse instead of better for the weeks in which longer-stay patients were discharged.

The new ALOS measure was calculated based on bed occupancy rather than individual encounters. The new definition for calculating weekly ALOS was acute patient days plus observation days in a given period divided by acute inpatient admits plus observations in that period. Shown as an equation, it is:

Weekly ALOS = (acute patient days + observation days)/ (acute inpatient admits + observation patients)

The standard definition was changed to provide more timely information and to allow the group to monitor trends during experimentation. Progress of the weekly metrics toward the goals was shared openly both electronically, through the web-based Horizon Business Insight (HBI) tool, and on paper, through informal charts posted in the meeting room of the senior leadership group. These reports served to inform all TAT members and all mid- and upper-level managers of the progress of the rapid turnaround work.

Projects and Experimentation

Complexity science was the foundational principle of TAT's work. It included providing minimum specifications, using the swarmware approach, and trying multiple actions to encourage the direction to arise naturally. TAT ultimately performed 20 distinct experiments to achieve its established goals, but in the process the team saw three areas of focus emerge: length of stay, "getting to yes," and capacity management.

Length of Stay

LOS was an obvious focus area, but the strategies employed were not. Two experiments--(1 ) the development of a medical department-based LOS report card and (2) the initiation of the role of complex case manager--were designed to increase attention to variability of practitioner data as well as LOS generated by outlier cases, ultimately to decrease variability and LOS.

Weekly departmental report cards gave department chairs in Medicine, Surgery, and Family Medicine access to overall, group, and individual physician LOS. The LOS information was provided to everyone affected, and, with a few keystrokes, data could be reviewed at the physician level. This data management approach allowed quick availability and transparency of information. Hospitalists were the initial group that TAT studied to understand existing systems. Experiments were conducted to determine the appropriate number of hospitalists needed to manage the patient volume. Different mechanisms were used to decrease LOS, such as resident rounds the evening before an anticipated discharge to prepare all paperwork and rounds by the hospitalist, nurse, and case manager on all long-stay (> 10 days) patients to determine and remove barriers to discharge. TAT found that sharing detailed LOS information, allocating hospitalist resources, and intensely reviewing long-stay patients all contributed to reducing LOS. Work continues to determine additional root causes of LOS issues.

In addition, a complex-case management process was designed quickly, with simple analysis, and was implemented for experimentation. One case manager was added to see all the outlier longer-stay patients referred to him or her by the unit case manager. The unit case manager could then pay attention to the utilization review and discharge planning functions for the majority of patients, while the additional case manager handled, on a one-by-one basis, those challenging longer-stay patients. The weekly LOS metrics allowed TAT to validate the effectiveness of this approach.

Getting to Yes

TAT's second goal of saying "yes" to all admissions or potential admissions allowed the hospital's access doors to remain open. The hospital's ability to accept patients through all access points was hampered by ED diversions and Transfer Center delays. Therefore, efforts were focused on "diversion aversion" and Transfer Center (2) acceptance.

Diversion aversion was supported by surge capacity mechanisms and patient transfers from the ED to a holding space or assigned inpatient bed. Surge capacity mechanisms included (1) an electronic alert system that informs major clinical stakeholders of anticipated diversion and (2) utilization of the Express Admissions unit (3) and cardiovascular holding areas (4) for patients awaiting admission as space allowed.

The automated bed management system implemented for the GOC initiative enabled the team to immediately know when patients had been discharged and had vacated their room. This alert occurred via an automated phone message placed by the discharging transporter signaling the bed was ready for cleaning. Once the bed was fully cleaned and readied, another phone message signaled the ED to transfer the patient. TAT members experimented with moving the patient before or during the discharge bed cleaning. Clear prioritization of cleaning allowed for the bed to be available upon arrival of the patient, not sitting idle as it had in the past until the next inpatient arrived. Preparing and moving the patient in a parallel process with bed cleaning saved minutes of occupancy in the ED for admitted patients, in effect adding to the hospital's capacity to say "yes."

The Transfer Center was established for the GOC initiative as a means of managing capacity. Increased demand placed additional pressure on those processes. Simply experimenting with rescripting the Transfer Center employees' message played a large role in improving access for the referral hospitals. Before the formation of TAT, staff at the Transfer Center informed referring facilities of a delay in bed assignment, which resulted in a transfer to another facility rather than waiting until beds became available. As a result of TAT's work, Transfer Center personnel changed their message to "yes" on the first call from referrers. Then, working behind the scenes, the Transfer Center communicated with units and moved patients as necessary without inconveniencing referral centers with a delay or having to place a second call.

Capacity Management

One area not previously addressed by the GOC initiative was the impact of isolation beds on capacity. In an environment of semiprivate rooms, taking beds out of service because of isolation restrictions limits capacity. TAT experimented with various methods of managing isolation capacity and bed utilization.

Rounds by infection control practitioners were initiated to review necessity of isolation precautions on all patients. Many times, isolation patients were placed in semiprivate rooms, thereby consuming two beds rather than one. Infection control practitioners, in collaboration with the physicians, were aggressive in assessing the medical necessity of isolation. This vigilant review allowed expeditious movement to cohort patients, promoted discontinuation of isolation, or led to decisions against placing a patient in isolation initially.

RESULTS

The hospital's rapid turnaround efforts through experimentation produced the results that enabled the achievement of TAT's two goals. First, the length of stay was reduced to 0.1 days below budget within the 60-day time frame. Second, the hospital said "yes" to all patients presenting through key points of access by decreasing Transfer Center denials to 0 in 19 days and monthly ED diversions from 110 hours to 20 hours, also within the 60-day time period.

By better managing the capacity, TAT created additional bed capacity, allowing the hospital to accommodate community demand, exceed the budgeted admissions target, and stabilize its market share. In addition, TAT continued to build the organization's human capacity so that staff could respond quickly to external environmental challenges. TAT captured its learnings and shared them with senior leadership and mid-level leadership:

* Weekly measurement, meetings, and progress reports are critical.

* Work must happen "outside the room."

* The ability to collaborate across function produces great results.

* Success is driven by strong leadership and an engaged, talented, flexible group.

* The hospital can say "yes" to each patient.

* Transparency of data is essential.

TAT recognizes that constant vigilance is needed and that this type of work is never done. While TAT accomplished its two immediate goals, the team is aware that sustainability of these improvements remains a challenge. TAT has taken steps to hardwire the new processes into hospital operating standards so that everyone can closely monitor trends in admissions, length of stay, and capacity. Hardwiring was emphasized in the following areas to maintain the gains achieved:

* HBI e-mail alerts regarding weekly variances from budget are sent to accountable managers.

* At their weekly meetings, members of the Senior Management Council (SMC) report (either monthly or more frequently) on the LOS numbers in their areas and provide detailed action steps for improvement when warranted. SMC (Lehigh Valley Health Network's senior leadership group) comprises about 30 executives, including the chief executive officer, chief medical officer, chief operating officer, chief information officer, chief financial officer, chief nursing officer, medical staff president, medical staff president-elect, senior vice presidents, and departmental chairs.

* The Capacity Throughput Council (CTC), a cross-functional network of hospital and physician leaders, provides ongoing LOS and admissions oversight. Every month, CTC works on at least one project that is an outgrowth of TAT's efforts, and then the group gives an update to senior leadership regularly.

* LOS and admissions goals are part of management and executive incentive plans.

DISCUSSION

The rapid experimentation process for this project has become the precursor for the Lean methodologies that the hospital is currently incorporating. Regardless of project management approaches, effectively addressing capacity management is difficult (Yancer et al. 2006; Pew 2004; Forster et al. 2003), and little literature on doing so exists (Bazzoli et al. 2003). Failure of capacity management efforts has tremendous consequences on financial performance (Falvo et al. 2007; Bayley et al. 2005; Gregory, Baigelman, and Wilson 2003).

In this article, several individual capacity solutions have been presented that may work for some institutions. Of course, no one-size-fits-all solution exists, but TAT's experience with swarmware, the capacity management approach used for this project, shows that this method can effectively attack capacity problems. Following are fundamental guidelines for organizational leaders and management who intend to try swarmware:

* The tendency to rely on past project management skills and strategies is strong. However, leaders must be willing to "experiment with experimentation." While novel, experimentation can be successful if performed with focus and an understanding of the swarmware concept.

* Organizational and operational leaders must have the fortitude to lead a capacity enhancement agenda and provide a risk-free environment for experimentation. The organization must be ready and prepare everyone for the change, especially its administrative and physician stakeholders (Burns 2001; Plsek and Greenhalgh 2001; Zimmerman, Lindberg, and Plsek 2001).

* Support resources (e.g., information technology, organizational development, management engineering, quality management) must be capable and available to assist management and teams in experimenting with and implementing solutions. Also, these resources must be able to help with understanding and mapping every step, encounter, and variable in an inpatient stay.

* Leaders must be skilled in change management processes and capacity enhancement strategies and must be dedicated to operations improvement.

Also, they must have the patience to accurately define the problem and bravely experiment with potential solutions.

* Leaders must be fearless in dealing with ambiguity and be adaptable in a world of anecdotes and imperfect data. A large organization can reverse a negative trend in only two months using several action-oriented (not analysis-oriented), empowered teams (Burns 2001).

* A commitment to ongoing measurement of progress and hardwiring gains into existing processes is critical to the continued success of such an initiative.

Some of these fundamentals revolve around adequate infrastructure and knowledge, but healthcare delivery remains a personal service, with employees at its heart. From the CEO's willingness to establish the rationale for a capacity agenda to the sponsors' and leaders' enthusiasm in mobilizing the capacity effort to the managers' and frontline staffs' ability to bring the capacity enhancements to life, the entire organizational workforce must be engaged in the proposition that improved throughput means higher-quality care at lower cost. Managing capacity demands the discipline of clockware sometimes and the experimentation of swarmware the rest of the time. Even when organizations are inexperienced with either approach, simply recognizing strengths and weaknesses will help in navigating obstacles.

Improving bed capacity and inpatient care delivery with available resources is smart management today and required for managers in the future, as capacity issues will continue to challenge hospital leadership. Healthcare leaders need to make more efficient use of current facilities while still improving quality and outcomes. Those organizations unable to find their unique solution to capacity management will be at a distinct competitive and financial disadvantage; this will be the collective challenge for the next generation of healthcare leaders.

REFERENCES

Bayley, M. D., J. Schwartz, F. Shofer, M. Weiner, F. Sites, K. Traber, and I. Hollander. 2005. "The Financial Burden of Emergency Department Congestion and Hospital Crowding for Chest Pain Patients Awaiting Admission." Annals of Emergency Medicine 45 (2): 110-17.

Bazzoli, G. J., L. R. Brewster, G. Liu, and S. Kuo. 2003. "Does H.S. Hospital Capacity Need to Be Expanded? Health Affairs 22 (6): 40-54.

Berwick, D. M. 1996. "A Primer on Leading the Improvement of Systems." British Medical Journal 312 (7031): 619-22.

Burns, 1. P. 2001. "Complexity Science and Leadership in Healthcare." Journal of Nursing Administration 31 (10): 474-82.

Emergency Nurses Association. 2006. "Emergency Nurses Association Position Statement: Crowding in the Emergency Department." Journal of Emergency Nursing 32 (1): 42-47.

Falvo, T., L. Grove, R. Stachura, D. Vega, R. Stike, M. Schlenker, and W. Zirkin. 2007. "The Opportunity Loss of Boarding Admitted Patients in the Emergency Department." Academic Emergency Medicine 14 (4): 332-37.

Feldman, I. A. 2002. "A Call to Action on Emergency Department Overload and Diversion." Academic Emergency Medicine 9 (8): 866-67.

Forster, A. l., I. Stiell, G. Wells, A. I. Lee, and C. van Walraven. 2003. "The Effect of Hospital Occupancy on Emergency Department Length of Stay and Patient Disposition." Academic Emergency Medicine 10 (2): 127-33.

Gregory, D. W., W. Baigelman, and I. B. Wilson. 2003. "Hospital Economics of the Hospitalist." Health Services Research 38 (3): 905-18.

Kelly, K. 1994. The Rise of Neo-Biological Civilization. Reading, MA: Addison-Wesley.

Liker, J. K. 2004. The Toyota Way, 224-25. New York: McGraw-Hill.

MacKenzie, R., T. Capuano, L. Durishin, G. Stern, and I. Burke. 2008. "Growing Organizational Capacity Through a Systems Approach: One Health Network's Experience." Joint Commission Journal on Quality and Patient Safety 34 (2): 63-73.

Miro, O., M. Sanchez, G. Espinosa, B. Coll-Vinent, E. Bragulat, and I. Milla. 2003. "Analysis of Patient Flow in the Emergency Department and the Effect of an Extensive Reorganisation." Emergency Medicine Journal 20 (2): 143-48; discussion, 148.

Pew, C. 2004. Managing Patient Flow: Strategies and Solutions for Addressing Hospital Overcrowding, 2, 8, 19, 63-97. Oakbrook Terrace, IL: Joint Commission Resources.

Plsek, P. E., and T. Greenhalgh. 2001. "Complexity Science: The Challenge of Complexity in Health Care" [comment]. British Medical Journal 323 (7313): 625-28.

Richardson, L., B. Asplin, and R. Lowe. 2002. "Emergency Department Crowding as a Health Policy Issue: Past Development, Future Directions." Annals of Emergency Medicine 40 (4): 388-93.

Senge, P. 1990. The Fifth Discipline: The Art & Practice of the Learning Organization. New York: Doubleday.

Yancer, D. A., D. Foshee, H. Cole, R. Beauchamp, W. de la Pena, T. Keefe, W. Smith, K. Zimmerman, M. Lavine, and B. Toops. 2006. "Managing Capacity to Reduce Emergency Department Overcrowding and Ambulance Diversions." Joint Commission Journal on Quality and Patient Safety 32 (5): 239-45.

Zimmerman, B., C. Lindberg, and P. Plsek. 2001. Edgeware: Insights from Complexity Science for Health Care Leaders, 2nd ed., 271. Irving, TX: VHA Inc.

PRACTITIONER APPLICATION

James Burhe, FACHE, chief operating officer, Hahnemann University Hospital, Philadelphia, Pennsylvania

With more than 25 years of healthcare leadership experience, I have had success in developing and implementing operations improvement strategies while working with key physicians and other stakeholders on strategic initiatives and cost-reduction projects within three major Pennsylvania healthcare systems. As chief operating officer of the inner-city academic medical center Hahnemann University Hospital, I am intimately familiar with emergency department overcrowding, the solutions to which depend on efficiency gains rather than new bricks-and-mortar capacity. In my former role as an operational leader at Lehigh Valley Health Network (LVHN), I applied the clockware complex adaptive systems approach to achieve the 7 percent admissions growth (as noted in the article) with no new physical capacity. I know the methodology works and have since used it at Hahnemann, most recently in work that received five CIGNA quality designations. The CIGNA designations are based on a hospital's effectiveness in treating a selected condition or performing a selected procedure. The designation measures and weighs complications, mortality, and the Leapfrog Group's Patient Safety Index.

The authors of this article built on their learning from the complex adaptive systems' clockware approach in testing swarmware. LVHN is committed to continually growing its internal talent; it has the human capability to efficiently experiment with swarmware. Another area of strength for LVHN is its access to data. While difficulties in translating all of the data into information do arise, there is sufficient evidence in this article to support the contention that LVHN is successful in capturing and reporting information in a meaningful way to allow for solid management decisions.

All healthcare leaders may benefit from the application of swarmware in efficiently managing capaciW, as the authors suggest. The authors, however, recognize that their working environment has some unique elements that may limit direct application of their methodology. First, LVHN's senior leadership exhibits the tolerance for experimentation, failure, and success. Second, they are dedicated to allocating internal support resources, especially in terms of data collection, analysis, and reporting. Finally, the organization has highly evolved quality, management engineering, and development functions, which strongly support project leaders through major improvement initiatives such as the implementation of the turnaround team.

Both the clockware and swarmware complex adaptive systems should be considered as leaders strategize to manage capacity constraints with ever-shrinking revenue streams. Regardless of the health policies that emerge from the Obama administration, we can expect our healthcare reimbursement revenue stream to be reduced more aggressively. In Pennsylvania, we can expect malpractice premiums to continue to constrain our attractiveness to physicians in a tight supply environment. In simple economics terms, we have a major supply-and-demand issue that needs to be managed.

The U.S. population continues to age, putting greater demands on our inpatient beds at a time when our financial and human resources to care for those higher-acuity, more complex patients continue to diminish. Each healthcare organization must continue to experiment with alternative methodologies for continuous improvement and efficiency. Lean and Six Sigma methodologies prevalent in manufacturing are additional areas worthy of experimentation. The approach that will yield success for an organization depends on that organization's infrastructure and philosophy. What is not negotiable is the need to better balance supply and demand, primarily through eliminating system waste and maximizing capacity.

NOTES

(1.) Gemba is a Japanese term meaning "the place where the truth can be found." In quality management, gemba is the idea that management must go to where the work is actually done and gather information from all sources to understand the problem that is affecting everything else.

(2.) The Transfer Center is a centralized location where referring hospitals and physicians can call to request and obtain transfer to LVH.

(3.) Express Admissions is a unit dedicated to the admission of patients through direct means or through the ED. The unit completes admission assignments, paperwork, and orders before a patient is placed in an inpatient bed.

(4.) The cardiovascular holding areas are dedicated to the pre- and post-procedure care of patients undergoing cardiovascular interventions.

For more information on the concepts in this article, please contact Ms. Capuano at Terry. [e-mail].

Terry Capuano, RN, senior vice president, Clinical Services, Lehigh Valley Health Network, Allentown, Pennsylvania; Richard MacKenzie, MD, vice chair, Department of Emergency Medicine, Lehigh Valley Health Network; Kristi Pintar, corporate director, Penn Medicine Academy, University of Pennsylvania Health System, Philadelphia; Deborah Halkins, director, Management Engineering, Lehigh Valley Health Network; and Brian Nester, DO, senior vice president, Physician Hospital Network Development, Lehigh Valley Health Network

FIGURE 2
Weekly Progress Update

                            Month

Sunday         Monday       Tuesday        Wednesday

5              6            7              8
IS processes   Data         Paper charts   Electronic
data           available    displayed in   charts made
               from prior   TAT meeting    available
               week         room           to network
                                           leadership
               Data         TAT full       at Senior
               verified,    membership     Management
               charts       meeting        Council
               prepared                    meeting
                            Paper charts
               Electronic   moved to
               charts       boardroom
               previewed    for display
               at TAT
               leadership
               meeting

               Month

Thursday       Friday       Saturday

9              10           11
Data cut off   Start new
at midnight    data week

Note: IS = Information Systems department