Improving patient flow.

As the 2007 ACPE Quality of Care Survey showed, hospitals today are facing several simultaneous challenges that are straining their existing capacity and driving the need for improved patient flow.

Increasing patient demand for services, clinical staffing shortages, lack of technology and tools to adequately measure and manage patient flow and, in some markets fewer available beds due to hospital consolidation or closure, are just a few of these pressures.

The impact of these challenges is wide-ranging, causing back-ups at key points of entry to the hospital, such as patient admitting areas, the emergency department or operating rooms (ORs), and delays and inefficiencies in discharging patients as well.

As these problems worsen, so do their outcomes--frustrated physicians, unhappy patients and families, and stressed and unmotivated employees.

Many areas of the hospital need to work together to identify and resolve patient flow problems. Patient placement and transfer personnel, nursing, case management, environmental services, patient transport, and social work all play important roles.

However, physicians are key players in improving patient flow efficiency and effectiveness, as well as the quality of care that relates to patient flow. Physicians control critical aspects of the care delivery process, including which patients get admitted to the hospital and when, the reasons for their admission and when they get discharged.

Involving physicians is important to the success of any large-scale patient flow improvement initiative. Achieving smooth, efficient patient flow requires ongoing physician executive sponsorship, leadership and participation, not only during the improvement process itself, but for the long-term, to ensure that change for the better lasts.

St. Luke's patient flow project

While many factors contributed to the need to improve hospital patient flow efficiency, our primary objective was to increase effective bed capacity. We were experiencing an ongoing capacity crunch on our medical, surgical, cardiac and other inpatient units and especially in critical care areas such as the intensive care unit (ICU).

Our organization also had established an affiliation with the Baylor College of Medicine that we anticipated would further increase patient admissions. In addition, our hospital's inner-city location limits our ability to add new beds and makes hospital expansion costly.

We engaged a consulting partner to conduct a comprehensive assessment of the people, work processes, tools and technology involved in hospital patient flow activities, to help identify and prioritize opportunities for improvement and to assist us in implementing solutions.

The assessment indicated the potential to improve effective hospital capacity by 5 to 7 percent, creating an opportunity to serve more than 1,400 additional inpatients each year. Important objectives included:

* Establishing a cohesive and consistent approach to managing patient flow activities, such as streamlining admission and discharge processes and effectively monitoring and reporting on holistic patient flow status and performance.

* Increasing access to hospital services by reducing patient waiting and transfer times.

* Improving patient safety, quality outcomes and consistency of care through better communication among interdisciplinary care team members. Identifying and applying Centers for Medicare and Medicaid Services (CMS) core measures and educating patients in a timely manner.

* Improving patient/family satisfaction by increasing their awareness of and participation in plans for patient care and discharge.

* Improving employee job performance and enhancing the consistency, accuracy and availability of decision-making data by implementing efficient and effective work drivers and reporting tools.

* Optimizing existing and new technology to better enable processes and employee accountability.

* Improving overall employee satisfaction and productivity through focused training and coaching.

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* Enabling and supporting more efficient participation of physicians in patient flow processes.

We began our patient flow improvement project in April 2005, focusing our efforts in the following three areas and consistently measuring and monitoring our performance.

Appropriate use of available assets

Activities included:

* Implementing appropriate house management roles, processes and communication protocols

* Forecasting demand for service

* Determining bed cleaning priorities and turnaround targets

* Aligning staffing levels with peak activity

* Providing real-time access to bed status and availability through integrated technology

Facilitation of timely patient transitions

Activities included:

* Designing a case management model and roles

* Facilitating timely rounding and ordering processes

* Ensuring timely completion of ancillary patient care

* Applying standard utilization review criteria

* Securing extended authorizations

* Creating accountability for proactive transition planning

* Improving communication and coordination between case managers, physicians and nurses

* Optimizing existing discharge planning and utilization review work drivers and reporting

Providing consistent, timely and high-quality care

Activities included:

* Conducting daily interdisciplinary care coordination meetings on each nursing unit to improve consistency and quality of care

* Expediting appropriate progression for all patients; anticipating and communicating discharges

* Implementing customized care coordination work drivers and reporting; driving concurrent interventions

* Increasing patient and family understanding of and involvement in the patient's plan of care.

St. Luke's 11-month patient flow improvement initiative produced the following results:

* A 5.1 percent improvement in overall capacity, enabling the hospital to serve some 1,420 additional patients per year and creating 23 additional "virtual" beds through improved used of existing assets

* A reduction of four hours in patient length of stay

* An accuracy rate of 93 percent in next-day discharge prediction by patient volume

* An 85 percent increase in the number of bed requests managed by the patient placement department

* A 76 percent improvement in bed turnaround time 

* A 48 percentage point increase in case management initial assessments completed within one day of patient admission

* A 40 percent decrease in bed assignment time, with a significantly higher volume of patients placed through the placement department

* A 38 percent improvement in discharge response time and transportation efficiency

The physician connection

Engaging our independent medical staff in improving patient flow was a challenge for several reasons. Our staff is large (about 2,000 physicians), somewhat geographically dispersed, and unlike employees, not directly under the control of the hospital.

Physicians also at times perceive their interests to be different from, rather than aligned with, the hospital's goals. For example, while hospitals want to move patients through resource-constrained areas such as the ICU more efficiently, physicians take a great deal of comfort from knowing their patients are being cared for in a high-resource area where they will receive lots of focus and attention.

Physicians also have been trained to take care of their patients in ways that may seem opposed to the goals of more efficient patient flow. For example, during their medical training, physicians are taught to visit their sickest patients first each day to monitor their progress, and then move on to patients who are doing well and may be ready for discharge.

Optimizing patient flow suggests the opposite approach--having physicians first take care of patients who are less sick or ready for discharge and then move on to sicker patients who will likely need to remain in the hospital longer.

To address this issue we needed to help our physicians balance their concern for the needs of individual patients with the broader societal concern for maximizing the number of patients who can gain access to the hospital resources they need.

In this situation, physician executives can play a key role in helping physicians understand how more efficient patient flow benefits physicians and their patients, as well as the hospital.

Our first step was to make the case for improving patient flow to physician leadership, then the medical executive committee and then the medical staff as a whole. Using existing meetings and forums, as well as our physician publication "Rounds," we introduced our patient flow improvement initiative and explained how the effort would help address common problems.

For example, our physicians were frustrated for several reasons. Referring physicians in the community who wanted to transfer their patients to St. Luke's could not admit them because no beds were available. Patients also were complaining to their doctors about long waiting times in the emergency department and admitting areas.

We explained that physicians could help the hospital reduce delays and make more beds available by ensuring their patients move smoothly through care delivery and discharge. We encouraged our physicians to participate in daily care coordination meetings with other members of the patient care team and to make sure they wrote timely discharge orders and prescriptions--examples of activities that would help achieve our mutual goals.

Because improving patient flow is a multidisciplinary effort, we also promoted the importance of teamwork with our physicians. We encouraged them to participate fully and visibly in helping to increase patient flow efficiency by ensuring they completed their own tasks in a timely manner and by attending medical staff and employee meetings where patient flow issues were discussed, so that it was easy for all to see that everyone was doing their part.

Hospital executive leadership also broadly communicated that the patient flow improvement effort was among the hospital's three primary goals for 2006, making it clear that the effort was a priority that would receive top leadership attention and support.

To further help align both physician and hospital interests, we also encouraged our physicians to see patients almost ready to leave the hospital at the end of their rounds on the evening before the anticipated day of discharge. We arranged for these patients and their family members to be present so that our physicians could talk with them about the pending discharge and provide discharge and medication instructions.

Physicians then informed nursing staff that if these patients continued to improve through the night, they could be discharged the following morning, without the need for the physician to see the patient again. In this way, physicians could ensure that their patients received the care they needed and the hospital could free up needed beds earlier in the day to admit new patients.

As the patient flow improvement initiative progressed, hospital leaders made sure to regularly update physicians, employees, the governing board and other key stakeholders about our progress and their important role in helping us achieve our goals. We engaged a variety of physician and other champions to help sponsor and support the effort. We also took time to celebrate our successes and publicly reward participants.

Physicians began to see the benefits of improving patient flow. They reported, for example, that after care coordination meetings case managers and other staff would approach them more frequently with questions that would help speed along patient discharge and enable them to participate more easily in the process. Feedback like this helped us see that physicians were beginning to help St. Luke's make its patient flow improvement goals a reality.

Keys to success

The success of large-scale performance improvement efforts, such as St. Luke's patient flow initiative, depends on vision and commitment from the top. Physician executives can play an important role in launching and sustaining such an effort by:

* Setting the tone. Executive leaders, and particularly physician executives, must demonstrate their commitment to significant change efforts. The chief executive officer and his or her team should make it clear upfront to the entire organization why the hospital is undertaking this type of initiative and that it is a top priority.

* Engaging clinical leadership. One or two top executives will not be enough to lead the charge. Large-scale performance improvement efforts require visible sponsorship from key executives and physician leaders throughout the process to ensure success. St. Luke's chief medical officer and chief nursing officer cosponsored our patient flow improvement project. Our hospitalists also participated in leading key change efforts. Ongoing leadership involvement is critical, not only to emphasize that the project is a top priority, but also to help move the process along by getting issues resolved, making decisions, committing resources to the endeavor, motivating and rewarding participants and minimizing obstacles to change. Don't underestimate the importance of getting buy-in and involving physician leadership in improving performance. Without their support, the medical staff is unlikely to get involved.

* Measuring and monitoring performance. It's amazing what a difference measurement makes. Performance improvement doesn't happen in an ongoing, sustainable way unless baseline performance is identified, followed by routine measurement of performance compared to the baseline. Make sure that performance measures and goals are established at the outset of any improvement initiative and that everyone knows performance will continue to be measured and results reported. Once people know that their performance is being measured and that they are responsible for their own as well as the organization's overall success, tremendous improvements begin to occur.

* Setting consistent goals. It's important to set goals that support all project objectives and avoid goals that place project objectives in conflict. For example, to ensure that we improved both the efficiency and quality of patient flow processes, we set a room cleaning goal of 30 minutes. We wanted our housekeepers to turn around a room in no more than 30 minutes, but we also didn't want them to spend less time than that because we knew it would be difficult to do a quality cleaning job in under a half hour.

* Leveraging technology to drive process improvement. Prior to the project, St. Luke's had focused for a number of years on improving patient flow. But we didn't have adequate, automated tools and reporting to help us measure and manage change, nor the resources to integrate such tools with the work processes needed to drive significant performance improvement. Frequently, organizations only realize a few of the potential benefits from new systems or technology they implement because they don't take into account the people, processes and tools that must work together to achieve real, lasting performance improvement. Our consulting partner provided process enhancements to our electronic bed board, housekeeping tracking, transportation tracking and case management technology, along with care coordination work drivers, a performance dashboard and management reporting. These resources helped provide the work drivers and management information we needed to understand, monitor and improve our patient flow performance for the long term.

* Sharing data and providing feedback. While it was important for us to give regular feedback to the entire organization about progress on the patient flow improvement project, sharing performance data with our physicians was critical. We communicated regularly with our physicians, sharing data, explaining project goals and the physician's role in achieving them; interpreting the significance of project results and enlisting physicians' suggestions and advice. We also encouraged physicians to participate fully in the process because, without their support, the initiative would not be successful.

* Celebrating success. Significant performance improvement and goal achievement deserve to be recognized and rewarded. We took the opportunity to praise and reward departments and individuals directly involved in improving patient flow, as well as support areas, such as information technology, that also were key to success.

Our patient flow improvement initiative not only achieved its objectives, but also is helping St. Luke's achieve its strategic goals:

* Furthering our relationship with the Baylor College of Medicine

* Increasing our ability to treat more patients more effectively, especially those who are sicker and need the resources our tertiary hospital can provide

* Making our current assets more productive, which helps eliminate wasted expense and improve overall profitability

Improving patient flow also helps us better serve one of our most important customers--our physicians. Their support and involvement is helping us better meet their needs, which in turn, provides better care to patients and the communities we serve.

David C. Pate, MD, JD, is senior vice president of St. Luke's Episcopal Health System, and chief executive officer of St. Luke's Episcopal Hospital in Houston, Texas. He can be reached at [e-mail]

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Michael Puffe is director of Stockamp & Associates, a consulting firm that provides revenue improvement solutions for health care organizations. He can be reached at [e-mail].

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By David C. Pate, MD, JD, and Michael Puffe