Vanderbilt University Medical Center didn't seem to have enough beds. A recent evident bed shortage forced staff to place patients in any available bed space, including empty beds in the emergency department and intensive care unit. At one point, 30 or 40 patients were boarded in the ED each night while staff waited for inpatient beds to become available.
To keep patients in the units in which they belonged, VUMC did what most hospitals would probably do: It opened a brand new 70-bed patient wing. Unfortunately, this did nothing to solve capacity problems, and staff continued to have difficulties accommodating inpatients. Having filled the new wing with patients, boarding patients in the wrong areas and still facing a buildup of patients, the hospital was at a loss. During April 2013, it finally brought in consultants.
"[Providers] are scientists — they respond to data and information," says Don McCall, a senior partner at Kurt Salmon, the New York City-based healthcare consulting firm VUMC called in to streamline their patient flow problem. To make the data clear, Kurt Salmon consultants walked VUMC staff through upstream and downstream of several patient processes to tease out the origin of the capacity problems.
"We began to look at patient care streams — the way the patient actually accesses care. We saw providers communicating together but not solving issues together. They weren't looking at the process cross-functionally," says Mr. McCall, identifying the source of the patient build-up. "So we evaluated the non-value in the VUMC system from the patient perspective to quantify the non-value time in the patient's stay — and when you have a throughput issue, you have a lot of non-value time."
To understand where patients were falling through the cracks, they examined instances where patients were waiting or delayed, or where staff had to repeat procedures or tests.
Cross-functional teams shed light on exactly what each department was doing and how it related to other departments, illuminating the root cause of the problem: delays in discharge and admission.
The hospital discovered 50 percent of a patient's admission and discharge days were non-value time; that is, the patient was spending nearly 20 of those 48 hours just waiting, which was creating significant delays in bed space and blockages in patient flow. To compound matters, when patients were boarded in any open bed rather than in appropriate wards, separations between care and patients created further inefficiencies, feeding a positive feedback loop.
This examination of care streams led to a permanent, more collaborative restructuring of patient care at the hospital. VUMC was able to use the insights to improve algorithms for bed placement, accommodating patients in specialty units when necessary rather than the ED or ICU. On wards, VUMC reduced delays by locating care supplies exactly where they were needed. This saved providers' time when calling for items like stretchers, which, for example, had been previously located only in the hospital's basement and had to be retrieved before each use. Cross-collaboration among departments also led to improvements in discharge planning and care coordination through better information collection. Information was collected in enough time to prevent delays and wait times for both caregivers and patients.
In the end, by examining how one care process is linked to the ones preceding and following it, VUMC increased its ability to admit patients by 10 percent, an additional 5,000 to 6,000 patients per year. The hospital also added a significant amount —$32 million — to its bottom line over nine months.
Non-value added time is a common problem, according to Mr. McCall, who says caregivers can't always see where the problems are, though they may have the best of intentions. He recommends that hospital leaders work with a patient advocate committee to understand where patients see potential for change that might not be obvious from the provider side.
"It's like the clinical decision model for a process — running diagnostics on a system instead of a patient," he says. So what can other hospitals do to identify and eliminate non value-added time? "It's a classic question. Follow the patient through what's happening to them when they're in your hospital, and measure it."