Every department in your facility is engaged in a hospital-wide system of patient flow or patient care.
The emergency department is connected to the ICU. The ICU is connected to the OR. Discharge and discharge processes are connected to admission capabilities and capacity. You may think that the complexity and interconnectedness of the patient care system makes waits and delays inevitable, but that's not actually the case.
Overall flow can be improved by applying these key strategic concepts to these disparate but equal parts.
Match Demand to Capacity
How do you match demand and capacity? You can predict demand by reviewing your historical data and matching service capacity to patient demands. The most effective approach is to develop hourly patient flow predictions. You should also implement a real-time dashboard for key operational cycle times and then measure, monitor, and service them. Don't forget to include the perspective and concerns of your team members. Demand-capacity management is critically important and to get it right you'll need planning, foresight, and action.
Monitor Real Time Patient Flow
Without an inpatient flow dashboard you are doing little more than managing chaos. The dashboard can be as simple as a grease board or as complex as a comprehensive electronic system. Whatever type of system you implement, it should:
• Grade how busy your units are
• Enable you to put a temporary halt to new admissions while you manage the patients you have
• Monitor hospital-wide patient flow
• Disseminate this information in real-time to all of the key departments and personnel.
Forecast
With good data and an adequate model, you can predict patient flow and unscheduled arrivals with about 80-85 percent accuracy. How many Friday nights does it take before you decide your next Friday night is going to be different? How many flu seasons does it take before you decide your next flu season's going to be different? Patient flow is predictable. The key questions are:
• How many patients are coming?
• When are they coming?
• What are they going to need?
• Is our service capacity going to match patient demand?
Match Fixed Resources to Unscheduled Demand
Queuing theory is the art and science of matching fixed resources to unscheduled demand. Your emergency department is essentially a queuing system. As utilization rises above 80-85 percent, waits and rejections increase exponentially. There is simply no way you can run a queuing system at 100 percent utilization. You want to be at about 80 to 85 percent. In unit after unit where they have been able to drop down to even 90 percent utilization, hospitals are better able to handle the inflows and the variation. As a result, throughput goes up, margins go up, and healthcare worker satisfaction goes up. Finally, patient satisfaction rises as waiting times decrease.
Identify and Eliminate Bottlenecks
One of the most effective ways to identify and then eliminate bottlenecks is through a methodology called the Theory of Constraints (TOC), a highly focused process for creating rapid improvement. The key is to identify the most important limiting factor that stands in the way of achieving your goal and then systematically improving it until it no longer causes a bottleneck. The key principles are:
• Patient care is a network of queues and service transitions.
• An hour lost at a bottleneck is an hour lost for the whole system.
• Time saved at a non-bottleneck is a mirage.
• Efforts spent improving a non-critical bottleneck will not improve the overall performance of your process or system.
Manage Variation
There are multiple sources of variation in healthcare. Are all sick patients the same? Is every congestive heart failure patient the same as every other congestive heart failure patient? The answer is a resounding no. There is clinical variability, flow variability, variability in our processes and variability in how people work. Each of these sources of variation is additive. They do not cancel out each other; they add up. Look at the variation in patients, processes and service delivery and think about what that does to your systems. Some of the key points are:
• Focus on operational efficiency
• Prioritize available resources
• Flexed responses
• Flexible scheduling
• Predict demand, smooth demand and improve the accuracy of your predictions.
Define Your Aim
A system must have an aim. Without one, there is no system. Your aim must be clear to everyone in the system, otherwise you will have good people working under significantly different priorities. For some people, it's patient safety. For others, it's patient satisfaction. For some, it's patient flow. It could also be workforce satisfaction or controlling costs. Look at patient flow and operations through a global lens to optimize the entire system.
Conclusion
You can't have every part of the system busy all of the time and have a system that's optimized and performing perfectly. Some components of the system need sufficient slack to take up some of the work of the other parts of the system. You cannot have every part of the system functioning at 100% utilization or capacity if you want flow through the system to be maximized. The larger the system, the harder it is to optimize, but the greater the total benefits. The work may be hard, but the results are gratifying. The number one reason to get this right is that it is good for your patients and the people who take care of them.
Dr. Kirk Jensen is an executive vice president for EmCare, where he leads innovation initiatives and develops operational best practices
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