On January 10th, TeleTracking held a webinar in conjunction with The Joint Commission discussing tactics for managing patient flow in hospitals.
Ann Scott Blouin, RN, PHD, executive vice president of customer relations at The Joint Commision, Cynthia Leslie, associate director of the standards interpretation group at The Joint Commission and Nanne Finis, vice president of consulting services at TeleTracking, spoke on symptoms of suboptimal patient flow, ways to address these issues and outlined two new patient flow-related standards from The Joint Commission.
Hospitals ideally want to keep patients moving through their system with efficiency. When hospitals efficiently keep patients moving through their system at the highest care quality, they are operating at optimal patient flow, Dr. Blouin said.
"[The] patient gets the right type of cure at the right time at the location without waiting or delays. There's no significant queue to get care," she says.
In order for hospitals to initiate a movement to improve patient flow, they first need to identify symptoms and characteristics of suboptimal patient flow.
Symptoms and causes of suboptimal patient flow
Dr. Blouin said many hospitals point fingers at a backed-up emergency department as the cause of patient flow issues when in reality it is a side effect of poor patient flow.
"You see long wait times all over the hospital, ambulance diversion from emergency department because they're full, patients leaving without being seen because they're frustrated, boarding and observation cases," she said, adding that all these symptoms contribute to an increased overall length of stay.
A number of factors play a role in causing patient flow issues, said Dr. Blouin, including insufficient numbers of hospital beds, saving beds for transfer patients and overusing telemetry, such as CT scans and ultrasounds. Dr. Blouin said physician-perceived legal risks often play a role in overusing telemetry because they don't want to fall short of adequate diagnostic testing.
"Routine use of CT scans and ultrasounds cause people to wait not only to have the test done, but also to wait for results," Dr. Blouin said.
The lack of resources for psychiatric care patients can also lay a burden on patient flow.
"Substantial decreases in psychiatric care options really result in increased number of behavioral health patients being boarded who have mental health and substance abuse issues," Dr. Blouin said. "They are problematic not just in a patient care perspective but also in a lack of familiarity in treating those types of patients."
Assessing patient flow
Once a hospital identifies a need to improve patient flow, they next have to examine certain metrics that are affecting their current flow.
First, Dr. Blouin said to take note of metrics in the inpatient area such as HCAHPS scores and how long patients are waiting for something to happen.
The perioperative area presents a number of metrics to analyze, Dr. Blouin said, mentioning hospitals should look at how fast beds are being turned over and the amount of time it takes to move a patient into the room, how long the procedure takes and then moving the patient out of the operating suite.
Another common barrier to optimal flow is the handoff process.
"One of the common problems people have is not taking care of patients during report time," Dr. Blouin said. "While the report is critically important in terms of handoff communication, [hospitals should focus on] figuring out solutions so patients aren't waiting 45 minutes to an hour in units [they] don't have to be in."
New Joint Commission standards regarding patient flow
To help hospitals address patient flow issues, The Joint Commission revised its LD.04.03.11 standard, which was effective Jan. 1, 2013. It also revised EP 6 and EP 9 of LD.04.03.11, which went into effect Jan. 1, 2014.
Standard LD.04.03.11 requires hospitals to actively manage the flow of patients through the hospital. The revised EP 6 requires hospitals to measure and set goals for mitigating and managing boarding for patients coming through the emergency department. The standard defines boarding as "the practice of holding patients in the emergency department or a temporary location for four hours or more after the decision to admit or transfer has been made." Ms. Leslie clarified that the four-hour mark of this provision is not a requirement to meet the standard; rather it is a recommendation that would greatly improve patient flow.
EP 9 of LD.04.03.11 encourages community collaboration with behavioral health providers and authorities to improve patient care quality and more effectively use emergency department services.
"A lot of resources are being decreased in the state and country, but how can your hospital interface with the community [and] interface with the state on these resources?" Ms. Leslie asked.
Quality, safety and financial impacts
"Unfortunately there is a relationship between higher mortality and morbidity associated with the problem of patient flow," Dr. Blouin said.
For example, patients may experience delayed pain control if they are not in the appropriate location to receive proper care, or they may get continually sicker the longer they have to wait for a bed.
"There are missed assessments, interventions and basic care" when dealing with suboptimal patient flow, Dr. Blouin said. "When the decision to admit had been made but they weren't in the inpatient bed, they were not getting the type of care they needed."
Hospitals also face financial ramifications from poor patient flow. Dr. Blouin said patients who walk out of a hospital without being seen can cost between $300 and $500. Additionally diverting ambulances because of an overflow in the emergency department can cost up to $3,000, she said. "And there's the old adage that you tend to share your experience with more people if you're unhappy than if you're happy," Dr. Blouin said.
Final thoughts
Even if hospitals identify, assess and makes attempts to improve patient flow, sometimes it is impossible to decrease the bottlenecks, Dr. Blouin said.
"The focus needs to be looking at 'how do you take care of patients safely and the management of the patients?'" Dr. Blouin said. "You may not be able to decrease patient flow. You may not be able to move them how you want to, but how do you look at that whole process?"
To initiate any change of any kind, the inertia and will to progress has to come from the hospital leaders and executives.
"Who are the leaders?" Ms. Leslie asked. "Members of medical staff, governing bodies, CEOs, other senior managers, nurse executives, clinical leaders and staff members in leadership positions in the organizations. The leaders are the ones who are going to set the culture in your organization."
More Articles on Capacity Management:
Surplus ICU Beds May Create Demand
4 Most Common Barriers to Centralizing the Patient Placement Process
3 Ways Healthcare Automation Eliminates Wasted Time, Not Workers