Patient flow getting increased scrutiny during surveys: You'll need these data
Joint Commission will ask how bottlenecks were alleviated
Seasonal increases in respiratory illnesses. Overflowing emergency departments (EDs) when other hospitals go on ambulance diversion. Scheduling issues with the operating room. Physicians failing to make timely decisions on transferring patients. Your facility failing to grow in response to the needs of the community.
These are some of the many factors — some controllable, others not — that can wreak havoc with patient flow at your organization.
With the addition of a new patient flow tracer for 2008, surveyors from The Joint Commission will use tracer methodology to look for "patient backflow" that creates congestion in the EDs, critical care units (CCUs), and surgical areas. "This often results in treatment delays, medical errors, and unsafe practices," says Michelle H. Pelling, MBA, RN, president of The Propell Group in Newberg, OR, a consulting group specializing in healthcare performance improvement and Joint Commission accreditation.
According to Pat Adamski, RN, MS, MBA, director of The Joint Commission's Standards Interpretation Group, surveyors will require organizations "to really take a serious look at this. We expect them to do a thorough assessment of flow, and determine any issues that may impact their ability to provide quality and timely care."
What surveyors will ask
Since the tracer will determine how well the organization is complying with the patient flow standard LD.3.15, surveyors won't merely ask questions during the Leadership Interview — they'll want to review actual processes in the hospital. Staff should be able to answer the questions: "How have you improved patient flow?" or "What has the hospital done to remove barriers to patient flow?" says Pelling.
Surveyors will identify patients who experienced backflow during their hospital stay, even if it didn't affect the care they received, by reviewing medical records, interviewing staff members involved in patient care, and visiting different units and departments throughout the hospital.
Patient flow tracers won't necessarily be done during every survey — it will depend on what surveyors see onsite. A surveyor may decide to do a patient flow tracer because they identify a delay in treatment during another tracer, or because they see patients backed up in the ED hallways.
"Those kinds of things could set off a red flag in the surveyor's mind to do a patient flow tracer to see what they can learn," says Adamski.
During the Leadership Interview, surveyors may ask about the process for identifying barriers to patient flow, results from data collection, how the medical staff have been involved, and actions taken to lessen the impact of patient backflow.
"We don't say, 'You have to be at this level.' We say you have to identify what your problems are and be actively working on them," says Adamski.
Surveyors won't automatically assume there is a problem with flow if your ED is backed up with patients; however, they're more interested in the process in place to address inevitable backlogs. For example, if a surveyor happens to be onsite on a day that three other hospitals are on diversion, that is a valid explanation for why your ED is crowded with patients.
"Share with the surveyor how you manage the situation," says Adamski. "We may see a backup of 30 patients in the ED in the morning, but if you have an effective plan in place, we can go back down in a few hours and it could be empty."
Use data to evaluate flow
Patient flow is a "network of queues" throughout the hospital that need to be studied, and then improved wherever possible, says Kirk Jensen, MD, chief medical officer for Best Practices, a Fairfax, VA-based consulting group specializing in physician leadership and management. Jensen also is a faculty member of the Institute for Healthcare Improvement, and served on the expert panel for urgent matters, a Robert Wood Johnson Foundation initiative aimed at helping hospitals eliminate ED crowding and congestion
Performance improvement teams should monitor the relevant metrics to create a "road map" of the patient's journey, identify where waits are occurring, and then work to improve or eliminate those waits, says Jensen.
Joint Commission surveyors will want to see your data on four specific areas: available supply of patient bed space, the efficiency of patient care treatment in service areas, the safety of patient care treatment in service areas, and support services that impact flow.
"Organizations can develop their own indicators, as long as those four areas are addressed," says Adamski.
However, data are not enough on their own — surveyors will want to see what's been done. If the data have revealed problems, expect to field questions from surveyors about the process improvement plan in place to mitigate those.
A common pitfall: Organizations have all of the required data in hand, but aren't analyzing them properly. "The person in charge may have left unexpectedly and no one picked up the ball. Or, you may fix a problem and think you've got it resolved — and then the dam breaks loose in another area," says Adamski. "You need an ongoing PI process to constantly re-evaluate the situation, put fixes in place, and follow through to make sure they hold up."
Since the patient flow tracer is new this year, it should be practiced internally, says Pelling. She recommends tracking a sample of patients from the time they enter the hospital until they reach their initial destination, such as an inpatient bed, and following them until discharge.
"This can be done both concurrently and retrospectively," says Pelling. "Track the time from when each order was written to the time it was executed. Establish a reasonable time goal for each stage."
Benchmark with other organizations to compare your performance, which will give you a "high-level view" of the process, says Pelling. "If there are delays at any point, follow up by drilling down to determine the cause. Evaluate whether they are isolated incidents or problems that occur frequently," she says. "If it's the latter, evaluate the potential causes and establish plans to improve."
Pelling recommends collecting these data to evaluate how efficiently care, treatment, and services are being provided:
- time of the physician's order to the time of transfer or discharge;
- time of a request for housekeeping to the time the room is clean;
- time of notification to bed control that beds are available;
- time of the patient's arrival to the unit.
For the ED, specifically, she advises tracking arrival to discharge, arrival to admission, arrival to transfer, and average length of stay.
Collect data on hospital length of stay, ED boarding hours, hours on diversion, and bed turns, recommends Jensen. "Just like in a restaurant, you need to be able to turn those tables," he says.
Diane Jacobsen, MPH, CPHQ, director of the Institute for Healthcare Improvement's initiative on Improving Flow through Acute Care Settings, recommends measuring the time the patient presents to the ED to the time he or she in placed in an inpatient bed, the number of hours that a hospital is on diversion, the percentage of patients leaving EDs without being seen, and overall length of stay.
"There are guidelines as to what the normal length of stay should be for some diagnoses, and if it is very long for a certain patient population, it provides an opportunity to understand why some of the delays might be occurring," says Jacobsen. For example, you might find that there is a delay in transferring patients to a nursing home because of lack of available beds at that facility.
"Data are helpful and important, but collecting large amounts of data should not become the only thing that we do," adds Jacobsen. "You need a big picture understanding of the measures, and also the chronic bottlenecks that affect those measures."
To eliminate barriers, work on reducing delays between units, such as the time it takes to get patients from the ED or the intensive care unit to inpatient floors. "The first measure that you will see an impact on is between units, not the overall hospital measure," adds Jacobsen.
Collaboration is needed
Improving patient flow requires a number of "puzzle pieces" to come together, with the involvement of physicians and hospital staff. "Quality professionals are not the only ones in their hospitals concerned about efficient patient flow. They are part of a team working to improve it, and often 'in the middle of all this,'" says Pelling.
This is one reason why sustaining gains for patient flow is particularly challenging for quality professionals. "It requires a systemwide focus that hospitals often don't have," says Jensen. "It's easier to focus on individual silos."
Physicians are key players in the process, since the assessment of whether a patient is ready for discharge is often delayed due to surgery schedules and unexpected patient crises, says Pelling.
Once the discharge order is present, hospital operations come into play. This includes cleaning and turning over the room, timely communication with bed control or others who assign beds, and ensuring appropriate staffing levels for patient volume and complexity, says Pelling.
Working with individual departments or units isn't enough — you need to work across the system to get results. "We can improve a process within the ED, but the ability to move a patient from the ED requires a connection to the next place that the patient is going to," says Jacobsen. "So matching those up is very important. That requires working together with all of the different areas."
Staff on inpatient floors are a resource you shouldn't ignore — they know which patients will be going home, and the number of patients coming into their units. "There needs to be a partnership between quality and the hands-on experts on the units, with communication about where the demand is coming from," says Jacobsen.
Frontline staff are the group that "can make or break you," says Adamski. "If they know you are working to move through patients quicker, they may see it as creating more work for them," she says. "But in reality, if you correct a lot of these flow issues, it should help the staff as well."
Staff must answer questions
To demonstrate to Joint Commission surveyors that impediments to patient flow were mitigated, staff at Virginia Mason Medical Center in Seattle will point to the following, says Dana Nelson-Peterson, RN, MN, administrative director of hospital operations: hourly divert/bypass logs, graphs showing the number of hours on diversion, and 90 day re-measures from rapid process improvement workshops on ED throughput.
"We will also encourage them to observe our standard work processes, including twice daily bed flow huddles, surgery schedule review huddles, and how our bed board is used for communication of bed availability," she says.
The organization has implemented the following to prepare for the new patient flow tracer:
- A 24-hour bed control/flow area, staffed with nurses in supervisory roles.
- Twice-daily "bed flow huddles," with representation from all floors and peri-operative services.
- A visual bed board to manage the flow of admissions, discharges, and bed turnover.
- A "bed ahead" standard for floors — a process where the assistant nurse manager on each floor indicates electronically where the next patient admission will be placed on the unit.
- A 9 a.m. standard for physician discharge orders. "This has allowed us to move up the average time of discharge significantly throughout the hospital, creating capacity to absorb the postoperative patients and unplanned admits through the ED," says Nelson-Peterson.
- A daily huddle with peri-operative services to review the upcoming three days of OR schedules to ascertain CCU/monitored bed needs and capacity.
Patient flow is assessed continuously through Virginia Mason's "bed board," which tracks discharge orders. "This allows us to measure cycle time from order placement to discharge, and identify barriers from which we create our improvement plan," says Valerie Ferris, RN, administrative director of the Hospital Kaizen Promotion Office. "We assess the impact of improvements on flow by routinely measuring cycle times, lead times, and designated quality metrics."
For example, cycle times were reduced on transfers to skilled nursing facilities, freeing up bed capacity earlier in the day to accommodate unplanned admissions through the ED.
At Lucile Packard Children's Hospital in Palo Alto, CA, questions about patient flow are incorporated into monthly tracers, to increase the ability of staff to articulate what the organization has done. "When we go to the surgical floor, we ask staff about how they plan for admissions, and what resources are available to them for this," says Vicki Link, RN, BSN, MBA, director of quality management. "We also expect managers and nursing education to do tracers and give feedback to staff."
The hospital is having a mock survey done by an independent company and has asked them to do specific tracers for patient flow. "Since patient progression is such a huge component of our daily procedures, we feel staff will be comfortable with these new tracers," says Link.
[For more information, contact:
Valerie Ferris, RN, Administrative Director, Hospital Kaizen Promotion Office, Virginia Mason Medical Center, 1100 Ninth Ave., Seattle, WA 98101. Phone: (206) 341-0883. E-mail: [email protected].
Diane Jacobsen, MPH, CPHQ, Institute for Healthcare Improvement, 20 University Rd., Cambridge, MA 02139. E-mail: [email protected].
Kirk Jensen, MD, BestPractices, 10306 Eaton Place, Suite 180, Fairfax, VA 22030. Phone: (703) 667-3499. Fax: (703) 667-3495. E-mail: [email protected].
Vicki Link, RN, BSN, MBA, Director, Quality Management, Lucile Packard Children's Hospital, 725 Welch Rd., Palo Alto, CA 94304. Phone: (650) 497-8508. Fax: (650) 497-8465. E-mail: [email protected].
Michelle H. Pelling, MBA, RN, President, The Propell Group, PO Box 910, Newberg, OR. 97132. Phone: (503) 538-5030. Fax: (503) 538-0115. E-mail: [email protected]. Web: www.propellgroup.com.
Dana Nelson-Peterson, RN, MN, Administrative Director of Hospital Operations, Virginia Mason Medical Center, 1100 Ninth Ave., Seattle, WA 98101. Phone: (206) 341-1140. E-mail: [email protected].]
Seasonal increases in respiratory illnesses. Overflowing emergency departments (EDs) when other hospitals go on ambulance diversion. Scheduling issues with the operating room. Physicians failing to make timely decisions on transferring patients. Your facility failing to grow in response to the needs of the community.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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