System issues are at the heart of flow woes
IOM calls for a halt to ED boarding, diversions
As the Institute of Medicine (IOM) addressed the issue of patient flow, "system" was once again the magic word.
"I think for the EDs to function in the communities in which they exist, the thing of primary importance is that they not be places where admitted patients are boarded because there is not enough space in the hospital," notes Peter Viccellio, MD, FACEP, vice chairman of the department of emergency medicine in the School of Medicine at State University of New York at Stony Brook, and clinical director of the ED at Stony Brook University Hospital. "If you eliminate that, you eliminate ED crowding and ambulance diversion." This is exactly what the IOM called for in its report: that hospitals simply stop going on diversion. The IOM also recommended that federal programs revise their reimbursement policies to reward hospitals that appropriately manage patient flow and penalize those that fail to do so.
Viccellio repeats the mantra that this is a hospital problem, not an ED problem. "As ED managers, if nothing else, we have to change the language of the discussion," he says. "We should use this in all settings: Any time we are boarding patients, it should be viewed as an institutional situation."
When his ED is holding admitted patients and has no space to see new patients, "we start to move admitted patients to the inpatient floor — regardless of whether there is a normal bed or available or not," he shares. "They are placed in hallways, the solarium, and so forth."
He got administrative buy-in for this approach, he says, only after having tried for several years to find other solutions. "It just didn't get fixed," he recalls, "But we were afraid the approach we were considering was against state regulations."
He called the senior person at the state health department and learned no such regulation existed. "Once you're overcrowded and people are lying around, what difference does it make if they are here or there?" he poses.
Viccellio has one major bone to pick with the report. "I was disturbed in the preamble when they talked about unnecessary visits," he says. "We aren't on diversion because we have too many sprained ankles; it's because there are too many seriously sick people."
For example, Viccellio notes, a sore throat might not be considered a serious symptom. "We just had a resident conference on a patient with a cough, a rash on their elbow, and we diagnosed Lyme disease," he relates. "If they had been discharged with a cold, the visit would have been called 'unnecessary.'"
The report's emphasis on accountability makes a lot of sense, says Diana S. Contino, RN, MBA, CEN, FAEN, manager of public services-healthcare for Costa Mesa, CA-based BearingPoint, which provides strategic consulting, application services, technology solutions, and managed services for clients in public services (including health care), commercial services, and financial services. "The IOM report is an excellent summary of the key operational flow issues we should be assessing," she says. "The system approach is critical, as is the importance of the process owner — who should own and be accountable for their entire process."
For example, she continues, the admitting units should own the "time from admit request" to the "time of arrival on the unit." "They should be in their [key performance indicators], and you should post them publicly, and their process improvement efforts should be focused on creative ways to decrease these times," says Contino.
The laboratory and radiology departments, she adds, should own the "time order placed" to "time result delivered to the provider," she adds. "If they own and are held accountable for improving this full process, they have the incentive and motivation to critically evaluate the data and work collaboratively to decrease the processing times," she explains. Recently, she notes, the Wall Street Journal reported laboratories using Lean and Six Sigma techniques to make significant improvements in the turnaround times and the quality of their tests results.1
While the IOM was correct in saying hospitals need to align incentives to improve flow, "we can't wait for incentives to be aligned to make improvements," insists Contino.
"Managers who are grappling with long turnaround times and minimal staffing resources, and who don't have the necessary automated data resources, can't go wrong if they focus initial improvement efforts on several key issues that impact flow," says Contino. They are:
- decreasing practice variation;
- eliminating unnecessary steps;
- matching the right clinical resources (registered nurse, licensed practical nurse/licensed vocational nurse, technician, physician assistant/nurse practitioner, and doctor) to the patient's acuity (clinical needs);
- implementing rapid improvement events. (No longer can you wait months for change. Why not just do it now?)
"Using the IOM report and leading practices at other facilities can expose managers to the tools and methodologies used to identify and focus on the improvements that will produce the biggest results," Contino concludes.
Reference
- Landro L. Hospitals move to cut dangerous lab errors. Wall Street Journal, June 14, 2006. Accessed at www.post-gazette.com/pg/06165/698180-114.stm.
Sources
For more information on improving patient flow, contact:
- Diana S. Contino, RN, MBA, CEN, FAEN, Manager, Public Services-Healthcare, BearingPoint, 600 Anton Blvd., Plaza Tower No. 700, Costa Mesa, CA 92626. Phone: (949) 683-0117. Fax: (949) 861-6426. E-mail: [email protected].
- Peter Viccellio, MD, FACEP, Vice Chairman, Department of Emergency Medicine, School of Medicine, Clinical Director of Emergency Department, Stonybrook University Hospital, Health Sciences Center, Level 4-Room 080, State University of New York at Stony Brook, Stony Brook, NY 11794-8350. Phone: (631) 444-3880. Fax: (631) 444-3919. E-mail: asa. [email protected].
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