SDS Accreditation Update
Patient flow getting increased scrutiny
Scheduling issues with the operating room. 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 (TJC) will use tracer methodology to look for "patient backflow" that creates congestion in the surgical areas, as well as the EDs and critical care units (CCUs).
"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 health care performance improvement and TJC 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."
Surveyors to examine flow
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. 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 on-site. 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 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.
What surveyors will ask
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.
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. 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 affect 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.
Avoid this pitfall
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 facility until they reach their initial destination, and then 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
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 data to evaluate how efficiently care, treatment, and services are being provided, such as time of the physician's order to the time of discharge. Collect data on length of stay, recommends Jensen.
Diane Jacobsen, MPH, CPHQ, director of the Institute for Healthcare Improvement's initiative on Improving Flow through Acute Care Settings, also recommends measuring the 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.
"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."
Collaboration is needed
Improving patient flow requires a number of "puzzle pieces" to come together, with the involvement of physicians and staff.
Physicians are key players in the process, since the assessment of whether a patient is ready for discharge often is delayed due to surgery schedules and unexpected patient crises, says Pelling.
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."
To demonstrate to 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:
- Twice-daily "bed flow huddles," with representation from all floors and perioperative services.
- 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 perioperative services to review the upcoming three days of OR schedules to ascertain CCU/monitored bed needs and capacity.
Monthly tracers performed
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. Vicki Link, RN, BSN, MBA, director of quality management, says they expect managers and nursing education to perform tracers and provide 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.
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