Improving patient flow is a two-pronged process: correct delays as they happen, and look at patterns of avoidable delays and develop solutions, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.
The reasons for delays may vary, Cesta points out. That’s why it’s important to track delays and look for patterns.
“There’s not one right was or wrong way to work on improving patient flow. It depends on the culture of the hospital, the location, the support from hospital leadership, and so many other factors,” she adds.
It takes data to identify delays and understand what is causing the delays, says Connie D’Argenio, MS, BSN, managing director of Huron Healthcare Practice at Chicago-based Huron Consulting Group.
You can’t rely on anecdotal information, she adds.
“What people think caused the delay may not necessarily be a major contributor to the problem. Hospitals need hard data to show what is happening and identify what needs to be changed,” she says.
Start by establishing what happens when patients enter the system until they are discharged, and determine what happens to slow the process down, Cesta says. Divide all the delays into categories and examine each category to come up with ways to improve the process.
Concentrate on avoidable delays related to operational inefficiencies, payer issues, delays in transition, or patient placement, D’Argenio suggests.
Look for unwarranted variations in the expected standard of care, D’Argenio says. Keep in mind that patients aren’t all alike and some variation is always expected, she adds.
“This isn’t standardizing care — it’s standardizing the approach and eliminating unwarranted variations in care,” she says.
She recommends bringing the entire primary team together to discuss avoidable delays. Make sure the team agrees on the categories to track, and determine who is going to collect information, where it will be collected, and how it will be reported.
Observe what happens as patients move through the system to get an idea of how the patient flow process works in your hospital and conduct detailed time studies at every step, suggests Mark Krivopal, MD, MBA, vice president at Boston-based GE Healthcare Camden Group.
Enter delays and causes into a database and aggregate them. Look for volume and patterns to determine where the barriers to discharge are and take steps to correct them, Cesta says.
Analyze patient discharges by the day of the week, suggests Bonnie Barndt-Maglio, PhD, RN, managing director at Prism Healthcare Partners in Chicago. “Most of the time, the analysis will show that patients who are discharged on a Monday or Tuesday did not receive services to progress their care on Saturday and Sunday,” she says.
Drill down and look for the reasons patients stay over the weekend, Barndt-Maglio suggests. “Sometimes it’s organizational issues that arise when services aren’t available,” she says.
For instance, calculate the number of patients who stay over the weekend waiting for a stress test or other procedure, and conduct a cost-benefit analysis to determine if it would be cost-effective to offer the procedure on weekends, Krivopal suggests.
It could be the physical therapy and occupational therapy departments aren’t on hand to sign off on discharges, or there is nobody to read an EKG or echocardiogram, Barndt-Maglio says.
Barndt-Maglio suggests performing a cost-benefit analysis to determine if it would be more cost-effective to have a cardiologist or physical therapist come in for a few hours during the weekend versus keeping the patient for two extra days.
“If there is enough impact on the bottom line, the hospital can take steps to correct the problem and add resources on the weekend — but you have to have data available to justify the additions,” Cesta says.
Determine if you could reduce ED boarding time by extending case manager hours in the department. Look at whether hiring more inpatient doctors or non-physician providers would result in orders for tests or discharge issued in a more timely manner, Krivopal suggests.
Create a daily dashboard that tracks key performance indicators and post it in a place where everybody on the floor can see it, Barndt-Maglio suggests. Indicators to track include ED wait time, additional days for patients waiting for nursing home placements, patients waiting for tests and procedures, delays because of transportation, or delays due to family decision-making. Also track excess days associated with patients who stay five days compared to those of patients with longer stays.
In addition, create a physician dashboard that tracks performance on timely discharge.
“We often see physicians whose patients have more excess days, but their readmission rates are the same as or higher than the rates of other physicians,” she says.
When a physician has a pattern of excess days, Barndt-Maglio recommends working with the case management physician advisor to talk to the physician.
Another tactic is to assign a case manager specifically to the physician to support moving patients toward discharge. For example, the case manager could suggest that a non-emergent test be performed after discharge. Including the chief medical officer on the team and trending statistics supports the ability to provide guidance to physicians to improve performance, Barndt-Maglio adds.
Improving patient flow is a two-pronged process: correct delays as they happen, and look at patterns of avoidable delays and develop solutions.
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