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Hospital Flow Professional Development Program
May 7-11, 2018Boston, MA
Pat Rutherford, RN, MSVP, Institute for Healthcare Improvement
February 26, 2018
Informational Call
So-Called "Flow Failures" are Disrespectful to Patients
“The number one reason to improve the movement of patients through health
care settings is because “bad flow” is disrespectful to patients and families.
Our inability to more effectively design and manage processes also wears on
clinicians and staff — decreasing their efficiency and productivity,
undermining joy in work, contributing to burnout, and decreasing job
satisfaction. But our patients and families bear most of the burden.
We make patients wait in the wrong places. We make them seek care in the
wrong units. If you were to walk through most hospitals today, you will
probably find multiple problems with patient flow.”
So-Called "Flow Failures" Are Disrespectful to Patients
By Maureen Bisognano | Thursday, August 25, 2016
On Wasting My Time – The NumbersPosted by Jess Jacobs
If you've wondered why I've been under the radar lately, look no further than my odyssey of medical
maladies; in addition to my ongoing struggle with POTS, this year I've had: a kidney infection, shingles,
pneumonia, a pulmonary embolism, and four blood transfusions. Since I’m a numbers person, I
downloaded my claims data from my insurer to get a better idea of how much time I’ve wasted in the
healthcare system since January 2014.
Useful VisitsThis last year I had 56 outpatient doctor visits, 20 emergency room visits, and spent 54 days inpatient. But how many of these visits were useful? As you can see in the table below, not many. http://jessjacobs.me/on-wasting-my-time-
the-numbers/
On average I wait 20 hours to get a bed in the hospital. My last two admissions were doozies – last time I
spent 48 hours in an on-call room, the time before that I spent 27 hours in a hallway (with a pulmonary
embolism). I didn’t sleep the entire time I was in these makeshift environments which is obviously
detrimental to the healing process.
I understand that my case is complicated and it takes a significant amount of time to
coordinate. However, there's no reason I need to physically be in the physician's office or at
the hospital while they make phone calls on my behalf. I’m a social person and every
second I spend in the hospital or ill is another second I’m missing out on friends and family,
that I'm missing out on life.
So yes, I owe the medical system my life for giving me blood when my hemoglobin drops
deathly low. But there's no reason a 4 hour transfusion required 84 hours of negotiation and
frustration. There's no reason that only 4.75% of outpatient visits and .08% of my
hospitalizations are spent actively treating my condition. There's no reason that I spent two
solid months (1540 hours, 64.2 days) of this year waiting instead of healing.
So, please, stop wasting my time. Stop wasting my life.
Patient Story
A year ago, I went to the ED at a nearby hospital because I was experiencing
severe head pain, extreme vertigo, some numbness on my left side, and was
rather confused. I got there around 7PM, and I was seen in an exam room the
first time around midnight. Since I suffer from migraines, they may have
assumed that I had a migraine headache (regardless of that fact that I was
telling them that this experience was very different than my usual episodes).
My impression was that I was waiting for so long because the ED was filled with
people and there were only 2 nurses in the ED. It was close to 4:30AM when I
finally saw a physician, who said “there’s really not much we can do for you”.
He said it would be best to go home and rest in my own bed, since the hospital
was way too crowded for me to stay. So I went home.
Patient Story (continued)
I woke up the next morning around 9AM, and I felt like things were getting
worse. I spoke to a friend, and she told me to go back to the ED immediately to
request imaging. I did, but it was a fight to get neurological tests done. Pushing
and pushing, they finally agreed. I had suffered a vertebral artery dissection and
a massive blood clot had formed near the tear in the artery.
From that, I experienced a Transient Ischemic Attack that could have resulted in
a major stroke. When the doctors saw these results, they apologized for
sending me home because of the overcrowding in the ED and hospital the night
earlier. I was cared for in the Neuro Unit for more than a week, and it took over
six months to recover.
Patient Story (continued)
Reflections:
While confirmation bias may have played a part in the doctor’s decision to
discharge this patient from the ED to home, the overcrowding (and perhaps
understaffing) in the ED and hospital likely played a significant role in the
doctor’s clinical decision-making. First and foremost, this decision was clearly
harmful and potentially life-threatening for the patient. Secondly, the
burdensome working conditions and constrained resources within the hospital
may have compromised this doctor’s ability to make the best clinical decision.
ED Boarding and Mortality
Emergency department (ED) boarding has been associated with several negative
patient-oriented outcomes, from worse satisfaction to higher inpatient mortality
rates
This was a retrospective cohort study set at a suburban academic ED with an
annual ED census of 90,000 visits.
Boarding was defined as ED LOS 2 hours or more after decision for admission.
Descriptive statistics were used to evaluate the association between length of ED
boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU),
and mortality controlling for comorbidities.
Hospital mortality and hospital LOS are associated with length of ED boarding.
Singer, A. J., Thode Jr, H. C., Viccellio, P. and Pines, J. M. (2011), The Association Between Length of
Emergency Department Boarding and Mortality. Academic Emergency Medicine, 18: 1324–1329.
Association Between Intensive Care Unit Transfer Delay
and Hospital Mortality: A Multicenter Investigation
Observational cohort study on medical-surgical wards at 5 hospitals to investigate the impact of delayed ICU transfer.
A total of 3789 patients met the critical eCART threshold before ICU transfer, and the median time to ICU transfer was 5.4 hours.
– Delayed transfer (>6 hours) occurred in 46% of patients (n = 1734) and was associated with increased mortality compared to patients transferred early (33.2% vs 24.5%, P < 0.001).
– Each 1-hour increase in delay was associated with an adjusted 3% increase in odds of mortality (P < 0.001).
– In patients who survived to discharge, delayed transfer was associated with longer hospital length of stay (median 13 vs 11 days, P < 0.001)
Delayed ICU transfer is associated with increased hospital length of stay and mortality. Use of an evidence-based early warning score, such as eCART, could lead to timely ICU transfer and reduced preventable death.
Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive
care unit transfer delay and hospital mortality: A multicenter investigation. J Hosp Med. 2016 Nov;11(11):757-762.
Don Berwick’s Reflections on Patient Flow
“As in the world of patient safety, the intellectual challenges in the sciences of flow proved to be of two major types – to master the complex theories and approaches that had matured in other industries and academic disciplines far from healthcare, and, at the same time, to adapt and invent new theories helpful in special contexts of healthcare systems.” p.xi
“Will flow ever acquire the patina of charisma that fuels today’s work on patient safety? I doubt it….But whether so honored or not, the problem of flow is every bit as consequential for the health of our systems and the well-being of our patients.” p.xii
-- Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement
Kirk Jensen, Thom A. Mayer, Shari J. Welch, Carol Haraden, Leadership for Smooth Patient Flow, ACHE
Management Series, Health Administration Press, 2007
The Problem and the Opportunity
Addressing vexing issues of patient flow in hospitals is essential to
ensure safe, high quality, patient-centered care. Failure to provide
the “right care, in the right place, at the right time” puts patients at
risk for sub-optimal care. Poorly managed hospital flow also adds to
the already taxing burden on clinicians and staff and diverts their
attention from clinical care. Improving hospital flow is critical lever
for increasing value -- for patients, clinicians and health care
systems.
What would success in achieving hospital-wide flow
look like at your hospital?
Recommended Performance Goals
Decrease overutilization of hospital services
– Relocate care to more appropriate care settings outside the hospital
– Decrease complications and harm resulting from errors and hospital-acquired conditions
– Manage LOS “outliers”
Optimize patient placement to insure the right care, in the right place, at the right time
– Reducing delays in treatment, surgery, transfers, discharge, etc.
– Decrease internal diversions (boarders and “off-service” patients)
– Decrease external diversions
Increase clinician and staff satisfaction with hospital operations
Demonstrate a ROI for the hospital or the health system
– Is your goal to have a high utilization of your hospital resources (procedures, beds and
staff)? What is the right goal?
– When do you consider adding more bed capacity?
Hospital Occupancy Rates in MA
Source: Massachusetts Hospital Profiles, Data Through Fiscal Years 2012-2015, Center for
Health Information and Analysis
Average Occupancy Rates (at hospital or unit levels) and the
Day-to-Day Realities of Managing Patient Flow
Time
# o
f P
ati
ents
“If I had to reduce my
message for
management to just a
few words, I’d say it all
had to do with reducing
variation.”
W. Edwards Deming
System-wide View of Patient Flow of Helps to Avoid Isolated Perspectives and Flow Projects
Use of Simple Rules in Complex Systems
When establishing hospital-wide goals, consider adapting three “simple rules for
governing complex systems” for achieving hospital-wide patient flow (right care, right
place, right time).
Right Care/Right Place: Patients are placed on the “right” clinical unit alongside the
“right” clinical team with disease-specific expertise
Right Time: No delay greater than two hours in patient progression (based on clinical
readiness) from clinical areas and units throughout the hospital (e.g., two hours from
ED to inpatient unit, one hour from PACU to surgical unit, etc.)
Operational Capacity: Ensure capacity on each unit or clinical area at the beginning of
each day (e.g., 1 or 2 available (and staffed) beds at 7:00 AM)
The hospital flow oversight team should create a hospital-wide learning system to
understand failure to achieve these “simple rules” and develop approaches to mitigate
these failures.
The challenge of complexity in health care, British Medical Journal, September 2001
James M. Anderson Center
for Health Systems Excellence
Daily Critical Flow Failures
0
1
2
3
4
5
6
7
8
9
7/1
6/2
008
10/1
4/2
008
1/1
2/2
009
4/1
2/2
009
7/1
1/2
009
10/9
/20
09
1/7
/201
0
4/7
/201
0
7/6
/201
0
10/4
/20
10
1/2
/201
1
4/2
/201
1
7/1
/201
1
9/2
9/2
011
12/2
8/2
011
3/2
7/2
012
6/2
5/2
012
9/2
3/2
012
12/2
2/2
012
3/2
2/2
013
6/2
0/2
013
9/1
8/2
013
12/1
7/2
013
3/1
7/2
014
6/1
5/2
014
9/1
3/2
014
12/1
2/2
014
3/1
2/2
015
6/1
0/2
015
9/8
/201
5
12/7
/20
15
3/6
/201
6
6/4
/201
6
9/2
/201
6
12/1
/20
16
3/1
/201
7
5/3
0/2
017
8/2
8/2
017# o
f P
ati
en
ts w
ith
a N
ew
Fa
ilu
re
Delayed or Canceled Surgery Due to Bed Capacity
0
1
2
3
4
5
6
7
8
9
7/1
6/2
008
10/1
4/2
008
1/1
2/2
009
4/1
2/2
009
7/1
1/2
009
10/9
/20
09
1/7
/201
0
4/7
/201
0
7/6
/201
0
10/4
/20
10
1/2
/201
1
4/2
/201
1
7/1
/201
1
9/2
9/2
011
12/2
8/2
011
3/2
7/2
012
6/2
5/2
012
9/2
3/2
012
12/2
2/2
012
3/2
2/2
013
6/2
0/2
013
9/1
8/2
013
12/1
7/2
013
3/1
7/2
014
6/1
5/2
014
9/1
3/2
014
12/1
2/2
014
3/1
2/2
015
6/1
0/2
015
9/8
/201
5
12/7
/20
15
3/6
/201
6
6/4
/201
6
9/2
/201
6
12/1
/20
16
3/1
/201
7
5/3
0/2
017
8/2
8/2
017#
of
Pati
en
ts w
ith
a N
ew
Fa
ilu
re
PICU Bed Not Available for Urgent Use
0
1
2
3
4
5
6
7
8
9
7/1
6/2
008
10/1
4/2
008
1/1
2/2
009
4/1
2/2
009
7/1
1/2
009
10/9
/20
09
1/7
/201
0
4/7
/201
0
7/6
/201
0
10/4
/20
10
1/2
/201
1
4/2
/201
1
7/1
/201
1
9/2
9/2
011
12/2
8/2
011
3/2
7/2
012
6/2
5/2
012
9/2
3/2
012
12/2
2/2
012
3/2
2/2
013
6/2
0/2
013
9/1
8/2
013
12/1
7/2
013
3/1
7/2
014
6/1
5/2
014
9/1
3/2
014
12/1
2/2
014
3/1
2/2
015
6/1
0/2
015
9/8
/201
5
12/7
/20
15
3/6
/201
6
6/4
/201
6
9/2
/201
6
12/1
/20
16
3/1
/201
7
5/3
0/2
017
8/2
8/2
017
# o
f P
ati
en
ts w
ith
a N
ew
Fa
ilu
re
Patients who Utilize an ICU bed b/c an Appropriate Bed is Not
Available
0
2
4
6
8
10
12
7/1
6/2
008
10/1
4/2
008
1/1
2/2
009
4/1
2/2
009
7/1
1/2
009
10/9
/20
09
1/7
/201
0
4/7
/201
0
7/6
/201
0
10/4
/20
10
1/2
/201
1
4/2
/201
1
7/1
/201
1
9/2
9/2
011
12/2
8/2
011
3/2
7/2
012
6/2
5/2
012
9/2
3/2
012
12/2
2/2
012
3/2
2/2
013
6/2
0/2
013
9/1
8/2
013
12/1
7/2
013
3/1
7/2
014
6/1
5/2
014
9/1
3/2
014
12/1
2/2
014
3/1
2/2
015
6/1
0/2
015
9/8
/201
5
12/7
/20
15
3/6
/201
6
6/4
/201
6
9/2
/201
6
12/1
/20
16
3/1
/201
7
5/3
0/2
017
8/2
8/2
017
# o
f P
ati
en
ts w
ith
a N
ew
Fa
ilu
re
Psychiatry Patients Placed Outside of their Primary Unit
James M. Anderson Center
for Health Systems Excellence
System Wide Patient Flow Delays
Six Ways Not to Improve Patient Flow:
A Qualitative Study
Narrowly focused initiatives reflected a decentralized system and the lack of a coherent
system-level strategy for patient flow
Well-established principles exist for improving timeliness and efficiency -- assess capacity
and demand, ascertain and address the causes of variation and streamline care
processes.
Improving efficiencies in isolated areas will not lead to improved hospital-wide patient flow
(need to focus on the greatest system constraint and scrutinize how different sub-systems
throughout the hospital impact each other)
Move beyond a proliferation of piecemeal initiatives to a coherent strategy of identifying
the greatest constraints, and after the greatest constraint has been addressed move to the
next constraint in the system.
Without a system perspective to inform improvement efforts, the most promising initiatives
may become just another dismal entry in ‘The How-Not-To Guide’ to patient flow
Kreindler SA Six ways not to improve patient flow: a qualitative study
BMJ Qual Saf 2017;26:388-394.
Success is Possible!
Based on AHA data, overall nationwide hospital inpatient occupancy was
67.8% (AHA 1991–2011); range was from 33.6% to 74%)
Once managed efficiently, US hospitals, on average, could achieve an 80–90
percent bed occupancy rate—without adding beds at capital costs of
approximately $1 million per bed.
As a result of “smoothing” the scheduling of elective surgeries, improving
discharge efficiencies, use of advanced data analytics and other interventions
to improve flow at CCHMC, the hospital’s quality of care improved even as the
occupancy rate grew from 76 percent to 91 percent. Hospital officials also
report improved overall safety for patients and reduction in stress on the
doctors and nurses who treat them.
Litvak E., Bisognano M. More Patients, Less Payment: Increasing Hospital Efficiency In The Aftermath Of
Health Reform . Health Affairs, 2011, vol. 30, No. 1, pp. 76-80
http://www.ihi.org/resources/Pages/IHIWhitePaper
s/Achieving-Hospital-wide-Patient-
Flow.aspx?utm_source=ihi&utm_campaign=Flow-
WP&utm_medium=rotating-feature-2
System-Level Improvement Requires Will, Ideas, and Execution
Strategies
1. Shape the Demand (reduce bed days; reduce ED visits and
admissions; smooth elective surgeries and downstream bed
utilization)
2. Match Capacity to Demand (reduce delays in moving patients
to appropriate units throughout hospital; ensure patients are
admitted to the appropriate unit)
3. Redesign the System (increase throughput; reduce bed days,
manage LOS outliers, and reduce delays and waiting times)
Demand System
Hospital Flow: Strategies for System Optimization
28
Specific Change Ideas
C1.1 Reliably identify patients’ end-of-life care wishes and proactively create and execute advanced illness care plans C1.2 Develop hospital-based and community-based palliative care programs
C2.1 Improve transitions and post-hospital care to reduce readmissions for high-risk populations
C3.1 Increase capacity in primary care practices to provide timely access to a care teamC3.2 Develop partnerships with urgent care centers and retail clinicsC3.3 Enroll patients in community-based mental health servicesC3.4 Have paramedics and EMTs triage and treat patients at home
C4.1 Use enhanced care management and coordination of services for patient populations with complex medical care and social needsC4.2 Provide home-based primary care for high-risk populations
C6.1 Decrease complications and harm, and subsequent increases in hospital lengths of stay, resulting from errors and hospital-acquired conditions
C5.1 Redesign elective surgical schedules to create a predictable flow of patients to downstream ICUs and inpatient units
Shape or Reduce Demand
S1. Provide end-of-life care (what care, and where) in accordance with patients’ wishes
S2. Decrease demand for medical-surgical beds by preventing avoidable hospital readmissions
S3. Relocate low-acuity care in EDs to primary care and community-based settings
S5. Decrease artificial variation in surgical
scheduling
S6. Decrease demand for hospital beds by
reducing preventable harm
S4. Decrease ED visits and acute care hospital admissions
C7.1 Forecast seasonal variations and changes in demand patterns to proactively plan for predicted volumeC7.2 Assess the number of beds and staffing needed for each service to make plans to accommodate patient volume for each service
C8.1 Use hospital-wide patient flow planning huddles and real-time demand and capacity problem solving C8.2 Use flexible staffing models for clinicians and staff to meet daily and hourly variations in patient volume in each unitC8.3 Use early recognition of high census and “surge” protocols to expedite plans for accommodating unplanned increases in patient volume
C11.1 Use case management and care management for patient populations with complex needs C11.2 Use advance planning and cooperative agreements for transfers to rehabilitation facilities, skilled nursing facilities, nursing homes, and mental health treatment facilities
C9.1 Increase OR throughput by improving efficiencyC9.2 Improve efficiency in the ED to decrease length of stay (LOS)C9.3 Improve efficiency in the ICUs to decrease LOSC9.4 Improve efficiency in medical-surgical units to decrease LOS
C10.1 Use proactive discharge planning focused on patients’ “medical-readiness criteria” for discharge
S7. Utilize a data-driven operational management system for hospital-wide patient flow
S8. Utilize real-time demand and capacity management processes
S11. Reduce length of stay for patients with complex needs
S9. Improve efficiencies, length of stay, and throughput in key units and departments where clinical care is delivered
S10. Improve the efficiency and coordination of hospital discharge processes
• Decrease overutilization of hospital services
• Optimize patient placement to ensure the right care, in the right place, at the right time
• Increase clinician and staff satisfaction
• Demonstrate a ROI for health systems moving toward value-based care strategies
Redesign the System
Match Capacity and
Demand
Outcomes Primary Drivers Secondary Drivers
Driver Diagram: Ideas to
Improve Hospital Flow
Hospital (Macro)
• Average Occupancy Rate (monthly, day of
week)
• Readmissions within 1 week after
discharge
• Number and percentage of readmissions
within 30 days after discharge
• Patient experience (HCAHPS measures
related to waits & delays)
• Clinician and staff satisfaction related to
workload (ex. NDNQI)
• Number of “off-service” patients by
service (monthly, day of week)
• Number of hospital-acquired conditions
(ex. falls with injury, VAPs, etc.)
• Number of flow failures (definition TBD)
• Length of Star “outliers”
Emergency Department
• ED diversions (# of diversions; hours per
month)
• Number and percentage of patients who
“left without being seen”
• Visits per day (time of day, day of week)
• Average length of stay (patients who are
discharged; patients who are admitted)
• Door to provider time
• Time from decision to admit to transfer to
inpatient unit (ICUs, Med/Surg Units)
• Time from decision for emergency surgeries
to OR
• Number of “ED boarders” waiting to be
admitted to a hospital bed (day of week,
time of day)
• Percentage of ESI level 4 & 5 patients (low
acuity)
Hospital-wide Flow Measures
Hospital-wide Flow Measures
Critical Care Units
• Average Census (monthly, day of week)
• Average Length of Stay
• Number of “LOS outliers” per month
• Number of decedents spending 7 or
more days in the ICU in the last 6 months
of life
• Number of ICU diversions due to lack of
capacity (# of “off-service patients”)
• Hours of core nursing overtime and
temporary nursing time
• Number or rate of hospital-acquired
conditions
• Time from clinical readiness to transfer
to medical or surgical beds
Medical and Surgical Units
• Average Census (monthly, day of week)
• Average Length of Stay
• Number of “LOS outliers” per month
• Hours of core nursing overtime and
temporary nursing time
• Number or rate of hospital-acquired
conditions
• Time from clinical readiness to discharge
time
• Number of “off-service” patients (by
unit, by service)
Hospital-wide Flow Measures
Operating Rooms
• Number of emergency cases by day
• Number of scheduled cases by day
• Percentage of OR utilization (monthly, day of
week)
• Number of changes from schedule for Elective
Surgical Cases
• Actual and Scheduled Start Times for Elective
Surgical Cases
• Hours of core nursing overtime and temporary
nursing time (OR and PACU)
• Number of overnight PACU patients
• Time from clinical readiness to transfer from
PACU to an inpatient unit
S1 Provide end-of-life care (what care,
and where) in accordance with patients’
wishes
S2 Decrease demand for medical-
surgical beds by preventing avoidable
readmissions
S3 Relocate low-acuity care in EDs to
primary care and community-based
settings
S6 Decrease demand for hospital beds
by reducing preventable harm
S5 Decrease artificial variation in surgical
scheduling
C1.1 Reliably identify end-of-life care wishes and proactively
create and execute advanced illness care plans
C1.2 Develop hospital-based and community-based palliative
care programs
C2 Improve transitions and post-hospital care to reduce
readmissions for high-risk populations
C3.1 Increase capacity in primary care practices to provide
timely access to a care team
C3.2 Develop partnerships with Urgent Care and Retail Clinics
C3.3 Enroll patients in community-based mental health
services
C3.4 Have paramedics & emergency medical technicians
triage & treat patients at home
C6 Decrease complications and harm, and subsequent
increases in hospital lengths of stay, resulting from errors and
hospital-acquired conditions
C5 Redesign elective surgical schedules to create a
predictable flow of patients to downstream ICUs and inpatient
units
S4 Decrease ED visits and acute care
hospital admissionsC4.1 Use enhanced community-based coordination of
services for patient populations with complex medical and
social complex needs
C4.2 Provide home-based primary care for high-risk
populations
Shape or
Reduce Demand
Changing the Cultural Norm
A national campaign
encouraging everyone to
have a conversation about
their wishes for end-of-life
care
Collaboration to ensure
health care systems are
ready to receive and honor
wishes for end of life care
Advanced Illness Planning:
Respecting Choices
http://www.gundersenhealth.org/upload/docs/respecting-choices/Respecting-Choices-return-on-investment.pdf
30 Day Readmissions:Primary & Secondary Heart Failure 65+
UCSF Health35
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
30 Day ReadmissionsPrimary & Secondary Heart Failure
UCSF Medical Center Heart Failure Program
Goal Line:
Annual Averages
2009 = 24%
2010 = 19%
2011 = 13%
2012 = 12%
Reducing Non-Urgent Emergency ED Services
Extend hours in Primary Care
Use of Telemedicine in Emergency Departments
Urgent Care Centers (many now part of health care systems)
Retails Clinics
Paramedics and Emergency Medical Services managing non-emergency
calls*
Community Health Workers connecting frequent ED users with community-
based services*
Coordinated, Intensive Medical, Social, and Behavioral Health Services*
https://innovations.ahrq.gov/scale-up-and-spread/reports/reducing-non-urgent-emergency-
services-learning-community-september-2015
Atrius Health ACO: Reducing ED Visits & Admissions
Utilization of emergency rooms, hospitals and drugs tends to be lower than average:
With Medicaid, demonstrated 39% fewer admits/1000 on hospital (medical)
admissions and 37% fewer Emergency Room visits/1000 as compared with the
health plan's network.
With Medicare Advantage, demonstrated 12% fewer Emergency Room visits/1000
and 5% fewer SNF admits/1000 as compared with the plan's network.
For a commercial PPO product, 30-day readmission rate that is half of the plan's
network rate, and 25% fewer Emergency Room visits/1000.
For a commercial HMO, demonstrated 8% fewer inpatient admits/1000 and 9.5%
less Rx scripts/1000.
Managing and Reducing Variability
Natural Variability (Clinical Variability, Flow Variability, Professional
Variability)
o Random
o Can not be eliminated (or even reduced)
o Must be optimally managed
Artificial Variability
o Non-random
o Not always predictable (driven by unknown individual priorities)
o Should not be managed, must be identified and eliminated
Eugene Litvak, PhD Institute for Healthcare Optimization
“Level-loading” Electively-Scheduled Surgical Cases
By applying variability methodology, queuing theory and the Flow Variability Management, hospitals can identify and eliminate many of the patient flow impediments caused by operational inefficiencies
By smoothing the inherent peaks-and valleys of patient flow, and eliminating the artificial variability, that unnecessarily impair patient flow, hospitals can improve patient safety and quality while simultaneously reducing hospital waste and cost.
http://www.ihoptimize.org/what-we-do-methodology-flow-variability-management.htm
Average Occupancy Rates (at hospital or unit levels)
and the Day-to-Day Realities of Managing Patient Flow
Time
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Eliminate Artificial Variation >> Shapes Patient Demand
C.diff Infection Rates in Hospitals
Many hospitals acknowledge that C. diff infections are a widespread problem,
especially as the CDC estimates that 94 percent of cases occur in hospitals. C.
diff infections increase patient length of stay by more than 55 percent and may
increase the cost of their care by 40 percent or more. More worrying, 500,000
patients are infected annually and 29,000 patients die each year from the drug-
resistant superbug, so researchers are focused on finding potential treatments.
Two solutions for hospitals to cut down on the infection risk: make sure staff
follow hand-hygiene protocols and establish antibiotic stewardship programs
S7 Utilize data-driven
operational management system
for hospital-wide patient flow
S8 Utilize real-time demand and
capacity management
processes
C7.1 Forecast seasonal variations and changes
in demand patterns to proactively plan for
predicted volume
C7.2 Assess the number of beds and staffing
needed for each service to make plans to
accommodate patient volume for each service
C8.1 Use hospital-wide patient flow planning
huddles and real-time demand and capacity
problem-solving
C8.2 Use flexible staffing models for clinicians
and staff to meet daily and hourly variations in
patient volume in each unit
C8.3 Use early recognition of high census and
“surge” protocols to expedite plans for
accommodating unplanned increases in patient
volume
Match Capacity
and Demand
Use Data Analytics to Understand and Manage
Seasonal and Day of the Week Variations in Demand
Can you predict a surge in admissions for patients with medical conditions in the
winter months?
➢ Use seasonal flex units to manage increases in medical patients during
the winter months
Can you anticipate which units need more bed capacity? (clue – which services
consistently have a large number of “off-service patients)
➢Use data analytics to quantify needs of each service
Do you have a regular surge of activity mid-week with the hospital census
regularly reaching >95% occupancy?
➢Smooth elective surgical schedules (particularly for patients who will
require ICU care post-op)
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Aggregate Demand/RN Capacity
Projected Total RN Demand Total RN Staffing
RN Capacity for Predicted ED Demand
Right-Sizing Hospital Units
Unscheduled and scheduled patients should be provided with
separate bed capacities
Capacity for scheduled demand (mostly surgical) could be
determined by computer simulation modeling; average utilization
of beds for scheduled admissions could potentially be ≥ 90%
Capacity for the unscheduled demand (medical and
emergent/urgent surgical) should be determined by Queuing
Theory modeling; the rule of thumb for the average utilization of
beds for scheduled admission is ~ 80%.
© Institute for Healthcare Optimization 2016
Demand/Capacity Management
Time
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Time
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Eugene Litvak, PhD, Institute for Healthcare Optimization
What nurse staffing is needed to consistently provide safe and
quality care?
Staffing for >95% census/occupancy Staffing for > average census/occupancy
Nurse Staffing, Hospital Operations, Care Quality, and
Common Sense
1. Staff hospitals 24/7 according to the peaks in both bed
occupancy and admissions.
2. Be "creative" by introducing dynamic PNRs that will fluctuate in a
synchronous manner with census and admissions
3. Legislate PNRs
4. Preserve the status quo and do nothing.
5. Change hospital patient flow management.
Litvak E, Laskowski-Jones,L; Nurse staffing, hospital operations, care quality, and common
sense; Nursing, August 2011.
Nurse Staffing and Hospital Mortality
In this retrospective observational study, staffing of RNs below target levels was
associated with increased mortality, which reinforces the need to match staffing
with patients' needs for nursing care
Maintaining RN staffing levels that are consistent with each patient's requirements
for nursing care underscores the importance of flexible staffing practices that
consistently match staffing to need throughout each patient's stay
Nurse staffing models that facilitate shift-to-shift decisions on the basis of an
alignment of staffing with patients' needs and the census are an important
component of the delivery of care.
Risk of death among patients increased with increasing exposure to shifts with high
turnover of patients. Staffing projection models rarely account for the effect on
workload of admissions, discharges, and transfers
Nurse Staffing and Inpatient Hospital Mortality, Needleman J., Buerhaus P., et al. N Engl J Med
2011; 364:1037-1045, March 17, 2011
Real-Time Demand and Capacity (RTDC)
Management Processes
Using Real-Time Demand Capacity Management to Improve Hospitalwide Patient Flow; Resar, R; Nolan, K;
Kaczynski, M, Jenson, K; The Joint Commission Journal on Quality and Patient Safety; May 2010, Vol 37, No 5
Results at UPMC
Resar, , Roger Resar, M.D.; Kevin Nolan, M.A.; Deborah Kaczynski, M.S.; Kirk Jensen, M.D., M.B.A., F.A.C.E.P. ,
Management to Improve Hospital wide Patient Flow, Joint Commission Journal on Quality and Safety, May 2011
Volume 37 Number 5, pp 218-227 r
Surge PlanningGreen Yellow Orange Red
Census
Acuity
Other
StaffReflects an optimally functioning system, a
state of equilibrium, homeostasis. Staff describe
it as, a good day.
Reflects the state of early triggers which identifies and allows the system to initiate early interventions.
Reflects escalating demand without readily available capacity. In this state aggressive action required to avoid system overload and ultimate gridlock.
Reflects a state of gridlock as a result of system overload. The system should respond by using its organizational Disaster Plan.
Orange
Green
Yellow
Red
Redesign the
System
S11 Reduce length of stay for
patients with complex needs
S9 Improve efficiencies, length
of stay, and throughput in key
units and departments where
clinical care is delivered
S10 Improve efficiencies and
coordination of discharge
processes
C11.1 Use case management and care
management for patient populations with
complex needs
C11.2 Use advance planning and cooperative
agreements for transfers to rehabilitation
facilities, skilled nursing facilities, nursing homes,
and mental health treatment facilities
C9.1 Increase OR throughput by improving
efficiency
C9.2 Improve efficiency in the ED to decrease
LOS
C9.3 Improve efficiency in ICUs to decrease
LOS
C9.4 Improve efficiency in medical-surgical units
to decrease LOS.
C10 Use proactive discharge planning focused
on patients’ “medical-readiness criteria” for
discharge
Separate Flows for Elective and
Non-Elective Surgical Cases
Mayo Clinic Florida
Surgical volume and surgical minutes increased by 4% and 5%, respectively;
Prime time use increased by 5%;
Overtime staffing decreased by 27%;
Day-to-day variability decreased by 20%;
The number of elective schedule same day changes decreased by 70%;
Staff turnover rate decreased by 41%. Net operating income and margin
improved by 38% and 28%, respectively
C. Daniel Smith, et al. Re-Engineering the Operating Room Using Variability Management to
Improve Healthcare Value. Journal of the American College of Surgeons, Volume 216, Issue 4 ,
Pages 559-568, April 2013
Foundational Elements for
ICU Efficiencies and Patient Flow
Stabilization
• Sepsis protocol
• Fluid stability• Ventilator
management
Weaning
• Decrease Vent hours
• Sedation protocol/w holiday
• Weaning criteria – “no MD”
• 24-hour weaning, extubating
Mobility
• Protocol online
• Standard workflow
• Delirium assessment (CAM-ICU)
• Metrics
Prevent Complications
• VAP, CLABSI protocol
• FMEA –low volume
• Renal injury• DV ??
End of Life
• Secure and respect wishes
• Family meeting in 24 hours
• Clear follow-up plan
James M. Anderson Center
for Health Systems Excellence
Increasing Nurses’ Time in Direct Care
Eliminate waste (hunting and gathering, re-work, workarounds, etc.)
➢ mandated ratios isn’t the only solution
Nurses spend more time in direct care (goal = 60%)
➢ show that waste has been eliminated and nurses’ time is reallocated to
direct patient care activities that create value for patients and family
members
Nurse spend more time in value-added care
➢ includes important work, such as customization of care to meet needs and
preferences of patients
➢ more appropriate measure than direct patient care (but more subjective)
Rutherford P, Bartley A, Miller D, et al. Transforming Care at the Bedside How-to Guide: Increasing Nurses’
Time in Direct Patient Care. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available
at www.IHI.org.
James M. Anderson Center
for Health Systems Excellence
ED Median Total Length of Stay (min)
New ED
Partially
Open
New ED
Fully Open Patient
Partner
Rapid
Assessment
Cambridge Health
Alliance
59
ED Median Door to Provider Time (min)
New ED
Partially Open
New ED Fully
Open
Patient Partner
Rapid AssessmentRapid
Assessment
Cambridge Health
Alliance
KP Sacramento ED Flow
Measure Before After
Hours on Divert per year 450 0
Percent LWOBS 6.6% 0.4%
Door-to-Doc (minutes) 55 19
LOS – Treat & Release
(hours)
4.5 2.4
LOS – Treat & Admit
(hours)
8.0 6.0
(c) Murrell 2015© Murrell 2017
KP Sacramento:
Treatment Goals of ED Psychiatry
(c) Murrell 2015
Exclude medical etiologies for symptoms
Rapid stabilization of acute crisis
Avoid coercion
Treat in least restrictive setting
Form a therapeutic alliance
Appropriate disposition and aftercare plan
Not just assessment and boarding!
© Murrell 2017
Shape Demand Match Capacity and Demand Redesign the System
Aims: Reduce bed days; reduce low-
acuity ED visits; reduce day-of-week
census variation
Aims: Reduce delays in moving patients to
appropriate units; ensure patients are
admitted to the appropriate unit
Aims: Reduce bed days, reduce length of
stay; reduce waits and delays
Hospital-Level
(Macro)
• Provide end-of-life care in accordance
with patients’ wishes
• Reduce avoidable readmissions
• Reduce readmissions for patients with
complex needs
• Reduce hospital-acquired conditions
• Data-driven operational management
system for hospital-wide patient flow
• Real-time capacity and demand
management
• Early recognition of high census and surge
planning
• Single rooms
• Seasonal “swing” units/beds
• Service line optimization (frail elders,
SNF residents, stroke patients, etc.)
Emergency
Department
• Provide end-of-life care in accordance
with patients’ wishes
• Relocate patients with low-acuity
needs to community-based care
settings
• Improve predictions of admissions for
various units
• Create staffing plans to meet predicted
patient volume
• ED efficiency changes to decrease
length of stay (for patients being
discharged and patients being
admitted)
• Separate flows in the ED
Critical Care
Units
• Provide end-of-life care in accordance
with patients’ wishes
• Decrease complications and harm
• Improve real-time capacity and demand
predictions
• Create staffing plans to meet predicted
patient volume
• Decrease length of stay (timely
consults and procedures; aggressive
weaning and ambulation protocols)
Medical-Surgical
Units
• Provide end-of-life care in accordance
with patients’ wishes
• Decrease complications and harm
• Reduce avoidable readmissions
• Create cooperative agreements with
rehab facilities, SNFs, and nursing
homes
• Improve real-time capacity and demand
predictions
• Create staffing plans to meet predicted
patient volume
• Decrease length of stay for patients
with complex medical care and social
needs
• Discharge patients when patients
meet clinical readiness criteria
Operating Rooms • Decrease artificial variation in surgical
scheduling
• Improve predictions for transfers to various
units
• Create staffing plans to meet predicted patient
volume
• OR efficiency changes to improve
throughput
• Separate flows for scheduled and
emergency OR cases
May 7-11, 2018 | Boston, MA
ihi.org/hospital-flow
IHI’s Hospital Flow Professional Development Program is designed
for a team or individuals who are tasked with hospital operations,
throughput, and ensuring optimal patient flow in the acute care hospital.
• 5-day intensive shared learning and capability building
• 20 leading health care expert faculty presenters
• Leverage opportunities to collaborate with expert faculty and successful
hospital leaders to develop or refine a detailed, customized action plan
Hospital Flow Professional Development Program
Delivering the right care, in the right setting, at the right time
Participants will learn from: • Expert faculty• Case study presenters• Other program participants
Participants will have opportunities to engage in: • Pre-work and data collection• Working sessions with team members• Exchange of ideas with other program
participants & faculty• Ad hoc faculty coaching sessions
More information at ihi.org/hospital-flow
Hospital Flow Professional Development Program
Who should attend?
This program is designed for teams who are
responsible for implementing and maintaining
operational efficiencies, throughput, and optimizing
patient flow in acute care hospitals.
While individual participants will gain value from this
professional development program, IHI strongly
recommends that hospitals and health care
systems consider sending teams of 4 or 5
individuals (those who have accountability for
outcomes related to delivering the right care, in the
right place, at the right time) to this program
Recommended Team Members:
CEOs, COOs, Chief Nurse Executives, Surgeons
and Medical Directors, Nursing Directors, Service
Line Leaders, Financial Analysts, Quality
Improvement Leaders
More information at ihi.org/hospital-flow
What you will learn
Designed for a team or individuals who are tasked with
hospital operations, throughput, and ensuring optimal patient
flow in the acute care hospital, this intensive IHI program
helps participants:
• Make sense of the variety of approaches needed to
achieve timely, efficient person-centered care
• Gain actionable strategies, skills, and tools that help
ensure that demand for hospital service matches capacity
— daily, weekly, and seasonally
• Prevent diversions and overcrowding in EDs
• Eliminate waits and delays for surgical procedures,
treatments, and admissions to inpatient beds
• Increase the number of patients admitted to the
appropriate inpatient unit (based on the patient’s clinical
condition)
• Identify opportunities to collaborate with expert faculty
and successful hospital leaders to develop or refine a
detailed, customized plan of action
• Explore ways to calculate the return on investment
More information at ihi.org/hospital-flow
Hospital Flow Professional Development Program
Contact Caitlin and get 15%! Get 15% off the enrollment fee when you are one of the first
10 people to enroll after the info call. To redeem this offer,
contact Caitlin Littlefield at 617-301-4875 or
