Designing Patient Flow
in the Hospital
to Make Patients Safer
John B. Chessare, MD, MPH
Interim President, Caritas Christi Health Care System
President, Caritas Norwood Hospital
Senior Vice President for Quality and Patient Safety,
Caritas Christi Health Care System
Why should we care about patient flow?
1. To make our patients safer
2. To increase throughput (volume, $$)
3. To reduce expenses (cost, $$)
4. To improve staff satisfaction
5. To improve patient satisfaction
A question to run on …….
What can I do as a healthcare leader to improve patient flow?
Agenda
•
Introduction
5 minutes
– What is the fundamental problem?
– What management model will help us improve it?
•
Some examples of designing flow
15 minutes
– Smoothing Flow at Boston Medical Center:
Changing the Surgical Schedule
– Designing Flow out of the Emergency Department at Caritas
Norwood Hospital
Luckily, this type of communication does not happen
in commercial aviation…….
•US Air 562 from Boston to Albany in its final approach
•Captain: “Albany this is US Air 562”
•Air Traffic Controller: “Roger US Air 562 this is Albany Control. You’ll
have to hold at your present altitude. We’ve got a lot more planes in our
airspace than usual. The airlines decided to add some flights but no one
told us and we’ve got some rerouted planes due to bad weather in metro
New York.”
•US Air 562 from Boston to Albany in its final approach
•Co-pilot: “Boy, we’ve got to get this plane down or we’ll have
some angry passengers. There’s the airport. Lets pick a runway.
I usually call the gates myself and find out if any are open and
then I just go for it. If you don’t, the controller will give it to
someone else”
•A Physician and Two Nurses Discussing a Patient in the ED
Waiting to Be Admitted
•Physician: “ This guy is ready to go upstairs. Its now 5pm, he
came in at 10 this morning. The unit clerk called admitting
but I guess they are at dinner”.
•First Nurse: “Ok, I’ll call around to the floors and see if there
are any empty beds….I know who to call.”
•Second Nurse: “Oh, I usually call the supervisor. Did you call
report?”
•First Nurse: “Oh no, I leave it on the floor’s voicemail just
before I leave the ED with the patient so they can’t slow the
transfer down”.
Hospitals have been managed sub-optimally
• Too much is happening by chance. Too little is happening
by design and therefore we function at low reliability
• Managers have been managing inputs: studies per FTE;
deviation from budget, etc. but not the system.
• The hospital is full of batching; Patients are admitted and
discharged in batches. Tests are run in batches. Surgeries
are done in batches without consideration of the effect on
the system.
• Safe patient care is easier to reach with continuous flow
and not with the artificial variability of batching!
• There is a need for scientific management in the hospital
industry
Reason’s Swiss Cheese Model of
Error
We are managing the efficiency
Of individual inputs and not the
system
Latent failures at the
managerial levels
Local triggers
Intrinsic defects
Atypical conditions
We allow patients to aggregate
and move in batches that
overwhelm our staff
Trajectory of
accident opportunity
Psychological
precursors
Unsafe acts
Defence-in-depth
“Hard work and good intentions are necessary
but insufficient for exceptional care”.
“Every System is perfectly designed to get
exactly the results that it gets.”
Time
# o f P a t ie n ts
Variability
1.
“Natural”: you can’t control it …you just have to manage it.
(e.g.. sick patients coming to the ED). Tool to manage it:
queuing theory
2.
“Artificial”: you can control it….you must eliminate it to
create flow. (batching) (e.g. elective surgery scheduling,
reading stress tests)
When we “batch and push” we create artificial
peak loads that create overcrowding
•
•
•
•
•
•
•
Internal Diversion –patients sent to alternative
floors\Intensive Care locations
Internal Delays – PACU backs up
External Diversion - ED diversion; inability to accept
transfers
Staff overload – increased errors and staff unhappiness
System Gridlock – Increase in LOS
Decreased Volume
Unhappy patients
What business model should we use to improve flow?
Performance Improvement
1.
2.
3.
4.
5.
Focus on the patient and his or her family
Deep Process knowledge (Design)
Decisions driven by data
Teamwork
Empowerment
“How can we use the ideas of individuals on the team to
redesign our systems to measurably improve the health
and satisfaction of our patients and their families while
driving out waste?”
Flow Teams at Boston Medical Center
Flow Leadership
Team
ED Team
Inpatient Team
Surgical Scheduling
Team
Average total ED throughput time
Boston Medical Center
6
5
3
Improvement from 4.5 to 3.75 hours
30 minutes x 1050 cases = 31,500 minutes or 525 hours per week saved
2
1
Weeks
Series2
Series3
69
65
61
57
53
49
45
41
37
33
29
25
21
17
13
9
5
0
1
Hours
4
Improving Inpatient Flow
Team
•
•
•
•
•
•
Janet Gorman
John Chessare
Linda Guy
Jane Damata
Dina Brauneis
Brian Brisbois
•
•
•
•
•
Sue Doherty
Jacque O’Shea
Cil Weekes
David Roney
Kim Wood
The Inpatient Cycle, Key Points, Key Process Indicators
Bed Turnover Time
Patient
Leaves
15:01
Clean
Bed
Bed
Assigned
120 minutes
Bed Assignment to Arrival Time
60 minutes
Patient
Arrives
In Bed
Dirty Bed
Average Discharge
Time
5.5 days
Patient Clinically Ready
to Leave
Length of Stay
Maximizing Throughput:Smoothing the Elective Surgery Schedule
to Improve Patient Flow
James M. Becker, MD
Keith P. Lewis, MD
John B. Chessare, MD, MPH
Eugene Litvak, PhD
Richard J. Shemin, MD
Gail Spinale, RN
Demetra Ouellette
Abbot Cooper
Surgical Smoothing
1.
2.
3.
Smoothing Elective Vascular Surgery
Smoothing Elective Cardiac Surgery
Separating Elective From Urgent Surgery in the Menino
Pavilion
•
•
•
Creating reliable urgency data
Separating a room for urgent/emergent cases
Eliminating Block Scheduling
Bed Need by Day of Week for Vascular Surgery (18 months of data)
1.2
Progressive Care Unit
1
0.8
Abramson
Restucci
0.6
Madison
Sampson
Wong
0.4
0.2
Thu
W ed
Tue
SI C U
Mon
S at
F ri
Thu
W ed
Tue
PC U
Mon
F ri
Thu
W ed
Tue
8W
Mon
F ri
Thu
Tue
W ed
Mon
7W
0
7/
1/
20
7/ 0 2
2/
2
7/ 00 2
3/
20
7/ 0 2
4/
2
7/ 00 2
5/
20
7/ 0 2
6/
20
7/ 0 2
7/
20
7/ 0 2
8/
2
7/ 00 2
9/
7/ 200
10 2
/
7/ 20 0
11 2
/2
7/ 0 0
12 2
/2
7/ 0 0
13 2
/2
7/ 0 0
14 2
/
7/ 20 0
15 2
/2
7/ 0 0
16 2
/2
7/ 0 0
17 2
/2
7/ 0 0
18 2
/2
7/ 0 0
19 2
/2
7/ 0 0
20 2
/2
7/ 0 0
21 2
/2
7/ 0 0
22 2
/2
7/ 0 0
23 2
/
7/ 20 0
24 2
/2
7/ 0 0
25 2
/2
7/ 0 0
26 2
/2
7/ 0 0
27 2
/
7/ 20 0
28 2
/2
7/ 0 0
29 2
/
7/ 20 0
30 2
/2
7/ 0 0
31 2
/2
00
2
Vascular Elective PCU Cases by Day
Random Month July 2002
Volume
4.5
4
3.5
3
2.5
Volume
2
1.5
1
0.5
0
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
/3
1/
/3
0/
/2
9/
/2
8/
/2
7/
/2
4/
/2
3/
/2
2/
/2
1/
/2
0/
/1
7/
/1
6/
/1
5/
/1
4/
/1
3/
/1
0/
/0
9/
/0
8/
/0
7/
/0
6/
/0
3/
/0
2/
/0
1/
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
# of Scheduled Cases
5
Vascular Scheduled PCU Cases - Weekdays Only
(October 2003)
4
3
2
1
0
E6W Direct Nursing Hours per Patient Day
8.70
8.60
8.66
8.50
8.40
8.30
8.16
8.20
8.10
8.00
7.90
Prior to Vascular Smoothing
After Vascular Smoothing
Average CT Surgery Unscheduled Cases Weekdays
Average Scheduled CT Surgery Cases by Weekday
Cardiac Scheduled Cases Histogram
January & February Non-holiday Weekdays Only
35%
30%
25%
20%
2004
2003
15%
10%
5%
0%
Monday
Tuesday
Wednesday
Thursday
Friday
1M
ar
2M
ar
3M
ar
4M
ar
5M
ar
6M
ar
7M
ar
8M
ar
9M
a
10 r
-M
a
11 r
-M
a
12 r
-M
a
13 r
-M
a
14 r
-M
a
15 r
-M
a
16 r
-M
a
17 r
-M
a
18 r
-M
a
19 r
-M
a
20 r
-M
a
21 r
-M
a
22 r
-M
a
23 r
-M
a
24 r
-M
a
25 r
-M
a
26 r
-M
a
27 r
-M
a
28 r
-M
a
29 r
-M
a
30 r
-M
a
31 r
-M
ar
12
March Daily PCU Census - 2003 vs. 2004
10
8
6
2004 range
2003
2004
4
2
0
2003 range 10 – 1 = 9
7 –2 = 5
55% reduction in variability
Operating Outside of the
Block at BMC
Separating the Flow of
Elective Surgery from
Urgent/Emergent Surgery
Menino Pavilion compared to Newton Pavilion
Variable
NP
MP
# Rooms
13
8
# Cases Day
30-35
25-32
# Cases Year
8601
6608
Cancellation Rate
10%
20%
#Add Ons Per Day
1-2
5-12
#Weekend Cases
0-4
5-20
Unique Services
Cardiac, Ophth
Pediatrics, Trauma, Gastric Bypass,
OB
Pre-change Problems with the Daily Schedule – Menino
Pavilion
•Urgent/emergent bump elective cases
•Overall 50% block utilization
•Variable use of block (vacation,meetings)
•Most cases booked 3-4 days out
•33% of daily schedule is “add ons”
•Variable release time between services
•Cases can be lost waiting
•People live in fear of losing their block
The Radical Changes
#1
Eliminated Block Booking
#2
One Urgent Room Created
OR 5
Bumped Cases Before and After Separating “Flows”
Before
After
April 03 – April 04
April 04 – April 05
• 349 emergent cases (M – F)
• 354 emergent cases (M – F)
7:00 AM to 3:30 PM
• 771 elective patients were
delayed or cancelled
7:00 AM to 3:30 PM
• 7 elective patients were
delayed or cancelled
/2
1 /3 0 0 6
/2
1 /5 0 0 6
/2
1 /7 0 0 6
/2
1 /9 0 0 6
/
1 /1 2 00
1/ 6
1 /1 20 0
3/ 2 6
1 /1 0 0 6
5/
1 /1 20 0
7/ 2 6
1 /1 0 0
9/ 2 6
1 /2 0 0
1/ 6
1 /2 20 0
3/ 6
1 /2 20 0 6
5/
1 /2 20 0
7/ 2 6
1 /2 0 0
9/ 2 6
1 /3 0 0
1/ 2 6
2 /2 0 0 6
/2
2 /4 0 0 6
/2
2 /6 0 0 6
/2
2 /8 0 0 6
/
2 /1 2 00
0/ 2 6
2 /1 0 0
2/ 2 6
2 /1 0 0
4/ 2 6
2 /1 0 0 6
6/
2 /1 20 0
8/ 6
2 /2 20 0
0/ 6
2 /2 20 0
2/ 2 6
2 /2 0 0
4/ 2 6
2 /2 0 0 6
6/
2 /2 20 0
8/ 2 6
00
6
1 /1
M in u te s
500
400
300
200
100
0
50
40
30
20
10
0
Date
Time
Range = 176 – 418 minutes (3 hours – 6 hours)
Mean = 300 minutes (5 hours)
Number of ED Admits
Range = 23 – 45
Mean = 30
A d m iss io n s
Norwood: Biggest Operational Dilemma
Daily ED Admits and Time from Decision to Departure
Time in Minutes
Number of Admits
Goal = 120 minutes
What is the true constraint?
Physician workup in the ED.
Find it and elevate it.
Moved to the inpatient unit.
What is now the true constraint?
Floor not ready.
Find it and elevate it.
Create Transfer Time.
Some other constraints
• No transporter: included transport in synchronization and
added transport capacity
• No nurse to staff an inpatient bed: stopped staffing to
monthly historic mean; create prediction software based on
historic natural variability and today’s census for tomorrow
ED Medical Admissions Process: IN THE EMERGENCY DEPARTMENT...
1. ED MD evaluates new patient
and decides that this is a medical
patient (non-ICU) that needs to be
admitted.
3. ED MD completes
admission order and
submits to ED
secretary.
2. ED MD informs ED
primary RN of
admission (probably
when informing pt.).
8. ED MD signs out
patient to Lead
Hospitalist (LH).
**The secretary should use the
“special comments” field to denote
information that is necessary for
bed placement (e.g.: “1:1”, “not
suitable for U31”, etc.).
4. ED secretary enters
order into Meditech,
which generates print
out in Admitting office.
A
5. ED secretary
updates admission log.
9. ED MD informs charge
RN of LH contact (during
board run).
6. ED secretary
informs ED charge
RN of admission.
10. ED charge RN denotes
LH contact on white board
(during board run).
7. ED charge RN
denotes admission
on white board.
E
11. Is a bed
likely available
for the patient?
NO
14. ED charge RN fields
call from BPC confirming
bed and transfer time.
G
20. ED secretary fields call
from BPC with bed and
transfer time. **If bed and
transfer time are not
written on the white board,
ED secretary makes sure
ED charge RN is aware of
bed and transfer time.
12. Bed
availability
summary
sent by BPC
YES
15. ED charge RN puts bed
and transfer time on board.
13. ED charge RN
instructs primary RN to
tape voicemail report.
16. ED charge RN
informs primary RN of
bed and transfer time.
21. ED secretary enters bed and
transfer time on admission log.
22. Transport arrives to move
the patient and collects
necessary paperwork.
I
B
23. Transport moves
patient out of ED.
24. ED secretary uses copy of chart
to depart the patient in Meditech,
and to transfer the patient from U10
to the receiving unit.
17. Primary RN tapes
voicemail report (if
not already done).
18. Primary RN calls
receiving floor to
deliver the voicemailbox number.
H
19. Primary RN prepares patient for
transfer, copies chart, and places copy
of chart in order bin.
Page 1
ED Medical Admissions Process: THE BED PLACEMENT COORDINATOR
A
(25) When Admit Order prints out, BPC:
a) enters name, etc. into BPC log
b) admits pt. in Meditech
c) prints packet to ED printer
d) sends text to Adm. Mgr. and
Admissions RN (11a-11p) which
includes name, age, Dx, bed type,
potential unit (e.g. ?U31), precautions or
1:1 if known
If the bed type is changed (whether
by ED order or LH contact), BPC
alerts the Administrative Manager
by text page.
Our target is to set the transfer time
within 30 minutes of the call to the
floor. When contacting the receiving
unit, the BPC should state, “We’d like
to send this patient up in 30
minutes. Is there any chance we
could send the patient sooner?” The
floor reserves the right to request a
transfer time greater than 30 minutes,
but must inform the BPC of the reason.
C
(26) BPC receives text
from Lead Hospitalist,
which includes: pt. name,
diagnosis, bed type, ESI,
and acceptance time.
BPC enters time of page
and ESI into log.
If 120 minutes elapse from the time
of admission order without contact
from the LH, BPC sends a text page
to the LH to ask about the patient.
(27) If there are any discrepancies or
questions about an admission, BPC
contacts the administrative manager.
Otherwise, BPC chooses a bed for
the patient.
D
(28) BPC calls charge RN (or
secretary if charge not
available) on receiving unit to
inform of admission (including
Dx and ESI) and to confirm bed
assignment and transfer time.
Either the receiving unit or the ED may
request a change in the transfer time.
If this happens, BPC contacts the
opposite unit (e.g. if ED calls, then
BPC calls the receiving unit) to confirm
new transfer time. BPC notes the
changed transfer time in the log and
then resends a text page to
Administrative Manager and Lead
Hospitalist beginning with “Change:”
and then the pt. name, bed, and
transfer time.
(29) BPC calls ED charge RN
(or sec. if charge not avail.) to
confirm bed assignment and
transfer time.
(30) Once bed assignment and
transfer time are confirmed, BPC
sends a text page to
Administrative Manager,
Admissions RN (11a-11p), ED
Admitting, and Lead Hospitalist
with the following info:
a) pt. name
b) bed assignment
c) transfer time
(31) BPC calls ED secretary
to deliver bed assignment
and transfer time.
E
F
G
(32) BPC checks to ensure that
patient moves upstairs on time. If
patient is still in ED after transfer
time, BPC contacts ED charge RN.
Page 2
ED Medical Admissions Process: HOSPITALISTS AND INPATIENT UNIT
B
(33) Lead Hospitalist (LH) receives
sign-out and determines when a
hospitalist can see the patient.
(34) LH communicates the following
to Bed Placement Coordinator: pt.
name, diagnosis, bed type, ESI, and
acceptance time.
(35) Assigned hospitalist begins
work-up (regardless of patient
location) as soon as possible.
F
C
D
(39) Charge RN informs
receiving RN of admission.
(36) LH receives bed assignment
and transfer time from BPC.
(37) Assigned hospitalist
proceeds to floor as soon as
possible.
(38) Charge RN or unit
secretary on receiving unit
fields call from BPC and
establishes bed and
transfer time.
H
(40) Unit secretary (??)
fields call regarding report
and informs receiving RN of
mailbox number.
(41) Receiving RN retrieves
voicemail report and calls
ED primary RN for
clarification if necessary.
I
(42) Patient arrives on floor.
(43) If patient does not have
admission orders, unit secretary
texts Lead Hospitalist that patient
has arrived.
Page 3
Date
4 /1
6
06
00
/2 0
6/ 2
4 /9
6
6
6
06
00
00
00
/2 0
6/ 2
9/ 2
4 /2
3 /2
3 /1
2/ 2
700
600
500
400
300
200
100
0
3 /1
6
6
6
06
00
00
00
/2 0
6/ 2
9/ 2
2/ 2
3 /5
2 /2
2 /1
2 /1
6
6
06
00
00
/2 0
9/ 2
2/ 2
6
06
06
00
/2 0
/2 0
5/ 2
2 /5
1 /2
1 /2
1 /1
1 /8
1 /1
M in u t e s
ED Time from Decision to Departure and Total ED LOS (admits)
Redesign
Go live
SERVICE
Reduce the average time from ED admission decision to departure
to inpatient unit to 120 minutes calculated monthly.
A v g . T im e fro m D e c is io n -to -A d m it to E D D e p a rtu re
350
300
200
150
100
50
06
/2
0
/1
9
/2
0
11
/2
/1
9
10
9/
19
/2
19
8/
06
6
00
6
00
/2
7/
19
/2
W e e k B e g in n in g ...
00
6
6
00
6
6/
19
/2
5/
19
/2
4/
19
/2
19
00
6
00
6
00
6
00
3/
2/
19
/2
19
1/
/2
00
6
05
/2
0
05
/1
9
/2
0
12
/1
9
/2
0
11
/2
/1
9
10
19
9/
19
8/
05
5
00
5
00
/2
00
/2
19
7/
19
/2
00
5
5
0
6/
Minutes
250
D TA -D E P
Question Mean Score: Speed of Admission
Key change concepts of the Design
• Do tasks in parallel: move the patient to the floor while the
workup continues
• Synchronize: assign a transfer to floor time (creates pull)
after communication with charge nurses and hospitalist
• Central command: all beds are assigned by the nursing
supervisor/bed facilitator
• Direct Communication: ED physician hands-off to
Hospitalist
• Predict Demand: Use data on natural variability to get ready
for staffing changes
Summary
• There is much artificial variability in healthcare. We can no
longer afford this waste.
• We must redesign our systems to maximize flow which will
make our patients safer, improve volume, staff and patient
satisfaction and reduce the waste.
• Separating the flow of urgent surgery from scheduled
surgery reduces waste and rework.
• No-Block scheduling is a good way to help the surgeons,
patients, and staff.
• All hospitals should map inpatient flow and test changes to
improve it.
References
•
•
•
•
•
The Goal; by Eliyahu Goldratt
Leading Change; by John P. Kotter
The Improvement Guide; by Langley et al
http://management.bu.edu/research/hcmrc/mvp/index.asp
Rathlev NK, Chessare J, Olshaker J, Obendorfer D, Mehta
SD, Rothenhaus T, Crespo SG, Magauran B, Davidson K,
Shemin R, Lewis K, Becker JM, Fisher L, Guy L, Cooper A,
Litvak E. Time Series Analysis of Daily Emergency
Department Length of Stay. Ann Emerg Med 2007;
49:265-271