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Designing Patient Flow in the Hospital
to Make Patients Safer
John B. Chessare, MD, MPHInterim President, Caritas Christi Health Care System
President, Caritas Norwood HospitalSenior Vice President for Quality and Patient Safety,
Caritas Christi Health Care System
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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
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A question to run on …….
What can I do as a healthcare leader to improve patient flow?
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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
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•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’llhave to hold at your present altitude. We’ve got a lot more planes in ourairspace than usual. The airlines decided to add some flights but no onetold us and we’ve got some rerouted planes due to bad weather in metro New York.”
Luckily, this type of communication does not happen in commercial aviation…….
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•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 havesome angry passengers. There’s the airport. Lets pick a runway.I usually call the gates myself and find out if any are open andthen I just go for it. If you don’t, the controller will give it tosomeone else”
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•A Physician and Two Nurses Discussing a Patient in the EDWaiting to Be Admitted
•Physician: “ This guy is ready to go upstairs. Its now 5pm, hecame in at 10 this morning. The unit clerk called admittingbut I guess they are at dinner”.
•First Nurse: “Ok, I’ll call around to the floors and see if thereare any empty beds….I know who to call.”
•Second Nurse: “Oh, I usually call the supervisor. Did you callreport?”
•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”.
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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 flowand not with the artificial variability of batching!
• There is a need for scientific management in the hospital industry
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Reason’s Swiss Cheese Model of Error
Defence-in-depthUnsafe acts
Psychologicalprecursors
Latent failures at themanagerial levels
Local triggersIntrinsic defects
Atypical conditions
Trajectory ofaccident opportunity
We allow patients to aggregateand move in batches that overwhelm our staff
We are managing the efficiencyOf individual inputs and not thesystem
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“Hard work and good intentions are necessary but insufficient for exceptional care”.
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“Every System is perfectly designed to get exactly the results that it gets.”
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Time
# of
Pat
ient
s
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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)
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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
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What business model should we use to improve flow?Performance Improvement
1. Focus on the patient and his or her family2. Deep Process knowledge (Design)3. Decisions driven by data4. Teamwork5. 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?”
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Flow Teams at Boston Medical Center
Flow LeadershipTeam
ED Team Inpatient Team Surgical Scheduling Team
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Average total ED throughput timeBoston Medical Center
0
1
2
3
4
5
61 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69
Weeks
Hou
rs
Series2 Series3
Improvement from 4.5 to 3.75 hours30 minutes x 1050 cases = 31,500 minutes or 525 hours per week saved
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Improving Inpatient FlowTeam
• Janet Gorman• John Chessare• Linda Guy• Jane Damata• Dina Brauneis• Brian Brisbois
• Sue Doherty• Jacque O’Shea• Cil Weekes• David Roney• Kim Wood
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The Inpatient Cycle, Key Points, Key Process IndicatorsClean Bed
Bed Assigned
PatientArrivesIn Bed
Bed Assignment to Arrival Time
Patient Clinically Ready to Leave
Length of Stay
PatientLeaves
Average Discharge Time
Bed Turnover Time
Dirty Bed
120 minutes
5.5 days
15:01
60 minutes
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Maximizing Throughput:Smoothing the Elective Surgery Schedule to Improve Patient Flow
James M. Becker, MDKeith P. Lewis, MDJohn B. Chessare, MD, MPHEugene Litvak, PhD
Richard J. Shemin, MDGail Spinale, RNDemetra OuelletteAbbot Cooper
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Surgical Smoothing
1. Smoothing Elective Vascular Surgery2. Smoothing Elective Cardiac Surgery3. Separating Elective From Urgent Surgery in the Menino
Pavilion• Creating reliable urgency data• Separating a room for urgent/emergent cases• Eliminating Block Scheduling
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0
0.2
0.4
0.6
0.8
1
1.2
Mon
7W
Tue
Wed
Thu
Fri
Mon
8W
Tue
Wed
Thu
Fri
Mon
PC
U
Tue
Wed
Thu
Fri
Sat
Mon
SIC
U
Tue
Wed
Thu
AbramsonRestucciMadisonSampsonWong
Bed Need by Day of Week for Vascular Surgery (18 months of data)
Progressive Care Unit
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Volume
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
7/1/20
027/2
/2002
7/3/20
027/4
/2002
7/5/20
027/6
/2002
7/7/20
027/8
/2002
7/9/20
027/1
0/2002
7/11/2
0027/1
2/2002
7/13/2
0027/1
4/2002
7/15/2
0027/1
6/2002
7/17/2
0027/1
8/2002
7/19/2
0027/2
0/2002
7/21/2
0027/2
2/2002
7/23/2
0027/2
4/2002
7/25/2
0027/2
6/2002
7/27/2
0027/2
8/2002
7/29/2
0027/3
0/2002
7/31/2
002
Volume
Vascular Elective PCU Cases by DayRandom Month July 2002
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Vascular Scheduled PCU Cases - Weekdays Only (October 2003)
0
1
2
3
4
5
10/01
/0310
/02/03
10/03
/0310
/06/03
10/07
/0310
/08/03
10/09
/0310
/10/03
10/13
/0310
/14/03
10/15
/0310
/16/03
10/17
/0310
/20/03
10/21
/0310
/22/03
10/23
/0310
/24/03
10/27
/0310
/28/03
10/29
/0310
/30/03
10/31
/03#
of S
ched
uled
Cas
es
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E6W Direct Nursing Hours per Patient Day
8.66
8.16
7.90
8.00
8.10
8.20
8.30
8.40
8.50
8.60
8.70
Prior to Vascular SmoothingAfter Vascular Smoothing
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Average CT Surgery Unscheduled Cases Weekdays
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Average Scheduled CT Surgery Cases by Weekday
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Cardiac Scheduled Cases Histogram January & February Non-holiday Weekdays Only
0%
5%
10%
15%
20%
25%
30%
35%
Monday Tuesday Wednesday Thursday Friday
20042003
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March Daily PCU Census - 2003 vs. 2004
0
2
4
6
8
10
12
1-Mar
2-Mar
3-Mar
4-Mar
5-Mar
6-Mar
7-Mar
8-Mar
9-Mar
10-M
ar11
-Mar
12-M
ar13
-Mar
14-M
ar15
-Mar
16-M
ar17
-Mar
18-M
ar19
-Mar
20-M
ar21
-Mar
22-M
ar23
-Mar
24-M
ar25
-Mar
26-M
ar27
-Mar
28-M
ar29
-Mar
30-M
ar31
-Mar
20032004
2003 range 10 – 1 = 9
2004 range 7 –2 = 555% reduction in variability
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Operating Outside of theBlock at BMC
Separating the Flow of Elective Surgery from
Urgent/Emergent Surgery
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Menino Pavilion compared to Newton PavilionVariable 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
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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
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The Radical Changes
#1 Eliminated Block Booking
#2One Urgent Room Created
OR 5
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Bumped Cases Before and After Separating “Flows”
After
April 04 – April 05
• 354 emergent cases (M – F) 7:00 AM to 3:30 PM
• 7 elective patients were delayed or cancelled
Before
April 03 – April 04
• 349 emergent cases (M – F) 7:00 AM to 3:30 PM
• 771 elective patients were delayed or cancelled
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Norwood: Biggest Operational Dilemma
Daily ED Admits and Time from Decision to Departure
0100200300400500
1/1/20061/3 /20061/5 /20061/7 /20061/9 /2006
1/11/2006
1/13/2006
1/15/2006
1/17/2006
1/19/2006
1/21/2006
1/23/2006
1/25/2006
1/27/2006
1/29/2006
1/31/2006
2/2 /20062/4 /20062/6 /20062/8 /2006
2/10/2006
2/12/2006
2/14/2006
2/16/2006
2/18/2006
2/20/2006
2/22/2006
2/24/2006
2/26/2006
2/28/2006
Date
Min
utes
01020304050
Adm
issi
ons
Time in MinutesNumber of Admits
TimeRange = 176 – 418 minutes (3 hours – 6 hours)
Mean = 300 minutes (5 hours)Number of ED Admits
Range = 23 – 45Mean = 30
Goal = 120 minutes
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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.
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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
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1. ED MD evaluates new patient and decides that this is a medical patient (non-ICU) that needs to be
admitted.
11. Is a bed likely available for the patient?
3. ED MD completes admission order and
submits to ED secretary.
4. ED secretary enters order into Meditech,
which generates print out in Admitting office.
8. ED MD signs out patient to Lead Hospitalist (LH).
6. ED secretary informs ED charge RN of admission.
7. ED charge RN denotes admission
on white board.
5. ED secretary updates admission log.
ED Medical Admissions Process: IN THE EMERGENCY DEPARTMENT...
2. ED MD informs ED primary RN of
admission (probably when informing pt.).
9. ED MD informs charge RN of LH contact (during
board run).
12. Bed availability summary
sent by BPC
NO
YES
13. ED charge RN instructs primary RN to tape voicemail report.
14. ED charge RN fields call from BPC confirming
bed and transfer time.
15. ED charge RN puts bed and transfer time on board.
16. ED charge RN informs primary RN of bed and transfer time.
17. Primary RN tapes voicemail report (if not already done).
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.
21. ED secretary enters bed and transfer time on admission log.
19. Primary RN prepares patient for transfer, copies chart, and places copy
of chart in order bin.
10. ED charge RN denotes LH contact on white board
(during board run).
18. Primary RN calls receiving floor to deliver the voice-mailbox number.
22. Transport arrives to move the patient and collects necessary paperwork.
23. Transport moves patient out of ED.
E
G
B
24. ED secretary uses copy of chart to depart the patient in Meditech,
and to transfer the patient from U10 to the receiving unit.
A**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.).
Page 1
I
H
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ED Medical Admissions Process: THE BED PLACEMENT COORDINATOR
(25) When Admit Order prints out, BPC:a) enters name, etc. into BPC logb) admits pt. in Meditechc) prints packet to ED printerd) 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 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.
(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.
(27) If there are any discrepancies or questions about an admission, BPC contacts the administrative manager. Otherwise, BPC chooses a bed for
the patient.
(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.
(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 assignmentc) 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.
(31) BPC calls ED secretary to deliver bed assignment
and transfer time.
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.
A
C
D
E
G
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(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.
F
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ED Medical Admissions Process: HOSPITALISTS AND INPATIENT UNIT
(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.
(36) LH receives bed assignment and transfer time from BPC.
(37) Assigned hospitalist proceeds to floor as soon as
possible.
(42) Patient arrives on floor.
B
D
C
F
I
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(43) If patient does not have admission orders, unit secretary
texts Lead Hospitalist that patient has arrived.
H
(38) Charge RN or unit secretary on receiving unit fields call from BPC and
establishes bed and transfer time.
(39) Charge RN informs receiving RN of admission.
(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.
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ED Time from Decision to Departure and Total ED LOS (admits)
0100200300400500600700
1/1/2 0061/8/2 006
1/15/ 20061/22/ 20061/29/ 2006
2/5/2 0062/12/ 20062/19/ 20062/26/ 2006
3/5/2 0063/12/ 20063/19/ 20063/26/ 2006
4/2/2 0064/9/2 006
4/16/ 2006
Date
Min
utes
Redesign Go live
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SERVICE
Reduce the average time from ED admission decision to departure to inpatient unit to 120 minutes calculated monthly.
Av g. T im e from Decis ion-to-Adm it to ED Departure
0
50
100
150
200
250
300
350
6/19/2
0057/1
9/2005
8/19/2
0059/1
9/2005
10/19
/2005
11/19
/2005
12/19
/2005
1/19/2
0062/1
9/2006
3/19/2
0064/1
9/2006
5/19/2
0066/1
9/2006
7/19/20
068/1
9/2006
9/19/2
00610
/19/200
611
/19/200
6
Week B eg inn ing ...
Min
utes
D TA -D EP
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Question Mean Score: Speed of Admission
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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
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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.
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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