Robert Wise MD, VP of the  Division of Standards and Survey Methods at JCAHO, is interviewed by "Q," an otherwise nameless writer for Urgent Matters' eNewsletter.   The Patient Flow performance standard started out targeting emergency department overcrowding.  As the standard was developed, it became clear that the ED was the canary in the mine; ED overcrowding is usually a symptom of downstream patient flow bottlenecks.  These bottlenecks have many process, policy and personality causes.  Effective solutions require collaboration and action between the ED, hospital administration and all other sectors of the hospital (including medical staff). Consequently, the standard was renamed to reflect the root cause of ED overcrowding rather then the symptom.

The "Managing Patient Flow" standard puts an obligation on hospital leadership to develop plans to maximize efficient patient flow throughout the hospital. Knowledgeable champions working for broad-based change, like that required to improve patient flow, must have active senior management support and involvement.   JCAHO sees this management commitment expressed as committed resources and personal involvement.

"They need to provide the necessary manpower, funding and time to collect data about the extent of the problem at their facility, analyze the data, and coordinate the hospital's resources across the board."

One of the most challenging areas impacting patient flow is the medical staff.  Physician admission and discharge decisions have a huge impact on patient flow.  Gathering the data and developing effective strategies to foster a productive discussion and effective resolution of these issues is critical.

Patient flow problems also have an impact on Risk Management and patient safety.  Getting patients the most appropriate care, in the most efficient setting is critical.

"Inefficient patient flow starts a cascading of problems that are significant safety threats. When you have people waiting to get into beds from the ER, people being boarded, people in hallways, people stacked up in a recovery area, or not getting in or out  of the ER, that's a safety threat. When I give presentations, I often ask the audience whether their hospital has people lined up in the hallways on a unit or in the ED. The hands always go way up. [These backups can put the hospital in] ...violation of the Joint Commission, but also of CMS and probably their local fire codes, too."

Dr. Wise also mentions the challenges that a hospital's existing physical plant can present.  Many hospitals have architectural (or capital budget) limitations that may preclude certain responses to patient flow issues. Here is what Dr. Wise recommends as actions a hospital can take to demonstrate they are addressing patient flow:

  1. Take a leadership position on patient flow, making a resource commitment to study, plan and execute patient flow solutions
  2. Make a serious effort to understand the root causes impacting patient flow in their hospitals
  3. Map out a strategy and plan to address the root causes (don't forget measuring results)
  4. Be able to demonstrate resulting flow improvement changes and their results
  5. Any issues of patient safety must be addressed immediately

The following is the fine print on the JCAHO standard:

 Elements of Performance for LD.3.15

  1. Leaders assess patient flow issues within the hospital, the impact on patient safety, and plan to mitigate that impact.
  2. Planning encompasses the delivery of appropriate and adequate care to admitted patients who must be held in temporary bed locations, e.g. Post Anesthesia Care Unit and Emergency Department areas.
  3. Leaders and Medical Staff share accountability to develop processes that support efficient patient flow.
  4. Planning includes the delivery of adequate care, treatment, and services to those patients who are placed in overflow locations, such as corridors.
  5. Specific indicators are used to measure components of the patient flow process and address the following:
              * Available supply of patient bed space
              * Efficiency of patient care, treatment, and service areas
              * Safety of patient care, treatment and service areas
              * Support service processes that impact patient flow
  6. Indicator results are available to those individuals who are accountable for processes that support patient flow.
  7. Indicator results are reported to leadership on a regular basis to support planning.
  8. The hospital improves processes related to patient flow identified as inefficient or unsafe.
  9. Criteria are defined to guide decisions about initiating diversion.