The other day I came across a Baltimore Business Journal article from late last year that describes patient flow experiences at Baltimore area hospitals.
There is some good background on the problem like the impact of capitated reimbursement and the rapid drop in LOS in the '90s. But the rapid drop in LOS started to level off in the late '90s because the easy fixes to patient flow problems, like optimizing individual departments, had been done. Impacting patient flow (and reducing LOS) today requires cross-silo organizational review and broad based solutions. The solution of final resort is adding capacity. At a cost of $1 million per new bed, building your way out of a capacity problem is an expensive proposition.
“The system doesn't like to pay a lot for standby capacity,” said Caroline Steinberg, vice president for trends analysis for the American Hospital Association in Washington. “It's a balance of extra capacity that the system is willing to pay for to make sure you only have gridlock a certain percentage of the time.”
Solutions discussed include:
the addition of hospitalists
acquiring capacity management software
increasing hospital operating hours from 5 to 6 days per week
optimizing diagnostic testing
aggressive discharge management
Of course this is a partial list of fixes, and few of them are quick and easy. Johns Hopkins was the exception. Their secret was, “asking doctors where the problems were and fixing those problems.” I don't doubt that this quote was taken out of context — if improving patient flow was that easy, there would be no problem. But, there is some truth to the comment.
The people working in your hospitals (including the doctors) know the bottlenecks, and have good ideas how to fix them. Tapping this knowledge, with some process observation and analysis of data you already produce, is key to work flow optimization. This 20% of effort will get you 80% of the benefit. Stopwatches and time-in-motion studies are only required for that final 20%, if you want to up your effort considerably.
St. Joseph Medical Center in Towson increased admissions 7% from 2002 to 2003. Emergency room overcrowding resulting in ambulance diversions came down from several hundred hours a month to just ten hours. Improving lab results report turnaround times pulled ER wait times down 70% (a typical patient waits less than 30 minutes to see a doctor). The time required to admit an ER patient has come down 50 percent. Hopkins cut a half day off their average LOS and increased hospital admissions by 20 percent.
None of these Baltimore area hospitals appear to be using one of the most effective means to improving patient velocity, universal units. Emergency department overcrowding is typically the symptom of a lack of open ICU or Telemetry beds. The universal unit can handle a wider range of patient acuity, combining more aggressive therapies with a higher level of surveillance for safety. The end result is providing appropriate patient care in the lowest cost setting. This new care model reduces ICU and Telemetry utilization by reducing inappropriate admissions, reducing ICU/Telemetry LOS, reducing readmissions and reducing off-service admissions.