CMs' role in patient throughput initiatives

CMs know where the roadblocks are

Case managers play a critical role in patient throughput and their voices should be heard whenever hospital staff meet to discuss barriers to admission and discharge and how they can be eliminated, says Charlotte Thompson, RRT, BA, MBA, manager in KPMG LLP's health care advisory practice.

"Case managers are sometimes excluded from throughput teams but they should be a part of this multidisciplinary decision-making group. They are in a unique position to see where the roadblocks occur and to do something to expedite patient flow," she adds.

As part of their job, case managers identify delays and deal with them as they occur. This puts them in a good position to play a supportive role in identifying patterns in delays, adds Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization at the North Shore-Long Island Jewish Health System.

Hospitals have to understand where the problems are before they can decide what steps to take to make maximum impact, she adds. "It's not always so obvious where delays occur. You might know anecdotally what is happening but you need data to support it before developing an improvement plan," Cesta says.

Hospitals should have several teams that look at patient flow and throughput, collecting data and identifying where the biggest opportunities are. Staff who are working closest to patient care should serve on those teams, she says.

The teams should brainstorm on possible hold-ups to patient throughput, collect data on potential glitches, analyze the data, and identify the greatest opportunities for improvement, Cesta says.

Take the team approach

Thompson advocates the team approach to patient care and patient throughput.

"When multidisciplinary teams meet and discuss patient flow, you can almost see the light bulbs go off. These meetings break down the cultural silos that occur in today's busy hospitals. The disciplines begin to actually communicate with each other and start resolving issues," Cesta says.

A multidisciplinary throughput team should include the unit secretary, housekeeping, pharmacy, lab, radiology, and transportation as well as representatives from the clinical team, she says.

Case managers should deal with problems as they occur and point out patterns at the patient flow meetings, Cesta says. For instance, if a hospital doesn't perform MRIs on Sunday and the case managers observe patients who stay longer because they have to wait until Monday for the MRI, they should point it out to the throughput team.

"Improving throughput involves providing care when it's needed and that means seven days a week, as opposed to five days a week. If hospitals provide certain services only Monday through Friday and patients are languishing in the hospital over the weekend, they're not getting what they need from a quality-of-care standpoint," Cesta says.

Spreading services out across seven days a week optimizes a facility's resources and personnel and helps get patients through the continuum of care in a timely manner, improving quality and patient satisfaction along the way, she adds.

"Patient flow is more than just discharging patients. It's the entire process from the time that patients come into the hospital until [they leave]," Cesta says.

Identify opportunities where patient flow may be affected, she suggests.

Look at all the places in your hospital where case managers can affect patient throughput. Identify what you want to measure in each category and set targets.

Determine where you are off-target and focus on specific issues and initiatives that can help clear up the problem.

Look at how patients access the hospital. How long are they waiting in the emergency department? Are patients being admitted inappropriately, taking up beds that other patients need?

All of that affects patient flow, Cesta says.

Look at laboratory and ancillary services and track the delays in getting the results.

Examine the relationship between case management and housekeeping. Track how quickly housekeeping is notified when a bed is ready and how long it takes for them to clean the room.

Internal transportation may be another potential glitch. Look at how patients are transferred to ancillary departments for tests and procedures and how long it takes. Find out how long it takes for a patient to be transported out of the hospital when they are discharged.

"There are a thousand little things that may mean only short delays, but they can all add up," Cesta says.

Evaluate preadmission testing time and how long patients wait for the operating room. Track operating room cancellations, how often they occur and why.