Safety expert blames poor flow for many errors

The recent fining of nine California hospitals for patient safety violations underscores just how high a cost health care facilities might pay for safety shortcomings, and puts an even greater emphasis on identifying new causes of errors and their solutions.

According to one expert, a key factor that contributes to reduced quality of care; reduced patient safety; and overworked and disgruntled nurses, doctors, and administrators is the lack of managing patient flow — in particular, poorly controlling the timing of elective (scheduled) admissions, which then results in periodic episodes of high stress on the entire system.

"What we have found is that patient demand is extremely variable," says Eugene Litvak, PhD, co-founder and director of the Program for the Management of Variability in Health Care Delivery at Boston University, and a professor of health care and operations management. "One day the hospital is under stress, and another day its resources may not all be utilized."

What is behind this variability? Hospitals, Litvak explains, have three main portals:

  • admission through the ED, which accounts for more than 50% of all admissions;
  • elective surgery, which represents a much smaller percentage; and
  • transfers.

The logical assumption would be that the ED holds the key to solving this problem, but that's not the case, Litvak argues. "We have found that elective admissions are more variable than admission through the ED," he says. "In other words, it's easier to predict when somebody will break a leg than when the hospital will schedule an elective surgery."

Peak demand equals stress

The way hospitals are staffed today, these periods of peak demand cannot be addressed adequately, says Litvak. "About 40 years ago we used to staff up to peak; today, nobody can afford to do that." With staff levels well below what is needed to meet peak demand, he says when that peak demand occurs, the hospital and staff are under great stress.

This relates directly to the problems in California, he asserts. "Not having beds available to move patients up from the ED is cited as the No. 1 reason why EDs are overcrowded, and California experiences that full-scale," he says. "In two of those hospitals, problems arose because people were waiting in the ED too long — and when you have a peak in scheduled admissions, all the beds are taken away," Litvak explains.

"On top of that, all the nurses are under stress," he continues. "What happens? Nurses under stress are known as one of the major sources of medical errors and sentinel events."

More resources not the solution

The solution, says Litvak, lies not in gaining additional resources, but in better allocating them. "If you reduce the number and frequency of peaks and valleys, you will dramatically increase revenue, improve your nurse staffing, and dramatically improve your quality of care," he argues.

"Bed occupancy can jump from 25% to 80% in one day, and yet you have fixed staffing; how can you ask your nurse to perform quality care if she is overburdened?

"The solution is to smooth those artificial peaks," he says.

He and his colleagues suggest changing the scheduling of elective admissions so they fall evenly across all workdays. To accomplish this, he says, you need to get your CEO involved. "If he's not, forget about it," he says.

But why should surgeons agree to change their way of operation? "As soon as you smooth out the peaks and valleys, the number of surgeries performed increases dramatically, so the surgeons benefit dramatically," Litvak says. "You also need to make sure that ancillary services like physical therapy are available on weekends."

And what about the financial penalties for hospital safety violations? Does Litvak think this will be a growing trend? "I think it will happen if hospitals do nothing," he predicts.

[For more information on Dr. Litvak's approach to patient flow, as well as studies quantifying his results, go to He can also be reached via phone at: (617) 358-4547.]