Patient flow takes on new importance with health care reform

Hospitals can't afford for patients to stay longer than necessary

As hospitals face cuts in reimbursement and patients who become insured under health care reform legislation seek care, moving patients safely and quickly through the continuum of care is going to become important, experts say.

"Hospitals are expensive places to be, and in today's reimbursement climate, hospitals need to reduce waste. Any time a patient is staying longer than necessary, he or she is utilizing services resulting in a waste of limited resources," says Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for Covenant Health System.

Medicare payments are based on the geometric mean length of stay, which means that the hospital loses money on patients who stay longer than expected for their DRG, Fugate points out.

In addition, commercial payers are tightening their reimbursement, making it necessary for hospitals to ensure that patients get the care they need in a timely manner, she adds.

"Hospitals simply can't afford to have patients who do not need to be there. Health care is one of the most inefficient industries. Hospitals are going to have to become more efficient in order to survive," she says.

Any time a patient stays in the hospital, he or she is at an increased risk of infection, falls, and medical errors, Fugate points out.

"It's important for patients to be treated and discharged as quickly and efficiently as possible, not because of the hospital's bottom line but from a standpoint of providing appropriate quality care," she says.

When hospitals have an increased length of stay and patients stay too long in the inpatient setting unnecessarily, it creates a bottleneck that results in overcrowded conditions in the emergency department. This adds additional time to the length of stay while patients wait for an inpatient bed and the emergency department ultimately runs the risk of going on diversion, adds Roxanne Tackett, RN, MBA, vice president of clinical services for Compirion Healthcare Solutions, a health care consulting firm based in Elk Grove, WI.

Reducing waits for beds in the emergency department improves patient satisfaction as well as improving quality and safety outcomes, which ultimately will improve the hospital's bottom line, Tackett points out.

"Patients shouldn't be on a stretcher for multiple hours waiting for an inpatient bed. Emergency department and post-anesthesia care unit [PACU] nurses are experts in stabilizing emergent patients, but they are not experts in providing ongoing critical care. Patients need to be transported to the appropriate inpatient bed as soon as possible in order to receive care from a particular unit that matches their treatment needs and so they can receive their medication in a timely manner," she says.

One way to help reduce the length of time admitted patients wait in the emergency department and eliminate boarding in the ED is to improve patient flow to the inpatient areas. It takes the entire team from throughout the organization working together to accomplish length-of-stay initiatives, she adds.

But improving patient flow doesn't just mean getting patients out of the emergency department and into a bed as quickly as possible, points out Ann Kirby, BA, BSN, MSN, MPA, managing director at Wellspring + Stockamp HuronHealthcare, a Chicago-based consulting firm.

Managing the 'balancing act'

"Good patient throughput is a balancing act. It's about getting patients into a bed where they can get the best care," she adds.

For instance, if a cardiac patient is placed on the orthopedic floor because that's the first bed available, it's not best for the patient because the staff don't have the level of expertise to provide optimal care, she adds.

"It sounds like a great idea to get patients in the emergency department admitted to an inpatient bed as fast as you can. But, if hospital patients are placed in a bed on an appropriate unit, then being moved the next day, it creates a lot of extra work for the staff and adds to the length of stay," she says.

For instance, suppose there are two patients waiting for beds — an orthopedic patient who has been in the emergency department for an hour and a cardiac patient who has been there two hours.

"If there is a bed on the orthopedic unit available and the cardiac patient is stable, it would be better to admit the orthopedic patient to that bed, particularly if a cardiac bed is expected to open up soon," she says.

Addressing patient flow in a comprehensive manner is very important, Kirby says.

"Everybody knows that they need to improve flow, but it doesn't work well to tackle just one area at a time. Decisions on the unit or the department level don't necessarily make sense for the rest of the house," she says.

For instance, many hospitals focus on case management functions, but if people throughout the hospital are not involved, the initiative is likely to have limited impact, she adds.

"Capacity management no longer can be just the responsibility of care management. It requires collaboration between all disciplines to drive the flow from admission to discharge. Everybody who is involved with patient care has to work as a team to achieve timely patient flow," Fugate adds.

Hospitals in Covenant Health System's East Tennessee Region collaborated on improving efficiency and the quality of patient care by creating teamwork and ownership in bed capacity management, she says.

"The key for hospitals to survive in today's health care environment is for everyone who is directly or indirectly related to patient care to understand how what they do every day impacts patient flow and the ramifications for the hospital when patients stay longer than necessary and overutilize resources," she says.

Capture the entire patient episode

Kirby recommends developing a flow diagram that outlines all the processes that span the entire patient episode from the time a patient comes into the hospital until he or she leaves.

Look at how people are organized, how they are trained, the processes they use, and the tools that support them, Kirby recommends.

For instance, outline how the nursing supervisor helps facilitate getting patients to the unit, the roles of case management and social work, how the interdisciplinary team interacts, and how nonclinical staff such as housekeeping and transportation are involved in patient flow, she says.

"The patient flow process has a lot of moving parts. It's no wonder organizations are struggling to fix their flow," she says.

Look at the length of time it takes to place patients into a bed from the emergency department and how often the patient is placed on the most appropriate unit, she says.

Most hospitals need an automated bed board in order to effectively manage and measure patient flow performance, Kirby says.

The bed control staff have to have a good view of the beds available, who is ready to leave, and who is waiting to come into an inpatient bed in order to make the best decision for the patients.

In some hospitals, nurses approach housekeeping directly when there's a bed that needs to be cleaned. This process may impede patient flow because the housekeepers may be working on one unit when there are patients waiting for beds on another unit, she says.

"The people in the central bed hub should be the only ones to say a bed needs to be cleaned immediately. The nurse may see that her unit has four empty beds but the most critical need for beds may be in another unit," Kirby points out.

Have good processes in place so you automatically track your metrics and drill down to see the causes of the delays, she says.

"So often we see hospitals that have a lot of information, but they haven't set up a way to get the team together to discuss information and set goals," she says.

For instance, if statistics show that housekeeping's response time is 25 minutes and the goal is 15 minutes, the roadblock could be that the unit secretaries aren't entering discharges in a timely manner and are processing them all in a big group.

"All of the processes are interconnected, and everyone involved must be aware of the impact they have on patient flow," Kirby says.

When making changes in processes, it's important not to underestimate the length of time it takes to make the changes stick, Kirby says.

Some hospitals have invested in tools such as a case management system or an automated bed board but don't spend the time helping people transition through the new way of doing work or develop the metrics to monitor and recognize success and identify opportunities for improvement, she says.

It typically takes eight to 12 months for a hospital to determine what needs to be done and how to do it and to ingrain the behavior in the entire hospital staff, Kirby says.

[For more information contact: Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for Covenant Health System, e-mail:; Ann Kirby, BA, BSN, MSN, MPA, managing director at Wellspring + Stockamp HuronHealthcare, e-mail:; Roxanne Tackett, RN, MBA, vice president of clinical services, for Compirion Healthcare Solutions, e-mail:]