Collaboration on capacity management

Helps with discharge delays, waits for beds

When a hospital in downtown Knoxville, TN, closed and volume soared at other nearby hospitals, two hospitals in the Covenant Health System joined forces to develop a systematic approach to capacity management that allows each hospital to create variances in the process to meet its individual needs.

The process reduced discharge delays, increased discharges early in the day, and reduced waiting time in the two hospitals.

"Patient flow is a huge process that needs to be managed every day in real time. We developed a process for ensuring good patient flow, but it's also about relationships and communication. The success of the process depends on a 'trifecta for patient flow'— the physicians, the nursing leadership, and the case managers," says Sheila Gordon, RN, MS, director clinical effectiveness/ nursing administration at Fort Sanders Regional Hospital.

The volume at Fort Sanders Regional spiked to 1998 levels last year after the downtown hospital closed.

"All of a sudden, we were having 90% census days. ParkWest Hospital took some of the volume we couldn't handle, but we knew that we had to improve on our capacity management process," Gordon says.

The hospitals replicated a best practice in patient flow from the Institute for Healthcare Improvement, according to Lori Myers, RN, MSN, capacity management manager at ParkWest Hospital.

"To achieve good patient flow, hospitals need an open conduit that goes from the administration down to the person who sees the patient first, and spreads out across the hospital from the charge nurse, to the primary nurse, to the case manager, to the ancillary units, and everyone else who touches the patient," Myers says.

Representatives from both hospitals formed a multidisciplinary team and developed a systematic approach to capacity management that allows for each hospital to create variances to meet its individual needs.

For instance, the process they developed calls for daily huddles between the nursing manager and the case managers on each unit and a daily hospitalwide capacity management meeting, but each hospital handles the practice a little differently.

At Fort Sanders Regional the first meeting of the day is the huddle during which the nurses and case managers identify what should happen with the patients during the day. That meeting is followed by the hospitalwide capacity meeting to discuss patient flow, any potential new patients, and which patients are expected to leave.

ParkWest holds the hospitalwide meeting first, followed by the huddle.

At Regional, if the hospital is approaching capacity, the team meets again, in the emergency department at 3 p.m.

"We look at how many patients have moved in the past six hours. At 3 p.m., most of the patients waiting for a bed are in the emergency department. We collaborate with the staff there to help us think through what we need to do to get those patients in a bed," Gordon says.

Fort Sanders Regional has designated specific overflow areas when patients need a bed, such as the catheterization lab recovery area. The hospital can shift critical care staff to the step-down unit if critical care beds are needed.

"When we are approaching capacity, there is a lot of creative thinking and critical thinking and a lot of dialogue between the physicians and the rest of the staff," Gordon says.

For instance, if the emergency department is full and holding acute care patients and the hospital is being called to accept transfers from outlying hospitals, the team looks for ways to accommodate the new patients.

"We look at how many patients we have on a unit that have not been discharged, and the staff concentrate on getting them moved so the hospital can put patients holding in the emergency department in a bed on the unit and receive patients from the outlying hospitals," she says.

The staff at ParkWest have three daily bed capacity huddles regardless of census, Myers says.

The shift leaders and case managers from throughout the hospital meet at 8:30 p.m. and 4 p.m., and the shift leaders meet again at 4 a.m. when the day crew starts work.

Then each unit holds a daily huddle at 9 a.m.

If it appears that the census is going to be high, a 7 a.m. bed alert goes out all over the hospital.

"The administration, nursing managers, hospitalists, emergency department staff, charge nurses, and case managers all receive the bed alert and they know that they need to start looking at their part of capacity management first thing," Myers says.

For instance, when the bed shortage is significant, the 7 a.m. alert cancels all meetings for administration and management to free up their time to concentrate on the flow. It alerts surgeons to go to the floor and discharge patients before they start their surgery.

When Regional has a high census, the team is alerted at the original bed huddle and meets again at 12:30 p.m., 3 p.m., and 8:30 p.m., depending on the capacity issues.

"We call down to the areas that are having a high census and try to involve them in improving patient flow. At Regional, we tend to have bottlenecks in critical care and cardiology, and less frequently, the pulmonary floor and oncology," she says.

"We identify areas where there are flow issues and call the nurse manager, shift leader, and case manager to the extra bed-control meeting," she says.

Keys to the success of the process are a discharge flow board that tracks all of the regulatory requirements for patients, as well as procedures that have to occur before the patient can leave, and a computerized case management system that allows management to track glitches in the patient flow, Myers says.

For instance, Myers can determine if a patient was late leaving because the physician was rounding late in the day or if the insurance company took a long time to precertify post-acute services.

Case management drives the flow board process that informs the entire multidisciplinary team about what is going on with patients, Gordon says.

When a case manager believes a patient is likely to be discharged the next day, she lists him or her as an "intent to discharge" and enters it on the flow board.

Each morning the case manager and nurse manager on the unit use the flow board to determine which patients are labeled "intent to discharge," who can be discharged that day, who cannot be discharged, and the plan of the day for each patient.

"The intent-to-discharge list is what case managers look at first thing in the morning and work on throughout the day. They work to make sure that these patients get everything they need for discharge," Gordon says.

The team discusses any obstacles to discharge and assigns someone to take responsibility for overcoming them. For instance, if a patient's discharge depends on the results of an X-ray, the charge nurse alerts the primary nurse to let radiology know that the test is a high priority. The case manager makes sure that home health is ordered for patients who will need it.

The nursing and case management staff start holding conversations with post-acute facilities earlier in the day. If discharges depend on home health, they call the agency to let them know the hospital is on bed alert and they need to process the referral quickly.

Gordon and Myers track the reliability of the process to determine how many patients designated as "intent to discharge" are actually discharged and what kept them in the hospital if they are not discharged.

The hospitals track time frames at essential points, such as how long it takes from the time the patient arrives until the patient is in a bed, and use the information to develop targets for getting patients admitted and for housekeeping turnaround times.

"If we are efficient in our admission process and get patients admitted and the beds turned around in a timely manner, we can focus on discharge issues, such as physician orders and referrals for post-acute services," Gordon says.

The hospitals have collaborated on process changes that one or the other hospital piloted before the other rolled it out.

For instance, ParkWest added environmental services milestones to its flow board. These include adding when housekeeping arrives and when the bed is ready for the next patient to its flow board. Following the success of the project, Fort Sanders Regional is adding environmental services to its flow board.

The increased communication and awareness of patient flow needs has cut 20 minutes off the time between when a bed is empty and the room is clean, Myers says.

"We took two solid processes and combined them. Environmental services had their benchmarks and processes, and we had ours. By having conversations between the two areas and combining the benchmarks, we were able to improve efficiency," Myers says.

[For more information, contact: Sheila Gordon, RN MS, director clinical effectiveness/ nursing administration at Fort Sanders Regional Hospital, Knoxville, TN, e-mail: sgordon1@CovHlth.com or Lori Myers, RN, MSN, capacity management manager at ParkWest Hospital, e-mail: LMyers2@CovHlth.com.]