Patient flow gets new look, standards

Report puts more emphasis on psych patients

Patient flow and boarding have been recognized for some time as problems that hospitals need to address. But whatever is being done isn’t enough, and The Joint Commission (TJC) released a report in December outlining new standards in the Leadership section, some of which came into effect on January 1, and some of which will take effect in another year. The hope is that the new elements will help facilities take a more holistic approach and view the problem — and its potential solutions — in a more systemic manner. (The entire report is available at

Newly in effect are standards that require measurement and goal-setting of data such as the number of patient beds available, the throughput and safety of places where patients receive care and services, how efficient non-clinical services are (like housekeeping and transport), and patient access to services like case management and social work.

Coming into effect in January 2014 are standards that deal with the measurement and abatement of boarding patients from the emergency department, with a recommendation that the goal for time spent boarding not exceed four hours while taking into account the specific needs of the local community and resources available to the hospital. Leadership must review the goals and take action if they are not met, the new standards state. Teams involved in such review should include members of the medical staff, the hospital board, facility executives and senior management, and nursing.

Further, the new standards put special emphasis on dealing with the needs of patients experiencing psychiatric and behavioral health emergencies, to ensure they are not boarded for extended periods of time and that when they are, their care and safety and the safety of others in the facility are appropriately considered. If the hospital doesn’t typically deal with this type of patient, the standards require plans to ensure quality care and a safe environment when they do present. Further, the hospital leadership is encouraged to coordinate with the wider community to ensure that the needs of this special patient group are met.

Shine the light

That The Joint Commission is putting further emphasis on the topic is great, says Mary Baum, MPH, RN, chief healthcare officer of Connexall, a Toronto-based company that makes software designed to help hospitals improve patient flow. “It is a tough problem to break apart because healthcare is so complex, with interdependent parts, and patients and staff that have the freedom to act unpredictably,” she says. The four-hour goal for boarding is particularly welcome, she adds. “For most patients, that four-hour window won’t be hard to meet. But for some patients — mental health patients particularly — it’s going to be very, very difficult.”

There are fewer beds for behavioral patients — 11% fewer than just a couple of years ago, says Baum. These patients are often too incoherent to help providers figure out what is wrong with them. Some are brought to an emergency room because law enforcement doesn’t know what else to do with them. She mentions a large hospital system on the West Coast that Connexall worked with recently. “They never divert for trauma, but they do for mental health often. They don’t have hallways space for any more patients. They need a security guard for each one. These are usually patients who don’t need an inpatient bed, but need some kind of treatment.” The average time for a mental health patient in the system was 17 hours. And the staff were trying desperately to move the patients through the system, Baum says. “But what can they do? Create new beds? Build a new wing? Those are long-term things.”

The new standards are great, Baum says, but no single entity can solve the problem of mental health patients boarding in the ED by itself. It’s the language that calls on leadership to work in the wider community to serve the needs of this patient population that she hopes will energize action. “Acuity levels and volumes are up; there are fewer beds. One in ten suicides is seen in the ED within 60 days of the suicide. There is a tangled web of homeless people with drug and alcohol issues, who are uninsured and often present with grave comorbidities.”

What worries Baum is the emphasis on how other industries deal with workflow and how to apply those lessons to healthcare. While noting there are certainly lessons to learn and ideas to implement from others, “we aren’t Toyota,” she says. “Patients move in erratic ways, they come from a variety of places, and we don’t know their acuity level before we see them.” How can you put a flow system together for that kind of environment? “It has to be a systemwide thing. And these standards might help by shining a light on it. But every ED out there is already looking at throughput and growing volume. They do it, too, with limited dollars because so much of the available funding is going to technology ‘solutions’ like electronic records. But those things don’t change throughput or connectivity or how we work together in meaningful ways that solve this problem.”

Four hours is a goal, but not something that hospitals will be surveyed against, says Lynne Bergero, MHSA, project director at TJC’s Department of Standards and Survey Methods, Division of Healthcare Quality Evaluation. “Hospitals will set their own goals, based on their own reality,” says Bergero.

It’s particularly important for care to be delivered and dispositions made for mental health patients in a timely manner, Bergero says, since just being in an unfamiliar, noisy, and hectic environment can lead to a deterioration in that group’s mental condition. “But if a hospital can’t meet that four-hour goal as a practical matter, they can set their own goal. The surveyor will ask how they came to make that number and how they ensure safe and timely care for patients.”

For the elements related to working within the community to address the problems of psychiatric and behavioral health patients, Bergero recommends using the American Hospital Association’s resources related to finding community solutions to caring for them, such as a report from a year ago that not only outlines the issues, but examines some success stories from around the country (

The hope is that hospitals will start to think strategically about the continuum of care and the elements in it that affect how patients move through the hospital and the wider healthcare system, Bergero says. “This isn’t going to get easier and the pie won’t get any bigger, so don’t act like you are in a silo.”

Steps to take now

Baum reiterates that the new standards are a good thing, but don’t expect them to have a huge impact right away. And don’t be discouraged if it takes more time to get this right than you’d like, she says, because there are steps a facility can take to set goals that are meaningful, achievable, and will benefit both the hospital and the wider community.

“Think about how you work together across functions,” she says. “Look at your wider community for novel ways to address the needs, particularly of the mental health patients. The ED is just the door they access for care. Most don’t need hospitalization, and with proper treatment have the same risk of harming themselves or others as the rest of the population.” Involve police, social workers, EMTs, and community services for at-risk populations in your discussions. Hospitals can’t do it alone, Baum says, and there isn’t really best practice out there for what can work with this patient subset. “Best practice is not a security guard on each person. Putting them in hallways isn’t best practice.”

For more general throughput issues, Baum recommends taking time to go see what really happens in the ED, versus what your workflow charts say should be happening. “Patients don’t come in neat rows. This isn’t a linear problem that Lean and Six Sigma can solve. Reality is messier,” she says.

One option is to hire experts to do ethnographic studies on what really happens in your ER. It’s time-consuming, and it’s not cheap, Baum notes, but the results of such current state analyses can be eye-opening and provide ideas for simple fixes that will lead to meaningful improvements. Among the things that an expert can determine, says Baum, are how transitions are made, what happens when you send a nurse with a patient for imaging or other tests, and how moving that nurse with the patient impacts the care other patients or new admits get. “How does having a pharmacist in the ED impact flow? What’s the mean bed turnover time? Does admissions staff know how many patients are waiting for beds? Where are the bottlenecks and barriers to flow?”

Technology can capture some of this information, but Baum notes that often it’s put in separate systems, sent to different departments, and not shared with the wider audience whose work the data impacts. “Not everything even gets put in the computer in the ED. Providers shout information and write on their hands and on paper towels. How can other people access this information? If someone is shouting lab results to a doctor, and he puts the results in later, what does that do to your time from the order to a meaningful clinical decision?”

It’s all doable over time, but you have to prioritize, Baum says. “Map your reality with a huge degree of honesty, ideally with an objective person doing the mapping. Put teams together, including people from the community to find the root causes of the issues you face for all kinds of patients that lead to throughput problems. Then figure it out. It’s not going to all be about the ED.”

Most people who work in the ED know that already. But Baum thinks it’s great that others are getting this message from TJC, too.

For more information on this topic, contact:

  • Mary Baum, MPH, RN, Chief Healthcare Officer, Connexall, Boulder, CO. Email:
  • Lynne Bergero, MHSA, Project Director, Department of Standards and Survey Methods, Division of Healthcare Quality Evaluation, The Joint Commission, Oakbrook Terrace, IL. Telephone: (630) 792-5175.