Access Management Quarterly

System aims to improve patient throughput

3 hospitals have different issues, different strategies

Providence Health System is pulling out all the stops as it focuses this year and next on improving patient throughput at its three Portland, OR-area hospitals, says Kathy Campbell, black belt project manager for health services integration.

In June 2005, Campbell says, she assumed a leadership role in answering the question, "How do we improve our process so that we put the right patients in the right beds at the right time?"

A key part of the effort — but by no means the only tool being employed — is the quality assurance and process improvement strategy known as Six Sigma, which has teams led by people who have been trained as "black belts" or "green belts" in the organization.

The Hospital Flow Diagnostic, an electronic tool offered by the Cambridge, MA-based Institute for Healthcare Improvement (IHI) for measuring hospital throughput and activity based on bed turns, also will be used, Campbell adds.

Each of the three hospitals is doing different things to achieve throughput improvement, because the root cause of the problem might be a little different at each facility, she notes.

Patient throughput, or the efficient use of inpatient beds, is one of three principal areas being targeted this year by Providence Oregon, says Nancy Roberts, regional director for integrated performance/Six Sigma champion. Other areas of focus are labor productivity and patient safety.

An organizationwide initiative called "Operational Excellence," meanwhile, is the thread that runs through all the efforts to "make us efficient, excellent at the work we do," she adds.

"Our Operational Excellence strategies and tools are there to help us achieve our long-term goals," Roberts adds.

With the growth in the community served by the health system has come a large number of under- and uninsured people who make throughput improvement especially important, she points out. "We have a mission to serve the poor and vulnerable, so we need to be as streamlined as we can, so we can fulfill our mission."

There currently are four Six Sigma projects that are aimed specifically at improving throughput, adds Campbell, who described them as follows:

• Length of stay (LOS) for orthopedic patients discharged to skilled nursing facilities (SNF).

Patients on the eighth-floor east orthopedic unit at Providence St. Vincent Medical Center who had hip procedures and had to be discharged to an SNF were found to have a longer LOS than patients discharged home (5.01 vs. 2.45 days), she says.

Facilitating the timely and appropriate transfer of these frail patients, Campbell notes, not only will allow the hospital to better meet patient and family care needs and improve hospital divert times, but it is expected to have a positive financial impact of between $350,000 and $500,000 annually.

The project focuses, among other things, on identifying those patients early in the process and building preprinted order sets around caring for them, she adds.

It has identified a number of factors that can be used to predict LOS variation for these patients, including the day of the week when admission, surgery, and discharge occur; the timing of acute care manager and occupational therapist orders; and when the transfer form is completed.

The goal of the project is to reduce LOS for those patients to an average of 72 hours and a maximum of 84 hours.

While that project employs the extremely data-driven techniques of Six Sigma, Campbell points out, a project on the other end of the eighth floor focuses on communicating with patients at the point of admission about discharge planning.

Those conversations have to do with the expected LOS, whether a certain type of stay might require discharge to another setting or home care service, she says.

Another big piece of the project is working with physicians and nurses to get them to be more efficient at writing discharge orders, adds Campbell.

A third piece is encouraging physicians to do rounds first with patients who are ready to be discharged, rather than the traditional practice of going first to the more critically ill individuals, she says.

This project is people-driven, rather than data-driven, Campbell notes. "Sometimes Six Sigma fits, and sometimes it doesn’t."

• First-case surgery patient in operating room (OR) on time.

The second Six Sigma project has to do with smoothing out surgery schedules by ensuring that the first surgery case is in the OR on time, she continues. "The premise is that things get backed up during the course of the day because they don’t start on time."

In 2004, 44% of first-case surgery patients entered the Providence St. Vincent OR early or on time, Campbell notes. The goal is for 75% of elective first-case surgery patients to enter the OR early or on time.

The strategy for streamlining the surgery flow was to make sure there were enough beds for scheduled cases and enough surgery time for the "uncontrollable variation" that comes through the door, she explains.

There now is a ready room available for those emergency cases so the schedule doesn’t back up, Campbell adds.

• Providence Portland emergency department (ED) to floor transfer.

The third Six Sigma throughput project focuses on improving patient flow to get patients out of the ED or cared for more appropriately while there, she says.

"We spend a fair amount of time on divert because we can’t get certain types of patients out of the ED," Campbell explains. The goal of this project, which is at Providence Portland Medical Center, is to shorten the length of time it takes to get a patient from the ED to the nursing floor.

"They were finding that once they elected to admit a patient, it was taking an hour, on average, to actually get them into the bed," she notes. "They’re working to identify the reasons for the backup and what they can do to improve that."

The goal, Campbell says, is to reduce the time between ordering the inpatient bed and the patient leaving the ED to 30 minutes.

"Achieving that reduction on 15% of nonpsy-chiatric ED patients will more than accommodate a planned admission increase of 406 inpatients, which equates to $1,055,600 in revenue," she adds.

• Stroke unit process improvement.

The fourth Six Sigma project concerns the 350 stroke patients treated each year at Providence St. Vincent, 42% of whom have a LOS longer than four days, says Campbell, who notes that work flow inefficiencies cause delays in discharging some stroke patients who are medically ready for discharge.

The goal for this project, she adds, is a 50% reduction in the percentage of stroke unit patients with a LOS of more than four days. The resulting increase in bed capacity on the unit, Campbell says, will allow more stroke patients to be placed there, as opposed to being placed in other hospital units or extending their stay in the intensive care unit.

One of the other initiatives happening in the ED has to do with finding a streamlined way to communicate when the facility needs to go on diversion status, she says. Typically, the access department or the nursing units might learn that the ED is on divert, but they might not know the reason.

"A Providence research analyst built an electronic means of entering the information and a way to send it out to the key folks, so we know why we’re on divert and what we can collectively do as managers to get off divert," Campbell says.

Another initiative related to LOS, she notes, has to do with its link to secondary behavioral health problems.

At Providence Portland, a nurse practitioner who specializes in behavioral health will be developing a role in which she can support the nursing staff as they deal with patients whose conditions do not fall within the guidelines of mental illness, but whose behavior is interfering with their ability to be discharged. "Nurses who don’t primarily work with mental health patients may not have the skills to deal with behavioral issues, like noncompliance, that might keep patients from being discharged," Campbell says.

Rather than being patient-centered, this project is about the nurse practitioner educating nurses in medical-surgical areas, "teaching them to fish," so they can better address these special needs, she explains.

Campbell’s intention as she leads the throughput effort is to develop a high-level strategy to tie together operational and administrative improvement objectives. The next step will be to "build tactics for the subcategories to be in line across the board and get a result," she adds.

"One of the things I’ve heard recently is that [organizations] can get too many projects going, and many of them get diluted," she explains. "Sometimes, different divisions are tackling the same problem and we don’t necessarily do a good job of lining up the operational folks with the administrators who oversee the programs.

"From past experience, I know that [operational staff] have priorities that are coming in from various areas in the organization," Campbell says. "When you’re the lowest-level staff responsible for filling those [needs], you know you can’t do it all. You have to push some things aside and figure out who’s going to scream the loudest.

"We need to do a better job of prioritizing and linking those [objectives] together," she adds.

(Editor’s note: Kathy Campbell can be reached at Nancy Roberts can be reached at