CMs should take the lead as JCAHO patient flow standards go into effect

Hospitals must assess, manage throughput issues

The new patient flow standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) create opportunities for case managers to take the lead in their hospital’s compliance and adherence initiatives, says Hussein A. Tahan, SNSc, RN, CNA.

The standards call for the hospital leadership staff to have a process in place for managing patient flow and throughput, especially in the emergency department (ED) and post-anesthesia care units. The standards require hospitals to engage in an on-going evaluation of patient flow and to implement strategies for process improvement, with the main focus on patient access to care efficiently, effectively, and in a timely manner, he adds.

"If an organization doesn’t have case managers in the areas critical for throughput, they are going to be at risk for complying with the standard," adds Tahan, director of nursing for cardiovascular services and care coordination at Columbia University Medical Center, New York-Presbyterian Hospital in New York City, and chair of the Commission for Case Manager Certification.

The new standards, which went into effect Jan. 1, call on hospital leadership "to develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital."

The new standards mean that patients must receive access to care as soon as they are in the system and that there is no delay in admission to a bed or in receiving care or testing, Tahan points out.

Case managers can facilitate timely patient throughput by making sure patients in the ED are triaged in a timely manner, depending on their condition, by expediting delivery of care by coordinating tasks and procedures, as well as making sure the results of tests are available to physicians so they can make decisions about the plan of care and by evaluating the patient’s health insurance plans, or lack thereof, he adds. "The case managers should not be just checking on the appropriateness of admission; rather they should also make sure the patient receives the care they need in a timely manner, while they are in the emergency department awaiting admission as they are in an inpatient bed," Tahan says.

Inefficient patient flow can affect patient safety and quality of care, as well as affecting the hospital’s bottom line by increasing denials and avoidable days, points out Teresa C. Fugate, RN, BBA, CPHQ, CCM, manager at Pershing Yoakley & Associates, a Knoxville, TN-based health care consulting firm.

"Many hospitals are not managing throughput appropriately from the time the patient is admitted through discharge. As a business, hospitals should be looking at efficiency and economy of service and how it impacts everything that happens with the patient," she says.

For instance, if a physician orders an X-ray in the morning and it’s not completed until late afternoon, it results in an eight-hour delay in the physicians seeing the report and making changes in the patient treatment. "Delays in service can adversely affect getting the patient well enough to discharge and opening up the bed to another patient," adds Fugate.

The JCAHO standards call for hospital leadership to identify all processes critical to patient flow and monitor them from the time the patient arrives through admission, assessment, treatment, and discharge, she says. Fugate suggests hospitals create a multidisciplinary committee that starts with the top DRGs and follows patients through the system, identifying what is critical to the flow of patients being admitted and treated in an appropriate manner, and discovering the main issues that result in an extended length of stay.

She recommends starting with just one DRG and working from there because "it’s easier to understand what’s happening with 175 patients a year as opposed to looking at every single patient." However, you still need to monitor all patients. "If you can drill down to critical pieces of patient care by taking one or two DRGs and whittling down to the root cause of delays with these diagnoses, it may direct you to your overall problem," Fugate adds.

A hospitalwide multidisciplinary patient flow committee allows the hospital leadership team to understand the issues of patient volume, demand for inpatient beds, bed capacity and supply, and necessary resources, Tahan notes.

"Decisions can then be made more carefully about which product lines or programs need to be expanded and which need to be contracted. Case managers are ideal in sharing their day-to-day experiences and observations while such decisions are being made. They definitely can contribute to strategic decisions," he adds.

Delays may be caused by hospital operations issues, Fugate says. For instance, a patient comes in on Friday with chest pains, but the cardiac catheterization unit isn’t open until Monday, so the patient stays in the hospital over the weekend.

Pharmacy issues are another big problem in most hospitals, she adds. "In the majority of hospitals, it typically takes two to three hours to get medications that were ordered for a patient upon admission. Some of these medications should be on the floor, ready to give to patients immediately so we can move the patient from the acute phase."

For instance, patients who are admitted with congestive heart failure should receive Lasix intravenously upon admission.

As the number of uninsured patients using the ED for primary care increases, there is an increased need for patient care management in the ED and an opportunity for case managers to make an impact in the way their hospital admits patients and plans for their discharge, Tahan points out. The JCAHO standards state that the ED is particularly vulnerable to experiencing the negative effects of inefficiency, he adds.

The problem is exacerbated when there isn’t a case manager in the ED to assess patients when they come in, Fugate adds. "We’ve said for years that discharge planning begins with admission, but in all reality, it’s usually 24 hours later."

For instance, if there isn’t a case manager in the ED to begin the discharge planning process and the patient is admitted in the evening, it’s likely he or she won’t be seen by a case manager until 10 a.m. the next day.

If the patient is on observation status, the discharge planner has to scramble to make sure the patient’s discharge planning needs are met, she points out. Case managers in the ED can make sure the hospital isn’t admitting patients who could be treated on an outpatient basis and see a physician the next day and can work with physicians to avoid "social admissions," patients who are admitted for no other reason than the family can’t manage their care at home. "Case managers should be aware the physicians are worried about risk issues and may place patients in the hospital for that reason," Fugate says.

If there’s not a case manager in the ED, Fugate advocates training the ED nurses to assess patients for post-discharge needs at the same time they are treating patients. "Case managers should work with attending physicians to make sure they understand the importance of avoiding overutilization of resources and increasing the patient stay."

She tells of one patient who was admitted on observation status for chest pain. The patient had known for a long time she had to have stents for peripheral vascular blockages. While she was on observation status, her physician had a surgeon look at her and then perform the surgery. Because the patient was on observation status, she couldn’t have an outpatient procedure. In this case, the patient had surgery and spent time in the hospital for what could have been an outpatient procedure.

"The hospital gets paid only on the original reason for admission. The coding is based on the first diagnosis," Fugate points out.

Case managers should make sure that they complete appropriate discharge planning for patients to help them avoid being readmitted. For instance, they should make sure that patients can afford any medication they will be taking after discharge and that they understand what they need to do at home. Plan your discharges ahead of time, she adds.

If a patient is likely to be transferred to a lower level of care, talk with family members early in the stay and suggest they decide on a nursing home. "Don’t wait until the physician signs the discharge orders to talk to the family," Fugate says.

Click here to see "8 Steps to Better Patient Flow."

[For more information, contact:

  • Teresa Fugate, RN, BBA, CPHQ, CCM, Manager, Pershing Yoakley & Associates, Knoxville, TN. Phone: (865) 803-3135. E-mail:
  • Hussein Tahan, SNSc, RN, CNA, Director of Nursing, Cardiovascular Services and Care Coordination, Columbia University Medical Center, New York-Presbyterian Hospital, New York City; Chair, Commission for Case Manager Certification. E-mail:]