This year, surveyors to look for patient flow problems: Identify bottlenecks now

You’ll need to monitor improvements in any problem areas

Are patients on gurneys in hallways a typical sight in your organization’s emergency department (ED)? The growing problem of ED overcrowding is potentially dangerous to patients, resulting in the new leadership standard on managing patient flow from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The standard, effective Jan. 1, 2005, appears in the leadership chapter of the 2005 Hospital Accreditation Manual.

You’ll need to develop and implement plans to identify and mitigate obstacles to efficient patient flow throughout your organization, using specific indicators to measure components of the patient flow process and monitor capacity for areas that receive patients.

"This is a big safety issue, because many hospitals are running out of surge capacity," says Carol J. Gilhooley, director of survey methods development in the JCAHO’s division of standards and survey methods.

During 2005 surveys, surveyors will be looking for indications of problems with patient flow throughout the organization, such as overcrowding in the ED or patients being boarded while awaiting inpatient beds.

"If they see those kinds of things, they will want to hear how the organization plans to alleviate them," she says.

By analyzing data to reveal bottlenecks in patient flow, you will have powerful evidence to present to hospital leaders, Gilhooley emphasizes. "It’s hard to run from your own data — it’s very convincing," she says. "This helps people brainstorm and come up with solutions."

Not just an ED problem

"I hope that the JCAHO standard will bring these patient care barriers to the forefront and assist organizations in identifying issues across the organization, not just in the ED," says Toni G. Cesta, PhD, RN, FAAN, vice president of patient flow optimization at the North Shore-Long Island Jewish Health System in Great Neck, NY.

The lack of available inpatient beds is the root of the problem, says Gilhooley. "I think the word has gotten out that it’s not just an ED problem, and there is a lot of good research to show this. There must be a place for patients to go once the decision has been made to admit," she says. "Boarding issues are what we are trying to get at with the standard. It would be ideal if no patients were boarded, but this isn’t always realistic."

Work as part of a collaborative

Gwinnett Hospital System in Lawrenceville, GA, recently began participating with the Boston-based Institutes for Healthcare Improvement (IHI)’s patient flow collaborative. "The goal is not just to meet the JCAHO standards but to have a better flow process throughout the system," says Wendy Solberg, CHE, director of quality resources.

The organization has three primary goals: getting an ED patient to a room within an hour after the decision is made to admit, decreasing the number of discharges after 3 p.m. by 50%, and transferring every intensive care unit (ICU) patient to an inpatient bed within four hours from the time the patient is deemed ready to move from ICU.

"We’ve got a team with strong leadership support from our vice president of operations," says Solberg. "We’re using about nine key measures provided by IHI, as well as using rapid cycle improvement to change one process at a time."

Scottsdale (AZ) Healthcare also is participating in IHI collaboratives on patient flow, reports Sylvia Bushell, consultant for organizational effectiveness. "We have two projects under way: one on inpatient flow and one on operating room [OR] flow," she says.

The organization is using a new hospital diagnostic tool developed by IHI, which looks at the number of bed turns in a facility. The tool "diagnoses" patient flow by calculating bed turns based on variables such as length of stay (LOS), case-mix index, number of functional beds, and number of admissions.

"The tool helps us to focus our improvement efforts and also meets the JCAHO requirement for measurement and reporting for patient flow," Bushell says. "We are starting to use this tool to compare our hospital with other hospitals in the collaborative and share plans to improve."

To ensure compliance with JCAHO’s patient flow standard, consider the following:

  • Choose indicators carefully.

Gilhooley recommends looking at outcome and process indicators throughout the organization, such as length of stay and peak volumes in the ED, and balancing indicators such as patient and staff satisfaction and readmission rates. "Those kinds of things will help leadership to assess patient throughput."

Surveyors will want to see that you have done some analysis based on your findings and acted on this, she adds.

Another valuable indicator is transfer times from the ED or post-anesthesia care unit (PACU) to inpatient floors, Gilhooley notes. "The ED and the OR are frequently competing for the same ICU beds, so smoothing out an OR schedule can often help the ED," she says. "We know that hospitals can’t control the volume of patients in the ED, but you can control your OR schedule."

The new JCAHO standard requires you to define mechanisms for identifying and dealing with periods of overcapacity. "The ways in which this might be defined is up to the specific organization," Cesta says.

The indicators being used at her organization are percent of total occupancy, number of ED bed holds and type of beds, patient acuity level, PACU holds, diversion status, and anticipated discharges. (See the organization’s patient flow scorecard)

Cesta worked with nursing and bed management to identify these indicators. "You have to consider where your organization’s bottlenecks are. For most organizations, it is the ED, coupled with potentially available beds on the nursing units," she says. "If you are at 100% occupancy and are expecting less discharges than you have patients on hold in the ED, then clearly you have a capacity issue."

While monitoring patient flow indicators, you should continue looking at other quality measures, such as rate of readmission for both the ED and inpatients and the number of ED patients leaving without being seen, Solberg recommends.

  • Make small changes and monitor the impact.

"Rather than trying to fix the entire problem at once, find out where the bottlenecks originate and get at them one at a time," Gilhooley advises.

"We are suggesting that organizations test something for a couple weeks to see if it has an impact," she notes.

  • Be sure to involve physicians.

The JCAHO standard specifically requires the involvement of medical staff. Physician champions are selected for each patient flow project at Scottsdale Healthcare, and their input and feedback is solicited on a regular basis, Bushell adds.

"They are key stakeholders," she points out. Physician involvement was key in a project to improve OR flow, with patients being followed from the time they are scheduled for surgery in the physician’s office until a month after discharge.

"This included going into the surgery with them, rounding with the physicians, and going to follow-up appointments," Bushell says.

  • Make sure your data are valid.

Gwinnett’s physicians weren’t consistently documenting the time for when the decision was made to admit a patient, Solberg notes. "As a result, we had a tough time trying to figure out exactly when the decision was made," she says. "We defined the decision to admit’ time as when all the data and lab results are back and there is an order for admission from the admitting physician, and the physician talked to the admitting division. Clear definitions are key."

  • Find creative ways to turn beds quicker.

"There are a lot of creative things that can be done to get beds turned around more quickly," Gilhooley says. She gives examples of working with discharge planning, involving physicians, and creating a person who is accountable for the beds in the organization.

A daily bed huddle takes place at Gwinnett, with a group of clinicians from each floor giving reports on the number of available beds to representatives from surgery and the ED.

"The bed huddle is our biggest patient flow initiative right now," says Solberg. "When an ED patient becomes ready for admission, we want to have a spot to put them."

A bed coordinator is responsible for the bed tracking system and patient flow, says Solberg. "Her focus is making sure the beds are there when we need them and facilitating the daily bed huddle," she says.

Plans also are under way to invest in a bed tracking board and scheduling discharge times to tie with peak volumes in the ED, Solberg reports.

  • Give boarded patients the same level of care they would receive as inpatients.

Your organization should identify a location to safely house and care for overflow patients and should be prepared to staff the area appropriately as well as provide for medications and food, Cesta advises.

In response to questions from organizations about what constitutes "appropriate and adequate care" for boarded patients as required by the standard, JCAHO pulled together a group of experts, including representatives from the Irving, TX-based American College of Emergency Physicians, to create a list of 12 elements to address.

"We listed those things that organizations should be concerned about when they are boarding patients in a temporary location," Gilhooley explains.

"So surveyors will be talking to leaders about that, too — what planning they have done to make all those things that are important to their care available," she adds.

The list includes life safety code issues such as avoiding blocked corridors, ensuring patient privacy and confidentiality, providing appropriate access to ancillary services, staffing the area with appropriately privileged practitioners, and ensuring access to other practitioners who may be necessary for consultation or referral.

"Access to medical assistance in an emergency is also important — if a patient is on a gurney in the hallway, does he have a call button, or a way to access help if he needs to go to the bathroom?" asks Gilhooley.

To alleviate pressure on Gwinnett’s ED, an admissions unit was created so that patients could be moved into an intermediate holding area until a bed becomes available.

"It is essentially equivalent to an inpatient unit. Patients get the initial nursing assessment and the same level of care that a patient would receive on the floor," Solberg says.

  • Use a multidisciplinary approach.

To comply with the standard, interdivisional teams need to work together, says Gilhooley.

"Even lab turnaround time might have an important impact on patient LOS in the ED," she continues. "Some hospitals now have a phlebotomist working right in the ED, so patients don’t have to wait an extra 15 minutes for a phlebotomist to get from the lab to the ED."

  • Have a single person responsible for patient flow.

Consider having a single leader responsible for coordinating all patient flow initiatives, as the process is very complex and labor-intensive, Cesta advises.

As one of the only vice presidents for patient flow in the country, Cesta’s role is to identify and correct any patient flow barriers across the 17-hospital system, at the input access points, such as admitting and ED; inpatient throughput including pharmacy, laboratory, radiology, transport, housekeeping, case management, bed management, and physician practice issues; and output, including access to continuing care services, discharge planning, and barriers to timely discharge.

"The benefits to having this position include the opportunity to have systemwide processes that are consistent and effective and to ensure that each process represents best practice," Cesta notes.

"By having one person in charge, barriers to improvement are broken down because I do not belong to any one department or hospital," she adds.

[For more information on JCAHO’s leadership standard for managing patient flow, contact:

Sylvia Bushell, Consultant for Organizational Effectiveness, Scottsdale Healthcare, 3621 Wells Fargo Ave., Scottsdale, AZ 85251. Phone: (480) 675-4590. E-mail:

Toni G. Cesta, PhD, RN, FAAN, Vice President, Patient Flow Optimization, The North Shore-Long Island Jewish Health System, Great Neck, NY. Phone: (718) 470-7936. Fax: (718) 470-7671. E-mail:

Wendy H. Solberg, CHE, Gwinnett Hospital System, 1000 Medical Center Blvd, Lawrenceville, GA 30045. Phone: (678) 442-3439. Fax: (770) 682-2247. E-mail:]