The Quality-Cost Connection: Improve patient flow by reducing bottlenecks

Techniques for tackling patient waits and delays

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

A bottleneck is the part of the patient care journey that cannot meet the demand for services efficiently. At this point, services are delayed and patient care must wait.

Bottlenecks often occur where the demand from many sources converges into a single process, e.g., convergence of demand from throughout the hospital into the radiology department. Bottlenecks affect the whole pace of patient care activities. Improvements aimed at improving patient flow in the hospital are unlikely to be successful without addressing the waits and delays.

The only way to reduce these bottlenecks is to alter the design of the patient care system. Here are some common techniques for tackling unnecessary patient waits and delays:

Reduce hand-offs.

When the responsibility for patient care is transferred from one person or department to another, things can go wrong. Delays and duplications often occur at the point of hand-off. Reducing the number of hand-offs can reduce patient waits and delays significantly. Review patient flow to determine if there are process steps that can be combined into one single step rather than the present situation of separate discrete steps.

Do things in parallel.

Many health care processes are designed so that tasks are carried out in a step-by-step sequence. The second task in the process is not begun until the first task is completed. This particularly occurs where a number of disciplines or departments are involved in the different tasks that make up the patient care process. Improvements may be possible if the process can be redesigned to do all or some of the task simultaneously. For instance, the work in process Step 5 can commence as soon as Step 1 is complete, rather than waiting until Steps 2, 3, and 4 are finished.

Pull patients along the path.

In many health care processes, the patient is pushed along. This means that when transferring work from one step in the process to the next, the people in the earlier step are expected to manage the patient’s transition to the next step. For example, emergency department physicians push patients to the inpatient setting, where other caregivers push the patient to diagnostic tests, treatments, etc. Push systems, by their very nature, create waits and delays. Pulling patients through the system of care is a much more efficient use of resources. One example of this is a hospital-based rehabilitation unit that regularly pulls patients out of acute care beds into its unit, allowing the acute units to pull other patients along their journey and into the hospital beds.

Design customized processes.

Often, emergency patients clog the systems of diagnostic departments, causing lower priority inpatients and outpatients to wait for services. Some departments, such as radiology, may be able to redesign their services into three separate processes for each group of patients. These processes can be designed according to patient need, rather than immediate priority.

Do things simultaneously.

Patients often are scheduled for several diagnostic tests on the same day. The length of a patient’s stay can be reduced by scheduling the test that has the longest waiting time for results first so that subsequent tests can be undertaken at the same time as the first test is being reported. This enables the patient’s physician to receive the results of all the tests at approximately the same time.

Eliminate things that are not used.

Process steps or hard-to-break habits that do not add value to the process should be designed out of the process. For example, are patients routinely admitted to a hospital bed three to four hours prior to their elective surgery? In many instances, the preoperative preparation takes only 90 minutes or less. The remainder of the time, the patient is occupying a bed for no particular reason. Consider adding a lounge for early arriving patients and their families.

Relocate the demand.

As a result of process redesign, many hospital departments have developed the role of support technician. They are skilled in tasks that reflect the requirements of the patient process(es) that they are part of. This may include phlebotomy, blood pressure monitoring, clerical, and patient transport duties. If experts are the bottleneck, they should only be doing work for which an expert is needed.

Plan capacity to meet predictions.

A hospital emergency department analyzed historical patterns of patient demand over a 24-month period. This showed that the volume of patients on a given day, at a given time, could be predicted with 80% to 90% accuracy. However, when the staffing patterns were correlated with the pattern of patient demand, there often was little correlation. As a result, the system for scheduling staff was changed so that working hours reflected predicted levels of demand.

Eliminate backlogs.

The goal should be to do today’s work today. When a service is overburdened with patient demand, it not only cannot respond to today’s work but actually is doing work from yesterday. Large backlogs of demand accumulate and consume all of the department’s attention. Just managing the backlog can be time-consuming and actually creates more work. Elimination of backlogs should be one of the first steps in an improvement initiative. This may require additional resources in the short term.

Match capacity and demand on a daily basis.

Matching service capacity to patient demand is critical to ensuring a smooth journey for the patient. The capacity of the system needs to be flexible enough to cope with small changes in daily demand.

Although patient demand can be predicted and care needs anticipated, unexpected situations will occur. Clinical teams should develop contingency plans to meet overflow demand. This might include adding more staff or beds as needed or making temporary changes in patient flow and staff responsibilities.

To identify bottlenecks in patient flow, start with a process activity map. This map is best constructed by "walking" the patient’s journey to create a snapshot of that journey. The map of the patient’s journey is used by caregivers to identify unnecessary waits and delays and consider how the process can be managed more efficiently.

Steps in developing a process map includes:

  • Identify each step in the process, and number them in sequence.
  • Next to the step number enter a brief written description of that step.
  • Record the time taken for each step.
  • Record the time in each step that adds value to the patient.
  • Record the number of patients waiting between each step.
  • Record the number of people involved in each step.
  • Determine if a particular type of equipment is needed at each step.

Once the map is developed, the team charged with improving patient flow can begin to ask some questions:

  • What is the proportion of value-adding time vs. total time?
  • How much time is spent between various activities?
  • Are there any immediate problems or surprises that need to be handled first?
  • What are the areas of greatest opportunity for improvement?
  • Can the system be amended so more of the work is carried out upstream ahead of the bottleneck?
  • Can some stages or steps in the process be removed?
  • Can stages or steps be consolidated?
  • Can some work be transferred to nonbottleneck areas?

Once the team has improved the situation at one bottleneck, it is likely that others will emerge as flow-limiting steps in the patient journey. Patient flow management is a process of continual improvement.