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Improving Hospitalwide Flow is Key to Competitive Advantage

Development in any industry is like whitewater rafting — long stretches of calm waters can quickly turn into exhilarating, frightening Class V rapids — and healthcare is no exception. The healthcare industry, in fact, is in a perpetual whitewater of change, according to Thom Mayer, MD, CEO of BestPractices and executive vice president of EmCare.

To survive in such a turbulent industry, hospital and health system executives must stay laser-focused on becoming high-quality, cost efficient providers; delivering results that matter and becoming experts in change exhilaration, Dr. Mayer said in a recent webinar hosted by Becker's Hospital Review and EmCare, a leading physician practice management company.

"In healthcare one of our biggest challenges is how we can do more with less," he said. Dr. Mayer was joined by Kirk Jensen, MD, CMO of BestPractices and chief innovation officer at EmCare, to discuss how hardwiring hospitalwide flow can help organizations move forward and attain change in their facilities.

How flow can add value and eliminate waste

Optimizing flow can be a treasure hunt to add value to an organization and a bounty hunt to eliminate anything that does not contribute value, Dr. Jensen said. Patient flow, as defined in the webinar, is "adding value and decreasing waste to processes, services or behaviors by increasing benefits, decreasing burdens, or both, when applied to the movement of our patients through our service transitions and queues."

This process of hunting for value and waste starts at the top. Hospital leadership must examine why it uses its current strategy and why it should not use another. Managing the balance between benefits received and burdens endured requires a birds-eye view of the organization and how each of its departments and teams support each other.

"In a team-based healthcare system, we need to look at interdependent goals," Dr. Mayer said. "It's about processes and handoffs."

When flow is optimized, hospitalists care about emergency department boarders and patient satisfaction, emergency physicians consider hospital bed turns and readmissions, and radiologists mind oral contrast in abdominal CT scans. Hardwiring flow not only within teams but between teams creates the best patient experience, working environment and hospitalwide results.

Smoothing handoffs throughout an organization can also have a significant financial benefit, according to Drs. Mayer and Jensen. For example, if a hospital that has roughly 40,000 ED visits per year reduces its average length of stay in the ED by one hour, it can gain up to 40,000 hours of increased capacity a year. If each visit averages two hours, it gains 20,000 more potential visits, and at $100 per visit in physician revenue, that translates to $2 million in new revenue for the physician group. If the hospital makes $400 from each ED visit, it could make $8 million in new revenue each year by reducing ED visits by one hour.

"The primary drivers are workforce satisfaction and patient safety, but there is a significant trailing economic benefit," Dr. Mayer said.

Critical flow strategies and concepts

According to Drs. Jensen and Mayer, there are two kinds of patients: horizontal and vertical.

"For vertical patients, speed matters. The more vertical you are the more you are a customer. The more horizontal you are, the more you are a patient," said Dr. Mayer. "Keep your vertical in motion."

As customers, vertical patients are visiting the hospital by choice; the healthcare services are a discretionary purchase. Horizontal patients are generally more dependent and passive and have less choice in the care they may need.

Tracking, managing and forecasting the capacity and demand for these two types of patients starts at the front door. Dr. Mayer recommended thinking of flow as a cascade from input to throughput to output, not only in the ED, but throughout the hospital.

Input strategies may include triage bypass, advanced triage and provider triage, among others. Triage is a process, not a place, Dr. Mayer said. Properly triaged patients should improve throughput, he said, as well as patient satisfaction, quality, safety and revenue. Throughput solutions may include bedside registration, fast tracking and a results waiting room. Output strategies may include early decision to admit, door to discharge programs and express admission units, among others.

Another important concept is that of utilization, Dr. Jensen noted. Any system with unscheduled arrivals is a queuing system, which follows certain mathematical principles. The most important one to note, however, is that as utilization rises, the wait time or back-up time rises logarithmically, not linearly.

"In any system involving either lots of variation or unscheduled arrivals, it is important to back up from this concept of thinking if everybody is busy all the time, you are operating at maximum efficiency," Dr. Jensen said.

In a setting with unscheduled arrivals, he said, a utilization rate of 80 to 85 percent is usually the point when wait times start to significantly increase.

Incorporating flow into hospital medicine

"Many units and departments attempt to optimize flow and it ends up penalizing other departments," Dr. Jensen said. "If the ICU is full, it hurts the emergency department."

Flow must be considered across the acute care system as well as within departments. "It is important emergency physicians and hospitalists work together as a team," Dr. Jensen said. He recommended requesting beds early, using a rapid admission process, fast tracking ICU patients, implementing parallel processes and using the "adopt-a-boarder" strategy, which spreads boarded patients throughout the hospital rather than keeping them in the ED.

However, to make the most of these strategies, physicians and staff members must be engaged in collaboration.

"People have made engaging doctors far more complicated than it needs to be," Dr. Mayer said. To hold physicians and nurses accountable, recommend the following strategies:

  • Clearly state group values
  • Make achieving group values a team-oriented process
  • Set measurable goals to achieve those values
  • Offer transparent, easily accessible results
  • Provide actionable ways to improve or fix issues
  • Create a culture that accepts coaching and mentoring

According to Dr. Mayer, engaging physicians can be one of the top challenges in hardwiring flow. "We've got to move from a culture of optionality to a culture of accountability, where physicians are held accountable and more importantly, hold themselves accountable," he said.

After all, in an industry akin to whitewater rapids, every passenger, and every physician, must help steer the raft.

To view the full webinar, click here. To download the webinar as a PDF, click here.

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