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Opening the front door: Improving patient flow in hospitals

Most patients enter hospitals as the result of an unexpected emergency or for a planned surgical procedure, making the emergency room (ER) and the operating room (OR) the two “front doors” of the hospital.

In a healthcare reimbursement environment — where patient satisfaction is ever more important to a hospital’s bottom line — making sure the ER and OR are efficient, effective and well-run is vital to maximizing revenues. Focusing on patient flow and how patient services are presented can help drive quality, satisfaction and savings to your organization.

The ER is particularly important — 70-75% of patients are admitted through the ER while approximately 25% come through the ORs. How patients are treated in the ER and OR is increasingly important. Receiving full reimbursement for Medicare patients is dependent on high patient satisfaction ratings and efficient delivery of care. Indeed, many hospitals lose out on Medicare reimbursement dollars because they’re not meeting the quality and patient satisfaction expectations of the CMS Value Based Purchasing program.

Research shows that satisfaction is particularly affected by two factors — the speed with which patients are seen, and the quality of the care received. Starting care faster by having a provider triage patients when they arrive at the ER is a key way to drive both quality and satisfaction. High performing hospitals have a goal of seeing patients in their ER within 20 minutes or less. A growing number of hospitals advertise their door-to-provider performance on billboards and on their websites with up-to-the-minute information for each of their locations. While seeing a provider faster is helpful, best in class hospitals have created processes that start care faster through ordering tests and delivering medications as part of the triage process.

Most ER physicians can determine if a patient will need to be admitted to the hospital within the first 15 minutes of the ER visit. Still, many hospitals wait to start the process of finding a bed for the patient until the official admission order is written. This increases the problem with boarding patients in the ER and delaying their in-patient care. Lean process improvement techniques can help to improve patient flow from the ER to the nursing unit.

Finally, healthcare systems are often the safety net for patients who don’t have a family doctor or primary care provider. As many as 80% of adults use emergency rooms because of a lack of access to a healthcare providers. Healthcare systems must focus on how to provide appropriate care locations for all patients in their population and create access paths for patients who may be struggling to navigate the system. Treating both the illness and the healthcare navigation needs of the patient presenting in your ER today can prevent future unnecessary ER visits –– especially if your ER discharge plan helps connect your patients to appropriate out-patient care programs and providers. Investing a small amount of time in addressing the social needs of the patient can significantly impact return visits to the ER that eat up hospital resources.

While some surgical patients come to the OR as an emergency case, the vast majority of surgeries in hospitals are planned and scheduled in advance. This is important, as 60-65% of a hospital’s revenue is generated from the surgical suite. Preparing and optimizing patients for a successful surgical experience can significantly reduce cancellation and delays. Having a pre-admission nurse contact the patient by phone as soon as the surgery is scheduled is important for patient safety and good outcomes. A simple interview to determine a patient’s medical history, surgical history, social needs and current medication list can help the surgical team determine if any testing is needed prior to surgery. These tests are usually labs, an EKG or maybe a chest x-ray, and the results help the surgical team develop a safe anesthesia plan, identify any special equipment or supplies for the case and determine recovery needs after the operation. The goal of a high performing hospital is to ensure that every patient is properly screened as soon as possible once the surgery is scheduled.

Time in the OR is expensive, and maximizing the efficiency of each surgery hour is critical to managing costs. Even with scheduled cases, many ORs struggle to start their first cases on time each morning. Similar to the first flight of the day for a commercial airline, if the first surgery of the day starts late, the room will run late for the rest of the day. With operating room costs running between $80 and $120 per minute, there’s no time to waste. As the adage goes, proper planning prevents poor performance. Taking time to huddle and plan out the needs for each case the day before the scheduled surgery is the single most important thing an OR team can do to improve first case on-time starts. The 10-minute planning huddle should include key staff from all areas of the surgical services experience such as patient registration, pre-admission testing, surgical pre-op, the OR and the recovery room. Ancillary staff members from supply and instrument areas and the OR scheduler should also participate. The goal of this short huddle is to identify and address any factors that may cause a case delay the next morning and to highlight any special set-up needs for the surgical team.

Once the afternoon OR planning huddle is complete, the OR board runner should finalize the surgical lineup for the next day, optimizing for patient flow and timeliness. Often, patients will receive a final phone call from the hospital confirming their arrival time for the next day and delivering any important reminders about eating, taking medications and other preparations. The arrival time phone call is also a good opportunity to confirm any day of surgery labs that may be drawn and any other special needs the patient may have. This focus on patient needs and the flow through the surgical suite helps to reduce wait times before surgery and other delays during the day.

Having an efficient and smoothly flowing ER and OR is important to the financial bottom line of a hospital, but it ultimately plays a significant role in how patients choose a hospital. That’s especially important given that hospitals have suffered $136 billion of cuts to Medicare and Medicaid payments since 2010. Patients come to the hospital through one of two front doors, and how they experience care delivery is shaped by how well the care team plans and functions together. Changing the workflow in chaotic and high energy areas of the hospital can be challenging, but the effort can open the doors to retaining patients, capturing lost revenue and finding new opportunities in the healthcare market.

(Sharon K. Ulep is a principal at Plante Moran’s healthcare consulting strategy and operations practice.)

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