Patient Throughput Success Stories

Mid-Atlantic Urban Hospital

Patient Flow Redesign to Reduce Overcrowding in the Emergency Department

This mid-Atlantic hospital was, at one time, a community hospital located in a near suburb of a major city. Over the years, the demographics in the community changed and the hospital became more of a city hospital. As crime increased in the city, the number of homeless and uninsured skyrocketed, affecting the hospital. In addition, the hospital, located in close access of a major interstate, was served by community-based ambulances. Although not designated as a trauma center, the hospital often received trauma patients from the nearby highway. In a 10 year period, the ED visits grew from under 60,000 to 83,000 per year. The ED of this 300 bed, teaching facility housed 18 adult beds, five chest pain beds, and a pediatric ED that shared space with the Fast Track ED. The pediatric ED saw 20,000 visits per year. The ED faced a crisis with long waits, bypass hours greater than 300 per month, and a high turnover rate in staff.

Relevent Outcomes

• Decreased overall wait time, including time in the waiting room, time to be seen by independent practitioner, time to decision, time to disposition
• Decreased bypass for both critical care and medical/surgical patients
• Decreased boarding of critical care patients
• Validated use of step-down and telemetry beds
• Stabilized the clinical staff, decreased agency use, and improved RN retention
• Improved intra- and inter-departmental working relations between nurses and physicians 

Sample operational improvements to improve patient throughput included:

• Implemented physician at triage to complete the medical screening and often the patient was discharged from triage
• Facilitated renegotiation of contracted physician services to align with the service coverage and financial impact
• Established an admission unit, a dedicated medical/surgical unit with an initial 10 beds that grew to 15 beds; established protocols, led by ED, and medical/surgical staff
• Designed and implemented an ED tracking system for monitoring patient status, using a color-coded system
• Established incentives for medical/surgical nurses to support a Pull System by pro-actively calling the ED for patient pending admission
• Established goals for ancillary departments for turnaround time, added additional beds
• Initiated a step-down hospitalist program for modifying the admission and discharge criteria for this open unit and work with the ED to evaluate appropriateness of admissions. The IMCU was no longer the biggest bottleneck.
• Created the role of a patient flow coordinator. This nurse was given the authority to place patients and work with physicians on transfers.

Regional Health System

Defining Metrics and Process Improvement

Summary

IMA Consulting worked with hospital administrators, department directors, physician leaders, and staff to identify a multi-phased process improvement plan to define realizable opportunities for improving patient movement from the Emergency Department through acute care services.

Problems

Leadership of a regional health system sought external assistance to create and implement a future state patient movement model. The desire to redesign patient movement activities stemmed from several important factors. Leadership recognized the importance of attracting and retaining satisfied patients, and providing seamless quality care and service. Further, it recognized that policies, practices, and staff accountabilities were not aligned to transform current state patient movement practices. The model resulting from this effort assisted management, physicians, and staff in their efforts to expedite patient movement throughout the acute care setting.

Solution

IMA Consulting focused a multi-disciplinary team on conducting an organization-wide assessment to identify opportunities for improving patient throughput originating from its Emergency Department, which accounted for 80 percent of its admissions. The team utilized detailed data analyses, interviews, and direct observation to build a knowledge base from which to surface opportunities. The analyses included direct observation of operations, data analysis, and review of departments and disciplines that impact patient throughput. Engagement of corporate, hospital, departmental, and physician leadership promoted understanding, acceptance, and ownership of the recommendations developed.

Results

This work resulted in 211 recommendations for action. The recommendations addressed changes in the functional areas of Emergency Department (62), inpatient Nursing (49), patient placement (37), case management (32), ancillary department (21), and administration (10). The change recommendations were delineated in the categories of people, process, and technology categories that were further delineated into the following subcategories.

The IMA Approach

A diverse team of knowledgeable subject matter experts expedited discovery, analysis, and recommendation formulation. Engaging executive and physician leadership expedited decision-making and action. Once compiled, consultants facilitated a steering committee session of the executive leadership team, during which it reviewed all recommendations. In this session, the executive leadership team, including the chief of staff discussed the recommendations, facilitated dialogue, and promoted acceptance of the recommendations and their implications.