Patient Throughput

Summary

Wait creates bottlenecks and can jeopardize a patient's safety. Wait usually equals waste. Hospitals that pursue excellence focus on removing waste and improving the patient experience. Improving patient flow throughout all areas of the hospital improves quality of care. Hospitals are having great success improving the flow of patients and many have provided their stories.

Hospitals are plagued with waits, delays and diversions. Patient safety, hospital revenue, staff satisfaction and patient satisfaction are all negatively impacted when patients, information and materials do not move through hospitals in a timely and efficient way. [i]

Patient throughput is defined as delivering the appropriate care to a patient at the right time and in the right setting. Improving patient throughout touches every department and requires hospital-wide improvement. Most capacity issues arise in areas of the hospital where demand fluctuates, such as the ED, OR and ICU. However, single-department solutions create or worsen bottlenecks in other areas. For example, if the OR improves patient flow, then the PACU will experience new or greater bottlenecks unless it also makes improvements. [ii]

A hospital's ability to optimize capacity is largely determined by how efficiently their processes and operations are managed. The ED is one entry point for care typically cited as an initial bottleneck in the overall system. The average time that hospital emergency room patients wait to see a doctor has grown from about 38 minutes to almost an hour over the past decade, according to the CDC. ED visits are up from 90 million in 1996 to 119 million in 2006. The result is that many EDs are either at or above capacity. Actions to address this generally fall into two categories—increasing capacity and increasing efficiency. Increasing capacity can facilitate the acceptance of more patients. However, it does not address the issue of moving patients through the system in an efficient manner.

In a recent report on ED crowding, the US General Accounting Office noted the connection between the ED and the rest of the hospital system: “The factor most commonly associated with crowding was the inability to transfer emergency patients to inpatient beds once a decision had been made to admit them as hospital patients rather than to treat and release them. When patients ‘board’ in the emergency department due to the inability to transfer them elsewhere, the space, staff and other resources available to treat new emergency patients are diminished.” [iii]

With a better understanding of the weakness in the patient care processes, organizations can shape, predict and manage variability and allocate resources appropriately. More effective and efficient process will improve patient outcomes, increase staff morale and retention and reduce costs. [iv]

Linkages to IOM Six Aims

Efficient — Managing variability and allocating resources appropriately will move patients through the delivery of care more efficiently.

 

Timely — Providing patients with timely access to appropriate care is an essential element of high quality care.

 

Safe — Waits, delays and diversions can lead to lapses in patient safety and the quality of care.

Business Case

Longer length of stays mean hospitals incur greater expenses. A more efficient process of moving patients through the system results in a lowered length of stay. It also translates into higher satisfaction among clinicians and patients. A more predictable workflow means nurses and other hospital staff can be scheduled appropriately. [v]

 

Based on the IHI’s report [vi], the costs of delays in care are many, including these: 

  •  The ED becomes an inappropriate and expensive holding area when patients are not transferred to an inpatient unit in a timely manner. “Parking” patients in hallways to await transfer is an issue affecting service, care and safety. 
  • When the ED is overcrowded, incoming patients can experience harmful delays in receiving care. Some leave without being treated.
  • Patients waiting to be transferred from the ICU to a patient care unit represent not only a service issue, but also a cost issue: the ICU is a very expensive place to wait.
  • When surgical schedules back up, patients and providers are affected across the continuum of care.

By eliminating the peaks and valleys of patient census the hospital can enlarge its functional capacity to increase patient volume without physical expansion, costly capital requirements and labor increases. [vii]  Enlisting the support of the clinicians, hospital leadership can identify the gaps in the process that frequently result in bottlenecks throughout the care delivery process.

Health Care Reform/Regulatory/Policy Considerations

The Emergency Medical Treatment and Labor Act (EMTALA) imposes special rules on hospitals and their EDs. EMTALA requires hospitals that accept Medicare funding to screen and stabilize all patients presenting for care at the ED; hospitals may then discharge or transfer these patients to another facility.

 

EMTALA imposes requirements on America’s hospitals, but for safety net hospitals these obligations and their concomitant challenges are even more pronounced.. These hospitals have a history, mission and often a legal mandate to care for some of the nation’s most vulnerable individuals. [viii]

Linkages to Performance Excellence

Manage organizational variability —By eliminating the peaks and valleys of patient census, the hospital can enlarge its functional capacity to increase patient volume without physical expansion, costly capital requirements and labor increases.

Perfect the patient experience —Improving patient flow will reduce the long patient waits and inconvenience and dissatisfaction for the patients and their families.

Eliminate defects — Providing patients with timely access to appropriate care is an essential element of high quality care.

Key Considerations for Executive Management

  • Are regular detailed assessments of patient flow performance measured?
  • Does the hospital board have a clear understanding of what is contributing to current performance metrics, such as LOS or diversion times?
  • Have front-line staff been asked to identify bottlenecks, sit on committees and help identify solutions?

Case Studies

More Case Studies

Resources & Tools for Patient Throughput

[i] IHI, Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. 
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement: (2003)
(accessed June 3, 2009)

[ii] Samuel Mahaffey "Optimizing patient flow in the enterprise: hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes". 
Health Management Technology. (August 2004)
(accessed June 1, 2009)

[iii] United States Government Accounting Office, “Crowded Conditions Vary among Hospitals” (March 2003)
(accessed June 15, 2009)

[iv] IHI, Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement (2003)
(accessed June 20, 2009)

[v] Healthcare IT News, “Hospitals uses business intelligence to boost patient throughput” (June 2, 2009)
(accessed June 15, 2009)

[vi] IHI, Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement (2003)
(accessed June 15, 2009)

[vii] Hospitals and Health Networks, “Improving Patient Flow” 
(August 19, 2008)
(accessed June 2, 2009)

[viii] National Association of Public Hospitals and Health Systems “Perfecting Patient Flow” (May 2005)
(accessed June 10, 2009)