Institute for Healthcare Improvement: Learning and Innovation Community: Improving Flow Through Acute Care Settings

Available through the IMPACT network or on a direct-enroll basis, IHI’s most intensive front-line improvement work happens in Learning and Innovation Communities. These are collaborative change laboratories in which teams from a wide variety of organizations work with each other and IHI faculty to rapidly test and implement meaningful, sustainable change within a specific topic area.

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Improving Flow Through Acute Care Settings is available either through membership in IMPACT or through direct enrollment in the Community. Learn more about the IMPACT network.

The Challenge

The Solution

Hospitals are increasingly challenged to reduce waits and delays in moving patients into and out of inpatient beds. The “competition” for inpatient beds from the ED, surgery, direct admissions, etc., creates waits and delays that negatively affect patient safety, and patient and staff satisfaction.

Thus far, most attempts to improve patient flow have focused on the ED. However, flow is a property of the entire system and can only be optimized at the system level. For example, EDs often divert patients because hospitals lack the space to move patients forward. Simply increasing capacity in the ED will not solve flow problems.

Poor patient flow also has direct effects on clinical care and the financial status of hospitals. When patients are placed off service and are “boarded” due to the inability to place them in inpatient beds, clinical decisions can be delayed and safety compromised. Hospitals lose revenue due to un-reimbursed days, diversions, and cancelled or delayed surgeries. Looking upstream and downstream from “problem” hospital units is essential to making changes that will result in hospital-wide improvements.

Understanding variability is key to making improvements in flow. The variation inherent in surgery scheduling, for example, challenges hospital staff to find inpatient beds at varying times of the day. In addition to reducing variability, establishing partnerships with other community resources such as long-term care facilities and outpatient clinics is crucial to solving flow problems. Ensuring that the patient is receiving the appropriate level of care in the appropriate setting further increases efficiencies in the system.

The work of improving flow through acute care settings focuses on increasing patient throughput and minimizing delays while ensuring that high performance in flow is not achieved at the expense of quality.

The “Hospital Flow Diagnostic Tool” is a method for measuring hospital throughput and hospital activity based on bed turns. The diagnostic is a tool for hospitals to better understand their current hospital flow and the impact of delays in the system, and to focus their resources to achieve the maximum impact.

Based on the results of the flow diagnostic, hospitals can focus their efforts on strategies targeted at increasing throughput/bed turns, optimizing the use of existing capacity, decreasing delays, and reducing length of stay.

Areas of Focus

Increase patient throughput, as measured by bed turns and utilization
Decrease delays in the system: diversions, left without being seen, waits in the ED
Reduce variation in elective surgical admissions or separate the flow of scheduled and emergent/urgent cases
Ensure that high performance in flow is not at the expense of poor quality (e.g., mortality, safety, readmissions)
Develop a sound administrative system, including a bed management process that incorporates planning based on predictions of capacity and demand

Aims

Participants will actively test changes aimed at achieving ambitious design targets:

Total hours of ED diversions (target: zero)
Wasted ED bed capacity (target: <5% bed hours)
Left without being seen (target: <1%)
ED to the floor (target: median time < 1 hour)
Adjusted bed turns (target: >90)
Reduction of aggregate LOS (target: TBD by the organization)
Revenue per bed (target: increase 3%)
Balancing measures of quality: Off-service patients, readmissions, mortality, adverse events, nursing turnover or vacancy, patient satisfaction