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The biggest myth about flow is that it’s unpredictable and unmanageable. It’s neither.
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So-Called "Flow Failures" Are Disrespectful to Patients

By Maureen Bisognano | Thursday, August 25, 2016
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Photo credit: "CL Society 287: Waiting for a doctor" by Francisco Osorio (CC BY 2.0)

The number one reason to improve the movement of patients through health care settings is because “bad flow” is disrespectful to patients and families. 

Our inability to more effectively design and manage processes also wears on clinicians and staff — decreasing their efficiency and productivity, undermining joy in work, contributing to burnout, and decreasing job satisfaction. But our patients and families bear most of the burden.

We make patients wait in the wrong places. We make them seek care in the wrong units. If you were to walk through most hospitals today, you will probably find multiple problems with patient flow.

The 10 Percent Problem

Some years ago, IHI Vice President, Pat Rutherford, conceptualized what she calls “the 10 percent problem” — that is, at least 10 percent of hospitalized patients in various care settings aren’t there because of a clinical need. In a hospital, this can mean:

  • 10 percent of patients are in the ICU because there’s no bed free on the medical-surgical unit;
  • 10 percent of patients are in the emergency department who could have been cared for in primary care; and
  • 10 percent of patients on the medical-surgical floor could go home if there were adequate resources to facilitate their discharge and ensure safe care at home.

Flow is an issue across the care continuum. More than 10 percent of patients sitting in the waiting room of most office practices wouldn’t be there if their presenting issue had been addressed upstream. Strategies such as education, adequate home-based or community support, technology to provide support and guidance, and effective use of preventive therapies could have helped them avoid the visit.

Our failure to see the burden we’re putting on patients can keep us locked into inaccurate and potentially paralyzing ways of thinking about flow. 

Flow Failures

The biggest myth about flow is that it’s unpredictable and unmanageable. It’s neither.

Cincinnati Children’s Hospital Medical Center challenged this common misconception by taking full ownership of the issue. You’ll hear people there say things like, “Every time a patient is in the wrong place, it’s a problem that we created.” Dr. Fred Ryckman of Cincinnati Children’s calls these problems “flow failures.”

Cincinnati Children’s puts the patient at the center when redesigning complicated systems issues. This drives them to think in innovative ways. For example, in most hospitals, to book an operation, a surgeon’s office calls the operating room, and they book the OR time. That’s it.

At Cincinnati Children’s, teams have studied every step in the process for standard surgical procedures. They use data to predict and map out a typical patient’s journey throughout a hospitalization, so they have data on how much time the patient will likely be in the OR, in the PACU, or in the ICU. They know what types of equipment they’ll need, and what tests, supplies, and medications they’ll use. Everyone, from pre-op through to the discharge team, can see every step of the child’s journey and this coordination helps greatly with flow. They partner with their surgeons and clinicians to predict any unique needs, and individually customize the standardized care as needed.

In other words, much of this is predictable. Analyzing data can help organizations determine the resources and the care hours patients will need. At Cincinnati Children’s, they book the OR time, and then everything else they anticipate a patient will need is put into place. 

Implementing these changes has decreased delays, meant fewer hassles for staff, improved the care experience for patients and their families, and improved throughput time. Cincinnati Children’s can now perform more surgeries in the same number of operating rooms, and manage more patients in the same number of inpatient beds. 

Fixing Ambulatory Flow

ThedaCare in Wisconsin has an ambulatory care center that coordinates patient care across multiple providers to a degree I haven’t seen elsewhere. Called Encircle Health, it co-locates a range of primary care providers, specialists, and ancillary services in one building. This means that patients only need to register once for all care they have scheduled on a given day. All providers in the building agree to use a shared registration process and electronic health record (EHR) as part of their lease agreement. No more clipboards with forms asking for the same information over and over.

They’ve used their common systems to get test results to primary care physicians on the same day of their patient’s office visit. Unlike some practices that require patients to get their blood drawn days in advance, Encircle patients arrive for their doctor’s appointment, register, and go to the lab behind the registration desk. Within 10 minutes, the lab enters results in the EHR so they’re ready for review by the time a patient is in the exam room with their physician.

All the practices in the building have agreed to use data to predict how many slots in the day to keep open for same-day appointments. If a patient sees their primary care doctor, and gets a recommendation to see a rheumatologist or have a mammogram, they can do it that day.

ThedaCare doesn’t put avoidable burdens or stress on their patients. They don’t make patients return unnecessarily for multiple visits. They don’t make them wait for days without knowing their test results.

No More “Fix and Forget”

Not surprisingly, patients like care that is coordinated and designed with their needs in mind. Staff and physicians also appreciate systems that are streamlined and help them spend more time on patient care. People who work in redesigned care environments — like Cincinnati Children’s, ThedaCare, and others — experience joy in work because their organizations are relieving them of the burden of working in broken systems.

A 2015 article in BMJ Quality & Safety describes how often health care staff work in “fix and forget” mode. All day long they come across problems and work to solve the ones most relevant to the patients in front of them. They find missing medications, clean unsterile supplies, and find substitutes for broken equipment.

They find the workarounds. They fix the problems. No harm done to their patients, right?

But what about the next patient?

Instead of fix and forget, the goal should be to do what Steve Spear calls “see, solve, and share.” Organizations need to develop a process that includes designating a particular person and a simple reporting process to aggregate and address problems, even if no patient harm results from those problems. Doing this will help you see similar issues that pop up in different places, times, or situations. You can address them as the systems issues they are, rather than treating them all as a series of one-offs. When we create systems-based solutions, we remove the burden of “fix and forget” from staff and help prevent delays, confusion, or harm to patients in the future.

Flow is our problem. It shouldn’t be the problem of our patients. Effective flow of patients and information throughout health care systems is essential to providing safe, high-quality, and person- and family-centered care. We must use quality improvement and redesign principles to revamp how patients move through our health care settings.

When we can honestly say that all interactions patients have with the health care system are respectful, and deliver the right care, in the right setting, at the right time​ — every time, for all patients — then we’ll know we’ve made meaningful change.

Maureen Bisognano is IHI President Emerita and a Senior Fellow.

You may also be interested in:

Hospital Flow Professional Development Program (October 30–November 2, 2017, Boston, MA)

Optimizing Flow Is Everyone’s Job: How Cincinnati Children’s Improved the Efficiency of Their Hospital Operations

Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings

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