To quote IHI President Emeritus and Senior Fellow Don Berwick, “Improvement requires will, because durable improvement is not an accident; it takes effort.” Accordingly, it’s necessary to build will throughout an organization to provide optimal and efficient care as patients move through an entire hospital environment. The following adapted excerpt from IHI’s Achieving Hospital-wide Patient Flow white paper presents five strategies for building will, from the highest levels of leadership to point-of-care managers and staff.
Make Delivering the Right Care, in the Right Place, at the Right Time a Strategic Priority
The operational challenges inherent in our highly complex health care systems often mean that patients do not receive the right care, in the right place, at the right time. This leads to wasteful, suboptimal care; it is also potentially harmful to patients. Harm as a result of poor patient flow manifests itself in many ways — an anxious ED patient waiting in pain to be admitted to a hospital bed that is unavailable; delays in initiating treatments or procedures for an acutely ill patient because of waiting times for transfer to the appropriate service or hospital unit; a patient, boarded in a medical-surgical bed instead of an ICU or specialty-unit bed due to overcrowding, receiving less than optimal care because of the respective skills sets of each unit’s care teams.
When viewed from the perspective of a system-wide approach to improving flow, these patient experiences are clear examples of waste and potential harm. Yet, our health care systems and the existing incentives often create conditions for this type of care to exist. Without addressing flow as a strategic priority, clinicians and hospital staff are left to fix flow failures on an ad-hoc, reactive basis — repeatedly addressing the same problems and flow failures without addressing recurring system constraints and inefficiencies.
Achieving system-wide hospital flow requires strong leadership; in fact, the role of executive leaders is critical for success. The executive oversight team for this work must prioritize four things: carefully craft and communicate a long-term aim and its rationale; put in place structures to execute on system-wide improvement, shifting the focus from localized initiatives to hospital-wide results; be ready to resolve the tough dilemmas on a timely basis; and focus on a few important initiatives to demonstrate organizational capability, then expand the scope to hospital-wide flow initiatives.
Align Medical Staff and Hospital Executives to Achieve Improved Flow
The relationship between senior leaders, who set organizational priorities, and medical staff and other care providers, who implement changes at the point of care, is integral to the success of a system-wide effort to improve flow. Some hospitals use financial incentives for improved performance. However, a more promising approach is for hospital executives, physicians, and care providers to implement strategies to overcome barriers and adopt changes to improve hospital-wide patient flow. For example, Virginia Mason Hospital and Medical Center has a compact with physicians and other care providers that outlines what each party can expect from the other. The compact creates space for honest conversations and setting expectations about strategic priorities and approaches to achieve Virginia Mason’s mission. The incentive for improvement stems from involving the people who will be most affected by the changes. Honest discussions, with clear data analysis, about the needs of both the organization and clinicians surfaces barriers to desired performance and creates a path forward to real improvement.
A well-crafted aim statement and a shared vision for achieving hospital-wide patient flow is critically important, but perhaps not sufficient. These developments may not be adequate to mitigate the influence of special interests (e.g., those of surgeons, ED physicians, hospitalists) that are not oriented to the needs of the whole organization. Hospital executives need the authority to mitigate the influences of special interests in order to align efforts to achieve new levels of performance for hospital-wide patient flow.
Adopt Value-Based Care Models to Support Improved Flow
As hospitals move toward more integration across the system of care, or toward value-based care models like accountable care organizations (ACOs), there are increased incentives to deliver the right care, in the right place, at the right time. Timely access to care providers and community services, a proactive approach to care management and coordination, and collaborations among health care providers across the continuum of care to best meet the needs of patient populations often reduce patients’ need for acute care services and hospitalizations.
For example, when patients rely on emergency departments for low-acuity visits, high-cost resources are used inefficiently and inappropriately, and continuity of care across providers becomes more difficult. ACOs or other value-based models of care are in a unique position to work with patients to ensure they receive care in the most appropriate setting based on their health needs. Full implementation of this type of system of care requires a dramatic improvement in providing patients with timely access to providers, particularly for patients with chronic illnesses; extended clinic hours; open slots for urgent care visits; phone contact with care providers for clinical advice and guidance; access to medications and refills; and contact between ED physicians and clinic staff to ensure adequate and timely outpatient follow-up for those who do seek care in the ED. In a two-year study comparing patients who joined an ACO between 2012 and 2013 with patients in traditional health system models, the ACO patients visited EDs 3.6 percent less often than their non-ACO counterparts and were less likely to utilize the ED for conditions that could be better treated in outpatient settings.
Demonstrate That Improved Flow Has a Positive Return on Investment
Realizing a return on investment (ROI) for flow improvements will vary based on hospitals’ payment models and local contexts. The selection and timing of specific flow improvement initiatives should take this into consideration. In both value-based and fee-for-service payment systems, a positive return on investment is attainable. In predominantly fee-for-service environments, the two major drivers for increasing ROI are eliminating diversions and improving efficiencies, leading to increased capacity and throughput. Organizations realize cost savings in value-based payment models by reducing the following: patient length of stay; complications; and avoidable ED visits, hospitalizations, and readmissions. In both payment models, improved patient satisfaction scores can lead to patient loyalty and increases in market share.
While average hospital occupancy rates in the US stay close to 65 to 67 percent, due to significant fluctuations in demand (i.e., predictable increases in patient demand related to seasonal events) hospitals often find themselves at or above 100 percent occupancy. With a system-wide approach to improving flow, hospitals can more effectively manage these fluctuations and thereby reduce costs and retain more revenue within the hospital system.
Connect the Work of Departments and Units to Hospital-wide Flow Strategies
Implementing and sustaining improvements in hospital-wide flow requires alignment, cooperation, and coordination between hospital units and departments. Without effective executive oversight and collaboration, teams operate in isolation from one another and the aggregated impact of their efforts is limited. In many cases, this isolation leads to duplicative work, rework, or work that runs counter to overall goals to improve hospital-wide patient flow.
Before embarking on a coordinated, system-wide approach to improving flow, leaders need to recognize the work already undertaken by various teams, celebrating and highlighting their successes, while also acknowledging the systemic nature of ongoing flow challenges. Hospital leaders must present a vision of flow as a system-wide issue with cross-departmental improvement opportunities, so that every team and every individual understands the connection between their work and overall improvement for the hospital. To facilitate this, it helps to create a unified system of measures used throughout the hospital, including all units and clinical services, such as operating rooms. Visual displays of data and improvements related to the work (e.g., patients waiting in the ED, admissions and discharges pending, critical test backlog) allow for real-time situational awareness for all caregivers. This helps create an environment in which each team has a direct line of sight to the overall efforts of the organization to improve flow, which increases buy-in to the effort.
For guidance on creating an action plan to get started, refer to the Achieving Hospital-wide Patient Flow white paper.
You may also be interested in:
Hospital Flow Professional Development Program (May 6-10, 2019, Boston, MA)
So-Called "Flow Failures" Are Disrespectful to Patients
Optimizing Flow Is Everyone’s Job: How Cincinnati Children’s Improved the Efficiency of Their Hospital Operations
