IHI’s Achieving Hospital-wide Patient Flow white paper is the culmination of approximately two decades of IHI’s research, innovation, and learning about how to more efficiently provide optimal care to patients as they move through the hospital environment. The white paper guides leaders and quality improvement teams through an in-depth examination of a systems view of patient flow, theories for improvement, and high-leverage strategies and interventions to achieve hospital-wide patient flow. The following provides an overview of IHI’s recommended approach for improving patient flow.

While health care systems are making progress toward more value-based, person-centric care practices, the majority of hospitals are experiencing significant operational and financial stress. Costs continue to escalate, while reimbursements are waning. Even though there is an oversupply of hospital beds in the US, emergency department and inpatient bed capacity fail to meet daily patient demand in many hospitals, particularly in large academic medical centers.

Diversions, long waits, and delays in the emergency department (ED) are a hospital-wide issue, not solely an ED operations issue. Delays are often the result of ED beds being occupied by patients waiting for admission to the hospital. Larger hospital-wide issues include mismatches in bed and staff capacity and demand for various clinical services; inefficient processes for transferring patients among units and for discharging patients; long waits for transferring patients to skilled nursing and long-term care settings; and patients with mental health conditions occupying hospital beds due to inadequate mental health facilities in the community. Lack of inpatient capacity also results in delayed or canceled surgical procedures, patients being “boarded” in the post-anesthesia care unit, and patients being cared for in “off-service” units. Health care systems must also understand and address disparities in timely access to and progression of care for underserved patient populations.

Failing to achieve hospital-wide patient flow — the right care, in the right place, at the right time — puts patients at risk for suboptimal care and potential harm. It also increases the burden on clinicians and hospital staff and can accelerate burnout. Yet, while many understand the problem, they often lack the comprehensive strategies to address it.

Optimizing hospital flow, and ultimately improving outcomes and the experience of care for patients, requires an appreciation of the hospital as an interconnected, interdependent system of care. It also requires strong leadership; in fact, the role of executive leaders is critical for success. The executive oversight team committed to achieving system-wide flow 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.

IHI bases our recommended approach on these principles:

• The integration of various approaches (e.g., quality improvement, Lean management, operational engineering, complex systems analysis, operations research) to achieve hospital-wide patient flow.
• The utilization of advanced data analytics to reduce artificial variation in elective surgical scheduling, forecast patient demand patterns, and match capacity and demand.
• A focus on reducing demand, with change ideas to reduce hospital utilization by relocating care to less costly and, in many cases, higher-quality care; and on shaping demand by expansion of operating room scheduling system capabilities to predict and plan for patients who need intensive care and care in other inpatient units.
• A system-wide approach to patient flow, with a few “simple rules” to govern complex systems. Simple rules are design principles to guide system-wide improvement (e.g., no delay greater than two hours in patient progression, based on clinical readiness, from clinical areas/units throughout the hospital; available capacity on each unit or clinical area at the beginning of each day).
• A learning system that utilizes the science of improvement to understand and prioritize solutions to mitigate “flow failures.”

Interested in learning this framework in person? Join us for the Hospital Flow Professional Development Program in May 2018.

For guidance on creating an action plan to get started, refer to the Achieving Hospital-wide Patient Flow white paper.

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