Matching capacity and demand by making minor adjustments in the availability of health care providers or the scheduling of elective surgeries is often sufficient to reduce delays. If the demand for care is greater than the capacity of the system, there will be a delay in providing care. If the capacity is greater than demand, then resources are being wasted. When capacity and demand are matched, delays in care are reduced. Whenever a quantitative analysis indicates that the system has the capacity to meet the demand during normal functioning, then specific change concepts can be implemented relatively quickly to help align capacity and demand during predicted or unpredicted periods of high demand.

Changes for Improvement

Predict Surgical Case Length Accurately

Scheduling surgical cases and adhering to the schedule during the course of the day are complicated by the fact that the demand for surgery is often unpredictable and the length of the surgery itself varies. To better manage the surgical schedule, use control charts to plot data over time to study the variation in case length. The control chart provides estimates of the variation that must be taken into account in scheduling. A control chart will identify the normal variation in the system (common cause variation), as well as variation that is due to unusual or unpredictable cases (special cause variation).

Special causes of variation in surgery may be related to routine cases that develop unpredictable complications, unexpected shortages of staff, last-minute changes in physician schedules, and unavailable or malfunctioning equipment. These special causes of delay are not predictable, but can be eliminated or minimized by building contingencies into the surgical system to reduce their impact on the system.

Tips

• Study variation in given different types of surgical cases, variation among surgeons, and other sources of variation.
• Schedule complex or unpredictable cases at the end of the day or in a separate room to minimize their impact on the start of other cases.

Institute a Room-Cleaning Strategy

Cleaning rooms and beds in optimal time improves the availability of inpatient beds upon discharge of previous patients. Efficient room and bed turnaround streamlines patient placement and overall system-wide patient flow. The person responsible for cleaning beds on a unit should be clearly defined, for example, a bed turnover assistant (BTA) or dedicated housekeeper. As soon as a patient bed is vacated, the nurse assigns a prioritization number to the bed based on demand. The nurse notifies the BTA by pager that a bed is vacant and ready to be cleaned and indicates the prioritization status for cleaning. (Status One: Bed should be ready in 15 to 30 minutes; Status Two: Bed should be ready in 31 to 60 minutes; Status Three: Bed should be ready in 61 to 90 minutes.) The BTA prioritizes the cleaning of the bed, as appropriate, and uses a pager to notify the nurse as soon as the bed is ready for patient admission.

Tips

• Assign responsibility for cleaning beds to one person, the bed turnover assistant.
• Have nurses and BTAs carry pagers to notify each other quickly of the bed status. Test on one unit, with one nurse and one BTA, for one day.
• Work closely with environmental services to proactively plan for room and bed turnaround and avoid “stats” or urgent calls for beds.

Institute a Fast Track in the Emergency Department

Patients who are cared for in a hospital’s emergency department (ED) vary in the complexity and seriousness of their conditions. Rather than having the same process for all types of patients, create a separate process for patients with less serious conditions who can be treated more quickly and then released. ED staff identify charts for these patients through the care process as quickly as possible, while at the same time balancing the need to treat the critically ill or injured patients (often, a physician is able to treat one or two patients while waiting for the test results on more complex, or more seriously ill, patients). The ED Fast Track can also allows organizations to maximize resource use as mid-level providers such as nurse practitioners and physician assistants can care for less seriously ill patients.

Tip

• Use the triage nurse to evaluate patients in the ED. This allows for things like labs, x-rays, etc. to be performed prior to the patient's meeting with the doctor. With nurse triage, the doctor has time to see critical patients and the non-critical patients are not in the waiting mode. Another advantage of nurse triage is that patient results are available by the time the doctor sees the patient, and the patient can be admitted or discharged more efficiently. [Submitted by: Mary Shamblin, MSN/ED Student, University of Phoenix] 

Examine Average and Peak Daily Emergency Department Admissions

Plans, resources, and staffing are based on predictions. Examining historical data on average and peak daily emergency department (ED) admissions helps predict the demand and allows for planning for the capacity needed to meet the demand. Predictions can be used to make system adjustments to meet the conditions. The ED staff can track demand in order to identify the days of the week, and hours of the day, when demand is especially high. Historical data also help predict the number of ED patients requiring admission to the inpatient setting. This allows ED staff to predict periods of high demand and make system adjustments to meet the demand. For example, ED staff can be rescheduled from low-demand to high-demand periods. Outpatients seen in the ED for scheduled treatments, such as transfusions, can be scheduled in low-demand periods. And the ED can alert other departments of the need for inpatient beds.

Tips

• Plot ED admissions by various time periods to help identify seasonal, weekly, or daily patterns.
• Use leading indicators to develop predictions (e.g., early indications of a particularly severe flu season).
• Anticipate special causes (e.g., ED preparing for heart attacks and sprains after a heavy snowfall).
• Use simple averages of historical data to aid in making predictions (e.g., arrival time and type of admissions and when patients are transferred from the ED).
• Use ED historical data to plan with other hospital departments for the need for inpatient beds.