Wednesday, March 16, 2011

Optimizing Patient Flow to enhance productivity and safety

 What if the healthcare system could introduce a method of improving productivity by 15-20% within months, at no extra cost, but by doing so improve safety dramatically, reduce stress, burnout, absenteeism, patient experience, and all the other good things? There is such a system, with very good evidence behind it. See link here.

1.    Safety:
a.    Arguments around safety in healthcare worldwide usually centre around the need for extra resources, rather than in the first instance optimizing the system in place. By reducing variability in the system, cases can be more closely matched to the available infrastructure and staffing resources, thereby reducing the dramatic peaks and troughs that are seen in every hospital, especially with respect to elective activity. These artificial peaks (due almost entirely to elective activity) may then give rise to the impression that the facility is under-resourced and under-staffed; by reducing this artificial variability the current infrastructure and staffing levels can be utilized to deliver a service that is safer (right patient in the right bed at the right time), and avoid a mismatch between staffing (esp. medical and nursing) and patient numbers.

2.    Efficiency/ productivity:
a.    By utilizing resources as outlined in the previous section, expensive plant such as diagnostics, operating rooms, and intensive care beds can be utilized more effectively and productively. The traditional upper estimate of hospital occupancy has been estimated at 80%; the only rationale for this figure is to provide a surge capacity, a buffer for times of increased demand on the system because no control was placed on how the elective component of demand was managed. By properly managing this demand, it is likely that overall occupancy can reach 90-95% on average safely. One hospital has reported a continuous occupancy rate of 91% since implementing this system. Rather than reducing the number of cases performed, this efficient allocation of a scarce resource allows each individual surgeon to perform more procedures.

3.    Financial benefits:
a.    Obviously, under the current Irish hospital reimbursement scheme, financial benefits are harder to estimate and realize. However, it is clear from point 2 that the return on investment is greater by optimizing hospital flow. Whether this equates to greater revenue as in the US system, or more patients treated for a given budget as in the Irish setting, the end result is greater productivity.

4.    Patient satisfaction:
a.    Hospitals that have (in the US) implemented this system have eliminated wait lists, ER waits, cancellation of elective procedures etc.

Evidence base.

1.    The American Hospital Association has identified six priority areas in its efforts to accelerate hospital performance improvement; these include health care acquired infections, health information technology, medication management, patient safety, and of relevance to this document, optimizing patient flow and throughput. The AHA state that “patient safety is negatively impacted when patients do not move through hospitals in a timely and efficient way. The AHA endorses the methodology of the Institute for Healthcare Optimization as a means of improving patient flow.

2.    The Leapfrog Group for Patient Safety is an umbrella group representing some of the largest employers in the US, (IBM, Intel, Toyota, Boeing, Motorola, FedEx). Collectively they represent employers and agencies that purchase care for more than 35 million people in the US. Leapfrog ranks hospitals in the US publicly on a number of patient safety measures. A study by the Commonwealth Fund (June 2008) reported that hospitals publicly reporting their Leapfrog Quality data had a lower mortality rate for Acute Myocardial Infarction and Pneumonia. Participating hospitals are asked if they adhere to the following quality and safety practices:

                                               i.     Computerized Physician Order Entry
                                             ii.     ICU Staffing with intensivists
                                            iii.     Compliance with performance standards for certain high risk treatments
                                            iv.     Leapfrog Safe Practices Score

3.    From 2011, the Leapfrog Group will measure a hospitals policy around flow optimization and safer scheduling, (personal communication). The group states that patient safety can be negatively impacted by a hospitals scheduling policy. The Leapfrog group supports the methodology of the Institute for Healthcare Optimization as a means of improving patient flow and reducing patient risk.

4.    In 2006 the Institute of Medicine (IOM) released “The Future of Emergency Care in the United States Health System”, a series of reports assessing the severe problems facing the nation’s emergency care system and offering recommendations to improve it. The report states "hospitals should reduce crowding by improving hospital efficiency and patient flow and using operations management methods and information technologies."
5.    The Joint Commission, the body responsible for accreditation of US hospitals, endorses a strategy of providing scientifically grounded methods to optimally manage patient flow and reduce variability as part of a policy to improve patient safety. It endorses the methodology of the Institute for Healthcare Optimization.
6.    Don Berwick, the head the Center for Medicare and Medicaid Services (CMS), one of the most powerful positions in American Medicine, has stated that there are two sleeping giants in trying to achieve quality healthcare, patient safety and patient flow.
7.    A number of the largest and most renowned US academic health centers have recently begun work on redesigning their patient flow and throughput, (personal communication). One 212 bed hospital has seen a revenue boost of $50 million annually within one year of implementing this system. Cincinnati Children’s has seen its productivity increase by the equivalent of a 100 million dollar capital rebuild, (100 beds) and its annual revenue increase by $137 million.
8.    A number of Childrens Hospitals including Cincinnati, Lucille Packard, and Great Ormond Street have adopted this approach.
9.    There is emerging evidence in the medical literature that failure to incorporate these principles is associated with serious adverse outcomes. In one study by Pronovost (2009), the odds of being readmitted to an ICU were five times greater when the number of patients admitted to the ICU were above a certain volume. 

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