Institute for Healthcare Improvement: Learning and Innovation Community: Improving Flow Through Acute Care Settings

We are no longer accepting teams in this Community. If you have questions, please contact impact@ihi.org.

****************************************************

The Challenge
Excessive delays for patients to be seen in emergency departments across the country are reported regularly. Many hospitals attempt to improve patient flow by focusing primarily on the emergency department which misses the larger picture: patient flow is a property of the entire system and can only be optimized at the system level. EDs often divert patients because hospitals lack the space to move patients through the ED to an inpatient bed in a timely manner. Simply increasing capacity in the ED alone will not solve flow problems.

The “competition” for inpatient beds from the emergency department, surgery, and direct admissions creates waits and delays that negatively affect patient safety, as well as patient and staff satisfaction. Poor patient flow has direct effects on clinical care and the financial status of hospitals. When patients are placed off service and are “boarded” due to the inability to place them in inpatient beds, clinical decisions can be delayed and safety compromised. Hospitals lose revenue due to un-reimbursed days, diversions, unneeded overtime, and not optimizing surgical throughput.

The Solution
Reducing delays and optimizing patient throughput in a hospital cannot be achieved by focusing on individual units or on a number of disconnected projects. A systems approach is needed that matches in real time the beds available to place patients (capacity) and the number of patients waiting to be admitted or transferred (demand). Real time management will enhance a hospital’s current patient placement process by including methods to improve predictions of capacity and demand. Better predictions will result in better planning to avoid mismatches. Studying the reasons for failed predictions and plans will help to identify chronic barriers to patients flow. Select improvement projects can then be focused on areas that actually affect flow.

Areas of Focus

Reliably predict demand for patient beds and available bed capacity
Increase patient throughput, as measured by bed turns
Decrease delays in the system: diversions, left without being seen, and waits in the ED and the OR
Ensure that high performance in flow is not achieved at the expense of quality (e.g., readmissions)

Aims

The overall aim of the Community is to improve patient flow by increasing throughput and minimizing delays while assuring that high performance in flow is not at the expense of quality. Progress will be measured against aggressive design targets including:

Total hours of ED diversions (target: zero)
Left without being seen (target: <1%)
ED LOS for admitted patients (target: median time <3.5 hours)
Bed turns (target: increase without equivalent increase in resources)
Reduction of aggregate length of stay (target: TBD by each organization)
Balancing measures of quality to consider: readmissions, off-service patients, nursing turnover or vacancy, and patient satisfaction

Participating hospitals also identify and monitor intermediate measures to assess progress in impacting chronic barriers to flow: telemetry and ICU delays, transitions between units, transitions to extended care facilities, LOS for certain conditions (e.g. cardiac patients), and wasted capacity.