Why It Matters

While some organizations may have put some of their improvement work “on hold” during the pandemic, The Nemours Children’s Hospital, Florida, has continued their award-winning efforts to improve patient flow even during an uncharacteristic increase in patient volume this past summer. In the face of tremendous stress and uncertainty caused by COVID-19, Connie Pantano, Manager for Nemours’ Continuous Improvement Resources Office, says, “Work on flow has become more critical than ever.”

Past participants in the Institute for Healthcare Improvement (IHI) Hospital Flow Professional Development Program, Nemours has seen their work to improve patient flow put to the test this year. Says Pantano, “We’ve had to be confident and rely on the structures we’ve put in place so we could manage our operations and care for our patients.” According to Sophy Rodriguez, Nemours’ Director of Patient Flow and Professional Excellence, the challenges they are experiencing have shown them their systems can be resilient and less reactive than in the past. “We’ve had surges, and yet we’ve had fewer high-census huddles.” She adds, “We've had to make the tough decisions to cancel elective procedures but knowing how to be proactive this season has helped manage the new health care demands we’re facing.”

In the following interview, Pantano and Rodriguez describe how working to improve flow has pulled their organization together in ways that benefit their young patients and their families as well as the clinicians who care for them.

On their organization’s history of working on flow

Pantano: We had done some patient flow improvement work as an organization early on, and we had great success with it. We had great engagement, great improvement, and great results. But as we started moving toward the challenges of operations, we continued to experience discharge delays, staffing challenges, and high-census huddles. We started to feel the crunch of the inefficient flow in our processes. Our leaders were committed to figuring out how to continue to improve, and they sent a team of us to participate in the IHI flow program.

LEARN MORE: IHI Hospital Flow Professional Development Program

Rodriguez: We were feeling the crunch of our volumes and our demands that were exceeding where we were operating, yet we had beds [available]. So, before we talked about expansion, we knew we had to think about how to do something differently or better. We had to reflect on how we managed our throughput here locally.

On the patient discharge process that won a Florida Hospital Association (FHA) award

Pantano: The Path to Home process we received the FHA award for was one of the initial flow improvements that we had embarked on as an organization. The Path to Home project focused on discharge delays. By analyzing data collected over several weeks, our care teams learned that the top discharge delays were happening for controllable reasons. These included waits for transportation, consults, orders, and the scheduling of follow-up appointments. A cross-functional full care team came together to figure out how to have discussions at admission [with patients and families] to help us prevent controllable delays when it was time for discharge.

On the power of data

Pantano: We knew we had the information, but we weren’t using it in the best way to help drive our decisions. We’ve learned how to utilize data in a proactive manner so we could be purposeful versus always reacting.

Rodriguez: When we came back from the IHI program with all these new tools, we did an assessment of our best opportunities and our biggest struggles. We decided to focus on matching capacity and demand. We took the key driver diagram from IHI [found in the Achieving Hospital-wide Patient Flow white paper] and went through each bullet to figure out where to start. Where do we have the most control? There are a lot of factors that impact throughput that are out of our control or are external barriers. We focused on getting data-driven utilization and reviews of our demand to project more efficiently. Since completing the IHI program, we’ve developed a tiered system of reviewing our capacity. We have a capacity management structure that’s based off our daily bed huddles and leads to our weekly capacity management. That’s probably been the biggest success we’ve had. We started by determining our three-week trends of admissions and discharges. What are we seeing? What is the ED volume showing us? What can we predict? What season are we in? What are we seeing in the community? We input all those factors so we can have a data-driven review. Then we started to add the staffing component to the same review we do every week. Now I can tell you what my projected staffing is next Thursday and how it compares to my projected demand based on our trends and what we have scheduled for the OR.

On seeing flow from the patient and family perspective

Rodriguez: We learned how to talk internally about patient flow failures versus patient flow delays. We’ve standardized the language we use when we have issues. This allowed us to align our focus on the patient: right patient, right place, and right time with the right care team.

Pantano: As I always like to say, patients and their families know where we have our gaps and opportunities. It’s crucial to make sure we’re listening to them, understanding how our adjustments are impacting them — whether that’s favorably or unfavorably — and putting their voice at the center of what we’re trying to do.

On the importance of clinician and leadership engagement

Pantano: The engagement of our physicians and nurses and the relationships that have solidified while doing this work have been so important. It’s been great to see people seek to understand each other’s processes and work together wholeheartedly for the good of the patient. Sometimes you hold an improvement event where you get several providers and nurses in a room, and they’re not sure how to interact with each other in the beginning. By the end of the event, it’s interesting to see the comfort they have with each other. It’s that personal connection that you build with your colleagues and your teammates that helps drive the improvements and the success.

Rodriguez: Support from our leadership has been so important. Making [improving flow] one of our top priorities and giving us the support to do what we need and the resources to implement these projects and initiatives. I also think it’s been important to understand that [improving flow] is not about creating a certain level of capacity by building more and spending more money. It’s about improving our efficiencies and understanding that we’re going to gain just as many beds if we do things differently.

On the value of teamwork

Rodriguez: We’ve created a high-census algorithm that includes who [in the organization] to notify when we reach different levels. People used to want to know when we were overcrowded or at almost full capacity. Now, people say, “I want to know before [we reach that point] so I can help you brainstorm and problem-solve.” It’s been so rewarding to see more people at the table over the last year.

Pantano: This work has always taken a high degree of coordination, but now it takes more than ever before. There are so many additional factors we have to consider and external barriers that impact our flow. The strain on community resources, the restrictions on patient and family interactions, and all the different factors we’ve had to adapt and adjust and then readjust. It’s been keeping all of us on our toes. It goes back to the relationships, the partnerships, and the collaboration we’ve all developed. There’s more recognition that flow is not a single unit or area’s problem. We’ve put the right structures and tools in place, but I think it’s also where we are as an organization from a COVID perspective. We’re all in this together, and it’s helped us get through it in a better way.

Editor’s note: This interview has been edited for length and clarity.

You may also be interested in:

IHI Achieving Hospital-wide Patient Flow white paper

Why a Cookie-Cutter Approach Won’t Work to Improve Patient Flow