Factors Impacting Patient Flow

Posted on Tue, Feb 10, 2015
Factors Impacting Patient Flow

Poor patient flow can have a significant negative impact on hospital performance, slowing throughput and effectively decreasing capacity. The 2012 Patient Flow Challenges Assessment (PFCA) report by AHA Solutions, an American Hospital Association company, reveals that, along with HCAHPS and readmissions, poor patient flow was one of the top three areas of concern for hospital leaders. The PFCA report breaks down each aspect of the patient care path in order to identify the key barriers throughout each of the eight stages of patient flow: (1) pre-admission, (2) admission, (3) diagnosis, (4) procedure, (5) recovery, (6) discharge, (7) post-discharge and (8) home (AHA Solutions, 2012, p. 5).

Undoubtedly, both the causes and effects of poor patient flow can be found throughout a hospital system. While many factors contribute to overall inefficiencies, a primary culprit is physician communication and hand-offs at one of the key stages — admission — moving patients from the emergency department to the inpatient units. The negative impact of inefficient patient flow is often felt most in the emergency department — the very department that requires faster movement, more flexibility and greater efficiency in order to effectively care for patients. Poor collaboration, strained communication, silo mentalities, differing incentives and other contributors to the highly fragmented relationship between the emergency medicine and hospital medicine physicians are common challenges.

The constant demand to address these issues led to a deeper study of the conflict between the departments. Of note, hospitals with patient flow issues consistently demonstrated the following:The existing culture allowed physicians and staff to work in silos instead of focusing on a broader picture of patient-centered care.

The divergent perspectives and priorities of the emergency medicine and hospital medicine physicians were causing inefficiencies, communication breakdowns and slow patient hand-offs.

Inpatients who were ready to be discharged still filled hospital beds well into the late afternoon, blocking admissions from the emergency department.

The average time to move the admitted patient from the emergency department to the inpatient unit was commonly 3½ hours or more (E.D. boarding time).

Ultimately, the solution has been found in an integrated approach to emergency medicine and hospital medicine in order to improve communication, collaboration and performance. Evaluating the Major Flow ManagersThe emergency department (E.D.) is the front door of the hospital addressing urgent and acute care needs of patients who are sick or injured. For many patients, the E.D. is only the first phase of their hospital experience. Nearly half of all inpatient admissions come from the E.D. In many hospitals, this percentage is far higher.

In the E.D., efficiency and productivity are critical. Seconds count in an emergency and minutes count in E.D. metrics. Processes are carefully monitored for continuous improvement, and lean methodologies and rapid process redesign efforts focus on staffing, triage, registration and other factors that are critical to patient-centered care. Improving E.D. throughput has a distinct impact on value-based success. Centers for Medicare & Medicaid Services (CMS) goals for 2013 and 2014 include measures to record improvement in E.D. efficiency and throughput times.

While E.D. efficiency is important, it is not the only determinant of good patient flow. Patient flow controllers can exist throughout the hospital system including areas such as diagnostic radiology, laboratory, transport services, housekeeping and, most notably, inpatient services.

Hospital medicine physicians, or hospitalists, direct the aspects of care for patients who may require admission to the hospital for inpatient services. Some consider the hospitalist to be the quarterback of the patient care team, teaming up with multiple players: E.D. physicians and personnel, primary care physicians, specialists, nursing staff, case managers, laboratory staff, radiology personnel, patients, family members, program coordinators, home care agencies and longterm acute care hospitals, rehab facilities and/or nursing homes. As many fullservice hospitals move to a model where laboratory services, radiology and other essential services are available 24 hours daily (and not just on a “7 a.m. to 5 p.m.” basis as has traditionally been the case), the advantages of 24-hour hospitalist services will likely become even more dramatic. Because hospitalists provide the majority of clinical care for admitted patients, the impact of the hospital medicine group on HCAHPS scores is hefty.

As a hospital-based practice, hospitalists are positioned to effectively manage hospital admissions and discharges. Therefore, from a patient flow perspective, hospitalists have come to play a major role in improving flow efficiency, satisfaction and cost (McHugh et al, 2011).

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