The Secret of Great Hospital Performance

When you pull out to pass a car on the highway, what do you care about?

Do you care about speed or…

do you care about your gas pedal?

We press on the gas pedal (input) in order to pass (output).

We focus on the job at hand, what we need to get done. We do not care about the gas pedal. We care about passing safely.

Healthcare focuses on the gas pedal.

How much will this cost?
How big is our budget deficit?
Where can we trim costs?
Why are costs going up so fast?

It’s understandable. Money grabs our time and attention in hospital leadership. But, like the gas pedal, inputs should be secondary. Our biggest concern should be outputs, are we delivering great care?

Block funding for hospitals died years ago in most countries. Unfortunately, block funding still thrives in many Canadian hospitals.

Block funding = stretch one pile of cash out for a whole year of hospital services.

No funding for growth.
No funding for acuity.
No incentives to deliver more care.
Focus on the budget; don’t spend a penny more…keep the gas pedal in focus.

Fortunately, most jurisdictions are starting to admit that block funding doesn’t make sense.

Focus on Outputs

The secret to great hospital performance = focus on outputs. Focus on great service and outcomes for patients, first.

112 Patient Flow Solutions for Emergency Departments

This list should get us started… Please add your ideas in the comment section at the end!

Close your waiting room – bring patients straight inside to chairs if no beds open
Use triage to enhance flow: triage = sorting and nothing else
Limit the number of nurses at triage – 1 nurse can SORT 200 patients per day easily
Have patients self triage
Use on-line triage
Use Bedside registration
“Quick Reg” – limited registration; just enough to create a chart
Have patients use self registration
Offer pre-registration on line
Post live wait times on-line to smooth patient volumes
Use patient passports – patient education hand-outs at front door
Educate the community to arrive in ‘slow’ hours (e.g., before 11am Tues – Fri)
Educate community to avoid the surges on Sunday evening/all day Monday
Limit 1 visitor per patient
Encourage patients to bring med lists with them
Encourage community MDs to send in referral notes
Have on-call MDs
Have flexible start and stop times for MDs
Get MDs to take responsibility for flow in real time
Have on call RNs
Shorten nursing documentation (1-2 pages max)
Use combined triage & nursing secondary assessment form
Use physician scribes/navigators
De-zone – move staff to where need is greatest; don’t leave a zone overstaffed
Use advanced directives
Use pre printed orders
Measure and reward MD performance
Measure consultant response times
Insist on in-house consultant coverage for internal medicine, anesthesia, pediatrics…
De-unionize – flow will improve
Have nurses only do nursing tasks (carry out orders, give medications), not clerical work
Track RN break times – insist on accountability
Reward RN extra effort (staying late, skipping breaks, going the extra mile)
Match RN staffing to patient volumes by hour
Match MD staffing to patient volumes by hour
Never allow MDs to go home if waits are long
Staff extra MD and RN shifts on known high volume days (Mondays, holidays)
Encourage MDs/RNs to work in teams and hand over readily
Stagger RN shift changes
Have dedicated ED X-Ray
Have U/S (and tech) in the ED
Use techs for lab draws and ECGs
Stat labs
Prioritize ED lab and DI
Don’t batch
Dedicated porters (RN/tech should porter if porters overwhelmed)
Track DI and lab turn-around times
Get a great EDIS (ED information system)
Create meaningful alerts on EDIS to identify LOS, reassessments, etc
Have a modern EMR linked to the EDIS
Retire outdated EMRs – an old, slow EMR might be worse than none at all
Consider a real time locating system (e.g., RFID)
Consider EMR on tablets for each MD
Computer terminal in each room
Link ED EMRs with community EHRs
Have forms available on-line
Bypass ED for STEMI identified by EMS (straight to PCI)
Eliminate phone calls for CT, etc
Extend CT hours of operation
Encourage the hospital to work on a 24-7 service model (at least a 7 day service model!)
Do not schedule big surgical cases on Monday
Track admits and discharges by time of day and day of week
Eliminate day-day variations of admits/discharges
Perform nurse handover on the ward; not by phone from the ED
Get admitted patients straight up to the ward before a bed becomes available
Use a visual bed management system for inpatient flow admitted patients leave promptly
Use patient flow navigators
Create robust medicine clinic follow-up clinics (next day)
Do not allow consultants to ‘send patients to the ED’ and see them there
Teach residents about quality and efficiency as paramount in their education
Use PO instead of IM, and IM instead of IV treatments if possible
Position EMS off-load in-front of the main nursing station – not hidden away where patients can languish
Form psychiatric patients promptly as needed
Do not perform an internal medicine ‘ward’ work-up in the ED
Order all tests and treatments on the first touch
Plan on disposition from the first encounter
Have Multi-use rooms (eliminate bottle-necks)
Establish procedures to sedate patients in any room
Partner with volunteers – they can help a ton!
Establish CDUs on in-patient wards – do consultations there
Give every MD, RT and Consultants a phone to carry
Do not scale down services over holidays when demand always goes up!
Encourage same day, out-patient cardiac diagnostics and consultation
Establish direct referrals to cardiology (not internal med, NP, cardiology, etc)
Have everything needed for work in every area (don’t make staff walk to the ‘tube system’)
Use pre-printed prescriptions
Have the chief call in 2-3 times per day to monitor flow
Create an internal, real-time ED surge plan
Create a hospital wide surge plan and link it to the ED surge plan
Give admin on call authority to move admitted patients out the ED
Have back on-call to support internal medicine consults
Do not allow surgeons to be on-call to the ED on their OR day
Teach all nurses to apply splints and/or casts
Use ‘just in time’ approach to patient movement – don’t stock-pile patients by loading rooms
Avoid batching
Assign patients to areas; not rooms
Use overhead paging liberally – don’t walk around looking for patients
Improve patient signage
Use patient instruction sheets
Use a re-assessment check-list so MDs aren’t called to reassess prematurely
Build a minor treatment area (aka fast track)
Get rid of as many stretchers as possible (limits holding admitted patients)
Use exam tables where-ever possible
Use some chairs instead of stretchers in the acute area for telemetry patients
Get rid of walls – use curtains to divide most rooms
Eliminate sequential processing
Insist on parallel processing
Look for bottlenecks – theory of constraints
Learn queuing theory and how it applies to your department
Learn and love LEAN
Employ an unlimited capacity mindset – don’t limit flow for lack of ‘rooms’
Adopt a ‘get it done NOW‘ attitude across the organization!

More ideas? Questions? Feedback? Click on leave a reply or # replies below:

Fix Patient Flow Bottlenecks – Forever

Patient flow seems impossible to fix in most hospitals.

Nearly every step in a patient’s journey can stop flow. Even the most LEAN-ed processes require fanatical vigilance to guarantee patients don’t get stopped as they move through our hospitals.

Eli Goldratt popularized ‘bottleneck’ in his classic ‘The Goal‘ – a long narrative presentation of the Theory of Constraints. A worthy read.

Bottlenecks decrease flow.

They cause havoc by showing up unplanned. In industry, bottlenecks turn up as critical processing steps whose maximum speed determines the maximum speed of a whole production line.

In healthcare, bottlenecks change all the time. In fact, a dozen different things could be the bottleneck – the rate limiting step – over 1 day in the ED. During the morning, it’s lack of staff; during the afternoon, it’s lack of beds. Despite this, most folks like to blame their favourite bottleneck:

“If we only had more beds. If only we didn’t have admitted patients!”

“If only we didn’t have such slow docs!”

“If only we had more nurses (or faster nurses…)!”

“If only we had more space!”

If only…

Picking one bottleneck – usually out of our control – removes responsibility to address all the bottlenecks within our control.

In recent posts, we’ve been talking about closing the waiting room, bringing patients straight into the ED and cycling them from chairs to exam tables. These steps bypass the ‘bed block’ excuse most EDs use for making patients wait for hours in the waiting room. Once patients get ushered straight in, dozens of new bottlenecks show up: nursing shift change, waiting for porters, DI/Lab back-up, not enough MDs, patient reassessment delays…running out of patient gowns…

There’s only one way to guarantee a bottleneck will never slow flow in your ED.

Parallel processing

Like putting together an IKEA cabinet, some things need to be done in order. Sequential processing means doing things one after the other – like a long train of boxcars. However, insisting on sequential processing creates hundreds of potential bottlenecks. Parallel processing unhitches the boxcars and lets them all run on separate tracks at the same time. That way, if any process stops, all the others can continue.

Simple enough…

But, medicine loves process. Many of the sacred cows in emergency medicine are core to sequential processing:

Triage followed by

Secondary Assessment followed by

MD assessments followed by

Lab and DI followed by

Portering…

Reassessments…

Discharge

Most providers fight to keep care in a general order. It’s what they’re used to.

A parallel approach looks like this:

Triage (sorting only…more in another post) followed by

Everything else

Easy, right? It’s not.

If you truly adopt this thinking, you might have MDs assess and discharge a patient before the patient even sees an RN. Or, you might have Lab/DI and discharge planning involved before an MD gets to a patient. This requires huge flexibility for providers who’ve been bound by historical process.

But…but…what happens first?

After triage, everything else gets done ‘as soon as possible’. Whoever can get to the patient first, gets started on their part of the process even if it means they can’t complete it before another provider arrives. Get it done, now! Sequential steps can never be tolerated as an excuse for making patients wait.

What bottlenecks are holding you back? What’s holding you back from adopting a fully parallel approach? Share your thoughts by clicking on ‘leave a reply’ or # replies below.