Strategic Planning
Enhancing Patient Flow
By Barry Freedman, Susan Bernini, Robert W. Champion and Kathleen Lennon
Emergency department diversions for EMS crews, long waits in the ED for inpatient admissions--these are just a couple of the new realities that hospitals and patients are facing.
A telltale sign that you may have problems with patient flow becomes evident when average lengths of stay (LOS) exceed industry benchmarks and/or are increasing monthly. You also know you have a problem when a significant percentage of patients leave the ED without being seen, which can also frustrate physicians if they perceive this as a sign of inefficient internal processes. Between patient flight and physicians admitting their patients to other, more accommodating facilities, hospitals consequently lose volume and, therefore, revenue.
Poor patient flow has other financial implications as well. Many markets across the country have seen a significant increase in the percentage of case-rate reimbursements compared with per diem payers. Under case-rate reimbursement, hospitals are paid a fixed fee for the case. This payment structure relieves both insurance carriers and hospitals of an entire layer of administrative burden, but shifts the responsibility for managing the patient's stay efficiently to the hospital. When patient flow is poor, care delivered during long lengths of stay may not be fully reimbursed.
Some hospitals are poorly positioned to assume this responsibility and to realize the administrative and financial benefits of a case-rate reimbursement system. Through their physicians and case managers, hospitals must develop the tools and skills needed to function in this new financial environment. Proactive management of each patient's LOS is a financial and logistical necessity.
These challenges stretch beyond hospital operations into strategy. Capacity constraints impede hospitals' ability to develop new markets, grow service lines, and generate new revenue streams. When patient flow is poor, hospitals may be too full with patients for whom they cannot get full reimbursement to accept new admissions. Boards can stay alert to potential problems with patient flow by monitoring patient census, emergency department diversions, LOS and other relevant metrics, as detailed in monthly progress reports.
The Assessment
When hospital leaders suspect problems, they can conduct an objective assessment of processes and procedures designed to maximize patient flow. The assessment should ask these questions:
Does the hospital have a comprehensive, coordinated strategy and approach to manage patient flow, or are there various and competing approaches to bed management and patient placement, with multiple managers responsible for associated processes--such as admitting, case management and discharge planning--and protocols?
Could the current care management structure, processes and roles (e.g., care coordination, social work and discharge planning) be used to manage patients in a case-rate environment?
Do physicians understand the hospital's need to use its beds more productively? Do they have incentives to treat patients in a timely fashion and discharge them as soon as appropriate? Is the use of specialty beds (such as critical care, step-down and telemetry) managed carefully? Is the nursing staff actively engaged, with a common understanding of the hospital's priorities for enhancing patient flow and reducing LOS?
The Solution
Once hospital leaders have completed their assessment and identified the specific areas that need to be addressed, there are several best practices they can follow. For example:
- Under the leadership of hospital executives and the board, patient flow management should become an important organizational priority
- Hospital executives should partner with physician leaders to drive and oversee patient flow initiatives
- Key initiatives should involve physicians in policy and operational changes
- Interdisciplinary and collaborative initiative teams--comprising physicians, nursing staff, care managers, therapists and others--should redesign core processes, each focusing on a major patient flow improvement objective. Examples of such improvements include better bed management, improved patient movement through the inpatient setting and better care coordination
- Integration of admission, care management, discharge planning and other patient flow-related processes across departmental and functional lines is necessary to effect real change
- Continued monitoring by operational executives of the hospital's performance metrics is critical to sustaining improvements.
A Success Story
Albert Einstein Medical Center (AEMC) in Philadelphia is the 500-bed acute care facility of the 1,100-bed Albert Einstein Health Network. It is a tertiary care academic hospital with a Level I regional trauma center, a Level III neonatal intensive care unit, and one of the most active EDs in the area.
"The system we had in place wasn't working," says Cindy McGlone, vice president of clinical operations, who was assigned to implement an effective patient flow management system at AEMC. "Many of the core processes weren't working effectively: how you identify pending discharges and empty beds; how you evaluate the right bed for a patient; how you get the nursing units to accept overflow patients ... departments were functioning in silos rather than collaborating with each other."
The board supported the CEO's plan to address the patient flow problem, and authorized him to recruit any help he needed.
"I knew there were a number of firms out there who could help us organize this process," says CEO Barry Freedman. "We engaged a consulting partner to help us conduct a comprehensive assessment and look across our whole organization in a way that we had not done before."
The most significant change the firm recommended was the interdisciplinary initiative team. The team established specific criteria to determine when the need to divert ED patients was imminent and developed strategies to help avoid diversion and minimize the number of patients waiting in the ED.
Care managers in the emergency department now evaluate potential admissions using nationally accepted medical necessity criteria, instead of applying individual judgment, which often varied significantly. Social workers help reduce admissions for social problems (e.g., undocumented aliens and guardianship), and develop plans to assure that discharged patients receive appropriate post-hospital support when they go home.
A redesigned care management department with improved processes and appropriately sized caseloads now works more closely with physicians and nurses. Physicians helped redesign clinical processes based on nationally recognized best practice ICU admission and discharge criteria for common medical diagnoses. Additionally, physician advisors are now available to talk to their colleagues about barriers to moving patients through the hospital during their stay.
Weekly outlier rounds for patients with an LOS over 5 days bring together the full clinical team to brainstorm creatively about discharge plans for patients with complex medical and social needs. A redesigned bed control and allocation process led to the creation of a centralized coordinator position at the hospital to guide patient placement and increase nurses' involvement in bed allocation decisions.
The result is a robust measuring and monitoring toolkit now in place to evaluate the hospital's performance in improving patient flow.
The Results
AEMC's patient flow initiative, completed in July 2004, transformed a fragmented patchwork of isolated attempts to solve hospital overcrowding into an integrated and well-coordinated program of patient flow management. Ongoing attention to new policies and procedures and timely process changes will help AEMC improve and sustain the program's benefits, which have already been significant. The hospital has realized:
- A reduction in LOS from 6.1 days to 5.4 days
- Denials of reimbursement, for admission, or for continued inpatient stay when it was not medically appropriate, declined from 3.4 percent to 2.1 percent, as a percent of net revenue
- Current in-house census of outlier patients with a LOS greater than five days decreased by 13 percent, while outlier days decreased by 39 percent
- Increases in patient, staff and physician satisfaction.
In the ED, specifically, the following improvements have been realized:
- Diversions have declined 89 percent with volume up 16 percent
- Wait time for patients admitted through the emergency department has decreased 32 percent
- An ED case manager has helped the hospital avoid potential admission denials in 32 percent of reviewed cases
- The percentage of patients leaving the ED without being seen decreased from 5.2 percent to less than 2 percent
- ED patient satisfaction is up by 10 percent.
Through an objective assessment of their problems and by leveraging leading industry practices, hospitals can enhance patient flow. The ability to sustain improvements and fully attain strategic goals and benefits depends on leaders' continued commitment and ability to remain focused on key scorecard metrics.
Barry Freedman is the CEO of Albert Einstein Medical Center (AEMC), Philadelphia, and Susan Bernini is AEMC's chief operating officer. They can be reached at (215) 456-6010. Robert W. Champion is vice president and kathleen lennon, r.n., is a senior manager at Capgemini U.S. LLC, New York City. They can be reached at (732) 669-8119.
In April, Capgemini announced the sale of its health care practice to Accenture, subject to regulatory approvals.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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