A Case Study of Successful Patient Flow Methods: St. John's Hospital
Henderson, Diana, Dempsey, Christy, Appleby, Debra, Frontiers of Health Services Management
SUMMARY * Participating in the Institute for Healthcare Improvement (IHI) IMPACT collaborative has given St. John's Hospital the opportunity to improve patient flow and the delivery of patient care. This partnership has allowed us to experience a wealth of information shared by a collaborative network of hospitals. IHI has introduced rapid-cycle improvement methodologies, variability-reduction strategies, and strategies to aid in planning for the expected as methods that have enhanced our already established performance-improvement program. St John's has achieved breakthrough improvement with patient flow.
St. John's Hospital is a tertiary hospital located in Springfield, Missouri, serving 32 counties that cover 22,000 square miles in southwest Missouri and northwest Arkansas. The hospital has more than 30,000 admissions a year and an average length of stay (LOS) of 4.53 days for all patients.
St. John's senior leadership formed an alliance with the Institute for Healthcare Improvement (IHI) in May 2002 to assist our organization in achieving a superior level of performance. IHI measures of improvement include improved health status, better clinical outcomes, lower cost, greater access, greater ease of use, and improved satisfaction for individuals and their communities.
St. John's leadership team, including representatives from St. John's Hospital senior leaders and medical management services, selected "improving patient flow through the acute care setting" from the five domains offered by IHI. Perioperative services was identified as the initial focus of the project. St. John's perioperative services consists of 26 operating rooms in the hospital and 6 ambulatory surgery center rooms. An average of 25,000 cases are performed annually in these rooms. All specialties are represented, with the exception of organ transplantation. The rationale for selecting perioperative services was that it is a high-volume, high-risk, multifaceted area and displays strong leadership support. Issues with ontime starts, turnover times, and patient flow through the various areas of perioperative services are significant in terms of patient, staff, and physician satisfaction; cost and revenue; and quality of care.
Variability in caseloads, patient acuity, and specialty needs has a direct impact on not only perioperative services but also the hospital as a whole. This variability leads to the downstream effect of hospital bed capacity constraints, LOS issues, and intensive care unit (ICU) bed availability as well as the upstream effect of excessive emergency department (ED) waiting times. Therefore, to accelerate improvements in perioperative services, teams involving the ED (upstream effect) and the surgical ICU (downstream effect) were commissioned concurrently.
St. John's overall aim for this project is to ensure that patients receive timely access to appropriate care and move safely and efficiently through the system without unnecessary and unproductive delays. As discussed below, each team has established goals that contribute to achieving the overall aim.
Project teams were formed, and a physician champion and team leader were identified for each team. St. John's leadership team collaborated with the physician champion and team leader to determine what disciplines or stakeholders should be represented on the team. Team members were selected from each area affected by the improvement process. A walkthrough of each team's area was conducted to identify opportunities for improvement. Frontline staff not involved in the teams also played a crucial role in identifying opportunities for improvement by participating in individual department surveys. Performance-improvement tools were used to identify delays or bottlenecks in the process. Decisions were made scientifically, based on data rather than hunches. Once data were analyzed, changes were developed and tested.
St. John's uses the Plan-Do-Study-Act improvement model devised by Langley, Nolan, and Nolan (Berwick 1996). "The Plan-Do-Study-Act (PDSA) cycle describes inductive learning-the growth of knowledge through making changes and the reflecting on the consequences of those changes. Nolan's model intends that the enterprise of testing change in informative cycles should be part of normal daily activity throughout an organization" (Berwick 1996, 620).
The PDSA improvement model helps to build the organization's capacity for change by focusing on foundational issues such as the following:
* Creating a change culture
* Developing an infrastructure to support improvement
* Building the business case for quality
* Implementing strategies for rapidly spreading innovation
St. John's uses the rapid-cycle improvement methodology by including the key stakeholders on each team, conducting tests of change (trying a change on a small scale-e.g., one patient, one doctor, one room) to see what works and what does not, understanding that a failed test is an opportunity to learn, accelerating successes by holding weekly team meetings to evaluate effectiveness and to plan next steps to spread improvements, removing barriers, and communicating strategies and outcomes throughout the organization.
The key to improving flow lies in reducing process variation that impedes flow. While some variability is normal, other variation is not and should be eliminated (IHI 2003, 1). Litvak suggests that variability could be decreased by providing an operating room dedicated to unscheduled or "add-on" cases (McManus et al. 2003). By doing so, overall efficiency would be increased and the variability in surgical case flow would actually be reduced.
Operating Room Use
The concept of dedicating an operating room to unscheduled cases, thereby limiting its use for scheduled procedures or block time, is not one to be considered lightly in an era of increasing surgical case volumes, limited capacity both in terms of physical space and staff availability, and competition for managed care "covered lives." However, St. John's, in collaboration with its surgeons, set aside an operating room as a trial project in November 2002. Prior to this time, the operating room had been blocked for a general/trauma surgeon group for elective cases. By agreeing to release this room from use for their elective cases, the general/trauma surgeons' actual elective weekly block time was reduced. The trauma surgeons were agreeable to this test of change because potential existed to improve overall efficiency (Henderson et al. 2003).1
After approximately three months of segmenting this room as an "add-on" room, the data were reassessed. The following improvements were achieved (Henderson et al. 2003):
* During the hours of 7:30 a.m. to 1:30 p.m. on weekdays, the number of surgical cases increased by 5.1 percent.
* The number of operating rooms needed for surgical cases at 3 p.m., 5 p.m., 7 p.m., and 11 p.m. on weekdays decreased by 45 percent.
* A 2 percent overall reduction in overtime was achieved.
* The general/trauma surgeon group involved in the project realized a greater than 4.6 percent increase in revenue.
* The nursing floors are able to predict more accurately their evening and night-shift staffing requirements.
ED Patient Flow
St. John's is a Level I trauma center with 64,000+ visits annually. To reduce prolonged waiting times in the ED, we chose to focus on delays in admitting ED patients. Admission delays tie up ED beds for up to an hour or more after the ED has completed its work with the patient and he or she is simply awaiting a bed. We found that a key process step that accounted for much of the delay involved communication between the ED nurse and the accepting nurse on the floor. The communication process between the two departments sometimes required multiple phone calls to connect with the staff member needing to receive the patient status details.
In an effort to expedite this communication process, a standardized fax report form was tested for admitting patients to an intermediate cardiac floor. The fax report form was developed collaboratively by the ED and cardiac staff and evaluated by both staff each time a fax was sent. The fax reporting procedure provided great staff satisfaction, because it eliminated waiting time on the phone for the ED nurse and the floor nurse experienced less interruption from patient care activity. Multiple phone calls from both units were eliminated, which was a great time saver (Renderson et al. 2003).
After the initial trial, the use of this form was implemented as routine practice for this floor and on an additional intermediate cardiac floor, with similar success. The ED faxed report is now a standard part of the process throughout the hospital. In December 2003, the median time from the decision to admit to physical placement in an inpatient bed was 61 minutes. This is a 67 percent decrease, compared to baseline data. The implementation of the faxed report clearly has had a positive impact on this measure (Henderson et al. 2003).
Additional successes in the ED include the following:
* ED acute care center (fast track) hours have been expanded from 12 to 16 hours per day. Visits have increased from an average of 38 to 60 visits per day.
* ED internal patient-satisfaction survey results have improved from an average of 80 percent to 88 percent.
* The Behavioral Health Evaluation Center (BHEC) opened on September 29, 2003. Psychiatric patients presenting to the ED undergo a "quick screen" for medical clearance. If cleared, the patient receives a complete psychiatric evaluation in BHEC rather than the ED. Prior to the opening of BHEC, the ED psychiatric patient LOS was an average of 5 hours, with some patients exceeding a 12-hour LOS. The ED LOS for this patient population has decreased to less than 2 hours. November 2003 data revealed that 79 BHEC evaluations and 101 ED evaluations were performed. On December 22, 2003, BHEC hours were expanded from 12 hours (9 a.m. to 9 p.m.) to 14 hours (10 a.m. to midnight).
Processes in Other Areas
As the hospital's improvement project has progressed, additional teams have been formed for bed assessment, cardiac services, neurology, and discharge planning. Additional successes with patient flow initiatives include the following:
* Preadmission center phone interviews have increased from an average of 5 per day to more than 50 per day.
* Eighty-three percent of elective surgeries in the health center are admitted through the preadmission center, compared to a baseline of 77 percent.
* The time required to transfer a patient from a general nursing unit to an ICU in an emergent situation has decreased from 75 minutes to 25 minutes on average.
* Changing the process of the electronic patient discharge entry has resulted in an improvement in notification of the admitting area regarding bed availability from an average of 62 minutes to 20 minutes.
* The process for notifying the admitting area that a bed is clean and available on the second and third shift has been switched to environmental services. This has eliminated the delay associated with the nursing unit notifying admitting that beds are available.
* Twenty-nine percent of total discharges on the surgical unit have been scheduled. Of those discharges, 62 percent are meeting the scheduled appointment time.
* The bed assessment team meets daily Monday through Friday to discuss admissions, discharges, transfers, and surgeries for each unit/floor in the hospital. The purpose of this team is to communicate daily bed availability. Representatives from nursing, admitting, surgery, nursing administration, the ED, and environmental services are included. Qualitatively, representatives find this daily information most helpful in assisting with patient flow.
* The neurology ICU has implemented weekly multidisciplinary rounds that include a physician and a representative each from nursing, social services, physical/ occupational therapy, clinical nutrition, pastoral services, respiratory therapy, and case management. Neurology team members have reported that communication has improved among the various disciplines, resulting in improved patient care.
* The cardiac nursing unit has decreased the time from obtaining a physician discharge order to completing the discharge paperwork from a baseline average of 43 minutes to an average of 24 minutes.
* In December 2003, 77 percent of patients in the cardiac ICU were discharged by u a.m., compared to a baseline measurement of 70 percent in May 2003.
St. John's keys to success for the patient flow project include having strong senior leadership support; involving key stakeholders and multidisciplinary members on teams; having teams meet weekly to discuss successes, challenges, removal of barriers, and planning of tests of change for the upcoming week; having a physician champion(s) leading each team; and good communication to all staff in the hospital regarding the status of the project. Challenges have included issues related to units working in silos, staffed-bed availability, and work demands.
Understanding patient flow requires looking at the whole system of care, not just the isolated units. Developing the ability to shape, predict, and manage variability and to allocate resources appropriately at the front line of care can improve patient outcomes, increase staff morale and retention, reduce costs, and improve quality of life for both patients and caregivers (IHI 2003, 8).
The PDSA improvement model helps to build the organization's capacity for change by focusing on foundational issues.
A key step that accounted for much of the delay involved communication between the ED nurse and the accepting nurse on the floor.
Communication has improved among the various disciplines, resulting in improved patient care.
1. Material cited from Henderson et al. (2003) is used by permission of the Missouri State Medical Association. Copyright 2003.
Berwick, D. M. 1996. "A Primer on Leading the Improvement of Systems." British Medical Journal 312 (7031): 619-22.
Henderson, D., C. Dempsey, K. Larson, and D. Appleby. 2003. "The Impact of IMPACT on St. John's Regional Health Center." Missouri Medicine 100 (6): 590-92.
Institute for Healthcare Improvement (IHI). 2003. "Optimizing Patient Flow, Moving Patients Smoothly Through Acute Care Settings." Innovation Series 2003 paper. [Online article; retrieved 2/18/04.] http://www.ihi.org/newsandpublications /whitepapers/nowfmal.pdf.
McManus, M. L., M. C. Long, A. Cooper, J. Mandell, D. M. Berwick, M. Pagano, and E. Litvak. 2003. "Variability in Surgical Caseload and Access to Intensive Care Services." Anesthesiology 98 (6): 1491-96.
DIANA HENDERSON IS EXECUTIVE DIRECTOR FOR QUALITY; CHRISTY DEMPSEY IS DIRECTOR OF PERIOPERATIVE SERVICES) AND DEBRA APPLEBY IS SUPERVISOR OF QUALITY RESOURCES AT ST. JOHN'S HOSPITAL IN SPRINGFIELD, MISSOURI.…
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Publication information: Article title: A Case Study of Successful Patient Flow Methods: St. John's Hospital. Contributors: Henderson, Diana - Author, Dempsey, Christy - Author, Appleby, Debra - Author. Journal title: Frontiers of Health Services Management. Volume: 20. Issue: 4 Publication date: Summer 2004. Page number: 25+. © Health Administration Press Winter 2008. Provided by ProQuest LLC. All Rights Reserved.