• Going With the Flow: Three Strategies Help Improve Patient Throughput

    Oct 18, 2011

    By Jason Bramwell

    A patient flow initiative at Good Samaritan Hospital in New York sharply decreased door-to-floor and door-to-physician times and boosted volumes-spurning similar achievements at sister hospitals across Bon Secours Charity Health System.

    Patient flow affects every single unit and department in a hospital. So when Good Samaritan Hospital, Suffern, N.Y.-which is part of the three-hospital Bon Secours Charity Health System-looked to decrease length of stay and increase volumes, it formed a multidisciplinary patient flow team with representatives from nursing, emergency department (ED), case management, housekeeping, transport, admitting, and other areas.

    In 2006, Good Samaritan's door-to-floor time (from when patients walk through the ED to when they are admitted to an inpatient unit) was between 10 and 12 hours. After the patient flow team implemented key solutions-including centralized bed management and a new ED triage system-the door-to-floor time dropped to 5.9 hours, according to Shari Gold, quality improvement manager, Good Samaritan Hospital.

    "The short-term goal is to keep it under six hours, and our long-term goal is three hours," she says.

    In addition, the hospital has reduced its door-to-physician time (how fast patients see a physician when they come to the ED) from 40 to 50 minutes to 21 minutes.

    The hospital's success is now being copied-and further improved upon-at the system level. In March 2010, Bon Secours Charity Health System established a systemwide patient flow team, in which Gold and interim CEO Liz Ponte are co-leaders. The systemwide initiative has decreased ED wait times and opened up ED beds, enabling staff to care for greater numbers of patients, says Gerry Durney, COO and executive vice president, Bon Secours Charity Health System.

    The increased volumes have positively affected the bottom line. "Our finance department has attached an $8,000 amount on every admission from the ED, and a $450 savings on every patient who doesn't leave. (This savings is based for every additional outpatient visit to the ED and less for left without being seen.) Altogether, from September 2010 to July 2011, year-to-date revenue has increased by $4.7 million for the health system," says Gold.

    Three Flow Improvements

    Good Samaritan credits the following strategies for its improved patient flow statistics.

    Opening a Logistics Center. A key strategy in Good Samaritan's patient flow improvement initiative was the opening of a Logistics Center in July 2011. Directed by Kitty Welsh, RN, the Logistics Center manages bed availability, patient transport, patient discharges, and housekeeping from one centralized area.

    "There is a call center, and if a physician wants to direct admit a patient, he or she calls one number, and the Logistics Center takes care of it right then and there, which avoids admitting this same patient through the ED," says Gold.

    Two nursing bed coordinators and a patient transport dispatcher work with Welsh in the Logistics Center. "The nursing bed coordinators work with the admitting department to see who's coming in so they can coordinate the beds. Best practice shows that having one area that assigns and manages beds improves patient flow times and increases patient satisfaction and patient safety because patients aren't waiting so long in the ED."

    Bon Secours Charity Health System hopes to eventually manage patient flow at its other two hospitals-Bon Secours Community Hospital, Port Jervis, N.Y., and St. Anthony Community Hospital, Warwick, N.Y.-from the Logistics Center at Good Samaritan.

    Using an electronic bed board. Implemented in early 2011, the web-based bed board gives nursing and admissions staff a real-time snapshot of the status of beds across Good Samaritan.

    By looking at the bed board-which is viewable from any computer with Internet access and via a large monitor in the ED-staff can instantly obtain key bed information. As room information is updated, the changes are displayed in the "bed status" window.

    The bed board screen is divided into three columns:

    • Available: Beds are clean and do not have patients
    • Processing: Beds are currently being cleaned, or a cleaning request has been submitted
    • Not available: Beds are occupied

    Behind the scenes, Good Samaritan staff carry out-and electronically document-a series of steps that are then displayed on the bed board. "The nurse enters a discharge order into our hospital's order system, which prompts a discharge order in our transport system," says Durney.  "A transporter responds within 10 minutes to the nursing floor and takes the patient to the hospital lobby. Using any telephone, the transporter logs a code and places the transport 'in progress' in the system, which triggers the bed board to turn that bed to 'dirty.'

    "Also triggered is a text page from the bed board system to the housekeeper zoned to that unit," continues Durney. "Using the telephone in the patient room, the housekeeper puts in a specific code that updates the board to show the room's progress. Once the room is clean, the housekeeper then puts in a different code via phone, which prompts the bed to turn to 'clean/available' on the bed board. The patient flow coordinators can then assign that bed."

    Fast-tracking ED triage. Durney believes that a new triage system will further improve Good Samaritan's door-to-physician time.

    The ED at Good Samaritan has 19 bays: 14 in the main ED and five for minor procedures. Patients who bring themselves to the ED are now met by a greeter/registrar and sign in at a quick registration kiosk. A triage nurse then assesses the patient and triages them into three groups:

    • Emergent (send to the main ED bays)
    • Fast track/urgent (treat in minor procedure bays and discharge or admit, as appropriate)
    • Super track/nonurgent (provide any needed tests or minor treatments, discharge from ED)

    Take, for example, a patient with a swollen ankle who signs in at the registration kiosk, says Durney. A triage nurse would assess the patient's ankle. If the swelling is nonurgent, the nurse would immediately direct the patient to a physician assistant or nurse practitioner who would order an X-ray and direct the patient to radiology, rather than bring him into the ED. If the X-ray shows that the patient's ankle is not fractured, the physician assistant or nurse practitioner would wrap the ankle, provide any other minor treatment that is needed, and discharge the patient. If the ankle is fractured, the patient would be brought into a minor procedure room in the ED.

    "What is significant here is that nonurgent patients are not taking up ED rooms," says Durney. "There's a whole cadre of patients that never have to go through the whole ED process and can be treated and discharged right on the front end."

    Lessons Learned

    In addition to reducing ED wait times and boosting volumes, Bon Secours patient flow initiative has helped the health system's three facilities maintain a left-without-being-seen rate of around 1 percent, which is the national benchmark. (The left-without-being-seen rate is the percentage of patients who leave the ED before seeing a nurse or physician.)

    Both Durney and Gold believe that Bon Secours Charity Health System hospitals will continue to improve patient flow metrics and ED wait times. "We want to get to a point where we have no ED waits," says Durney.

    Gold says she learned three key lessons during the initiative to improve patient flow at Good Samaritan.

    • Support from leadership: "This initiative would not work without the support of Gerry and other health system leaders."
    • Give/receive input: "You have to have all the right people around the table for your Patient Flow Team, and you have to report on how you're doing and receive input from staff during leadership and directors meetings."
    • Don't reinvent the wheel: "We've learned from other hospitals, like Lehigh Valley Hospital, adapted their processes, and used them here."

    Gold adds that after taking a trip to Lehigh Valley Hospital, Allentown, Pa., she came away with something that will stay with her forever: The answer can never be "no."

    "They never take that for an answer, in terms of getting a patient moved to where they need to be," she says. "That's what we're pushing here. Little by little, we are going to chip away and get there."

    Jason Bramwell is associate editor, newsletters & forums, HFMA (jbramwell@hfma.org).

    Interviewed for this article:

    Gerry Durney is COO and executive vice president, Bon Secours Charity Health System, Suffern, N.Y. (gerry_durney@bshsi.org).

    Shari Gold is quality improvement manager, Good Samaritan Hospital, Suffern, N.Y. (shari_gold@bshsi.org).