Creating patient flow

Published on 10/02/2015 by admin

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Last modified 10/02/2015

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Creating patient flow

Richard Hamilton, Brian Dolan and Michael Ardagh

Chapter Contents

This book is dedicated to the improvement of individuals’ clinical and professional skills in emergency care. For some time now all the authors have been studying and working in wide-scale health system reforms and this work has exposed us to a wealth of knowledge that has enabled us to reconsider how we best serve communities of health need (Dolan & Hawes 2009, Ardagh et al. 2011). We realize now that in healthcare we have a responsibility as health practitioners beyond the patient in front of us right now; we have a responsibility to the patient in the waiting room, arriving in the ambulance, and to the patient who may not know they will shortly be on their way to the Emergency Department (ED). In other words, ensuring we are ready to handle the next patient that comes through the door in the same way we manage the patient in front of us right now, no matter how busy it gets.

This chapter introduces the key concepts of patient flow and how this impacts on both the immediate work environment and the journey of the patient seeking care. It introduces some of the techniques used in manufacturing and service industries and its application to health systems. This is by no means a comprehensive study of methods and tools, but an introduction to some key concepts and should act as a guide in the journey to making not just the patient but the health system better.

Health system environments

Health systems have not evolved significantly in the way they are organized in the last 100 years. New technology, bigger, brighter and more welcoming buildings and new clinical techniques mask what essentially is an industry that has kept its Victorian design into a new millennium. Just like craftsman-type industries prior to the 20^th century industrial revolution in manufacturing techniques, health is a collection of inter-related cottage industries (Swensen et al. 2010). Every clinical service can be compared to a craft-based business of old, where highly specialized individuals within a particular clinical specialty deliver specialist knowledge and techniques. A hospital is often like a large mall full of specialist businesses to which a patient is sent for expert assessment. As a result the patient gets passed from service to service, from cottage industry to cottage industry, during the course of their care and treatment.

The organization and leadership of hospital resources further exposes this sense of passing the patient from one process area to another. Figure 42.1 highlights how a hospital setting is a matrix of services attempting to get patient outcomes via a series of functional business areas that are vertical silos. Traditionally, the management model of hospital systems has focused on managing the functional business units, or the vertical slices of the patient journey, often as discrete businesses. Each functional business unit is charged with being as efficient as possible with the resources they are given, where the resources are usually monetary based. In this way each independent business is seeking to maximize the use of its resources to achieve either more revenue, reduce costs or higher utilization of resources. These functional business units serve many different clinical specialities whose needs can be very different and competing; therefore, by default, they create their own rules and business practices that may not align with the other functional business units.

Figure 42.1 Matrix of healthcare.

In the clinical service context (the horizontal slice), they are looking to move patients through the functional areas at a regular rate. The clinical services must meet the patient demand on their service and navigate the patient through each of the functional business units to create the right patient outcome.

This process can be very frustrating and disempowering for the clinical teams. The response can be to shrug one’s shoulders and say ‘that’s how it’s done around here’. Again each clinical service creates its own way of responding to the pressures on its service. So, while surgeons may take a long time to appear in the ED and make prompt decisions about patient admissions, physicians may be prompt in arrival but take an apparently protracted time to make a decision to admit. From a patient perspective there is an equally large variation in response and service in this type of environment. No two clinical events will be the same from a patient perspective, even when they attend regularly with the same presenting symptoms.

This traditional approach to hospital and specialist care creates a focus on episodic care rather than holistic care of the patient. How do we view this system with a fresh perspective?

Patient time

Health systems operate as complex supply chains where the goal is to achieve timely and appropriate outcomes for the population’s needs. Where manufacturing systems are moving inventory and parts around the world to wholesalers and assembly plants; health systems are managing time – patients’ time. Where Toyota is concerned about limiting its inventory to the next few hours of production as a way to reduce the time from paying suppliers to being paid by product buyers (Womack & Jones 1996), the health system has a focus on reducing the time a patient spends in the health system from the start of a health issue to the time the issue is resolved. In many respects, patient time is the health system equivalent of inventory.

Why is patient time so important?

Hospital systems can be likened to large warehouses of a supply chain where instead of storing parts and products like a manufacturing business, we are storing patients. Patients are stored in waiting rooms, cubicles, clinic rooms, beds, trollies, wards and discharge lounges; indeed, we even store them in their own home; with the home being the default waiting place for most patients on ‘waiting’ lists. A lot of the patient’s time in the health system is spent waiting; waiting for appointments, assessment, diagnostics, the next decision, clinical intervention, admission/discharge, etc. Some of the patient’s time in a health system is necessary such as waiting for a therapeutic response to treatment, but much of the patient’s time is wasted. Practitioners see these waits and delays, but become inured to them as we are always busy and having to prioritize our time where it can best be spent.

As a result, the health system has been inadvertently designed around staff needs, where staff are considered a precious and scarce resource that needs to be optimized. In some health systems staff are seen as a high cost so resource time must be optimized.

But what about the patient’s time, does that not have value as well? Imagine you are 81 years old and have just been advised that you need a hip replacement but cannot be seen for another six months, how would you feel knowing, on average, you probably only have another 24 months of life left. Time becomes very precious and the quality of time even more so. You do not want to be spending the latter years of your life in a hospital or at home on a waiting list, waiting for something to happen to you.

In the movie The Bucket List, Jack Nicolson and Morgan Freeman play two men, brought together in hospital, living on borrowed time, who are determined to live the last days as if they were the first. They remind the viewer of how precious time is, especially in the twilight years of life. So in a patient-focused health system, patient time and quality of life are guiding principles to system design. There are other reasons why patient time is such an important metric to the efficiency of any health system.

How Lean Thinking principles value time

Over 40 years, Toyota Motor Company has developed the Toyota Production System using techniques that are known more widely as Lean Thinking (Womack & Jones 1996, Stone 2012). Lean Thinking is a culture focused on delivering the most value with the least waste, for the end consumer (Liker & Convis 2011, Kaplan 2012). It has been designed to support complex supply chains, focusing on:

• ‘just-in-time’ (JIT) delivery of products thus minimizing storage space

• error-proofing processes, thereby minimizing waste and delays due to poor parts

• continuously eliminating excessive product movement/handling to create the fewest steps, therefore lessening the chance of errors (Westwood et al. 2007).

Staff in a Lean Thinking environment understand the importance of time and quality and the role they play in the supply chain. The goals of Lean Thinking are simple but intuitive and are based on a set of values where time is considered the most precious. The time it takes from paying suppliers and being paid by the consumer for the end product; or the time a patient spends in the health system.

The focus behind this philosophy is to keep inventory levels low, as the more parts sitting around in the supply chain the greater the cost of production and the longer the time it will take for the part to add value to an end product that the consumer will buy. The larger the number of parts in the system the bigger the warehouses we need to store them, therefore the more people needed to manage the warehouses and therefore the more money tied up earning no value for the shareholder; the risk of parts being scrapped goes up as well. This is the key driver of Lean Thinking; reducing the materials, effort and lead time required to produce a product that the customer is willing to pay for.

In patient terms, the longer patients wait, the more staff effort is involved, bigger waiting rooms are required, poorer quality of care can result. There is a direct correlation between waiting times in EDs and increased morbidity and mortality (Ardagh & Richardson 2004, Richardson 2006, Sprivulis et al. 2006, Richardson & Mountain 2009, Johnson et al. 2012, Mahler et al. 2012). Industry has much more to teach healthcare than we sometimes imagine, as it has addressed metaphorically similar issues many years ago. To achieve this focus Toyota recognized the contribution of staff, and in particular they recognized and valued frontline staff as long-term partners that learn, adapt and empower improvements. Managers and leaders in Toyota are driven to value frontline staff and their time; with particular emphasis on removing barriers to staff creating more value. Having staff spend time on producing a part that is not needed now, it may be needed but not now, is seen as disrespectful of the staff’s time; the work has added no value (Liker & Franz 2011). Having staff skills and capabilities under-utilized is also considered disrespectful of staff time, i.e., the time they have invested in developing these skills.

Lean Thinking during the first decade of the new millennium has been adopted widely by health systems and is increasingly recognized for its potential to transform individual business processes (Baker & Taylor 2009, Millard 2011, Stone 2012). The true value and opportunity is where the tools of Lean Thinking are applied across the health system, across the patient’s journey, where the patient is a substitute for inventory in a manufacturing environment, which must be moved through the health system in a timely manner. It is important to stress that in viewing the patient as metaphorical inventory is not about being disrespectful, rather the opposite, it is underlining that principles that apply in industry can readily be applied in healthcare. A true Lean Manufacturing culture seeks to have inventory valued in the same way we value people, with respect.

The concept of patient time being important in health systems and the reasons why it is so important can be hard to understand as it can be counter-intuitive to logic and professional training. The process for managing patients has its roots in Napoleonic warfare and is now pervasive in all clinical practice. The use of triaging and prioritization scores is viewed as a normal and necessary practice for determining who needs help now and who can wait, and who will never be seen (Allen & Jesus 2012). In war, where demand can rapidly outstrip supply of clinical resources, the use of battlefield triage makes sense; but why does this methodology continue in everyday practice? The underlying assumption of triage is there are not enough resources to treat everyone that seeks our help (see Chapter 35).

However, is this really true for normal population clinical needs? Most health systems are adept at treating the demand on the system; it’s just a matter of when they are treated. With the exception of emergency care where critical care demand may impact on resources, most of healthcare demand is stable and predictable. The biggest variable is created by us, the health professionals. By prioritizing demand (triaging), patients are placed into queues based on urgency of need. Every time someone with a higher need enters the system, someone of a lower need is asked to wait longer. This reprioritization may not be transparent to the majority of patients and staff as it happens on waiting lists, where the patient is waiting at home; but what about the patient that comes to the ED who may be categorized as triage 3 and ultimately is assessed as needing surgery? Every time a patient with a higher need comes into the system this patient will be asked to wait longer. In extreme examples, these patients may have been ‘nil by mouth’ for three to four days, sitting in a hospital bed waiting for access to a treatment room or operating theatre. The patient’s condition may have deteriorated and they pick up a hospital-borne infection. This patient initially needed a fifteen-minute surgical procedure, and would have gone home the same day. Instead they spent a week in hospital using up resources that could have been applied in other ways, as well as suffering needless pain, harm and distress. In patients with fractured neck of femur, the correlation between non-medical delays in surgery and increased morbidity and mortality is now well established (Bottle & Aylin 2006, Kalson et al. 2009).

This all too common story highlights how health professionals prioritize patients based on immediate medical need, with the underlying assumption being ‘we do not have enough resources to treat everyone right now’, so people have to wait. Health systems that are focused on valuing patient time understand this dynamic, and like Toyota realize the potential to release resources from tasks that add no value, such as storing patients that are waiting – waiting on waitlists, in waiting rooms, in ward beds, etc. The mindset of a Lean Thinking health system focuses on the way resources are used, before considering if there are enough resources.

EDs that use ‘streaming’, for example, split their capacity and resources into two separate patient streams, minors and majors, are focused on applying a key principle of Lean Thinking, First In First Out (FIFO). By streaming patients based on need, it is possible to prioritize patients based on time of arrival rather than just need. In this way patients with relatively minor conditions are processed faster (high turnover) with a focus on creating flow. This is also the theoretical basis of See and Treat (NHS Modernisation Agency 2004, King et al. 2006, Hoskins 2010).

Such an approach requires careful consideration of clinical capacity; understanding how much work is required in each stream, how frequent the work comes in, and having tools to predict future demand and potential changes in demand. Having event plans and buffer resources for those true emergency events that only occur occasionally and are outside normal variation of demand is another key design consideration. This chapter does not address the topic of capacity design in detail.