Designing Patient Flow

in the Hospital
to Make Patients Safer

John B. Chessare, MD, MPH

Interim President, Caritas Christi Health Care System
President, Caritas Norwood Hospital
Senior Vice President for Quality and Patient Safety,
Caritas Christi Health Care System
Why should we care about patient flow?

1. To make our patients safer

2. To increase throughput (volume, $$)

3. To reduce expenses (cost, $$)

4. To improve staff satisfaction

5. To improve patient satisfaction

A question to run on …….

What can I do as a healthcare leader to improve patient flow?

Agenda

• Introduction 5 minutes
– What is the fundamental problem?
– What management model will help us improve it?

• Some examples of designing flow 15 minutes

– Smoothing Flow at Boston Medical Center:
Changing the Surgical Schedule
– Designing Flow out of the Emergency Department at Caritas
Norwood Hospital
 Luckily, this type of communication does not happen
in commercial aviation…….

•US Air 562 from Boston to Albany in its final approach

•Captain: “Albany this is US Air 562”

•Air Traffic Controller: “Roger US Air 562 this is Albany Control. You’ll
have to hold at your present altitude. We’ve got a lot more planes in our
airspace than usual. The airlines decided to add some flights but no one
told us and we’ve got some rerouted planes due to bad weather in metro
New York.”
•US Air 562 from Boston to Albany in its final approach

•Co-pilot: “Boy, we’ve got to get this plane down or we’ll have
some angry passengers. There’s the airport. Lets pick a runway.
I usually call the gates myself and find out if any are open and
then I just go for it. If you don’t, the controller will give it to
someone else”
•A Physician and Two Nurses Discussing a Patient in the ED
Waiting to Be Admitted

•Physician: “ This guy is ready to go upstairs. Its now 5pm, he

came in at 10 this morning. The unit clerk called admitting
but I guess they are at dinner”.

•First Nurse: “Ok, I’ll call around to the floors and see if there
are any empty beds….I know who to call.”

•Second Nurse: “Oh, I usually call the supervisor. Did you call
report?”

•First Nurse: “Oh no, I leave it on the floor’s voicemail just

before I leave the ED with the patient so they can’t slow the
transfer down”.
Hospitals have been managed sub-optimally

• Too much is happening by chance. Too little is happening

by design and therefore we function at low reliability
• Managers have been managing inputs: studies per FTE;
deviation from budget, etc. but not the system.
• The hospital is full of batching; Patients are admitted and
discharged in batches. Tests are run in batches. Surgeries
are done in batches without consideration of the effect on
the system.
• Safe patient care is easier to reach with continuous flow
and not with the artificial variability of batching!
• There is a need for scientific management in the hospital
industry
 Reason’s Swiss Cheese Model of
Error
We are managing the efficiency
Of individual inputs and not the
system Local triggers
Intrinsic defects
Latent failures at the Atypical conditions
managerial levels

We allow patients to aggregate

and move in batches that
overwhelm our staff
Trajectory of
accident opportunity
Psychological
precursors

Unsafe acts
Defence-in-depth
“Hard work and good intentions are necessary
but insufficient for exceptional care”.
“Every System is perfectly designed to get
exactly the results that it gets.”
 # o f P a t ie n ts

Time
Variability

1. “Natural”: you can’t control it …you just have to manage it.

(e.g.. sick patients coming to the ED). Tool to manage it:
queuing theory

2. “Artificial”: you can control it….you must eliminate it to

create flow. (batching) (e.g. elective surgery scheduling,
reading stress tests)
When we “batch and push” we create artificial
peak loads that create overcrowding
• Internal Diversion –patients sent to alternative
floors\Intensive Care locations
• Internal Delays – PACU backs up
• External Diversion - ED diversion; inability to accept
transfers
• Staff overload – increased errors and staff unhappiness
• System Gridlock – Increase in LOS
• Decreased Volume
• Unhappy patients
What business model should we use to improve flow?
Performance Improvement
1. Focus on the patient and his or her family
2. Deep Process knowledge (Design)
3. Decisions driven by data
4. Teamwork
5. Empowerment

“How can we use the ideas of individuals on the team to

redesign our systems to measurably improve the health
and satisfaction of our patients and their families while
driving out waste?”
Flow Teams at Boston Medical Center

Flow Leadership
Team

Surgical Scheduling
ED Team Inpatient Team
Team
 Average total ED throughput time
Boston Medical Center

4
Hours

3
Improvement from 4.5 to 3.75 hours
2 30 minutes x 1050 cases = 31,500 minutes or 525 hours per week saved

0
1
5
9
13
17
21
25
29
33
37
41
45
49
53
57
61
65
69
Weeks
Series2 Series3
 Improving Inpatient Flow
Team

• Janet Gorman • Sue Doherty

• John Chessare • Jacque O’Shea
• Linda Guy • Cil Weekes
• Jane Damata • David Roney
• Dina Brauneis • Kim Wood
• Brian Brisbois
 The Inpatient Cycle, Key Points, Key Process Indicators
Clean Bed
Bed Assigned
Bed Turnover Time 120 minutes

Patient Bed Assignment to Arrival Time

Leaves 60 minutes
Patient
Arrives
In Bed
15:01 Dirty Bed

Average Discharge
Time

Patient Clinically Ready 5.5 days

to Leave

Length of Stay
Maximizing Throughput:Smoothing the Elective Surgery Schedule
to Improve Patient Flow

James M. Becker, MD Richard J. Shemin, MD

Keith P. Lewis, MD Gail Spinale, RN
John B. Chessare, MD, MPH Demetra Ouellette
Eugene Litvak, PhD Abbot Cooper
Surgical Smoothing

1. Smoothing Elective Vascular Surgery

2. Smoothing Elective Cardiac Surgery
3. Separating Elective From Urgent Surgery in the Menino
Pavilion
• Creating reliable urgency data
• Separating a room for urgent/emergent cases
• Eliminating Block Scheduling
Bed Need by Day of Week for Vascular Surgery (18 months of data)

1.2
Progressive Care Unit

0.8

Abramson
Restucci
0.6
Madison
Sampson
0.4 Wong

0.2

0
Thu

Thu
Thu

Thu
Tue

Tue

Tue
Tue

SI C U
S at
PC U
7W

8W
W ed

W ed
W ed

W ed
F ri

F ri
F ri
Mon

Mon

Mon

Mon
 7/
1/

0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
20
7/ 0 2
2/
2
7/ 00 2
3/
20
7/ 0 2
4/
2
7/ 00 2
5/
20
7/ 0 2
6/
20
7/ 0 2
7/
20
7/ 0 2
8/
2
7/ 00 2
9/
7/ 200
10 2
/
7/ 20 0
11 2
/2
7/ 0 0
12 2
/2
7/ 0 0
13 2
/2
7/ 0 0
14 2
/
7/ 20 0
15 2
/2
7/ 0 0
16 2
/2
7/ 0 0
17 2
/2
7/ 0 0
18 2
/2
Volume

7/ 0 0
19 2
/2
7/ 0 0
20 2
/2
7/ 0 0
21 2
/2
7/ 0 0
22 2
/2
7/ 0 0
23 2
/
7/ 20 0
24 2
/2
7/ 0 0
25 2
/2
Random Month July 2002

7/ 0 0
26 2
/2
7/ 0 0
27 2
/
7/ 20 0
28 2
/2
7/ 0 0
Vascular Elective PCU Cases by Day

29 2
/
7/ 20 0
30 2
/2
7/ 0 0
31 2
/2
00
2
Volume
10 # of Scheduled Cases

0
1
2
3
4
5
/0
1/
03
10
/0
2/
03
10
/0
3/
03
10
/0
6/
03
10
/0
7/
03
10
/0
8/
03
10
/0
9/
03
10
/1
0/
03
10
/1
3/
03
10
/1
4/
03
10
/1
5/
03
10
/1
6/
03
10
/1
7/
03
10
/2
0/
03
10
/2
1/
03
10
/2
2/
(October 2003)

03
10
/2
3/
03
10
/2
4/
03
10
/2
7/
03
10
/2
8/
03
10
/2
9/
03
10
/3
0/
03
10
/3
1/
03
Vascular Scheduled PCU Cases - Weekdays Only
 E6W Direct Nursing Hours per Patient Day

8.70

8.60 8.66

8.50

8.40
Prior to Vascular Smoothing
8.30
8.16 After Vascular Smoothing
8.20

8.10

8.00

7.90
Average CT Surgery Unscheduled Cases Weekdays
Average Scheduled CT Surgery Cases by Weekday
 Cardiac Scheduled Cases Histogram
January & February Non-holiday Weekdays Only
35%

30%

25%

20%

2004
2003
15%

10%

5%

0%
Monday Tuesday Wednesday Thursday Friday
 0
2
4
6
8
10
12
1-
M
ar
2-
M
ar
3-
M
ar
4-
M
ar
5-
M
ar
6-
M

2004 range
ar
7-
M
ar
8-
M
ar
9-
M
a
10 r
-M
a
11 r
-M
a
12 r

2003 range 10 – 1 = 9
7 –2 = 5
-M
a
13 r
-M
a
14 r
-M
a
15 r
-M
a
16 r
-M
a
17 r
-M
a
18 r
-M
a
19 r
-M
a
20 r
-M
a
21 r
-M
a
22 r
-M
a
23 r
-M
a
24 r
-M
a
March Daily PCU Census - 2003 vs. 2004

25 r
-M
a
26 r
-M
a
27 r
-M
a
28 r
-M
a
29 r
-M
a
30 r
-M
a
31 r
-M
55% reduction in variability

ar
2004
2003
 Operating Outside of the
Block at BMC

Separating the Flow of

Elective Surgery from
Urgent/Emergent Surgery
 Menino Pavilion compared to Newton Pavilion
Variable NP MP

# Rooms 13 8

# Cases Day 30-35 25-32

# Cases Year 8601 6608

Cancellation Rate 10% 20%

#Add Ons Per Day 1-2 5-12

#Weekend Cases 0-4 5-20

Unique Services Cardiac, Ophth Pediatrics, Trauma, Gastric Bypass,

OB
Pre-change Problems with the Daily Schedule – Menino
Pavilion

•Urgent/emergent bump elective cases

•Overall 50% block utilization
•Variable use of block (vacation,meetings)
•Most cases booked 3-4 days out
•33% of daily schedule is “add ons”
•Variable release time between services
•Cases can be lost waiting
•People live in fear of losing their block
 The Radical Changes

#1
Eliminated Block Booking

#2
One Urgent Room Created

OR 5
 Bumped Cases Before and After Separating “Flows”

Before After

April 03 – April 04 April 04 – April 05

• 349 emergent cases (M – F) • 354 emergent cases (M – F)

7:00 AM to 3:30 PM 7:00 AM to 3:30 PM

• 771 elective patients were • 7 elective patients were

delayed or cancelled delayed or cancelled
 M in u te s

1 /1

0
100
200
300
400
500
/2
1 /3 0 0 6
/2
1 /5 0 0 6
/2
1 /7 0 0 6
/2
1 /9 0 0 6
/
1 /1 2 00
1/ 6
1 /1 20 0
3/ 2 6
1 /1 0 0 6
5/
1 /1 20 0
7/ 2 6
1 /1 0 0
9/ 2 6
1 /2 0 0
1/ 6

Time
1 /2 20 0
3/ 6

Mean = 30
1 /2 20 0 6
5/
1 /2 20 0

Range = 23 – 45
7/ 2 6
1 /2 0 0

Number of ED Admits
9/ 2 6
1 /3 0 0
1/ 2 6

Mean = 300 minutes (5 hours)

Date

2 /2 0 0 6
/2
2 /4 0 0 6
/2
2 /6 0 0 6
/2
Range = 176 – 418 minutes (3 hours – 6 hours)

2 /8 0 0 6
/
2 /1 2 00
0/ 2 6
2 /1 0 0
Daily ED Admits and Time from Decision to Departure

2/ 2 6
2 /1 0 0
4/ 2 6
2 /1 0 0 6
6/
2 /1 20 0
8/ 6
2 /2 20 0
0/ 6
2 /2 20 0
2/ 2 6
2 /2 0 0
4/ 2 6
2 /2 0 0 6
6/
2 /2 20 0
Norwood: Biggest Operational Dilemma

8/ 2 6
00
6
Time in Minutes
Number of Admits
0
10
20
30
40
50

Goal = 120 minutes

A d m iss io n s
What is the true constraint?
Physician workup in the ED.

Find it and elevate it.

Moved to the inpatient unit.

What is now the true constraint?

Floor not ready.

Find it and elevate it.

Create Transfer Time.
Some other constraints

• No transporter: included transport in synchronization and

added transport capacity

• No nurse to staff an inpatient bed: stopped staffing to

monthly historic mean; create prediction software based on
historic natural variability and today’s census for tomorrow
 ED Medical Admissions Process: IN THE EMERGENCY DEPARTMENT...

1. ED MD evaluates new patient

and decides that this is a medical
patient (non-ICU) that needs to be
admitted.
3. ED MD completes 2. ED MD informs ED
admission order and primary RN of
submits to ED admission (probably
secretary. when informing pt.).

4. ED secretary enters **The secretary should use the 8. ED MD signs out

order into Meditech, “special comments” field to denote patient to Lead B
A which generates print
information that is necessary for
Hospitalist (LH).
bed placement (e.g.: “1:1”, “not
out in Admitting office. suitable for U31”, etc.).

9. ED MD informs charge
5. ED secretary RN of LH contact (during
updates admission log. board run).

6. ED secretary 10. ED charge RN denotes

informs ED charge LH contact on white board
RN of admission. (during board run).

7. ED charge RN
denotes admission
on white board.
11. Is a bed
E NO likely available 12. Bed
for the patient? availability
14. ED charge RN fields summary
G call from BPC confirming
sent by BPC
bed and transfer time.
20. ED secretary fields call YES
from BPC with bed and 13. ED charge RN
transfer time. **If bed and 15. ED charge RN puts bed
instructs primary RN to
transfer time are not and transfer time on board.
tape voicemail report.
written on the white board,
ED secretary makes sure
16. ED charge RN
ED charge RN is aware of
informs primary RN of
bed and transfer time.
bed and transfer time.

21. ED secretary enters bed and

transfer time on admission log. 17. Primary RN tapes
voicemail report (if
not already done).
22. Transport arrives to move
the patient and collects
necessary paperwork. 18. Primary RN calls
receiving floor to
deliver the voice- H
23. Transport moves mailbox number.
I patient out of ED.

19. Primary RN prepares patient for

24. ED secretary uses copy of chart transfer, copies chart, and places copy
to depart the patient in Meditech, of chart in order bin.
and to transfer the patient from U10
to the receiving unit.
Page 1
 ED Medical Admissions Process: THE BED PLACEMENT COORDINATOR
A
C
(25) When Admit Order prints out, BPC:
a) enters name, etc. into BPC log
b) admits pt. in Meditech (26) BPC receives text
c) prints packet to ED printer If 120 minutes elapse from the time from Lead Hospitalist,
d) sends text to Adm. Mgr. and of admission order without contact which includes: pt. name,
Admissions RN (11a-11p) which from the LH, BPC sends a text page diagnosis, bed type, ESI,
includes name, age, Dx, bed type, to the LH to ask about the patient.
and acceptance time.
potential unit (e.g. ?U31), precautions or BPC enters time of page
1:1 if known and ESI into log.

(27) If there are any discrepancies or

questions about an admission, BPC
If the bed type is changed (whether contacts the administrative manager.
by ED order or LH contact), BPC Otherwise, BPC chooses a bed for
alerts the Administrative Manager
the patient.
by text page.
D
(28) BPC calls charge RN (or
secretary if charge not Either the receiving unit or the ED may
available) on receiving unit to request a change in the transfer time.
Our target is to set the transfer time inform of admission (including If this happens, BPC contacts the
within 30 minutes of the call to the opposite unit (e.g. if ED calls, then
floor. When contacting the receiving
Dx and ESI) and to confirm bed
BPC calls the receiving unit) to confirm
unit, the BPC should state, “We’d like assignment and transfer time. new transfer time. BPC notes the
to send this patient up in 30 changed transfer time in the log and
minutes. Is there any chance we then resends a text page to
could send the patient sooner?” The Administrative Manager and Lead
(29) BPC calls ED charge RN
floor reserves the right to request a Hospitalist beginning with “Change:”
transfer time greater than 30 minutes, (or sec. if charge not avail.) to
and then the pt. name, bed, and
but must inform the BPC of the reason. confirm bed assignment and transfer time.
transfer time.

E
(30) Once bed assignment and
transfer time are confirmed, BPC
sends a text page to
Administrative Manager,
Admissions RN (11a-11p), ED
Admitting, and Lead Hospitalist F
with the following info:
a) pt. name
b) bed assignment
c) transfer time

(31) BPC calls ED secretary

to deliver bed assignment G
and transfer time.

(32) BPC checks to ensure that

patient moves upstairs on time. If
patient is still in ED after transfer
time, BPC contacts ED charge RN.

Page 2
 ED Medical Admissions Process: HOSPITALISTS AND INPATIENT UNIT
B

(33) Lead Hospitalist (LH) receives

sign-out and determines when a
hospitalist can see the patient.

(34) LH communicates the following

to Bed Placement Coordinator: pt.
name, diagnosis, bed type, ESI, and C
acceptance time.

(35) Assigned hospitalist begins (38) Charge RN or unit

work-up (regardless of patient secretary on receiving unit
location) as soon as possible. D fields call from BPC and
establishes bed and
transfer time.

(39) Charge RN informs

(36) LH receives bed assignment
F and transfer time from BPC.
receiving RN of admission.

(37) Assigned hospitalist

proceeds to floor as soon as (40) Unit secretary (??)
possible. fields call regarding report
H and informs receiving RN of
mailbox number.

(41) Receiving RN retrieves

voicemail report and calls
ED primary RN for
clarification if necessary.

I (42) Patient arrives on floor.

(43) If patient does not have

admission orders, unit secretary
texts Lead Hospitalist that patient
has arrived.

Page 3
 M in u t e s
1 /1

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Go live

3 /1
Redesign

9/ 2
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3 /2
6/ 2
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ED Time from Decision to Departure and Total ED LOS (admits)

4 /2
/2 0
06
4 /9
/2 0
06
4 /1
6/ 2
00
6
 SERVICE
Reduce the average time from ED admission decision to departure
to inpatient unit to 120 minutes calculated monthly.

A v g . T im e fro m D e c is io n -to -A d m it to E D D e p a rtu re

350

300

250
Minutes

200

150

100

50

06

06
05

05

05

6
6

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5

00
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/2

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W e e k B e g in n in g ... D TA -D E P
Question Mean Score: Speed of Admission
Key change concepts of the Design

• Do tasks in parallel: move the patient to the floor while the

workup continues
• Synchronize: assign a transfer to floor time (creates pull)
after communication with charge nurses and hospitalist
• Central command: all beds are assigned by the nursing
supervisor/bed facilitator
• Direct Communication: ED physician hands-off to
Hospitalist
• Predict Demand: Use data on natural variability to get ready
for staffing changes
Summary
• There is much artificial variability in healthcare. We can no
longer afford this waste.
• We must redesign our systems to maximize flow which will
make our patients safer, improve volume, staff and patient
satisfaction and reduce the waste.
• Separating the flow of urgent surgery from scheduled
surgery reduces waste and rework.
• No-Block scheduling is a good way to help the surgeons,
patients, and staff.
• All hospitals should map inpatient flow and test changes to
improve it.
References

• The Goal; by Eliyahu Goldratt

• Leading Change; by John P. Kotter
• The Improvement Guide; by Langley et al
• http://management.bu.edu/research/hcmrc/mvp/index.asp
• Rathlev NK, Chessare J, Olshaker J, Obendorfer D, Mehta
SD, Rothenhaus T, Crespo SG, Magauran B, Davidson K,
Shemin R, Lewis K, Becker JM, Fisher L, Guy L, Cooper A,
Litvak E. Time Series Analysis of Daily Emergency
Department Length of Stay. Ann Emerg Med 2007;
49:265-271