Friday, March 11, 2011

Making the Road to Optimal Care as “Smooth” as Possible

Over the past several weeks, our physicians and nurses in the Emergency Department have had to rise to the occasion to care for a significant number of “boarders.” A boarder is a patient who needs to be admitted to an inpatient bed, but there is no bed available. If it was my daughter (or me) I would not want her to be on a stretcher in the ED if she needed to be on an inpatient unit. I know that it is no fun for our doctors, nurses, and other clinicians caring for admitted patients in the ED, either. Overloading the ED because we can’t get admitted patients to the right bed is unsafe for the patient and it creates undue staff stress and dissatisfaction.
There are two ways to fix this. One way is just to open and staff more beds for these “crunch” times of high census. This takes care of the problem but at a significant financial cost. Hospitals can no longer afford to have a lot of extra beds and staff that are used only during peaks in demand.
If the peaks in demand were due to the “natural” variability in illness in the community, we would have to open the extra beds and just deal with the extra cost (although I am not sure how we would do this) because it would be the right thing to do for the patient. The good news for us is…our peaks in demand are very often created by us. They are “artificial.” They are created by the way we schedule some of our admissions.
Elective surgery patients who require overnight stays in the hospital take up some of our inpatient beds. We have not done as well as we might at spreading these cases to an inpatient unit over the 5 weekdays. We might send 10 post-op patients to Unit 58 on a Monday, three on Tuesday, 12 on Wednesday, four on Thursday and 10 on Friday. On “peak” days, we have a hard time finding a bed for every patient, so patients backup in the ED and in the Post-Anesthesia Care Unit (PACU) and nurses are asked to work overtime or come in on a day off. On “valley” days, we may be asking nurses to take an unexpected day off because we don’t have enough patients to care for.
Over the past few weeks you may have heard the term Surgical Smoothing. And many of you may be wondering, what is this? What it means for GBMC is smoothing the number of elective surgery patients by day of the week to improve patient flow…the flow out of the Emergency Department and out of the PACU and the OR’s...and therefore reduce waits and delays.
We need to stop “batching” and move to more continuous flow. Patients are admitted and discharged in batches. Tests are run in batches. Surgeries are done in batches. Our goal is to serve every patient in need the way we would want our own loved ones served. The goal is easier to reach with continuous flow and not with the artificial variability of batching. And the goal of this “smoothing” initiative is to improve surgical flow, which will ultimately reduce wait times in the ED and ensure patients have a bed when they need to be admitted.
Think of it this way – You’re going to Ocean City. Traveling across the Bay Bridge at 2:00 a.m. on a Tuesday in February, you’ll have no problems with traffic. But try to cross the bridge at 11:00 a.m. on a Saturday in July and you’ll encounter backups for miles. These peaks and valleys in traffic are what we are experiencing in the hospital setting – and at the highest peak, we have the longest wait times and lowest satisfaction rates.
Surgical smoothing and assessing the flow of patients is also about the application of science and logic as opposed to managing by intuition. Scientifically we can calculate our bed need for medicine patients using queuing theory, and that’s what we will do. We will create urgency criteria to calculate how many ORs should be dedicated to urgent/emergent cases. We will study the flow of patients to individual units so that we can eliminate “artificial variability” in demand and smooth the flow of patient to units. We will also develop a new group of “flow engineers” to manage the system moving forward. And, we will do nothing that makes it harder for surgeons to do their work; In fact, the idea is to be able to do more surgery quicker and better.  Jack Flowers, MD, Chairman of Surgery, and Lewis Hogge, MD, Medical Director of Perioperative Services will oversee any changes to surgical schedules to assure that this is the case.  
This initiative is the single best thing we can do to improve our patient satisfaction as well as employee satisfaction because the wait times and staff overload will be reduced. This will also help improve patient outcomes because research has shown that the mortality rates on a unit where the nurses are overwhelmed goes up significantly.
And at the end of this journey, we will be a more efficient and even safer healthcare organization, and will ultimately achieve the quadruple goal of better health, better care, lower costs and more joy for those providing the care.  

Finally, I wish to end this week’s blog on a personal note because I feel it’s important that we remind ourselves of all the good in our lives and that the things we think are so bad, maybe are not all that bad after all…This past weekend I was in church twice in one day. In the morning I attended a funeral of a 21- year old family friend gone too soon, a truly tragic event that touched the lives of so many people; and in the afternoon I was fortunate to attend my niece’s confirmation, a true celebration of a young life full of promise for the future. Talk about polarizing events. This day really put life into perspective for me. It reminded me that life is a gift – we have to reflect on what’s good in our lives and make the best of every minute we are given.

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