The First Law of Improvement: “…[E]very system is perfectly designed to achieve the results it achieves.”

—Donald M. Berwick, MD

When Dr. Bernard Lown was a cardiologist at the Brigham Hospital in Boston, he learned about the impact that a premature discharge from treatment can have on a patient. As he discusses in The Lost Art of Healing, Dr. Lown had been caring for Mrs. B. who underwent cardiac surgery, recovered uneventfully, and was preparing to be discharged when she felt abdominal pain. Dr. Lown writes, “The hospital, adhering to regulations for Diagnosis Related Groups, insisted on her leaving, but I persuaded the surgeons that she needed to stay until the nature of her complaint was clarified.” When Dr. Lown arrived back at the hospital, Mrs. B had already been discharged; he was assured her condition had improved. Mrs. B called him six weeks later with a different story: she said she was terribly sick, but the resident insisted she would be fine and the hospital didn’t allow a further extension of her stay. During her flight home, her pain increased, her intestine spilled out from her abdominal incision, and she found herself “sitting in a pool of blood.” She arrived in Florida in septic shock and was critically ill for weeks. Dr. Lown notes that focusing on discharging the patient after a predetermined amount of time has passed “compels doctors to practice a brutal, Procrustean brand of medicine,” ignoring patient needs.

In the Emergency Room (ER), assessing patient condition and crafting corresponding treatment timelines is commonplace—from the moment patients call for an ambulance or arrive in the ER. Some patients arrive in critical condition. Others schedule and plan for their visits, arriving in the morning with a packed lunch and reading material, prepared to wait hours before they’re seen. Once a bed is available, they wait for tests to be performed, and wait longer still for results to come back. If the doctor decides the patient needs to be transferred to an internal ward for further care, the patient then continues to wait—even if a bed is available, as highlighted in “Patient Flow in Hospitals: A Data-Based Queueing-Science Perspective.” The Joint Commission, an independent non-profit responsible for accrediting health care organizations and programs in the U.S. (a condition for licensure and Medicaid reimbursement in most states), recommends that hospitals limit the time patients spend waiting for transfer to four hours, but this limit isn’t strictly observed. In some cases, care that could have been delivered in under one hour can take over 12 to provide.

Waits and delays are common in ERs across the United States, and, according to the CDCthey’re increasing. Hospitals with sufficient funding have responded by adding more beds and hiring more staff—yet the problem persists. To a certain extent, the problem’s persistence makes sense. ER visits aren’t scheduled and are unpredictable. Patients with and without insurance rely on the emergency department as a source of primary care, so they are often overcrowded. In this system, perhaps waits, delays, and cancellations are inevitable.

But extended delays can be prevented. According to Carol Haraden, Vice-President at the Institute for Healthcare Improvement (IHI), “delays are… a flow problem,” which can be fixed by removing obstacles and blockages. IHI has worked with over 60 hospitals to “unblock” patient pathways by decreasing unnecessary variability in care practices. This streamlining results in decreased ER wait times, efficient transfers of patients, and improved transitions from the hospital to outside facilities. Since the ER serves as a major artery for patients coming in and out of the hospital, improving efficiency there has positive results for internal wards as well.

One target of IHI’s improvement strategies is discharge time. Most hospitals aim to discharge patients at the same time every day. This goal is rarely met, and creates additional work and workflow bottlenecks for hospital employees to navigate. Patients cannot be discharged until all the boxes are checked—orders are written, medications are delivered, patient education is complete—and these tasks involve collaboration across many disparate departments in the hospital. Any missing piece creates delays, and occupies hospital beds that could otherwise be used for new patients. Haraden and colleagues discovered that patients tend to arrive predictably, and that discharges can be matched to these admission patterns in order to ensure that beds are available when they’re needed. They work with patients to decide on specific discharge times throughout the day, and then work backwards create corresponding timelines for completing the preceding procedures. With this new model, they expect that 80% of the discharge time targets will be met.

Shortening waits not only prevents patient frustration; it also improves patient outcomes, as published in Critical Care Medicine. Their study showed that critically ill patient who waited for six hours or more before being transferred to the intensive care unit ended up staying in the hospital longer overall. Further, they were more likely to die during their stay. According to research in Annals of Emergency Medicine, ER crowding leads to delays in care delivery for patients waiting to be seen as well — some of whom must be sent elsewhere. Moving patients to areas of the hospital where their needs can be met in a timely manner has the potential to decrease hospital mortality rates and shorten stays. Efficiency can save lives.

As Dr. Lown noted, overemphasizing fast care delivery can be damaging. When healthcare workers care for a larger volume of patients in a shorter amount of time, patient stays decrease in the short term, but may increase in the long term as hospital staff become overworked. Patient care becomes rushed, prompting more mistakes. At the same time, patients are also more likely to be discharged prematurely. When patients leave the hospital before they have fully recovered, there is an increased likelihood of complications or death. Workflow solutions aren’t about doing standard practices more quickly. They’re about strategic transfers of resources that improve patient outcomes, decrease work, and allow patients care when they need it.

The simple question underlying hospital workflow analysis is: How do we get patients in need of care to the people who best know how to take care of them? The logistical operations required, especially in large urban settings, make the answer to this question complex. IHI and other healthcare workflow analysts have responded to this question by formulating streamlined pathways for offering care efficiently in hospitals. Patients also need to know where to find the care they need and how to get there. And hospitals need to have sufficient supplies to meet the demand at any moment. Is there an app for that?

Further Reading:

Image credit:  paul bica via flickr

  • keleee

    Thanks for the timely article. I just canceled a procedure at Mass General because It isn’t worth the suffering for hours to have it done. I have lung cancer and need Broncoscopy’s to keep my airway clear of cancer so I can breathe. They also use a balloon to stretch airways and other things like laser and cryogenics to keep my airway clear. Recently I had a collapsed lung and they went in and removed necrotic tissue and reopened my lung. I remember waiting on a hard gurney outside of the OR while the OR was being cleaned for me. It was 6pm and I had no food or water for 19 hours. I had been waiting all day to be called to the OR and they came for me at 3pm. I was still waiting at 6 pm. My mouth was dry and parched. My body hurt from being on the gurny for hours. Why did they call me so early just to have me lay on a hard board like gurney for hours? I prayed for relief. I finally got up to my room at 9 pm after waiting in post op for a bed to open up because the bed that was reserved for me was used by someone that needed it more then me? Finally I can have something to drink and I drank a quart of cold water because I was so thirsty. I think 19 hours without water is a little ridiculous in a civilized country. For me I have to be very short of breath to go to Mass General in Boston and I love my surgeon and the procedure helps my breathing but the long waits are so hard to endure. It is torture and I sometimes think that now that I am terminal with my lung cancer that I may just choose to die then go through it. I am not a priority (I’m a DNR) so all the emergency cases go before me in the OR which isn’t fair to me but the way Mass General uses the OR is not the norm either. Usually you go into a hospital at a certain time and have a procedure, come to in Post Op and go home. At Mass General they only have OR hours for Broncoscopies on Monday afternoons for routine procedures. So because of that the patient with a 2:30 pm operation is lucky to get into the OR until 6 pm or later. They want you to fast from 10 pm the night before and be at the hospital at 10 am for a 6pm operation which is wrong. I have had surgeries scheduled at 9 am and had them at 9 am and fasted from midnight the night before which is reasonable. It has to come down to money because I heard they do 150 surgeries a day at Mass General which is a ton of money. They make sure the OR’s are constantly in use 24/7 even if the patient suffers. Oh well, if you want the best doctors you have to wait!

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