Quick Tips for Optimizing Patient Flow Improvement

Susan: Welcome to Patient Flow Podcast. Today we're pleased to have Kathy Menefee, a consultant with TeleTracking's Advisory Services Team, with us. Kathy brings more than 30 years of clinical and executive management experience to her role, and has been a member of executive teams in hospitals, post-acute facilities, and community settings. Today, Kathy will be diving into the three things that you need to do to kickstart your patient flow improvements. Before we get started, could you please share some of the challenges that health systems are facing, and how that can hold them back on their patient flow journey?

Kathy Menefee: There are several that are top of mind for me that I'm seeing out there in organizations. One is this whole shifting healthcare environment. Hospitals are closing, there's always consolidations and mergers, and those have the effect of decreasing access to care in many communities. The hospitals that are left, then, are challenged with too many patients and not enough resources, including beds and staff to provide care.

Kathy Menefee: Another outcome I'm seeing of this is that the capacity of larger, tertiary care hospitals may also be constrained by patients that could be perhaps more appropriately cared for in a community setting. So what ends up happening is the beds in those tertiary care hospitals are not available for true tertiary level of care complex patients.

Kathy Menefee: A second area that I'm very interested in too is what seems to be a rising acuity of patients in general. Many lower acuity services are now provided on an outpatient, urgent care, or short stay basis, meaning that those patients who do present to EDs are likely to be sicker in general.

Kathy Menefee: There are also some environmental factors right now, such as the opioid crisis, which has added medical and behavioral health complexities, and associated social factors that are quite challenging to deal with - homelessness, lack of social supports, and just resources for healthcare in general.This winter was a very interesting season for every hospital that I visited. The seasonal impacts now are really hard to predict unless you happen to have very defined or clear seasons, such as Florida and Maine, which clearly have an in season and an off season.

Kathy Menefee: Weather impacts and effects have also been quite challenging. A seasonal impact that was worse than anyone ever imagined or predicted this past year was the influenza season, which ultimately became an epidemic. Every organization I was in struggled just to keep their doors open, even with enough beds, resources, and certainly the staff to provide care.

Kathy Menefee: Last but not least, is a huge one, and this really tugs at my heart as a nurse for a very long time, and that's staffing shortages. They are tremendous in all areas. Clinical and support team members, nurses, environmental services workers, therapists, patient care assistants are just hard to find and keep in most areas. This makes attention to patient flow and discharge planning more important than ever, and trying to make sure that the patients that really need to be in the hospital are there and have a bed. It's also a challenge to predict the resources that'll be needed to care for these patients.

Kathy Menefee: So, staffing again is something all hospitals are looking at. There's some really creative ways out there that folks are trying to address it. But it is clearly one of the major challenges right now.

Susan McLaughlin: When you have that type of effective patient flow strategy, you have happy patients and you have happy staff members. So that's why your three tips are going to be so incredibly powerful. How important is it to have senior leadership as a champion when you're launching a patient flow strategy?

Kathy Menefee: I think having that senior leader champion is probably even more important than having an effective Patient Flow Council. The senior leader typically oversees the Patient Flow Council, but has to have a very brave and very passionate demeanor. So we typically look for, with our organizations, C-suite leaders that are passionate about flow, that have the courage to make some tough decisions around flow and holding people accountable for good flow in hospitals. And they have to also understand a bit about the science of flow. In addition, I think having that person that can also understand that the adoption of best practices is paramount to successful patient flow, and ultimately having the beds you need for patients. 

Kathy Menefee: The engagement of that senior leader is critical to the success of any hospital or system to be able not only to make improvements, but sustain improvements. So, the courage to make tough decisions and stand ground on those decisions, hold team members accountable for using not just the technology, but the best practices and standard work processes that we know work, to create a safe, effective discharge and open beds for patients coming in. 

Kathy Menefee: I should stress that this senior leader does not have to attend, or even chair, every Patient Flow Council meeting, but can designate a chair of the Council that will then engage the senior leader when needed and as needed. I think the last role that the senior leader plays allows the organization to be tremendously successful is being the voice of patient flow for the organization, clearly communicating the vision for flow and capacity, and most importantly setting that expectation that the best practices and the technology will be used to the fullest extent.

Kathy Menefee: I cannot stress the importance of selecting that leader and selecting very early, even pre-sales, when the organization is considering purchasing of a system such as TeleTracking. That leader really needs to be involved at a very high level from that point forward.

Susan McLaughlin: Can you talk about the role a Patient Flow Council plays and what are some of the successful attributes that that Council would have?

Kathy Menefee: The Patient Flow Council's ultimate role is the governing body for all things related to patient flow, capacity management, and the use of TeleTracking software. This is an interdisciplinary Council. They determine and regularly review the process, or lead metrics used to assess compliance with use of patient flow practices and technology. These are things like bed clean times or the length of time between discharge order entry to patient departure.

Kathy Menefee: Then the Council also manages and reviews outcome or lag metrics - the overall impact of efficient, effective flow on patients, families, the organization, and the community. Those outcome metrics can include measures such as the number of ED boarding hours, length of stay, patient satisfaction.

Kathy Menefee: The Council also sanctions and governs all improvement work. So, any teams or sub-teams working on discharge readiness, for example, or perhaps piloting the use of transporters for patient discharge. The Council would oversee that work, make recommendations, approve ideas and action plans.

Kathy Menefee: Another key point of the Patient Flow Council is that technology enhancement requests go through the Council for approval. That is really important to have a strong structure for that. I think as most of our clients will know, a lot of technology enhancement requests can come in, and they're all great ideas but somebody has to really oversee which ones will be of most benefit to the organization. And that's another role the Council plays. A fun role the Council plays is to celebrate, plan recognitions and team member celebrations as certain goals are achieved and metrics improve, and as flow and capacity ultimate improves.

Kathy Menefee: Also, a couple of things about the Council. The Council is interdisciplinary in nature. A lot of folks always ask who should be on the Council. Again, the senior leader can be on the Council, can act as the chair, can designate a chair, but you need key members - representatives from Nursing, Med Surg, ED, PACU, Critical Care, the medical staff that's particularly helpful to have a Hospitalist, an ER physician, and perhaps a surgeon on the Council. EDS, Environmental Services, Transportation. If you have an Operational Excellence or Performance Improvement Department, that's a great area to involve and have those folks sit on your Council. Then certainly your Transfer Center and/or Bed Placement Leaders would be on the Council.

Kathy Menefee: A number of hospitals find it helpful to have an ad-hoc membership group as well. Depends on the organization, depends on the agenda whether or not those members might attend. Those are typically representatives from Case Management, Therapy - Physical Therapy, Speech Therapy, Occupational Therapy - Lab, Imaging, Information Technology, and others, depending on the composition in the hospital.

Kathy Menefee: If possible, it's also great to have some Direct Care Service Team members available to the Council, especially for specific process improvement projects or sub-team work. They really bring the flavor to the Council of what's happening in real time on the units and out in the hospital because they're doing the work. And their input and their understanding and buy-in is tremendously important.

Kathy Menefee: I think probably the last thing I want to mention about the Council is the agenda. The agendas need to be very, very focused. Typically what we see that works well is that metrics are always covered at every meeting - what's working in terms of metrics, whether that's on a monthly basis or a weekly basis. Sub-group work is presented there for input to the Council. Technology or equipment requests, as I mentioned. So, this could also be not just the technology or changes in the system. It could be an expenditure request, for example, for Portal monitors to be installed in certain areas. Or perhaps iPods for EVS or Transport. The Council also monitors action plans to make sure things are moving along appropriately.

Kathy Menefee: A tip that I always tell the organizations I work with is really spend some time not just talking as a Council about what's going badly, what's not improving, what's not progressing in the direction you'd like for it to, but spend some time discussing what's working well, and why it's working well. I think we can learn tremendous amounts from that and replicate our successes and turn our failures, perhaps, into successes by learning what's working in the organization.

Kathy Menefee: Councils, by the way, generally meet monthly. There are some organizations that choose to meet every other week, especially when they're standing up TeleTracking or they're making significant changes. But consistent attendance is expected at each and every meeting. So anyone and anybody in the organization working on patient flow would report out at those meetings. And again, it can be anything from working on bed churn times to looking at placement issues around ED patients moving to inpatient beds, even first case OR starts I have seen as a sub-team action item on Patient Flow Council agendas.

Susan McLaughlin: It really sounds like there's a lot of flexibility built into this that a health system can do whatever works best for them based on their particular circumstances.

Kathy Menefee: I've worked with hospitals that have census as small as 10, and others that have censuses as large as 1,200. You can modify your Council the way that you need when you need the attendance at the Council based on the size and complexity of your organization. And I think that's really the great thing about it - you can make it really work for you.

Susan McLaughlin: Could you discuss how a comprehensive patient flow management plan can really help a health system track their opportunities and successes? Really, the power that comes with data.

Kathy Menefee: A comprehensive patient flow management plan is really looking at all services and all areas that have the ability to impact flow, and ultimately, capacity, into one specific approach. And so, at the very least, you are looking at Patient Placement, Environmental Services, Emergency Department, Transportation, Bed Placement, Case Management - typically the areas that you would also see, by the way, represented on your Patient Flow Council.

Kathy Menefee: Some organizations think about centralizing those services into a single, centralized Patient Flow Management Center. And you'll hear these called Command Centers or Centralized Logistics Centers, which may even include Ground or Air Transport Services, Utilization Review, and other departments. But really, the goal of having this plan is to effectively manage supply and demand for inpatient services within a hospital or across a system or an enterprise. 

Kathy Menefee: There are a couple of key components to the plan, and Susan mentioned one, which is the measurement component. That really forms the backbone of your patient flow management plan. You have to have those process measures that I mentioned earlier, and those are things that tell you whether or not your team is really using the technology and using the best practices. And then you have the outcome metrics as well, which come later. And I always tell organizations - focus on process metrics, focus on the lead metrics first, then your outcomes will come. But both of these are necessary to measure what's going on in the organization, the use of the technology, the use of the best practices.

Kathy Menefee: If you look at the two other components of a plan like this, it would be that you have a single technology platform. Why? That's really the key to success of such an effort as well. That's where TeleTracking comes in. If you have an information system that's used by all of these areas I mentioned earlier, that backs everything up with real-time data - every process, every point and interaction along the way - and also give all of the team members the ability to communicate key information in one system, that really is the best case scenario.

Kathy Menefee: The third piece of a comprehensive patient flow management plan is helping your team understand that a 24/7 approach must be embedded in that plan. Teams have to understand that managing patient flow and creating capacity is not a Monday through Friday, or 8:00 AM to 4:00 PM responsibility. So, effective yet efficient bed meetings or bed huddles are a good way to have information sharing occur, support collaboration necessary to drive your plans for patient placement and patient accommodation, but the measurement piece is really the backbone of a comprehensive patient flow management plan.

Susan McLaughlin: I have one bonus question. Could you please share a recent example that you personally witnessed of an improved patient flow strategy?

Kathy Menefee:  This is so timely, Susan, because it's the client that I visited last week. It's a large academic medical center serving a significant population across an entire state. And so, as you can imagine, turning a ship literally this large can be quite a challenge and take longer than you would anticipate.So challenging. And so, what this organization decided to do was what I call light several small fires throughout their hospital to literally ignite their improvement process for patient flow. They have exceptional leadership in place - speaking about that patient flow champion on the senior leadership level - and they also have a high level of physician engagement.

Kathy Menefee: What they did was start several small tests of change in various areas around various processes in the organization. And really, those have come together - in the space of about 90 days - to make a big fire, so to speak. So what we have now is really engaged the entire hospital. Their metrics are moving in a positive direction, and they've really lit up the entire hospital. They, for example, reduced their ED boarding by almost 4,500 hours in the past year.

Kathy Menefee: It is tremendous, and it's so good to see for so many reasons. They had 230 more Transfer Center requests now coming in monthly that they're able to accommodate. And they reduced their ready to move to assigned times by 50%. They have a lot of strong pieces and parts in place, but I think the fact that those small fires have really come together now to engage the entire hospital and show, through small tests of change, that improvement can occur, is making a significant difference.

Susan McLaughlin: Thank you so much for joining us. These three tips, I think, are very powerful and I think they're really going to help a lot of people.