After reading this article, you will be able to:
- Identify the areas in which hospitals can focus performance improvement efforts
- Describe a flow sheet one facility created to improve patient flow
Poor patient flow affects patient care, safety, and satisfaction. Patients often face obstacles to quick and efficient care at multiple stages of their stay, from triaging in the ED to getting a bed in the inpatient unit to being discharged at the appropriate time.
But the daunting process involves multiple staff levels, departments, and documentation requirements. Where exactly do you start making performance improvements?
The first step is figuring out where to begin and focus your efforts, a step many hospitals tend to skip, says Derenda Pete, RN, MBA, senior accreditation consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
“One of the common mistakes is not taking a very good assessment of the patient process from the time they enter the emergency department until they are discharged from the hospital,” Pete says.
Without a thorough assessment, you can’t know where a hospital’s patient flow troubles lie. Although an assessment may take time, it gives hospitals the most return on their performance improvement efforts.
“Make it very simple,” says Pete. “Decide what to focus on and what that one or two—not 10—metrics need to be in order to show performance improvement. And make sure performance is reported to leadership in regular intervals.”
Pete cites three main problem areas in hospitals:
- Timely physician evaluation of ED patients
- Quick movement of patients to inpatient units
- Appropriate discharge of patients
The latter two are the responsibility of the inpatient unit, says Pete, adding that ensuring free beds in the inpatient units is critical to avoiding a crowded ED and potential patient safety issues.
“Whenever you reach or exceed your functional capacity, your potential for a sentinel event increases tenfold because there’s limited staffing and resources,” says Pete. “Things just don’t get done. Patients and documentation may be overlooked. … Efficient care is that much harder, effectively slowing down discharges.”
And patients may end up staying more days than what is truly required.
Focus on inpatient care
Every hospital must assess and determine specific areas on which to focus improvement efforts, but Pete says getting ED patients to inpatient beds should be a priority.
“The issue is that the ED is ready to get the patients upstairs, but they stay put because there are no beds available,” says Pete. A full inpatient department may be due to any number of reasons including staffing issues, inappropriate use of resources, long physician response times, and various discharge issues, which should all be part of the initial assessment.
“You’re not going to be able to improve everything,” Pete says, adding that the process will be a collaborative effort. Still, inpatient care should not be overlooked as a patient flow issue.
“One of the common things I hear … is that once patients get into the inpatient unit, things slow down,” says Pete. “Hospitals need to have care plans set up to treat common diagnoses on their units.”
Establishing these care plans and knowing where the variances lie will help patients get the best care without having extended lengths of stay, says Pete. Efficient care involves transforming the existing culture to a more goal-oriented one aimed at getting patients better quickly.
Work toward discharge
Focusing on efficient inpatient care through culture change is exactly what staff members at Jordan Hospital in Plymouth, MA, have been doing to help their patient flow processes. The 155-bed hospital has a core team of 10 staff members from multiple departments to work on revamping patient flow pathways. As this team focused on creating evidence-based guidelines, Karen Carafoli, MSN, RN, director of professional development, and Pam Almada, MSN, RN-BC, clinical educator in professional development, created a new documentation tool they call the AIM Flow Sheet©, which focuses caretakers on patient goals rather than day-to-day tasks.
So far, Jordan Hospital has implemented two versions of the flow sheet, one for pneumonia and the other for congestive heart failure. The hospital began to use these flow sheets in fall 2008.
“We’re going live with more down the road,” says Almada. Ultimately, Jordan hopes to have 10–15 such flow sheets, each tailored to a specific diagnosis.
The idea behind the flow sheet is simple: Record the patient’s condition levels at admission (e.g., temperature, white blood cell count, and other necessary clinical information). Then fill in evidence-based goals and criteria for discharge. Each day during the patient’s stay, nurses and other interdisciplinary caregivers (e.g., respiratory therapists and dietitians) note whether the patient remains at admission level or declines (indicated with an “A”), has improved since admission (“I”), or has met the goals for discharge (“M”). Everyone works toward filling the sheet with M’s. Carafoli and Almada say the worksheets help nurses, physicians, discharge planners, and others involved in care to visualize the patient’s progression toward the discharge criteria in one quick glance.
“The flow sheet is really a win for nurses because it helps to diminish documentation,” says Carafoli, adding that because the sheet focuses nurses on goals, not tasks, patient outcomes are better. Jordan Hospital has also begun staff huddles in which charge nurses spend a few minutes with hospitalists before they enter a patient’s room to discuss which goals the team should address that day. “It focuses the whole team with just a snapshot of what they need to do to drive toward discharge and positive patient outcomes,” says Carafoli.
The feedback from staff members has been positive. About 20 nurses and respiratory therapists who have worked with the new flow sheets were internally surveyed; 95% said the sheets helped save documentation time and improved communication.
“It also gives nurses more assurance,” says Almada. Nurses may feel empowered to ask a physician whether a patient is ready for the next step, such as moving to an oral antibiotic, with the sheet at hand.
In addition, Jordan has recorded a decreased length of stay for pneumonia patients in the past few months.
Adapted from Briefings on Patient Safety, March 2009, HCPro, Inc.