Patient flow is defined as the movement in and out of a healthcare institution. It involves physical resources, internal systems and patient care that is needed to get patients through services from the point of admission to the point of discharge while still maintaining quality services and a capable system. Effective patient flow ensures the meeting of patients demands for care by quickly and efficiently moving patients via care pathways and maintaining a high level of coordination of care, patient safety, and health outcomes ( Barak-Corren , Israelit, & Reis, 2017). Optimization of patient flow in any institution is vital in the processes of management and providers seek to successfully match the appropriate amount of resources to each of their admissions.
There are standards of patient flow recommended for the guidance of hospitals by a joint commission. The measures recommended all hospitals to, first; create processes that facilitate an effective patient flow throughout the hospital (Barak-Corren, Israelit, & Reis, 2017). Address what happens when beds are not ready for patients who are admitted. Make sure patients in overflow locations receive proper and quality care. Make proper and standard formalities on how ambulance diversion decisions are made and implemented. Set patient flow goals and measure progress towards these goals. The board recommended a cap of four hours on time that emergency department patients are boarded (Barak-Corren, Israelit, & Reis, 2017). Moreover, results of patient flow management should be regularly reviewed against stated goals and objectives. Finally, the joint board recommended, working with behavioral health providers to coordinate care better and taking of improvement actions when goals are not achieved.
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Poor patient flow may have a significant impact on hospital performance decreasing capacity and throughput. Poor patient flow is a leading concern for all hospital organizational leaders. Eight stages of patient flow that need to be effective including, preadmission, admission, diagnosis, procedure, recovery, discharge, post-discharge, and home. A primary cause of poor flow is physician communication and lack of hands-on care in any of the eight stages of patient flow (Chepenik & Pinker, 2017). The department that requires faster movement is the emergency department hence ineffective methods in patient flow are felt mostly in the emergency department. A mismatch in patient demand for service and the department’s capacity to deliver can often lead to poor patient flow and crowding in the department. Poor collaboration, ineffective communication, differing incentives and other factors contribute to a highly divided relationship between emergency departments and family medicine departments also causing a hitch in patient flow. To improve flow in an emergency department, for example, there should be an establishment of a fast-track process along with protocols of triage, rapid assessment streamlining and location of a primary care doctor. Moreover, a point of care testing when used effectively has shown to reduce patient time in the emergency department.
Establishment of health protocols such as triage is essential in improving patient flow (Chepenik & Pinker, 2017). It is a brief intervention that takes approximately 15 minutes of the patient's arrival at the institution. It aims at prioritizing patients depending on their presentations accordingly to help in the allocation of limited resources such as staff and physical space ( Barak-Corren , Israelit, & Reis, 2017). Use of triage to request for investigations early enough is vital in prompt diagnosis, shorter waiting times and faster flow of patients throughout the department, especially in emergencies. Having a physician perform triage has been shown to accelerate patient flow throughout the emergency department, reducing the number of admissions and improving time on important decision making.
Rapid assessment models are also ways to improve patient flow, especially in the emergency department. It is the assessment, investigation and initial treatment on patients as soon as they arrive in the department. Early evaluation and investigation together with prompt initiation of therapy reduce the amount of time wasted. It is typically for patient’s who do not require resuscitation room, high dependency unit or intensive care unit treatment. A review article has shown that the rapid assessment model reduces the total time taken by patients to see a doctor. On the downside, the quick assessment model has been seen to be very expensive to implement (Sayvong & Curry, 2015). Alteration of the existing work patterns in various emergency departments to be able to integrate the rapid assessment model with existing departmental resources has also been shown to improve patient flow.
Streaming is also an effective way of improving patient flow in any hospital, particularly in the emergency department. It is the process of allocating patients with similar nature of complaints or severity to a particular workstream. Patients in each stream are assessed in a specific area of the department (Chepenik & Pinker, 2017). Patients with less severe illnesses are dedicated to a particular clinical area, and dedicated healthcare providers assess and treat them in a ‘see and treat' type of model. The more critically ill patients are in another clinical area who also receive treatment from a dedicated team and are seen preferentially in cases of less staff. Research evidence shows that dividing patients in work streams results in reduced waiting time and shorter departmental journey times as compared to non-streamed Emergency Department models ( Barak-Corren , Israelit, & Reis, 2017). This model's effectiveness, however, depends on how patients are assigned to different work streams and whether there are enough staff and physical space to meet the patient demand for each work stream.
Point of care testing also provides healthcare providers with rapid results for commonly ordered investigations. It is also an effective method of improving patient flow. It is compared to moving the laboratory standard testing into the department, therefore, increasing the speed of diagnosis. Point of care testing reduces the turnaround time for investigations. It has also been shown that point of care testing reduces journey time in any department. There is an overall reduction of the amount of time a patient spends in the emergency department before a decision to discharge or admit is reached. A study comparing laboratory turnaround time and utilization of point of care testing in the emergency department with a centralized lab testing and air tube transport system for rapid blood transport showed that point of care testing yielded results 46 minutes earlier than the central laboratory (Sayvong & Curry, 2015). Since nurses and doctors mostly make a point of care testing, there ought to be a high level of training regularly to improve quality assurance. The cost of a single test in point of care testing is much expensive compared to the cost in the centralized laboratory. However, time saved from eliminating transportation, registrations of samples, and time spent retrieving results means that point of care testing utilization hardly exceeds the cost of analysis in a centralized lab.
In the hospitalization process, there are three main stages namely admission, inpatient period and the discharge process. Efficient admission, bed management discharge goes a long way in ensuring a steady patient demand and capacity (Barak-Corren, Israelit, & Reis, 2017). If bed demand exceeds capacity, patient admissions and surgical procedures are delayed or even at times canceled. Hospitals can make a combined strategy approach where they use management skills and information technology to redesign patient flow for maximum efficiency and positive clinical outcomes. In any patient flow initiative, information is the fundamental factor in a foundation. It is built upon collection, integration, and sharing of information within and across departments. By reducing the registration aspect of admission that is seen as tedious and repetitive, a significant reduction in waiting time is achieved. The paperwork and waiting for a bed to be assigned may be an issue to handle to improve patient flow. An admission may be planned- when a patient is scheduled for a procedure- or unplanned – when a patient presents to the physician, and the physician decides to admit them (Chepenik & Pinker, 2017).
Planned admissions are advantageous in driving patient flow since they involve better patient experience; shorter emergency departments wait time, and improved quality and continuity of care. Improved coordination among physicians’ nurses, registration staff, and other stakeholders is important. There are primary areas of concern in the admission process that may contribute to a reduced flow (Huang, Carmeli & Mandelbaum, 2015). First is the cumbersome manual process in admission. Errors, multiple phone calls to track down information may increase the patient waiting time. To solve this, automated systems should be introduced that efficiently handle patient information, assign beds and transmit doctor’s orders in one instance. Collaboration and education to improve the admission process is a viable solution to delay and hindered patient flow. Improvement of quality information from admitting physicians’ offices by education on the importance of completion of forms and patient-specific information (Sayvong & Curry, 2015). The admissions coordinator should also have a checklist on crucial information needed for admission with the aim being, ensuring that patients are admitted in the right unit, all needs of the patient are met especially in patients with special needs.
Reducing patients’ length of stay is one of the major ways hospitals use to cut costs and to reduce overcrowdedness. Delays in discharging inpatients cause bottlenecks in hospital operations and impact the whole patient flow process from admission (Chepenik & Pinker, 2017). In discharges, there’s a complicated process that requires coordination of multiple groups including doctors, nurses, auxiliary staff, patients and their relatives and in some instances the billing department. The six sigma methodology is effective to improve discharge time of patients (Kc & Terwiesch, 2017). It is a scientific concept that provides measurements for all activities in hospitals by using various statistical tools. In the work breakdown structure of the discharge process, consultants confirm discharge and inform the nurse. There is then the preparation of the discharge summary with consumable lists and details to the pharmacy together with the final bill. The nurse in charge later receives a confirmation that the bill has been cleared and finally, the patient is allowed to leave the room with all the required consumables and pharmaceuticals. The six sigma is used to address issues such as the reduction of length of stay, to reduce medical errors, to improve the admission process and to facilitate a faster-complicated discharge process.
Providing convenient parking for clients is vital. If patients cannot find a parking space, there is delayed arrival for appointments hence they leave without keeping their appointment. There also needs to be a covered drop off point for the elderly and those with disabilities for the safety reason (Huang, Carmeli, & Mandelbaum, 2015). Moreover, to reduce the crowding in lines at the check-out or check-in counters, by not scheduling more patients than the providers can handle. Gathering of pertinent insurance information when planning for appointments helps streamline the check-in process that reduces the time taken to fill in the information during the actual meeting. Provision of patient portals where new patients complete the registration paperwork is also crucial in helping a better flow (Kc & Terwiesch, 2017). Most healthcare providers can only handle a maximum of 3 occupied exam rooms. All exam rooms should be used wisely and temptations to use empty exam rooms as waiting rooms should be avoided. Setting up a mobile workstation is also crucial. Electronic health records without going back to the patient reduce journey time within the department easing up the patient flow.
Hospital administrators can improve patient flow by changing shift times and staff levels to meet demand. More staff should be scheduled on days that are busier. Procedures should also be spread throughout the month or week to provide shorter waiting times and lower stress levels to staff (Wunsch, Harrison, Jones, & Rowan, 2015). Laboratory, radiology and physiotherapy staff levels should be enough on weekends to assist patients who undergo procedures and surgeries within the week. In the occasion that staff is complaining that individual departments are making patients wait too long, administrators need to immediately convene meetings to encourage communication and find solutions to the issues that may hinder patient flow (Huang, Carmeli, & Mandelbaum, 2015). In a radiology department, for example, many tests might be ordered in mornings creating high demand and increasing patient waiting time. Proper communication is needed in such instances for the non-urgent tests to be ordered for the afternoon using a centralized scheduling system to make sure there is no overbooking.
According to a published Emcare white paper, slow throughput and a reduced overall capacity are some of the challenges in patient flow (Wunsch, Harrison, Jones, & Rowan, 2015). Healthcare professionals such as doctors, nurses, lab technicians and radiologist work in silos in their department instead of concentrating on the big picture in providing patient-centered care. In this regard, there is an increased challenge in facilitating patient flow because flow highly depends on staff and their attitudes not forgetting their communication skills that might be a hindrance to active flow between departments. Different perspectives among healthcare providers in inpatient versus emergency medicine doctors may cause communication breakdown hence inefficient handoffs. In many occurrences, patients who lack medical insurance policy and are unable to clear their bills occupy beds even though they are prepared for discharge. This interferes with the balance in patient flow between admission and discharge.
Equipment under repair and those that are faulty are a challenge in patient flow by creating delays and gaps. Daily meetings should be held to focus potential problems that may be a stumbling block to a smooth patient flow for the next day’s caseload. For example, a meeting could discuss whether any simultaneous procedures may require the same equipment, therefore, moving the procedures at different times if the resources are scares (Kc & Terwiesch, 2017). Lateness brings repercussions that affect the entire day by increasing waiting time for appointments. In the operating room, for example, a procedure that starts 20 minutes late affects all other procedures of the day increasing the overall patient waiting time, therefore, reducing flow.
There is importance attached to ineffective management patient flow. A patient who may suffer harm have a worsening of their conditions or spread infection and disease are treated sufficiently and quickly due to reduced waiting time (Sayvong & Curry, 2015). Healthcare professionals may also face disciplinary actions I poor patient flow system. As opposed to this, a working patient flow system alleviates occurrences such as reputation tarnishing of health professional and stress due to the feeling of failing their patients. Too many incidences occurring due to inadequate patient flow system put administrators in conditions where they could potentially lose their position, face criminal negligence charges and even getting imprisoned. Effective patient flow system is vital in preventing such occurrences. In conclusion, every healthcare facility success depends on the fundamentals of accurate and timely patient flow that involves patient information and an approach that combines management of patient data with voice capture of the patient needs.
References
Barak-Corren, Y., Israelit, S. H., & Reis, B. Y. (2017). Progressive prediction of hospitalization in the emergency department: uncovering hidden patterns to improve patient flow. Emerg Med J , emerged-2014.
Chepenik, L., & Pinker, E. (2017). The impact of increasing staff resources on patient flow in a psychiatric emergency service. Psychiatric Services , 68 (5), 470-475.
Huang, J., Carmeli, B., & Mandelbaum, A. (2015). Control of patient flow in emergency departments, or multiclass queues with deadlines and feedback. Operations Research , 63 (4), 892-908.
Kc, D. S., & Terwiesch, C. (2017). Benefits of surgical smoothing and spare capacity: An econometric analysis of patient flow. Production and Operations Management , 26 (9), 1663-1684.
Sayvong, R., & Curry, J. (2015, August). Using Patient Journey Modelling to Visualise the Impact of Policy Change on Patient Flow in Community Care. In MedInfo (pp. 429-433).
Wunsch, H., Harrison, D. A., Jones, A., & Rowan, K. (2015). The impact of the organization of high-dependency care on acute hospital mortality and patient flow for critically ill patients. American journal of respiratory and critical care medicine , 191 (2), 186-193.
