Who has an available bed? The question is all too familiar to hospital staff, particularly in the evening hours, as patients are backing up in the operating room and the emergency department.
In many hospitals, the frustrating process of managing bed capacity can take away essential time needed to properly care for patients. But there are basic strategies that can be put in place to develop a sustainable system that eliminates delays and creates patient-centric flow, ensuring the delivery of “the right care at the right place and the right time.”
Demand VS Capacity
We’ve all been at the grocery store when it was extremely busy but only two checkout lines are open. And everyone is fuming because they can easily see the eight checkout stations that are closed. As the lines steadily back up, each clerk is averaging about seven minutes to complete each customer’s sale.
The bottlenecks are clear. The “demand” at the grocery store is the increasing number of customers waiting to checkout. The “capacity” is two checkout lines. If the 10 stations were open, 10 customers approximately every seven minutes, would be on their way out the door.
In the hospital, the demand is all patients waiting for a bed and the capacity includes only beds currently cleaned and ready to receive the next patient. Bottlenecks or gridlock occur when the demand is greater than the capacity. Common reasons for bottlenecks include:
- Late inpatient discharges (after noon);
- Closed beds due to inadequate staffing; and
- Delays with environmental services cleaning rooms because it is late in the day and staffing has decreased to evening levels.
Add all of this together and a clear need for capacity management will begin to take shape. There are three operational components that must be addressed to improve capacity management and optimize care delivery.
1. Lay the Foundation
Evaluate the admission/discharge/transfer (ADT) criteria for each type of patient unit to ensure the level has a well-defined scope for nursing intensity. After key clinicians are well educated on the various criteria, create guardrails to ensure that newly admitted patients are appropriately placed upon arrival. Many bottlenecks occur due to a limited number of specialty beds, such as critical or intermediate care. Remember the “right place at the right time” mantra.
Another foundational strategy is development of a standard surge plan that clearly defines how to perform when operations “get behind” and your patient volume exceeds your capacity. Each leader should know their responsibilities. Surge plans should be activated early for the express purpose of decompressing the bottlenecks and returning “back to normal.” Don’t wait to justify the activation – use it as often as needed!
2. Apply Efficient Operational Tactics Daily
Seven days a week, activities should be well hardwired to ensure early discharges, preferably before noon. A disclaimer here is that this is not an advocacy to discharge patients too early and jeopardize a readmission. Instead, it is a strong admonishment to identify your candidates the day before for morning discharge in order to organize transportation and confirm all post-discharge needs. Waiting until the morning of discharge often results in delays that keep the patient well into the day.
“Huddles” are another method to facilitate operations. The purpose of huddles is to collaborate, prepare and expedite each unit’s discharges. Turning around these beds early opens up rooms and ensures capacity for the incoming patient demand. Dialogue during huddles should be very specific, such as “Mrs. Jones in room 201 is expected to leave at 11 a.m. when her therapy is completed.” These details are much more productive than high-level outgoing and incoming patient numbers.
Care managers are a vital part of this ongoing process as they work closely with nursing to identify early discharge candidates, communicate to caregivers when the discharge plan is complete, and resolve any disposition barriers that arise.
3. Promote Progression of Each Patient’s Care
Many high-volume diagnoses benefit from strong order sets, protocols and care bundles. Physician champions are critical to lead these efforts both to standardize to current evidence-based practices and to gain approval through their medical staff governance structure. Having providers at the table early improves the probability of compliance in these practices long term.
Optimizing capacity management is not an impossible dream, but does take time and perseverance. Laying the groundwork, performing daily tactical huddles, and coordinating each patient’s delivery of care will position your hospital to maximize operational efficiency.
To learn more about improving care delivery efficiency and outcomes, read Creating a Culture of Optimal Care Delivery or contact us.