WHITE PAPER. Hospital-Wide Flow: Cracking the Code. Content

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1 WHITE PAPER Hospital-Wide Flow: Cracking the Code BY: Kirk B. Jensen, MD, MBA, FACEP Content E.D. crowding and boarders. Accelerate movement. Partnering with hospitalists. Demand capacity management. Smoothing surgical flow. Key principals of patient flow.

2 CONTENTS

3 Contents HOSPITAL-WIDE FLOW: CRACKING THE CODE Introduction... 2 E.D. crowding and boarders...3 Accelerate movement...4 Partnering with hospitalists...8 Demand capacity management...9 Smoothing surgical flow to decrease hospital census variability Key principles of patient flow About the author Contact... 18

4 INTRODUCTION Every emergency department (E.D.) physician and nurse deserves an E.D. that works for them. Most clinicians spend a third of their careers in wellfunctioning E.D.s and the other two-thirds in highly dysfunctional E.D.s, dealing with work-arounds and living with the pain of inefficient systems. Much can be accomplished on flow and service within an E.D. by working on the front end, making changes within the E.D. s control and influence. 2

5 HOSPITAL-WIDE FLOW: CRACKING THE CODE There is an interesting paradox, however. An operational and management paradox in emergency medicine is that, if boarders occupy a significant percentage of productive E.D. capacity, the impact of those boarded patients constitutes the single biggest impediment to E.D. patient flow. This being the case, the quest for solutions must encompass overall hospital operations and flow. By exploring comprehensive service operations and learning to converse fluently about the full portfolio of tools available, one can become an expert resource on improving hospital-wide patient flow. Many tactics for improving flow exist which, once applied, can benefit both hospitals and E.D.s. Conversations about these tactics with hospital administrators will differ from clinical conversations with emergency physicians or staff physicians. Understanding the concepts and techniques engaged in ramping up flow empowers one to educate, influence and hold hospital administrators accountable for results. E.D. crowding and boarders Let s address the issue of E.D. crowding and boarders. Does it really matter? The answer is a resounding YES. E.D. overcrowding correlates with the boarding of admitted patients more than any other metric. ~ American College of Emergency Physicians Task Force Report on Boarding The greater the percentage of E.D. beds occupied by boarders (admit-holds), the more likely flow will be impeded or obstructed. Boarders occupy beds and consume resources staffed and allocated for incoming E.D. patients. There is an extensive body of literature on the negative impact of boarders in the E.D. (Bernstein SL. Et. Al. The effect of E.D. crowding on clinically oriented outcomes. AcadEmergMed. 16(1):1-10,2009 Jan.) Tipping the scales: concern versus danger The single metric with the strongest correlation to decreased patient throughput is the percentage of patients boarding in the E.D. What isn t clear is what percentage constitutes worry and what percentage constitutes danger. If a 20 bed E.D. is holding two boarders on a Monday morning, this clearly constitutes an irritant for the patient, a patient safety problem and an unfortunate circumstance for the nursing staff and team. It is an operational nuisance, however, and not an operational nightmare because if two beds are tied up with boarders, 18 beds are still available. Ten percent of productive capacity is tied up, but 90% of productive capacity remains wide open. If on the following Monday this same 20-bed E.D. is holding 10 boarded patients, the end result is a 10 bed E.D. instead of a 20 bed E.D. an operational disaster. So, while boarded patients are 3

6 always a problem from a patient safety and patient satisfaction point of view, the true operational impact is dependent on the percentage of productive capacity used up. The precise tipping point is unknown, and probably varies by E.D. and hospital. Based upon our work in queuing theory and variation, a boarding burden exceeding 10 or 15% clearly results in a significant problem. Once close to 20% of E.D. operational capacity is used up, the capacity and the extra slack necessary to allow for variations in presentations and throughput vanish. An extensive body of literature exists proving this point. It can readily be demonstrated to hospital administration that boarding is the single strongest driver of increased lengths of stay. It is a significant patient satisfaction issue. It is a major patient safety issue. It may be both surprising and helpful to realize is that the Joint Commission is one of the E.D. s best friends. Several years ago, the Joint Commission started a tracer program examining hospital-wide throughput in patient flow, from arrival to discharge. The Joint Commission s initiatives can be utilized to obtain the attention, support and resources E.D.s need in 2012, CMS began tracking throughput times in the E.D. and throughput times for patients arriving in the E.D. who were subsequently admitted. This is a quality measure that can serve to drive operational performance. These measures will also be considered in the pay for performance (P4P) plan. Healthcare Consumer Assessment of Hospital & Provider Service (HCAHPS) scores are also greatly influenced by lengths of stay in the E.D. Poor results in this patient satisfaction survey can put a hospital s financials at risk. Quite obviously, flow is a metric worthy of study and improvement. Accelerate movement How can movement out of the E.D. be accelerated? There are numerous options available for improving patient flow out of the E.D. and optimizing patient flow in areas such as surgery, the ICU and the hospital overall. Early decision to admit Ninety percent of the time when experienced E.D. doctors or nurses walk out of the examination room they know whether or not a patient needs to be admitted. Why wait four to six hours before making the decision? Clearly, one opportunity available to promote flow is an early decision to admit. There are undoubtedly cultural problems with this. It s not always in the best interest from the attending staff s time and work-flow management to adopt this policy. However, early decision to admit is a very potent tool in the toolbox. Delaying admission until every lab and diagnostic study is back is a commonplace, although unrealistic, expectation of the admission team. Early request for a bed This is similar to the above, but not quite the same. As soon as the needed bed type becomes clear, the emergency physician should consider ordering 4

7 HOSPITAL-WIDE FLOW: CRACKING THE CODE an inpatient bed. Twenty years ago Nordstrom s department stores were just opening in California. At Nordstrom s one could buy whatever one wanted and return it whenever one wanted. To make an analogy between a retail store and what occurs within a hospital, the E.D. is the number one admitter to the hospital. Fifty to 60 to 70% of admissions come out of the E.D. If the E.D. closed, half the radiologists in the hospital, half the pathologists, half the surgeons could lose their patients and their practices. The E.D. is the single best customer of the hospital. Ninety percent of the time emergency clinicians know whether a patient needs a bed and what type of bed is required. The idea of asking for a bed and getting it early makes a lot of sense. As occurs at Nordstrom s, 10% of the time E.D. clinicians might have to say, Whoops, I m sorry, I really don t need it, here is your bed back. But 90% of the time they ve got it nailed. An early bed request strategy is another driver for improving patient flow. The only time this strategy isn t necessary is if bed placement is so efficient that a bed can be obtained within 30 to 60 minutes of the bed request. This is obviously a superior system which some hospitals successfully employ. If this system is not in place, however, parallel processing and a request for an early bed is a very reasonable strategy. Proper bed selection The inpatient floors and admitting department worry about improper bed selection. Create a written agreement and policy on bed selection. The development of the optimal bed-selection process and tool is clearly the task of a multidisciplinary team. This agreement is best negotiated by diplomacy in a spirit of cooperation and mutual gain and not attempted in the heat of battle. Admitting physician preferences must be taken into consideration. Include key factors such as telemetry, isolation and vasoactive drip. The process goals are to add accuracy, reduce variation and improve cooperation in the bed selection process. The outcome goals are to efficiently and effectively place the patient in the proper nursing unit ( best-fit ) and to facilitate the acceptance of the patient by the nursing unit. Expedited testing There is definitely a place for expedited testing in the E.D. Point of care (POC) laboratory studies can decrease turnaround time by 60 minutes or more, allowing for early and accurate decision-making. As noted earlier, immediately following the history and exam, E.D. clinicians typically know or have an educated idea of which tests are required, who will be admitted and most likely where patients need to go. There are clearly patient streams, classes of patients, where this can be narrowed down with bedside testing. In many ACS patients, an ECG and a single troponin will determine the destination. This capability should be readily available. With other patients, a chest X-ray, ECG, dip urine and POC electrolytes are all that are required. 5

8 Early notification of the admitting team Getting the admitting physician or team involved early is helpful. As with the bed selection process, these consulting agreements should be worked out ahead of time. Understand that whatever metaphor makes sense - in the heat of battle, under the gun everybody is working within his or her own service delivery system. In the midst of a busy day, internists or surgeons will not necessarily be interested in facilitating flow for the E.D. at the expense of their work-flow. They re focused on facilitating their own patient care duties and priorities. If all parties can sit down and manage service agreements in quieter, calmer times, when the true north is the best interest of patients, they will and can understand that expedited admissions and early notification are beneficial to patients and patient flow. Admitting officer Placing an admitting officer in the E.D. is typically more viable in large hospitals with either residency or hospitalist services. It can expedite medical admissions, but can just as likely to impede patient flow if the incentives and the behaviors aren t aligned. An admitting officer who expects the captain of the E.D. shift to be a wall is not aligning incentives with patient flow. The admitting officer must avoid the temptation to perform an exhaustive evaluation in the E.D. and instead concentrate on the need for admission, emergency medications and admission orders. An admitting officer who s quick, efficient and understands that the goal of the health care system is to get sick patients in the hospital and keep healthier patients out can go a long way toward expediting admissions. An admitting officer who fails to manage these tasks well is likely to inhibit patient flow. The following point can t be emphasized enough; these techniques must not only be understood, but implemented well. Improper implementation of any of these concepts can actually hinder flow, leading to an inferior, slow process which then becomes yet another source of waits and delays. A facilitated admitting agreement can quickly degrade to a slow admitting agreement. An inefficient admitting officer can become a roadblock. Too much reliance can be placed on point of care testing with no plan for the times POC isn t available. The key is not merely being aware of these concepts; it s knowing how to implement them effectively and building up reliable systems and processes. Express admission units Within the right setting, an express admission unit in an E.D. holding area can improve patient flow. As sources of extra resources, with a focus on patients needing extensive work-ups or observation prior to admission out of the E.D., EAU s can be a tremendous asset. From a flow standpoint, the better express admission units are usually located physically outside of the E.D. It is easy, perhaps too easy, to utilize an EAU within the E.D. as a substitute for decision-making. This can result in walling off patients, with subsequent decreased flow through 6

9 the E.D. A clear-cut mission is required. The people working in the system must understand flow and timeliness and must think in terms of minutes and hours versus days. The incentives need to be aligned for getting patients in and getting patients out. In the best systems, inpatient floor throughput and turnaround time are fast enough that patients flow in and out without the need for an EAU. An EAU is clearly a workaround, but an effective workaround. Spending two to four hours observing the inner workings of a hospital admitting service or unit - patient flow. Air traffic control will enable one to intimately learn how the admission system works at the ground level. Admissions personnel are typically hardworking people trying to do the right thing, willing to share what they know. Understanding the complexity of admissions affords valuable insights which can be applied to driving overall flow. Holding orders There s been a great deal of controversy over holding orders. As it stands today, both the ACEP and the American Academy of Emergency Medicine (AAEM) have formally stated that holding orders are, with appropriate limits, a good thing. Holding orders, if clearly demarcated as such, are not a patient safety risk. In fact, they are an adjunct to patient safety because the orders get those patients who are ready to leave the E.D., admitted and free up beds for emergency visitors. Literature supports this. ICU management and the swoop Two powerful constraints or drivers for hospital-wide patient flow are ICU management and surgical flow management. At Northwest Community Hospital, in Arlington Heights, Illinois, a lean flow swoop team has been active in the ICU for several years. If patients arrive in the E.D. and meet certain criteria which are clearly spelled out in a policy and procedure, the swoop team is called. A nurse practitioner or a senior nurse will swoop down, grab the patient and deliver the patient to the ICU for a speedy and full evaluation. In the interests of operational efficiency, the quicker ICU patients (or any patient, for that matter) move to where they can receive definitive care, the better off they are. A number of hospitals utilize lean swoop techniques, but most of the time performance improvement team s simply do their work and move on so these strategies aren t widely published. Faxed nurse reports For many hospitals, a faxed nurse report can and should be a best practice. I have had the following experience with a small E.D. nurse focus group, nurses dedicated to quality patient care and wanting to do the right thing, lured in by two slices of pizza and a drink, meeting around a table to discuss the best times to admit a patient to the hospital. After going through the life cycle of a work day, they determined that the only good time to admit a patient from the E.D. was between 3:00 to 5:00 am 7

10 because, for the rest of the day they were literally busy with other tasks. This is not an anecdote about good people doing bad things (inpatient nurses refusing to take admissions from the E.D.). Inpatient units have constraints which may cause them to deny or put off admissions if they can. A faxed nurse report takes no out of the inpatient nurse s workload and avoids the issues of telephone tag or verbal reports. It s not a fixall. It won t solve all admission problems. But it can be a valid and efficacious tool. Adopt-a-boarder program This is a program that garners a lot of positive press from the E.D. team. We should immediately acknowledge this is a work-around begging for a better solution - expediently admitting patients up to the inpatient units. This said, an adopt-a-boarder program can be a powerful driver for improving both patient satisfaction and inpatient team behaviors. It is extraordinarily rare for the E.D. to successfully initiate this as the primary sponsor of the program, since E.D. and inpatient incentives aren t typically fully aligned. Thus an adopt-a-boarder program should be developed and deployed by your inpatient teammates. Virtually every hospital in the US boards patients every day. Unfortunately, most are in the same hallway that of the E.D. Sharing the burden with inpatient wards can improve patient care, safety and satisfaction. Dr. Peter Viccellio shares a wealth of overcrowding resources, including protocols and articles, on his website created with support of the Emergency Medicine Foundation (EMF), the education and research arm of ACEP. Partnering with hospitalists Many hospitals have hospitalist programs. Emergency clinicians often find, surprisingly, that hospitalist programs actually impede patient flow, dependent upon incentives, patient load and staffing levels. If incentives are aligned, if hospitalist s pay is based on patient volume or length of stay metrics, if adequate staffing is available at peak hours and under peak loads, if work is performed cooperatively, there is probably no better flow tool available than a good hospitalist program. In a perfect world, patient care should be seamless from the E.D. door to inpatient treatment and discharge. The two groups ought to work together on improved admission processes, open communication, shared goals and superior relationships. An ideal process looks like this: A patient is initially seen in the E.D. The E.D. and hospital physicians collaborate during the admission process with pre-agreed upon admission orders, criteria and timelines The patient is admitted to the inpatient floor as quickly as possible under with the hospitalist s care Then a further course of treatment is determined. This is the model one should aspire to. 8

11 HOSPITAL-WIDE FLOW: CRACKING THE CODE If a hospitalist program is a sub-optimal contributor to smooth patient flow, an emergency physician or nurse can undertake a number of practical steps. First, observe bed control to see how this set of processes actually works. Second, follow the admission of one patient (or several patients) from arrival in the E.D. to discharge from the hospital in order to obtain a true visceral understanding of the processes and the patient journey. Third, spend time with the hospitalist service to both observe and understand their work-flows and habits. Fourth, if possible, obtain relevant data or metrics about the processes, problems and goals at hand. Building on these skills and experiences, discuss the hospitalist program with the appropriate hospital manager and have a separate conversation with the lead hospitalist. Determine where the gap is between the current situation and where the two departments should be. Examine the people, processes and performance (as well as taking a hard look at the incentives, looking closely at what is aligned and what is misaligned). Build a plan to move forward together. Early warning and response system A hospital should have an early warning and response system for when flow is becoming problematic. When E.D. flow starts to back up, one should know whether or not it s time to call in an X-ray tech, a unit coordinator, a physician, a nurse or an entire team. Although most E.D.s have a written defined policy, there is seldom sufficient attention paid to the signs, signals, triggers and action plans that are needed. The same policies and procedures should be available on the inpatient side. One should also be trending the relevant metrics and paying attention to incentives, constraints and consequences. Demand capacity management If one thinks conceptually about admissions and governance on a hospital-wide basis, there are four significant components: (1) a bed management process, (2) an early warning and response system, (3) a forecasting and planning system and (4) a real-time demand capacity system. Bed management While it may or may not be fully optimized, it may or may not be working as effectively as it should; every hospital already has a bed-management process in place. Long-term forecasting and planning Just as one can predict or model this year s flu season, one can predict how many ICU beds will be required by day of the week, who s coming and what needs to be done. Most hospitals are engaged in informal modeling programs. They base next year s census on the previous year s census. Since patient flow is predictable, these numbers can be refined to a higher degree by examining acuity, resource needs and the gap between desired level of performance and actual performance. Real-time demand capacity system 9

12 Every hospital needs or should have, a real-time demand capacity system. This is a system whereby hospital units predict the evening before and the day of what the incoming patient load will be and what the discharge patient load will be, then come to a conclusion as to whether patient demand can be handled with the predicted capacity. More open beds than admissions make for a great day. If capacity does not meet demand, the unit needs to determine how to open up capacity in real-time to facilitate patient flow. An article entitled Using Real-Time Demand Capacity Management to Improve Hospitalwide Patient Flow was published in the May 2011 Joint Commission Journal on Quality and Patient Safety by my colleagues and I. This is actually a manual, a howto guide, on how to implement real-time demand capacity management. As outlined in the article, units at the unit level were asked to predict their capacity to accept admissions within a designated time period. The initial request was for the unit s prediction of its capacity to accept admissions from 9:00 a.m. to 2:00 p.m. for the following day. The goal was to first have units predict demand and capacity from 9:00 a.m. to 2:00 p.m. and once that prediction was obtained, the intention was to move on to predicting capacity from 2:00 p.m. to 9:00 p.m. The assumption was that actively managing these two time segments were required to permit daily planning of flow. The actual results were a complete surprise and a wonderful example of why prototyping and testing are critical. It was discovered that if hospitals could predict demand and successfully manage capacity for the 9:00 a.m. to 2:00 p.m. time segment, they didn t need to worry about the rest of the day; it took care of itself. Similar to a rising tide lifting all boats, if the unit could smooth and optimize admissions from the 9:00 a.m. to 2:00 p.m. segment, admissions for the entire day would be smoothed and optimized. With a few exceptions, this type of phenomenon has been demonstrated in other areas as well. In several studies, some published and some not, we prototyped team triage programs for eight hours in busy E.D.s of 50,000, 60,000 or 70,000 visits. A doctor, technician, scribe and nurse were placed out front for eight hours during the busiest time of day. The effect was improved patient flow during both the actual hours of operation and for the entire 24 hours of the day. This phenomenon is also true on the inpatient side. By utilizing the number of currently-available open beds and the number of patients planned for discharge, which can be predicted with about 80 percent accuracy, a level of capacity can be determined. Demand can then be predicted based upon historical admissions, upcoming surgical schedules and anticipated bed unit demand for the next day. It s as simple as this. If capacity exceeds demand, no action is required. If demand exceeds capacity, it must be determined whether a unit level 10

13 HOSPITAL-WIDE FLOW: CRACKING THE CODE change (an action that is both confined to the unit and can be successfully carried out by the unit) can address or solve predicted mismatch. The action may be as simple as rescheduling a patient s CT scan from 1:00 pm to 7:00 am so the patient can go home once the scan is complete. It may be as simple as a unit nurse following up to obtain written discharge orders from the doctor to permit a patient s discharge. Eighty percent of unit interventions involve a unit level activity. The other 20 percent involve deeper or bigger circumstances. In such cases, units can work cooperatively to help each other out, or C-level managers can arrange for the deployment of needed resources. Real-time demand capacity may appear complicated, but it s not; it can be readily understood and employed. Details are laid out in the above-referenced article. The processes can be discussed among E.D. clinicians, hospital administrators and admission teams and appropriate measures put in place to improve flow. Smoothing surgical flow to decrease hospital census variability The concept of smoothing surgical flow was prototyped and spread by Eugene Litvak, PhD and his team and was first instituted as part of a Robert Wood Johnson/Urgent Matters project. The premise is that the OR has a significant impact on patient flow through the hospital. The elective surgery schedule drives corresponding patterns in inpatient census. A trick question: if E.D. cases account for 50 percent of admissions and elective scheduled OR cases account for 30 percent of admissions, which is the greatest source of census variability? Surprisingly, both contribute equally. Why? Because surgical flow involves artificial variability. Artificial variability If cardiovascular surgeons operate only on Mondays and Tuesdays, thereby filling ICUs on Thursdays and Fridays, this is a source of variation, but not natural variation. It is unnatural or artificial variation which can and must be eliminated. A case in point: one hospital went on bypass every Thursday. Investigation revealed that the phenomena wasn t random, but occurred because the cardiovascular surgeons were operating heavily on Mondays and Tuesdays. Although convincing cardiovascular surgeons to change schedules may have been a difficult hurdle, this was accomplished. Scheduling one cardiovascular surgeon to operate on Mondays and one on Wednesdays smoothed the flow and the need to go on bypass disappeared. Natural variability If one examines ten successive congestive heart failure patients, one realizes not all CHF patients are the same. Similarly, in observing ten ankle sprain patients with the same grade ankle sprain, one will note 11

14 differences in management complexity. This is natural variation which cannot be eliminated but must be accounted for and managed. There is not a single global solution that will address all inpatient flow problems. However, there is a rich portfolio of options and opportunities available. The magic happens not when just one of these choices is implemented; the magic happens when a number of them are initiated and executed well. E.D. clinicians may not be the ones implementing these options, but it is essential to become familiar with them. E.D. clinicians must appreciate the available tactics, know where inpatient teams can get administrative and operational support and obtain the inpatient team s commitment to adopting these solutions. Key principles of patient flow Patient flow is a complex technical problem which cannot be solved by one discipline, one department or one process change. The solutions require high levels of cooperation and integration with multiple systems (or silos) working together; the ICU, the E.D., the PACU, surgery. This is both the challenge and the opportunity. The opportunity for gains is incredible, but the path is complex. The solutions cannot merely be installed. Effective diagnosis of the problems is required along with execution of successful Plan-Do- Study-Act (PDSA) cycles to test the changes and then ultimately prototyping PLAN DO and installing the solutions ACT STUDY appropriate for individual hospitals. The myth of 100 percent utilization A health care system cannot operate at 100 percent utilization. Since a hospital is packed with unscheduled arrivals, it is a partial queuing system. Thus, utilization needs to hover around percent, not 100 percent, so the built-in slack and flexibility can accommodate unscheduled events. This is an exceedingly hard concept for hospital managers to accept, but must be factored into any attempts at change. 12

15 IN SUMMARY The Joint Commission has mandated that hospitals appoint hospital-wide flow committees to examine processes, analyze data and make ongoing improvements. As physicians it s often easier to play the role of critic and criticize how things are working rather than actively becoming part of the solution. Few understand flow and systems management better, however, than E.D. practitioners for whom minutes and hours are critical concerns. Few understand the timely management of people and resources better. Thus, it behooves E.D. clinicians to either participate in or chair their hospital-wide flow committees. The good news, the exciting news, the practice-changing news, is that a broad portfolio of solutions exists which can radically smooth and improve both hospital-wide and E.D. patient flow. With will, ideas and execution, it can happen. 13

16 14 REFERENCES

17 HOSPITAL-WIDE FLOW: CRACKING THE CODE Bazarian J. J. and S. M. Schneider, et al. Do Admitted Patients Held in the E.D. Impair Throughput of Treat and Release Patients? Acad Emerg Med. 1996; 3(12): Building the Clockwork E.D.: Best Practices for Eliminating Bottlenecks and Delays in the E.D. HWorks. An Advisory Board Company. Washington D.C Christensen, C, J Grossman and J Hwang. The Innovator s Prescription: A Disruptive Solution for Health Care Crane, Jody and Chuck Noon. The definitive guide to E.D. operational improvement. Boca Raton, FL: CRC Press, Fitzsimmons J. and M. Fitzsimmons. Service Management: Operations, Strategy, Information Technology. 5th ed. Boston: McGraw-Hill Forster, Alan, et al. The Effect of Hospital Occupancy on E.D. Length of Stay and Patient Disposition. Academy of Emergency Medicine 10.2 (2003): Husk, G. and D. Waxman Using Data from Hospital Information Systems to Improve E.D. Care. SAEM 11(11): Jensen, Kirk and Thom Mayer. Hardwiring Flow: Systems and Processes for Seamless Patient Care. Gulf Breeze, FL: Fire Starter Publishing, Jensen, Kirk and Daniel Kirkpatrick. The Hospital Executive s Guide to E.D. Management. Marblehead, Massachusetts: HCPro, Jensen, Kirk and Jody Crane. Improving patient flow in the E.D. Healthcare Financial Management Nov. 2008: I-IV. Jensen, Kirk, Thom Mayer, Shari Welch and Carol Haraden. Leadership for Smooth Patient Flow. Chicago, Illinois: Health Administration Press, Jensen, Kirk. Expert Consult: Interview with Kirk Jensen. E.D. Overcrowding Solutions Premier Issue. Overcrowdingsolutions.com Kelley, M.A. The Hospitalist: A New Medical Specialty. Ann Intern Med. 1999; 130: Full Capacity Protocol. Goldratt, E. The Goal. Great Barrington, MA: North River Press, Holland, L., L. Smith, et al Reducing Laboratory Turnaround Time Outliers Can Reduce E.D. Patient Length of Stay. Am J Clin Pathol 125 (5): Langley J, Moen R, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide. 2nd Edition. San Francisco: Jossey-Bass Maister, D. The Psychology of Waiting Lines. In J. A. Czepiel, M. R. Solomon & C. F. Surprenant (Eds.), The Service encounter: managing employee/customer interaction in service businesses. Lexington, MA: D. C. Heath and Co, Lexington Books

18 Meade, Christine, Julie Kennedy and Jay Kaplan. The Effects of E.D. Staff Rounding on Patient Safety and Satisfaction. JEM 2010; 38.5: between Delay to Reaching an Inpatient Bed and Inpatient Length of Stay. Med J Australia 2002; 177:492. Norman, D. A. Designing waits that work. MIT Sloan Management Review 2009; 50.4: Norman, D. A. The Psychology of Waiting Lines. PDF version is an excerpt from a draft chapter entitled Sociable Design for a new book- org/dn.mss/the_psychology_of_waiting_lines Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; (Available on Resar, R, K Nolan, D Kaczynski and K Jensen. Using Real-Time Demand Capacity Management to Improve Hospital-Wide Patient Flow. The Joint Commission Journal on Quality and Patient Safety 37.5 (2011): Schull et al. E.D. Contributors to Ambulance Diversion: a Quantitative Analysis. Annals of Emergency Medicine 41:4 April 2003; Weintraub, Barbara, Kirk Jensen and Karen Colby. Improving Hospitalwide Patient Flow at Northwest Community Hospital. Managing Patient Flow in Hospital: Strategies and Solutions. 2nd ed. Oakbrook Terrace, Illinois: Joint Commission Resources, Wilson, M. and Nguyen, K. Bursting at the Seams: Improving Patient Flow to Help America s E.D.s. Urgent Matters White Paper. September, Richardson, DB. The Access Block Effect: Relationship 16

19 HOSPITAL-WIDE FLOW: CRACKING THE CODE About the Author Kirk B. Jensen, MD, MBA, FACEP, is Chief Innovation Officer for EmCare and Chief Medical Officer for BestPractices, Inc. Dr. Jensen has spent over 20 years in Emergency Medicine management and clinical care-coaching, consulting, and developing innovative patient care solutions including the award-winning Risk-Free ED, and is a national thought leader in patient safety, risk management, integrated care, practice management, standardization, emergency department flow and hospital-wide flow. Kirk B. Jensen, MD, MBA, FACEP, As a faulty member for the Institute for Healthcare (IHI), Dr. Jensen has held numerous leadership positions focusing on quality improvement, patient satisfaction, and patient flow both within the ED and throughout the hospital. Dr. Jensen also serves as a Medical Director for Studer Group. He was honored by the American College of Emergency Physicians (ACEP) as the Outstanding Speaker of the Year. Dr. Jensen has contributed to numerous articles and books including The Hospital Executive's Guide to Emergency Department Management, Emergency Department Leadership and Management: Best Principles and Practice, Emergency Department Management and The Patient Flow Advantage. Copyright 2012 BestPractices Inc. All rights reserved. This publication may not be reproduced, stored in retrieval system, or transmitted in any form or by any means-electronic, mechanical, photocopying, recording, or otherwise-without prior permission of the copyright owner. This White Paper is an informational document. Readers should note that this document does not represent an endorsement by an entity. All page headers and custom graphics are service marks, trademarks, and/or trade dress of BestPractices, Inc. All other trademarks, product names, and company names or logos cited herein are the property of their respective owners. Any comments relating to the material contained in this document may be sent to the BestPractices Marketing Department: Mail: info@best-practices.com BestPractices, Inc Eaton Place, Ste 180 Farifax, VA

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