Inpatient Flow Real Time Demand Capacity: Building the System Roger Resar, MD, Kevin Nolan, and Deb Kaczynski We would like to acknowledge the conceptual contributions of Diane Jacobsen, Marilyn Rudolph, and Kirk Jensen, MD September 2013 Introduction: Efficient patient flow requires both an understanding of current demand and capacity and the ability to adjust and improve at a micro and macro level. The Institute for Healthcare Improvement s Real Time Demand Capacity (RTDC) approach creates a means to build the infrastructure to improve the key outcomes of hospital-wide patient flow. It also creates a robust tool to identify key barriers to flow that, when appropriate, can become part of an organization s portfolio of improvement projects. By identifying key barriers, the RTDC approach can continuously and in a clearly articulated fashion allow a hospital to respond to changes in the external and internal environment that affect flow. The following is a description of how to build the RTDC system. Leadership: Successful implementation of RTDC requires significant leadership involvement by first making improvement in patient flow part of a hospital s strategic plan and second by investing in a day-today leader to oversee the development of RTDC. The day-to-day leader should be a mid-level employee able to devote a half-time equivalent to the implementation of RTDC over 6 months. Third a high-level leader needs to be assigned and responsible for the achievement of the strategic objective for patient flow and the building of the RTDC system. The day-to-day leader becomes responsible for initiating the 4 steps of RTDC, first on a pilot unit or units and then quickly to all units in the hospital. The day-to-day leader facilitates a hospital wide bed meeting each day in which the current state of capacity and demand in the hospital is evaluated. Lastly, the day-to-day leader is responsible for transparency of all the measurements needed to initiate and sustain the RTDC efforts. Four Steps to Design a Real Time Demand Capacity (RTDC) System Steps #1, #2, #3 should be done simultaneously Step #1: Predict Capacity (Discharges plus available beds) Develop a standard process to predict the number of discharges (Definition of a discharge: patient physically left the patient room and will not return to that bed) from a unit for the time interval 8AM to 2PM. The discharges combined with the empty staffed available beds in the AM will predict the 1
capacity of that unit for the time interval. A suggested process for predicting discharges for this interval is: Care Managers and nurses predict in the late afternoon or early evening potential discharges for the next day based on a described articulated process (who, when, where, how). Set criteria should be developed for placing a patient in the potential discharge category. List is updated by the evening and night staff as patient circumstances change. An early morning unit huddle with care managers and nurses is held to update the discharge list and generate a single number representing the patients predicted to be discharges between 8AM and 2PM. In addition, unit level plans are now finalized for the discharges anticipated to be accomplished by 2pm. Tips for Step #1: 1. The best start-up units in order of preference are connected units (ICU and step-down or PACU and surgical floor for example), service lines (all the medical units for example) or a willing unit. The goal should be to bring all units up within several weeks. 2. Predict the current reality. Whatever positively or negatively affects discharges in your hospital should to be taken into account when making a discharge prediction. Do not try to change clinician behavior or process at this time. 3. Each unit should increase the accuracy of their predictions by understanding why predictions fail and then improve the prediction process. High accuracy of predictions on the initial units is not a requirement before spreading RTDC because each unit should learn by prediction failures. The aim is to get all units up on predictions quickly so a useful hospital wide bed meeting can be convened. 4. The rate for predicting discharges by unit should be determined and tracked over time. The rate is based on whether the patients predicted to be discharged by 2pm were actually discharged. Discharge prediction rates can be displayed by unit for the week or month and for the entire hospital. The goal should be to improve this rate over time. Step #2: Predict Demand (All admissions to a unit) Develop a standard process to predict demand. Demand is the number of admissions (Definition of an admission: Patient has physically been placed in a bed) from the various steams (ED, Directs, PACUs, ICU transfers, etc.) coming into a unit during the time interval 8AM to 2PM. The admissions are those patients the unit predicts will require a bed during the time interval often considering the organizations throughput goals. For example, if a hospital s ED door to floor goal is 4 hours, a patient who needs admission arriving in the ED at 8AM will need to be admitted to a bed before 12PM (not 2PM). Some considerations for predicting admissions for the interval between 8AM and 2PM are: Develop a process to determine the number of admissions coming to your unit currently in the ED (divide medical admissions between medical units etc) Design a process to predict scheduled direct admissions before 2pm (make schedules available) Design a process to determine potential transfers either from specialized units to stepdown units or lateral transfers from like units by 2pm. 2
The exchange of the above information is best achieved by direct conversation between feeder units and receiving units at the beginning of the hospital-wide bed meeting, so a process should be developed to allow this information to be exchanged. Tips for Step #2: 1. Consider known admissions first. That is, patients already in the ED or PACU, patients on the surgery schedule, patients scheduled for a direct admit or an internal transfer 2. Historical data on admissions can be used to help in the prediction. The historical data should be limited to those patients that should be admitted between 8AM and 2PM. Organizations have used some combination of known admissions or historical admissions for the prediction. The historical data allows for variation between days of the week and seasons. 3. Since discharges from the ED are the source of admissions for all other units, the ED needs to be involved early on with the prediction work similar to any other unit. 4. Improve the prediction process for admissions much like the prediction process for discharges by understanding why failed predictions occurred. Step #3: Develop a Plan The prediction of demand (i.e. admissions) in Step #2 should now be compared to the prediction of capacity (i.e. discharges plus available beds) in Step #1. If the prediction of demand exceeds the prediction of capacity, a plan to match the capacity to the demand must be created by the unit either prior or in the hospital bed meeting. If the unit cannot create a plan that accomplishes the matching of demand to capacity using unit resources, then system level help will be required. (An example of system level help would be the opening of a flex unit.) The plan needs to be a written document in which the who, what, when, where and how of the plan are clearly articulated. Tips for Step #3: 1. The demand and capacity predictions and the need for a plan should be placed on a chart/board by each unit at the hospital bed meeting. The chart should be kept simple with 4 entries (unit name, predicted admissions by 2PM, predicted discharges by 2PM and whether capacity will meet demand for the interval. 2. Those units where capacity is greater than demand need special attention during the bed meeting during which a facilitator will ask whether unit level resources or system level resources will be needed to create the necessary capacity 2. If a plan to meet demand is needed, a unit should be asked first what adjustments (plan) they can make at the unit level to meet the demand. 3. Unit level plans utilize those resources that the unit has at its disposal. Examples might be adjusting unit staffing assignments, extra efforts by the unit staff to arrange a ride, or arranging for the diabetic educator to meet with the patient and family a little earlier. These are activities which units already are skilled at accomplishing. 4. If unit adjustments are insufficient to develop a successful plan, system level adjustments (e.g. Hospitalists expediting the discharge of patients from certain units, Director of Radiology moving up the priority of an x-ray for a particular patient, opening a flex unit) 3
need to be considered. Shared resources should be distributed at a macro level (bed meeting). 5. Plans should be unique based on current reality rather than from a list of unproven and generic possible solutions. 6. Whether it is a unit or system plan, the plan created at a bed meeting needs to be communicated back to the appropriate stakeholders in a clearly articulated manner (who, what, when, where and how). 7. The focus of the formal all hospital bed meeting should be on units that need plans and whether system level adjustments are necessary. 8. The unit level plan should be an actual written document both for clarity and to analyze the plans for success or failure. 9. A huddle at the unit level after the formal bed meeting should be held to develop the details for executing the plan for the time interval. 10. Focus initially on developing a plan for a specific time period (e.g. 8:00AM to 2PM). Finer synchronization of capacity to demand can then be considered (for example, a bed is needed at 10:30 for an early surgical patient.) Step #4: Evaluate the Plan (and the Predictions) At the end of the time interval, plans are evaluated with a simple yes or no as to whether the plan was successful. Plans are of various types: Unit level plans for the patients initially predicted to be discharged before 2PM. Each of those discharges will have actions that need to be accomplished before the discharge occurs Unit level plans developed when predicted demand exceeds predicted capacity System level plans (which use system level resources) which come out of the bed meeting when a unit cannot match capacity and demand with their own resources If a plan was not successful a determination as to why the plan failed is necessary. (For example, if the unit needed one more discharge to match demand and created a unit based plan to work with the Hospitalist to discharge one more patient and the discharge did not occur, then the unit needs to evaluate why this failure occurred.) Alternatively if the plan worked, the strategy used should be cataloged and be made available for use in the future. The day-to-day leader should be responsible for looking at these plans. Feedback to the hospital-wide bed meeting both on the success of the previous days plans at the unit and system level and also the predictions at the unit level should be done daily. Tips for Step #4: 1. The success of a plan is based on the plan initially designed in the morning by the unit or the system. Do not evaluate the plan based on modifications made to adjust to changing demand or capacity throughout the time interval. 4
2. Develop a process (who, what where, when) to assure the plan is evaluated. This could either be done at an afternoon meeting or assigned as a role to a person such as the patient placement coordinator. 3. Create a feedback process by which all plan successes and failures are noted. A 5 minute review at the next day s hospital bed meeting is recommended. 4. Successful plans should be cataloged for future use, while failed plans need to be analyzed for the barriers causing the failure. 5. It is advisable that a unit track whether capacity matched or exceeded demand each day (yes/no). The percent of days where capacity matched or exceeded demand should increase as predictions and plans improve. 6. Develop a process by which identified barriers causing recurrent problems are systematically improved within the confines of the improvement capabilities of the organization. 7. Barriers identified should be common problems. Working on a barrier that is seldom would waste resources and not substantially contribute to improving overall flow. 8. Successful plans that are continuously deployed should also be reviewed to determine whether a process change can be made so that the plan becomes part of the system (e.g. establishing a standard appointment for a physical therapy session before 10AM for a patient being discharged that day) Copyright Institute for Healthcare Improvement 2013 5