PATIENT FLOW 99
How re-aligning patient flow helped Palmetto Richland Hospital make substantial savings and dramatically improve quality of care.
F
ive years ago, Ellis Knight had a problem. As Vice President of Medical Affairs at Palmetto Health System in Columbia, South Carolina, one of his responsibilities was to evaluate and carry out root cause analyses of significant adverse events that had occurred in the Palmetto Richland hospital. Invariably one of the fi rst fi ndings in each case would be that these events had occurred during times when medical staff had had to manage a large number of patients in a short period of time. The peaks and troughs in the hospital’s case load were more than mere annoyances; they had the potential to cause serious harm. Around this same time, Knight – who is now the health system’s Senior Vice President of Ambulatory Services – and his senior management colleagues had signed up for a course in managing healthcare operations given by Eugene Litvak, President and CEO of the Institute for Healthcare Improvement. They came away inspired. “The course took place over nine months with a few on-site sessions in Boston, and some coursework and activity projects in between,” Knight recalls. “Over that time, we became quite enamored with his model for managing vari-
ability and helping patient flow throughout the hospital, and then, subsequently, made arrangements to work with his team at Boston University to come and help us implement some of that in our own organization.” Knight praises Litvak’s approach as “unique” and says it got to the root cause of a lot of the problems that his hospital – and indeed, many others – suffer from. These included long wait times in the emergency department, patient dissatisfaction, employee dissatisfaction, lower margins due to an inability to maximize volume and throughput, and most particularly, says Knight, a concern that these bottlenecks in flow were resulting in significant quality-of-care problems and potential patient harm. Many hospitals faced with a similar challenge would solve it by building more capacity, but Knight believes that far from solving the problem, adding more space can exacerbate it. “It seemed to us that by managing the flow, we would get more to the underlying cause of the dysfunction, as opposed to other measures which would simply put a Band-Aid, if you will, on those manifestations that we were seeing. For instance, with emergency department overcrowding, the first thing you think is, ‘Let’s build more capacity.’ “One of the genius aspects of Dr. Litvak’s approach is that he can show both mathematically and also in many instances where it’s been tried, that building new capacity doesn’t alleviate the problem, and, in fact, can exacerbate it by creating more capacity and more problems with high f low or peaks. And often at a great deal more expense than what you would have to put into trying to adjust the more basic problem, which is the f low variability.”
Smoothing flow Knight and his colleagues decided that the best way forward for their institution was to implement Litvak’s model for smoothing elective surgical flow through operating rooms. “We did that because – and this is one of the unique aspects of his design, I feel – he can show that the elective surgical flow is something that in most hospitals does come in peaks and valleys and does cause stress on the system, but fortunately it’s something that, theoretically at least, we can control. “The flow to the emergency department is more what we call natural variability, and has to do with how many people become ill with contagious illnesses, or trauma, or whatever may be causing those peaks and valleys. But the variability in flow in elective surgeries is all due to something that we can control, and that’s the desire of surgeons to operate on a certain day at a certain time and do certain cases. “Th is approach was something we could get a handle on, and Dr. Litvak does a very good job of analyzing your own data and showing you that that would create significant benefits. “We assembled a group of surgeons and began meeting on a monthly basis at the ungodly hour of 6 a.m., when surgeons can fi nd time to get together. We did that for more than a year, and went through a very methodical process
Knight_PATFLOW.indd 99
10/11/2010 15:36