«Prepared for California HealthCare Foundation Final Report December 2006 Program for Management of Variability in Health Care Delivery Boston ...»
Improving Patient Flow and Throughput in California
Hospitals Operating Room Services
California HealthCare Foundation
Program for Management of Variability in Health Care Delivery
Boston University Health Policy Institute
53 Bay State Road
Boston, MA 02215
Table of Contents
Chapter I: Basic Operations Management 9
Chapter II: Current Issues in Health Care 33 Chapter III: Variability in the Health Care Delivery System 46 Chapter IV: Re-Engineering the OR 65 Chapter V: Improved Quality of Care and Patient Safety 111 Chapter VI: Assessment of Patient Flow 122 Chapter VII. Boston Medical Center (Case Study) 131 Chapter VIII. St. John’s Regional Health Center (Case Study) 155 Chapter IX: Cincinnati Children’s Hospital Medical Center (Case Study) 176 About the Authors Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp Introduction In 2001 Institute of Medicine (IOM) report “Crossing the Quality Chasm: A New Health System for the 21st Century” described many problems in the
US health care delivery system.  In this report IOM suggested that:
“Health care should be:
• Safe—avoiding injuries to patients from the care that is intended to help them.
• Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).
• Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
• Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care.
• Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy.
• Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”  However, the current state of the health care delivery in California and nation-wide is far from even approaching these goals (see chapter II). As stated in : “There are at least four problems that are caused to a greater or
lesser degree by poor management of patient flow:
Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp
• ED overcrowding and limited access to care
• Nurse understaffing/overloading
• Diminished quality of care
• High health care cost”  It is clear that presence of the above four problems will prevent the health care delivery system from truly achieving any of the six aims formulated in the above cited IOM report. Do these problems have common cause? Is there a common remedy for addressing these four problems? We strongly believe that the answer to these questions is “yes”. “None of these problems can be satisfactorily resolved unless patient flow is properly managed. In turn, addressing variability in patient flow is absolutely necessary, although not sufficient, to managing patient flow.”  How to manage patient flow? What should be one’s starting point? Could it be the Emergency Department (ED), the Intensive Care Unit (ICU) or Telemetry unit? The answer is “no.” None of these units can be improved as long as scheduled admissions are not streamlined (see chapters III and IV); thus, one cannot start managing patient flow by addressing one specific unit. Indeed, as long as hospital is subjected to artificial swings in patient admissions, none of these units could operate in a non-stress environment.
Attempting to manage problems by adding more staffed beds to these units would only exacerbate the problem, as it would result in an increased magnitude and frequency of artificial peaks and valleys in elective admissions volume.
Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp Therefore, the starting point should be elective admissions and the Operating Room (OR) as the main source of these admissions that has a large ripple effect on all hospital operations . This document is focused mostly, although not exclusively on re-engineering OR services because, in our opinion, for most hospitals (except for those with low surgical volume) OR should be a starting point for re-engineering. Almost any improvement in other units (ED, ICU, etc.) could be diminished or negated by a “broken” OR scheduling system. Managing hospital patient flow, as recommended by  should extensively employ operation management (OM) methodologies. The adoption of these methodologies that are so widely and successfully used by almost every industry for dozens of years is long overdue in health care (see chapter I). Operations management, and particularly Variability Methodology, is only making its first steps in health care delivery, but has already demonstrated very impressive results (see chapters VII-IX). What does improved patient flow, particularly surgical flow, means for patient safety? A detailed answer to this question is given in chapter V. By no means is the OR the only unit that should be evaluated to improve patient flow. In chapter VI we provide a description of the typical hospital patient flow assessment performed by our Program.
Why did we write this document? For several years, Boston University’s Program for the Management of Variability in Health Care Delivery (referred to as "Management of Variability Program [MVP]" http://www.bu.edu/mvp) has focused its activity on developing and implementing in practice new and existing operations management methodologies, and has become a recognized national and international leader in this area. One of the highlights of MVP’s activity was developing Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp and implementing innovative Variability Methodology [see chapter III, 2, 3].
Program results in this area have been widely acknowledged and recognized by the IOM  the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [http://store.trihost.com/jcaho/product.asp?dept_id=34&catalog_item=712], the Institute of Health Care Improvement (IHI) and many others. While being an academic organization that develops new approaches to improving health care delivery system, MVP also concentrates its efforts on practical implementation of its research by working with individual hospitals, where it has achieved very impressive results at both community and academic institutions. To highlight some of the results (see chapters VII-IX for more
• Surgical annual case volume increased by 33% without adding OR resources
• Surgical “bumps” delays in surgery decreased by 99.5% from 700/year to 7/year
• Number of medical admissions through the ED increased by 59% without adding any nurses or beds and without creating ED “boarders”.
• Patient waiting times reduced dramatically, even when patient volume increases
• Significantly improved patient, surgeon and nurse satisfaction These and other results are described in details in the case studies below (chapters VII-IX).
Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp The limited size of this document does not allow us to describe in full detail the work and perspectives of our distinguished consultants—physicians, nurses, and hospital executives—who were the champions at their hospitals in achieving the results included above and in the case studies, and who should take the biggest credit for these achievements. It has been a great pleasure working with them over the past several years. We do plan to include their experiences and perspectives in more detail in our next publication. I would like, however, to thank a few of them, who have helped us to make this manuscript much better for both their editorial comments and their impressive leadership at their hospitals: John Chessare, MD, MPH, Interim President/CEO and Senior Vice President for Quality and Patient Safety, Caritas Christi Health Care System, President, Caritas Norwood Hospital; Christina Dempsey, RN, MBA, CNOR, Vice President for Perioperative and Emergency Services, St. John’s Regional Health Center; Janet Gorman, RN, Admissions and Transfer Coordinator, Boston Medical Center; Keith Lewis, MD, Chairman, Department of Anesthesiology, Boston Medical Center, and Professor of Anesthesiology, Boston University Medical Center; Marilyn Rudolph, RN, BSN, MBA, Vice President, Performance Improvement, VHA Pennsylvania, Inc.
We also would like to thank our colleagues at the hospitals, which have applied methodology described in this document for their leadership. They are: Elena Adler, MD, Associate Professor of Anesthesia and Pediatrics, Cincinnati Children’s Hospital Medical Center; James Becker, MD, Chairman, Division of Surgery, Boston Medical Center; Cindy Bedinghaus, RN, Senior Director of Nursing-Perioperative Services, Cincinnati Children’s Hospital Medical Center; Brad Bowenschulte, MD, Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp Chair of the Department of Anesthesiology, St. John’s Regional Health Center; John Chessare, MD, MPH, Interim President/CEO and Senior Vice President for Quality and Patient Safety, Caritas Christi Health Care System, President, Caritas Norwood Hospital; Peter Clayton, Senior Vice President of Surgical Operations, Cincinnati Children’s Hospital Medical Center;
Christina Dempsey, RN, MBA, CNOR, Vice President for Perioperative and Emergency Services, St. John’s Regional Health Center; Janet Gorman, RN, Admissions and Transfer Coordinator, Boston Medical Center; Kathryn Hays, RN, MSN, Senior Director of Nursing in the Operating Room, Cincinnati Children’s Hospital Medical Center; William Kent, MHA, Senior Vice President of Clinical Care Delivery, Cincinnati Children’s Hospital Medical Center; Uma Kotagal, MBBS., MSc., Vice President, Quality and Transformation, and Director, Health Policy and Clinical Effectiveness, Cincinnati Children’s Hospital Medical Center; Dean Kurth, MD, Chief of Anesthesia, Cincinnati Children’s Hospital Medical Center; Kenneth Larson, MD, General and Trauma Surgeon, Medical Director, Burn and Wound Center, St. John’s Regional Health Center; Keith Lewis, MD, Chairman, Department of Anesthesiology, Boston Medical Center, and Professor of Anesthesiology, Boston University Medical Center;
Neils Rathlev, MD, Executive Vice Chair of the Department of Emergency Medicine, Boston Medical Center; Frederick Ryckman, MD, Director, Liver Transplant Surgery, Professor of Clinical Surgery, Cincinnati Children’s Hospital Medical Center, Elaine Ullian, MPH, President, Boston Medical Center.
We are also enormously grateful to the California HealthCare Foundation for providing their support for the creation and publication of this document.
Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp We appreciate their recognition of this important issue and are indebted to them for making it possible to spread awareness and knowledge of the application of operations management in health care.
It is our hope that the material contained within this document can serve as a first step in helping our potential audience (physicians, nurses, hospital executives and managers) to significantly improve quality of care, patient safety, physicians and nurse satisfaction while substantially reducing the cost of care. Please note that the material contained within this document is written by various MVP faculty members, each of whom is addressing different aspects of hospital redesign. It is not the authors’ goal to make all of the chapters have similar style, as each chapter serves a unique purpose.
We would appreciate any of your comments, and would be glad to respond
to your questions, which you can send to us via our Web site:
Eugene Litvak, Ph.D.
Professor and Program Director Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp References
1. The Future of Emergency Care in the United States Health System.
Institute of Medicine. June 14, 2006.
2. Litvak E. “Optimizing Patient Flow by Managing its Variability.” In Berman S. (ed.): Front Office to Front Line: Essential Issues for Health Care Leaders. Oakbrook Terrace, IL: Joint Commission Resources, 2005, pp. 91-111.
3. Litvak E, Long MC. “Cost and Quality Under Managed Care:
Irreconcilable Differences?” American Journal of Managed Care, 2000 3(3):
Program for Management of Variability in Health Care Delivery December 2006 www.bu.edu/mvp
Short History and Description of Operations Management Operations management (OM) is defined as “the use of quantitative methods to assist analysts and decision-makers in designing, analyzing, and improving the performance or operation of systems.”1 Operations management (frequently called operations research) has been applied extensively across many industries including manufacturing, transportation, construction, the military, and financial planning, among others. Regardless of the industry, the application of operations management entails the following: “Mathematical, computational, and analytical tools and devices are employed to provide information and insight into systems and processes;