Emergency Room Throughput Diagnosis Part 2 - Removing the Blockage

AN OVERVIEW OF THE SITUATIONday, or 24 hours. The question was, could the
In Part 1: Blocked Arteries!, we had discoveredlength of stay be shortened that much by
that the highest corporate goals were producingcleaning up the Inpatient Process?
radically different - and conflicting - activitiesGETTING TO THE ROOT OF THINGS
among the staff in different departments. In thisSo, assuming that throughput in the Inpatient
article we will review the next steps that resultedProcess was critical to throughput in Emergency,
in the removal of the blockage, and how it setthe team got down to business systematically
the stage for greatly increased throughput in theidentifying "pinch points" within the Inpatient
Inpatient Process, and subsequently in theProcess. The interviews with staff and physicians
stagnant Emergency Process.had provided much input on common issues, and
HOW THROUGHPUT IS MEASUREDthe further work by the PI Department narrowed
Before picking up on the activities followed by thethose down to about 20, of which 12 were really
throughput team to relieve process blockages andactionable by the team.
improve Emergency through-put, it wouldThe focus of the team at this point was to speed
probably be a good idea to identify key measuresup operation of inpatient care, and to do that the
for success.root causes of the 12 targeted pinch points had
In a hospital, as in any organization, it's importantto be identified. It was here where some of the
to be able to monitor process flow. Manufacturingbiggest surprises came. Prior to this the team (all
usually focuses on the production of theof whom were well-trained in process and
manufactured goods. A mortgage company willproblem solving tools) had done root cause
monitor the speed with which the mortgage is putanalysis, but not to the depth the TOC tools
together and delivered. A hospital, in the samerequired. During the ensuing probing breakdown of
way, must monitor how quickly and how well theissues, it was found that many of the deep root
patient is diagnosed, treated, and moved throughcauses were "linked", or had two causes that had
the hospital system. The "how well" or qualityto happen at the same time, for the problem to
measure for the hospital inpatient is indicated inoccur. As these causes were isolated, team
the outcomes of the care, usually by monitoringmembers brainstormed solutions which were then
returns for care, either in re-admissions, returnstested in a limited fashion for effective-ness.
to surgery, or similar indicators. The "how quickly"AN EXAMPLE OF EFFECTIVE FINDINGS
measure is demonstrated through length of stay,To give an example of one key finding of the
how long the patient is in the hospital for a giventeam, we'll focus on the lab's interaction with the
diagnosis. It's important to understand that thepatient care units.
goal here is an optimum length of stay: theIn order for a physician to make disposition of the
shortest stay possible while still maintainingpatient in a timely manner, he/she must have
excellent clinical outcomes. Hospitals have togood lab data, preferably at the time rounds are
balance the two to be world class.made so the discharge process can be begun.
THE CONSTRAINT TO THROUGHPUT: THEThe team found that blood draws, although
INPATIENT PROCESSfrequently done as early as 2:00 AM, often did
Dr. Goldratt had postulated in his Theory ofnot arrive in the lab in time for the report to be
Constraints that every organization has aready for the physician. Further investigation
constraining process, one that holds all othershowed that because laboratory was budgeted to
processes back from producing at a higher output.a limited number of phlebotomists, lab staff
Since most of the hospital conflict diagramsfrequently batched the 40-50 draws that were
pointed to conflicts with Inpatient, the decisioncommon on first shift. That batching resulted in
was made to focus the team efforts there.late draws, and it was regular for time-critical
WHAT WOULD THE PAYOFF BE?draws to be missed, sometimes necessitating a
Understandably, executive staff was concernedwait of 30 hours before the draw could be done
that the process be worth the expenditures inagain. Did THAT contribute to increased length of
time and money, so a pro-forma was done bystay? Guess so!
the consulting firm that analyzed bed-days. ALENGTH OF STAY COMES DOWN
bed-day was defined as "a patient in a bed forThis lab issue was only one of more than a dozen
one day", and since reimbursement is a fixedfindings of the team. Over a four month period
amount for a given diagnosis, shortening theimprovements were put into place, and between
length of stay would allow more frequent use ofApril and June of that year length of stay
the bed - or more bed-days. If the bed can bedropped from a high of 5.23 days to 4.34 days -
used more frequently, which occurs if thealmost a full day. Not too shabby!
patient's stay is shorter, revenue would increaseAs the picture unfolded, it was discovered that
because of the increased volume. The caveatthe practice of budgeting by function, or
was that clinical outcomes could not bedepartment, was a key contributor to
compromised, the patient had to come out justinefficiencies in the Inpatient Process. As
as well, or better, than before the shortenedsupporting departments, such as Laboratory,
length of stay.Radiology, EKG, etc. "reigned in" their budgets to
The pro-forma showed that the hospital had themeet corporate fiscal requirements, the effect
potential, by shortening length of stay throughwas to delay delivery of the services Nursing
speeding up the Inpatient Process, of generatingrelied on to move the patient through in a timely
about $12,000,000 in new revenue! This could bemanner.
accomplished by reducing length of stay by one