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Overcrowded Hospitals --- and Bottlenecks

November 8, 2008
by Joe Bormel
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Overcrowded Hospitals --- and BottlenecksROI=Zero if you 'fix' anything other than the bottleneck

Overcrowded Hospitals --- and Bottlenecks

ROI=Zero if you improve anything other than a true bottleneck

Two weeks ago, Kate Gamble started

a terrific blog topic on Overcrowding at Hospitals. The posting is worth going back and reading. Kate provides the data and links that really describe the overcrowding situations well. In my blog on

ER wait times, I too elaborated the problem, the CDC data comparing now to ten years ago, and we addressed some solutions. Kate solicited input on "

patient flow systems", as part of the solution.

One smart reader, Julie E. Crowe, chimed in and offered the perspective that, at least in the ED, overcrowding is not a problem that can be solved by a CIO. I was comforted by that response, and it was concordant with my earlier blog on the topic. That said, what can a CIO, or CNO, COO, or CMIO, do to address the problem Kate so eloquently described?

Process Timing - a BI story

Working with Shakespeare Health, a pseudonym for a real, multi-hospital system in the Northeast, I co-led a team that asked exactly those questions: how can an EMR directly enhance patient care, safety, and throughput. To look at patient flow, clinical processes, clinical severity, overcrowding, and economics, we drew data from multiple systems managed by the CIO and his IT department. These included ADT, a clinical system (including lab, pharmacy, nursing, and co-existing illness data), several financial systems, including UB-92 claims and all charges, and data from a commercial, dedicated clinical profiling and outcomes system.

Here's what the conceptual model looked like: (exemplary ED->ICU->Floor path)

The most striking results were the process times, and how they informed the management options. For example, for the lowest severity patients, the median time spent in Resource Center A was 276 minutes. The average was well over twice that (not surprisingly). The median times for the all other severities was consistently in the 4 to 5 hour range.

Sensitivity analyses and other calculations showed that the distributions were not driven by a few 'outliers' but represented true bottlenecks. That's where the CXOs can determine is a patient flow system is the solution to overcrowding, or some other fixed resource constraint is driving the system behavior. To Julie's point, in the later case, a patient flow system wont change throughput.

The complete model, populated graphically with the process data and management actions is here:

This picture summaries the time spent in each care setting (E R, Floor, ICU), for each flow. For example, the top, left-most chart labeled "floor" were direct admission that did not go through the ED. This picture was used as part of an internal presentation to communicate the results.

In contrast with other approaches, this retrospective analysis revealed the annual monetary impact would be on Shakespeare Health for each of the initiatives listed. They are "Re-direct low risk patients ...", increasing the size of the observation unit, instituting new pathways, more aggressively using case managers than historical experience, etc.

These results were calculated based on actual payer mix implications on reimbursements. Scenario's were evaluated factoring in hospital census to calculate the capacity implications (e.g. overcrowding, diversion, and economic impact of not having a medical bed, against it's expected profitability.) The actions were also normalized to factor in the seasonality of overcrowding.

Process Timing leads to Bottleneck Management

The work described above was initially done using Bottleneck Management principle elaborated in an extremely popular book in it's time, The Goal, by Eli Goldratt. The book focuses on the management and social issues. It sneaks in inventory management, operating expenses, cost accounting, scheduling and other domains, in the context of a story.

The big take-aways for Overcrowded Hospitals are very simple:

1) If your process has a bottleneck, and you improve anything about the process other than the bottle, the bottleneck will guarantee that the throughput will be unchanged.

2) Work-in-process inventory will reliably build up in front of the bottleneck. Any good electronic transactional system you already have in place can probably see it today. I included the graphics here to provide an example. You don't need to put in a new patient flow system to see it; how you manage the bottleneck depends on what you see. Julie was right!




Thanks to everyone who has sent me email on this. The graphics, especially the "Process Control 'Rhythm Strip' " render beautifuly in the Firefox browser. They are hard to read in IE6 and IE7, even after I made the images larger. Sorry for the inconvenience.

Joe, these are very interesting findings. Overcrowding is a huge issue facing so many organizations. The line that really grabbed me in your post was: You don't need to put in a new patient flow system to see it how you manage the bottleneck depends on what you see.
While I do believe (based on what some have told me) that patient flow systems can play a part in improving throughput, I see your point in that until the real bottlenecks are addressed, the best system in the world isn't going to make a difference.

Thanks Kate.

Patient flow systems are critical to organizations with 'exposure' to flow problems. We have several clients like this and we, like you, have been reviewing available options.

What I shared was a wholistic view necessary to manage overcrowding within a complex enterprise, with the ability to bring strategic and financial views together, leveraging the comprehensive HIS investments already in place.

There are several IHI patient flow collaboratives that interested readers should investigate. It's likely that the learning will inform the ion of a patient flow system.