The Institute of Medicine, in its landmark report “Better Care at Lower Cost,” concludes at least $750 billion of the total national healthcare budget of $2.7 trillion represents waste as a result of poor IT infrastructure, supplier- rather than patient-centered reimbursement, lack of quality and transparency, and inefficient operations and flow.
Wasteful operations may include: delays, over-processing, redundant work, poor inventory management, inefficient transport, unnecessary motion, over-production (push instead of pull), and defects that cause harm and re-work.
The airline industry has worked on these problems for decades and although its operations and flow patterns are significantly less complex than healthcare, it has mastered basic elements we can learn from to give us a jump-start on mastering and taming a difficult but necessary component of operational design that will lead to improved outcomes at lower costs.
1: Air traffic control is managed as a system, not a place
Flow through the airport affects and directly result from flow outside the airport, and air traffic control does not make any distinction. We often treat emergency department or intensive care unit flow as an isolated problem whereas every aspect of an individual’s care from inpatient, to post-acute, to ambulatory has a direct impact on the other. As it turns out, what happens to an individual outside of a hospital has a greater effect on length of stay and flow than what happens inside. Thus, we will never master hospital flow until we master the flow of the entire system.
2: Airport operations function 24/7
Airports function 24/7 and so should healthcare systems. Flow should be managed around the clock and utilization managers should be replaced with flow coordinators who hand off their oversight continuously based on time of day and setting of care. For instance, when a plane takes off, airport air traffic control transfers responsibility to regional air traffic control, and oversight of the flight is continually monitored from control station to control station until the flight terminates at another airport.
Similarly, a flow coordinator should orchestrate a patient’s non-emergent arrival, the admission process, the inpatient care, the discharge planning process and then transfer responsibility for the patient to an outpatient flow coordinator to ensure appropriate follow up and continued optimal care. Ideally, the term “discharge” should be replaced with “care transition” so we stop thinking of moving from one environment to another as a beginning or end.
3: All departures are scheduled in advance
The three most common bottle-neck areas in a healthcare organization are the emergency department, the intensive care unit, and the surgical areas (pre- and post-operative). The vast majority of delays in these expensive settings involve the discharge planning process as patients in these areas often have no place available to go, thus backing up operations throughout, delaying treatment for others waiting to come in, reducing patient/staff satisfaction and increasing costs. Ironically, most discharges are predictable to within one hundredth of a day based upon risk and severity-adjusted length-of-stay data bases (e.g., Premier) for each diagnosis-related group.
Therefore, most discharges should be scheduled at least 24 hours to 48 hours in advance (ideally when the patient arrives) with arrangements made for nursing home or ventilator beds, physician appointments, home health on the day of admission in anticipation for discharge. Many healthcare organizations are purchasing or contracting with nursing homes, home health services, psychiatric facilities and physician practices to gain greater control and ease of scheduling by extending the chain of its operations into the outpatient setting.
4: All arrivals are scheduled in advance
One healthcare myth is that emergent arrivals are unexpected. As it turns out, if emergent ED, surgical, or ICU admissions are tracked over time, the vast majority are predictable. For instance, most emergency department admissions arrive between 3 p.m. and 11 p.m. with the fewest arrivals between 4 a.m. and 9 a.m. There will be rare disasters, which require special resources through a disaster planning process; however, these can be managed and illustrate the difference between random (uncontrollable) and non-random (controllable) variation in flow.
Truly random variation can and should be managed by policy whereas non-random variation should be eliminated by standardizing flow to accommodate predictable admissions in a predictable way through optimum staffing, resource allocation (including beds) and standardized admission processes.
5: Flight schedules are smoothed throughout the day and week
An airport only can handle its capacity of arrivals and departures at any point in time and so it manages the schedule to ensure a consistent schedule of flights throughout the week and time of day. Emergency departments, surgical facilities, and intensive care units can be similarly managed so that non-emergent patients who arrive at the ED can be transferred to lower acuity areas during peak hours, elective surgical schedules can be scheduled evenly throughout the week to avoid demand surges, and ICU admissions can be coordinated based upon regional transfer agreements in compliance with EMTALA to ensure appropriate stabilization and safety.
The system needs to be viewed holistically so all of the units and outpatient facilities coordinate flow in a synchronized and synergistic way to accommodate flow throughout the system and not within a unit alone.
6: Delayed flights are taken off of main runways and taxiways
When air traffic control delays a flight, the delayed flight does not block other flights but is directed to another area to await further instruction and movement. Delayed discharges, transfers and admissions should not sit in beds blocking patient flow but should be immediately moved to a comfortable and appropriately supervised holding area where they can be safely managed and not delay the timely diagnosis and treatment of non-stabilized patients.
Most patients waiting for beds are stable and should no longer receive top priority or undermine the overall efficiency and effectiveness of the system. Similar holding areas can be utilized for admissions, transfer, and discharges if beds are interchangeable and staff is cross trained to handle a broad range of diagnoses and conditions.
Although air traffic flow is simpler and easier to manage than healthcare, the industry can offer many lessons that will enable us to treat patient flow systemically as a 24/7, inpatient/outpatient, continuous operation that requires continuous management and oversight to standardize processes, exploit bottle-necks, manage random variation and eliminate non-random variation. By doing so, we can reduce costs, improve quality/safety/service and successfully compete globally for high quality-low costs services.
Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He also is president and CEO of The Burroughs Healthcare Consulting Network.