Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. Joint Comm J Qual Patient Saf

Boston University, Boston, USA.
Joint Commission journal on quality and patient safety / Joint Commission Resources 07/2005; 31(6):330-8.
Source: PubMed

ABSTRACT BACKGROUND: Increases in adverse clinical outcomes have been documented when hospital nurse staffing is inadequate. Since most hospitals limit nurse staffing to levels for average rather than peak patient census, substantial census increases create serious potential stresses for both patients and nurses. By reducing unnecessary variability, hospitals can reduce many of these stresses and thereby improve patient safety and quality of care. THE SOURCE AND NATURE OF VARIABILITY IN DEMAND: The variability in the daily patient census is a combination of the natural (uncontrollable) variability contributed by the emergency department and the artificial (potentially controllable) peaks and valleys of patient flow into the hospital fromelective admissions. Once artificial variability in demand is significantly reduced, a substantial portion of the peaks and valleys in census disappears; the remaining censsus variability is largely patient and disease driven. When artificial variability has been minimized, a hospital must have sufficient resources for the remaining patient-driven peaks in demand, over which it has no control, if it is to deliver an optimal level of care. DISCUSSION: Study of operational issues in health care delivery, and acting on what is learned, is critical. Al forms of artificial variation in the demand and supply of health care services should be identified, and pilot programs to test operational changes should be conducted.

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    • "The issue of patient flow variability has also been extensively analyzed by other authors [9,34–39]. Particularly, Litvak makes a distinction between natural variability and artificial variability [10] [11] [36]: natural variability is uncontrollable and is due to the intrinsic characteristics of health care delivery (for example, patient flow from the ED), whereas artificial variability is potentially controllable through managerial intervention and is due to process defects or incorrect behaviors. According to Litvak [11], the key to improving patient flow management – and, consequently, accommodate growing demand – is to increase the bed occupancy by eliminating patient flow variability. "
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    ABSTRACT: Through a comparative study of six Italian hospitals, the paper develops and tests a framework to analyze hospital-wide patient flow performance. The framework adopts a system-wide approach to patient flow management and is structured around three different levels: (1) the hospital, (2) the pipelines (possible patient journeys within the hospital) and (3) the production units (physical spaces, such as operating rooms, where service delivery takes places). The focus groups and the data analysis conducted within the study support that the model is a useful tool to investigate hospital-wide implications of patient flows. The paper provides also evidence about the causes of hospital patient flow problems. Particularly, while shortage of capacity does not seem to be a relevant driver, our data shows that patient flow variability caused by inadequate allocation of capacity does represent a key problem. Results also show that the lack of coordination between different pipelines and production units is critical. Finally, the problem of overlapping between elective and unscheduled cases can be solved by setting aside a certain level of capacity for unexpected peaks.
    Health Policy 01/2014; 115(2-3). DOI:10.1016/j.healthpol.2013.12.010 · 1.91 Impact Factor
    • "Many sources of variability in healthcare challenge hospital staffs and administrators' ability to efficiently manage resources. This variability may be a source of system defects or breakdown (Story, 2011; Litvak & Long, 2000; McManus et al., 2003; Litvak et al., 2005). Variability in patient flow stems from variation in arrival patterns (e.g., natural arrivals at an ED, scheduled patients within a clinic, electively scheduled procedures in an operating room) and patients' LOS. "
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    ABSTRACT: Healthcare organizations face challenges in efficiently accommodating increased patient demand with limited resources and capacity. The modern reimbursement environment prioritizes the maximization of operational efficiency and the reduction of unnecessary costs (i.e., waste) while maintaining or improving quality. As healthcare organizations adapt, significant pressures are placed on leaders to make difficult operational and budgetary decisions. In lieu of hard data, decision makers often base these decisions on subjective information. Discrete event simulation (DES), a computerized method of imitating the operation of a real-world system (e.g., healthcare delivery facility) over time, can provide decision makers with an evidence-based tool to develop and objectively vet operational solutions prior to implementation. DES in healthcare commonly focuses on (1) improving patient flow, (2) managing bed capacity, (3) scheduling staff, (4) managing patient admission and scheduling procedures, and (5) using ancillary resources (e.g., labs, pharmacies). This article describes applicable scenarios, outlines DES concepts, and describes the steps required for development. An original DES model developed to examine crowding and patient flow for staffing decision making at an urban academic emergency department serves as a practical example.
    Journal of healthcare management / American College of Healthcare Executives 03/2013; 58(2):110-24; discussion 124-5. · 0.73 Impact Factor
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    • "In addition, 20% reported attempting to implement surgical schedule smoothing but had met with failure. Surgical schedule smoothing is the process of balancing surgery loads throughout the week (ie, an equal number of surgeries every day), as opposed to what is commonly done in hospitals, which is to schedule elective surgeries during weekdays.32,33 Respondents did not detail why surgical smoothing and the use of inpatient floors, successful solutions to ED crowding in other states, had not been implemented in their EDs in Pennsylvania. "
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    ABSTRACT: Introduction: The state of emergency department (ED) crowding in Pennsylvania has not previously been reported. Methods: We assessed perceptions of ED crowding by surveying medical directors/chairs from Pennsylvania EDs in the spring of 2008. Results: A total of 106 completed the questionnaire (68% response rate). A total of 83% (86/104) agreed that ED crowding was a problem; 26% (27/105) reported that at least half of admitted patients boarded for more than 4 hours. Ninety-eight percent (102/104) agreed that patient satisfaction suffers during crowding and 79% (84/106) stated that quality suffers. Sixty-five percent (68/105) reported that crowding had worsened during the past 2 years. Several hospital interventions were used to alleviate crowding: expediting discharges, 81% (86/106); prioritizing ED patients for inpatient beds, 79% (84/106); and ambulance diversion, 55% (57/105). Almost all respondents who had improved ED operations reported that it had reduced crowding. Conclusion: ED crowding is a common problem in Pennsylvania and is worsening in the majority of hospitals, despite the implementation of a variety of interventions.
    The western journal of emergency medicine 02/2013; 14(1):1-10. DOI:10.5811/westjem.2011.5.6700
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