Improving Patient Flow Helps Conquer Health Care’s Complexities

In 1967, renowned management consultant, educator and author, Peter Drucker, wrote that hospitals were the most complex organizations ever created. In the more than 50 years since, they have only become more complicated with developments – like new technologies, sub-specialties and electronic health record systems – layered on top of poorly designed processes.

I have been a health care leader at Virginia Mason Health System in Seattle for more than 30 years and an executive sensei to health care organizations around the world. Over the course of my career, I have learned that while there are many things we can be working on, there are only a few things that will have a transformational and lasting impact on conquering complexities. Improving patient flow is one of those critical initiatives.

Important lessons

Virginia Mason has spent the last 20 years working to adopt a management system based on the core principles of continuous improvement, eliminating waste and defects, and demonstrating respect for people by giving staff the opportunity – and expectation – to drive improvement efforts.

When we began to change our mindsets as leaders, our senseis encouraged us to go into the organization to see what was happening on the front lines where patient care was being delivered. The sensei would often have me stand in the same place on a hospital or clinic floor to watch the movement of staff and what was happening with patients.

It was awkward at first and I was unsure what to look for. “No talking, no asking questions,” the sensei would say, “simply watch.” Over time, I was able to see the chaos and waste endemic in our organization. I saw nurses in the hospital leaving patient rooms multiple times to find supplies, and lining up to get patient medications from dispensing units. I watched physician assistants frequently interrupted by pages, and physicians hurriedly reviewing records – in front of waiting patients – to see what preventative tests needed to be ordered. I also saw doctors apologize to patients for long waits to get an appointment, only to see them wait again in an exam room.

Afterward, the sensei asked me, “What are you doing about the rework your team members are having to manage?” They said, “It is very disrespectful to staff that they have to do so many wasteful things because of poorly designed processes. This is your job as a leader.” Those experiences left an indelible impression and fundamentally changed my view of what my role as a leader is, and where I should focus my time.

Focusing on flow

Whether in a hospital or ambulatory care setting, improving patient flow is powerful work. It allows team members to understand why they need to change processes and it helps the entire organization change how it works to support patient flow in the hospital and clinics.

What it takes

First, it takes the commitment of leaders to sponsor and engage with this work. It requires active involvement of physicians, and all team members, to understand the current state – whether that is what steps occur when a patient makes an appointment, comes to the emergency department or is cared for on a hospital floor. It also takes making real-time observations to document what is currently happening and using data to help determine how patient flow can be improved.

Our 10 years of experience teaching the tools and methods for doing this in many organizations around the world has shown us that this is very doable. The secret is that it is the people who do the work making these observations. It is team members trained on how to use the standard tools who gather the information. Team members also learn guiding principles for creating patient flow, which means there is good standard work in place and bottlenecks and defects in processes have been eliminated.

By having the people who do the work improve the work, you ensure they understand why the changes are needed and can help the entire team support changes that are made.

“Improving patient flow is important work that begins and ends with leadership.”

Leaders as sponsors

For leaders to be sponsors of this work means they must identify this as a priority and ensure there will be sufficient resources committed to improvement work. The main resource is the time needed for team members to observe and document the current state, and to develop and implement improvements. Virginia Mason Institute’s approach emphasizes rapid cycle study and improvement cycles.

Our intent is to try things and measure whether they are improving processes. If they are not, we help change them. There is tremendous discipline and rigor to this method. It requires leadership at all levels to support the work by holding them – and their teams – accountable for making and sustaining improvements.

Results

Results are what make it all worth it. You see teamwork and collaboration increase among team members – people start to see each other as colleagues, not as the problem. You see patient satisfaction go up and positive comments multiply.

Collateral benefits

I often hear from physicians that they value the organization and its leaders’ understanding of the challenges they face in caring for patients and prioritizing improvement work. When you study patient flows within your health care organization, you start to see bottlenecks. If you are in the emergency department, bottlenecks can be delays getting test results in a timely fashion or getting drugs delivered quickly so patients can be sent home. It also could be that there is not a bed open on the appropriate hospital floor to admit a patient. Leaders start to understand the impacts of patient flow when they understand the most significant bottlenecks and inefficiencies for team members and begin to support them in designing solutions to alleviate them.

Metrics, metrics, metrics

Patient flow work is very metric driven. It is an important part of determining whether changes being made are making a difference and if gains are being sustained. To do this, we teach mid-level and front-line leaders how to monitor results on an ongoing basis. Seeing how even small process improvements can have a big impact on patients, staff, and the bottom line builds staff engagement and motivation to champion this work.

Food for thought

Virginia Mason Institute has developed robust tools and training to help organizations diagnose patient flow problems and develop customized improvement plans to begin addressing them. Improving patient flow is important work that begins and ends with leadership.

Whenever I think about the importance of flow improvement work, a powerful quote comes to mind. It was shared with us many years ago from the wife of a Virginia Mason patient. She said, “Some of us are spending our last moments with each other within these walls. Please always remember that you are treating people, not diseases. Please don’t add to our frustration, worry and grief by asking us to waste those last few, precious moments we have with our loved ones waiting unnecessarily in lines or in waiting rooms for appointments.”

Sarah Patterson, MHA, FACMPE, is executive director of Virginia Mason Institute. She helped Virginia Mason establish its own lean production system to eliminate waste, improve quality and patient safety and has been on seven study missions to Japan. During her 30-year tenure, Virginia Mason has received national and international recognition for its efforts to transform health care, most notably as the leader in adapting the Toyota Production System for health care. This management method engages leaders, providers and frontline staff to use lean tools and methods purposefully by focusing on improvements that advance quality, safety and value within organizations.

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