1. Improving Patient Flow by Managing Variability
2nd Annual Ellison Pierce Symposium
Positioning Your ORs For The Future
Improving Patient Flow by Managing Variability
Eugene Litvak, PhD
Program for Management of Variability
In Health Care Delivery, Boston University
Boston University School of Medicine
May 19, 2006
8:00-8:30am

2. QUESTION:
What do you think is the largest source of your hospital’s census variability?
the emergency room
the elective OR schedule
the ED and elective OR schedules impact is equal
No idea
0 / 10

3. Does your hospital try to smooth scheduled patient flow?
QUESTION:
Does your hospital try to smooth scheduled patient flow?
Yes No
Don’t know
0 / 10

4. Why should we smooth scheduled patient flow?
Can we afford not to smooth scheduled patient flow?

5. How unsmooth census looks like?

7. Systemic Effects of Peak Loads
Internal Divert –Patients sent to alternative floors\Intensive Care locations
Internal Delays – PACU backs up
External Divert - ED divert
Staff overload – medical errors and inability to retain staff
System Gridlock – Increase in LOS
Decreased throughput and revenue

8. Variability is the Universal Key
Litvak E. & Long MC. Cost and Quality Under Managed Care: Irreconcilable Differences? American Journal of Managed Care, 2000; 6 (3):
Litvak E. "Optimizing patient flow by managing its variability". In Berman S. (ed.): Front Office to Front Line: Essential Issues for Health Care Leaders. Oakbrook Terrace, IL: Joint Commission Resources, 2005, pp

9. The Ideal Healthcare System (100% efficiency)
All patients have the same disease with the same severity.
All patients arrive at the same rate.
All providers (physicians, nurses) are equal in their ability to provide quality care.

10. Variability as the source of system stress
Clinical stress.
Patient flow stress.
Stress by variaton in proffesional abilities or teaching responsibilities.

11. } Natural Variability I) Clinical Variability II) Flow Variability
III) Professional Variability }
Natural Variability
Random
Can not be eliminated (or even reduced)
Must be optimally managed
Optimal management of natural variability requires expenditure and can not be a source for cost reduction. The affect of such an attempt would be a decrease in quality. (e.g. forcing patients inappropriately on pathways by administrative decree)
At end - “Is this the end of the variability story?” [pause] “Let’s consider a real life example of a typical hospital problem - census variability.”

12. Why managing variability today is more important than before?

13. Designing and Testing Complex Mechanical Systems: Family Car
Hitting a pothole vs. high speed impact against the wall
Health care “financial bumper”
Are the stresses an intrinsic part of health care delivery?

14. What makes hospital census variable?
Why is this a problem for a hospital
Staffing: below or above average? Cost/quality of each option.

15. What makes hospital census variable?
If ED cases are 50% of admissions
and…
Elective-scheduled OR cases are 35% of admissions
then…
Which would you expect to be the largest source of census variability?

16. The answer is…
The ED and Elective-Scheduled OR have approximately equal effects on census variability.
Why?
Because of another (hidden) type of variability...

17. Artificial Variability
Non-random
Non-predictable (driven by unknown individual priorities)
Should not be managed, must be identified and eliminated
Relate concept of artificial variability to OR specifics (e.g. every weekday is different, there is no pattern, etc.)
In this example, artificial variability is caused by a dysfunctional scheduling process (i.e. competing individual priorities).

18. Variability in the Census - Rising Volume
Thursday July 14, /16/96
Variability in the Census - Rising Volume
26##

19. Variability and access to care
ICU ED
Scheduled demand
Floors

20. Variability and Quality of Care*
Inadequate numbers of nursing staff contribute to 24% of all sentinel events in hospitals.  Inadequate orientation and in-service education of nursing staff are additional contributing factors in over 70% of sentinel events
* Dennis S. O’Leary, JCAHO (personal communication)

21. Source: Carol Haraden, Ph.D., IHI

22. Variability and mortality
Litvak E, Buerhaus PI, Davidoff F, Long MC, McManus ML, Berwick DM. “Managing Unnecessary Variability in Patient Demand to Reduce Nursing Stress and Improve Patient Safety,” Joint Commission Journal on Quality and Patient Safety, 2005; 31(6):
“Each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue”*
* Linda H. Aiken, Sean P. Clarke, Douglas M. Sloane, Julie Sochalski, and Jeffrey H. Silber. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA, 2002; 288: 1987:1993

23. Example: Assumptions: 200 surgical beds
average census for surgical beds 160
staffing level 40 nurses (1 nurse per 4 patients)
average residual from 160 patients census is 20% or 32 patients
patients are distributed evenly between the nurses
How the mortality rate will change with
20% increase in surgical demand?

24. Results:
32 additional patients will be distributed evenly between 32 nurses: 1 additional patient per nurse or = 5 patient per nurse
these 32 nurses now will take care of 160 patients, whose mortality rate increases by 7%
if these additional 32 patients will be distributed evenly between 16 nurses, then each such nurse will take care of = 6 patients
these 16 nurses now will take care of 96 patients, whose mortality rate increases by 14%

25. Root Cause Analysis of Emergency Department Crowding and Ambulance Diversion in Massachusetts,
Boston University, 2002: ED diversions study under Department of Public Health grant
When the scheduled demand is significant, there was much stronger correlation between scheduled admissions and diversions than between ED demand and diversions

26. Elective Surgical Requests
vs Total Refusals
Michael L. McManus, M.D., M.P.H.; Michael C. Long, M.D.; Abbot Cooper; James Mandell, M.D.; Donald M. Berwick, MD; Marcello Pagano, Ph.D.; Eugene Litvak, Ph.D. Impact of Variability in Surgical Caseload on Access to Intensive Care Services, Anesthesiology 2003; 98:

27. Smoothing elective admissions: Success story
Managing Patient Flow: A Focus on Critical Processes      

28. St. John’s Hospital (OR)
Increased surgical annual case volume by 33% in the last three years.
Increased personal surgical revenue by 4.6%
OR overtime is record low 2.9%
Reduced waiting time for available OR by 45%
Dramatically improved OR nurse retention
Increased ED throughput by ≈ 60% with no patient boarding