***The following Questions 1-4 need to be answered in the order set up***
*** Please use the attached resources - especially chapter 33 in Emergency Department Management 2nd***
1) Why is it so important to try and match ER service capacity to patient demand?
2) What is the operational principle behind fast- tracking uncomplicated patients in the emergency department?
3) Why is patient flow so important to patients and clinicians?
4) Why should maximal operational efficiency & effectiveness not be based solely on process speed?
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1 Flow is an important concept, as it addresses making processes, people, place, and performance in the emergency department (ED) more efficient and effective, thus resulting in greater satisfaction and better outcomes for both patients and staff. This chapter briefly introduces the key concepts involved in flow, which other chapters examine in more detail. Most important, it presents a vocabulary or taxonomy of flow and highlights the key operational management principles that are essential for understanding the more detailed concepts and applications presented in other chapters. UNDERSTANDING FLOW The concept of flow can be found in a number of industries, but it is particularly important in service operations like health care, restaurants, and hotels. The concept of flow plays a critical role in the “Lean” approach to health‑care operations and services—a method that originated in Japanese manufacturing to streamline processes and improve productivity while always focusing on the needs of the customer. Flow in Emergency Medicine Theories, methodology, and applications of flow have been increasingly refined over the years and adapted for use in medicine. “Flow” in emergency medicine can be defined as the efficient movement of patients through the network of services that constitute ED operations (from arrival to evaluation, diagnosis, treatment, and discharge or admission to the hospital) while adding value and eliminating waste.1 The essence of flow as it pertains to health‑care service operations is that all of the steps in the process are highly coordinated and orchestrated in such a manner that patients progress smoothly through the continuum of care. Like water flowing in a river, patients should move continuously through health‑care processes toward desired outcomes and end points. Delays caused by inefficient or uncoordinated processes impede patient movement through the system just as rocks, sharp curves, and other obstacles can impede the flow of water. Flow is easy to misunderstand. For instance, ED managers can be tempted to map their processes and declare, “Here is our flow.” Having a process is not synonymous with having flow; in fact, a great deal of work and effort is usually required to fine‑tune the process. Because flow initiatives emphasize efficiency, it is tempting to think that PATIENT THROUGHPUT: WHY IT MATTERS, HOW IT IS DONE Kirk Jensen, Thom A. Mayer, With Jay Kaplan, Stephanie Baker CHAPTER 33 2 Emergency Department Management flow simply entails shaving time off of critical processes. While taking steps to improve flow often does involve making processes more efficient, such steps should only be taken if they lead to better patient care. Simply stated, improving flow both reduces waste and adds value. For some patients and conditions, these improvements mean allocating more time to diagnose and treat conditions properly. Another perspective, and an important one, is the psychological concept of flow, which can be found in studies originated by psychologist Mihaly Csikszentmihalyi in the mid‑1970s. Csikszentmihalyi describes flow as being deeply and constructively engaged or immersed in a task or action, with a resultant sense of clarity, where feedback is immediate and clear, challenges are matched with skills, a feeling of intense focus develops, self‑consciousness disappears, time seems transformed, and the results are at an extremely high level of performance (Figure 33.1). In other words, when flow exists, people are able to carry out their roles with an energized focus and a Clear goals: Expectations and rules are discernible, and goals are attainable and align appropriately with one's skill set and abilities. No self-consciousness: Action and awareness merge. Time distortion: One's subjective experience of time is altered. Direct and immediate feedback: Successes and failures during the activity are apparent, and behavior can be adjusted as needed. Balance: The activity is neither too easy nor too difficult. Control: One has a sense of personal control over the situation or activity. Intrinsic rewards: The activity is effortless to perform. Physical immersion: During the activity, one's own bodily needs are ignored, even reaching a point of great hunger or fatigue. Absorption: The focus of awareness is narrowed down to the activity itself. Concentration: The activity demands a high degree of engagement and concentration. FIGURE 33.1 ■ Mihaly Csikszentmihalyi on Flow Chapter 33 ü Patient Throughput: Why It Matters, How It Is Done 3 deep sense of fulfillment.2‑4 This feeling of “being in the zone” is what ED leaders and staff seek to attain when working to optimize departmental flow. The Seven “Rights” of Flow Effectiveness and efficiency capable of adding value and eliminating waste arise from ensuring that leaders have systems that are designed to produce the right application of the seven “rights” (Figure 33.2). The right resources ensure that only the necessary costs are applied to the problem, whether clinical or administrative. The right patient ensures that core measures are used to define what measures will be used to gauge success for this patient. The right environment means that the “MVP” of the health care system, the bed, is used to the best advantage, and only for as long as the bed adds value. The right reasons are the evidence‑based‑protocols (grounded in evidence‑based medicine [EBM])— based on randomized controlled trials whenever possible and open to iterative change as further evidence develops. The right team ensures that all those involved in the patient’s care are operating at the top of their license and are best deployed to add value. The right time means that flow metrics are in place and monitored over time, so that flow and efficiency are maximized. Finally, every patient, every time, every person is an embodiment of the commitment to patient safety and high‑reliability organizations. Right resources (costs) Right patient (core measures) Right environment (bed) Right reasons (EBM) Right time (flow metrics) Every time! Right team (best people) FIGURE 33.2 ■ Flow and the Seven “Rights” 4 Emergency Department Management The Importance of Flow Consider the following case study. In an ED averaging 40,000 patient visits each year, an initiative to improve flow cut the average length of stay by 1 hour (from 2‑3 hours). 2. Doing so provided 40,000 additional hours of service capacity in that department. At 2 hours per visit, that improvement in throughput provided the capacity for 20,000 additional patient visits annually, utilizing essentially the same staff and resources.2 If net collected revenue is $100 per patient in professional fees and $400 in professional fees, this flow improvement would result in an increase of net revenue of $2 million for the physician group and $8 million for the facility fees, as well as $3,000 to $7,500 per admitted patient. This example illustrates an important observation about flow and throughput: Flow can be affected positively or negatively by small changes in the number of patients moving through the department or small changes in service capacity. Changing those capabilities at particular points in the process can negatively affect the ED through delays or positively enhance it by smoothing flow and reducing delays. Processes can determine whether patients experience satisfying encounters or frustrating delays and whether staff feel energized, focused, and engaged or rushed and at risk of making mistakes. The reason small changes in volume or capacity can have ripple effects is mathematical: As these variables change, they influence the system exponentially and not linearly. Mathematicians can describe the theory and demonstrate the effects, but the important implication for attaining smooth flow is that small changes can lead to big impacts. Principles of Flow The lessons businesses and service organizations have learned about flow over the past half century fall into several categories listed in Box 33.1. By being familiar with these concepts and applying the insights gained from research, flow can improve dramatically in the ED.5‑7 Demand and Capacity As Figure 33.3 makes clear, “demand” and “capacity” are important concepts in flow. “Demand” means how many people—potential customers or, in health care, patients—want or need the services an organization offers. Demand in health care can also be viewed as the amount of resources those patients require. Correspondingly, “capacity” is the amount of BOX 33.1 ■ PRINCIPLES OF FLOW • Systems thinking and appreciation: a network of components that work together to achieve common aims • A theory of knowledge: an understanding of the ED, the hospital, and their processes • Key drivers of system performance: { Demand-capacity management { Queuing { Variation • High-leverage interventions: the theory of constraints • Method of improvement: Lean, Six Sigma, etc. • Where waiting exists: apply The Psychology of Waiting Lines gary Highlight delete gary Highlight bottlenecks. user Sticky Note Yup user Sticky Note Good Chapter 33 ü Patient Throughput: Why It Matters, How It Is Done 5 resources available to evaluate, diagnose, and provide treatment and service. The interplay between these variables determines how smoothly the process flows. Demand is created by the arrival of incoming patients who require various levels of treatment. The demand for services created by patients will be met by various servers in the ED, including beds, nurses, doctors, and advanced practice providers (APPs). Therefore, it is important to determine the specific demands patients will have on each type of server. The challenge faced by professionals staffing an ED is that demand can fluctuate on a daily and hourly basis. That being said, there are methods for characterizing demand within a service environment like an ED to account for this type of variation. In this sense, even though demand is uncertain, it is somewhat predictable, allowing managers to align or match capacity to meet it. One has to appreciate that there are trade‑offs between cost, throughput, productivity, length of stay, patient waiting times, and safety. Recognizing these trade‑offs is the key to staffing an ED that meets throughput targets while simultaneously providing high‑ quality care to patients, a satisfying work environment for staff, and financial stability for the department. A sophisticated demand/capacity analysis should be based on arrivals and acuity by hour of the day and day of the week, and even by season of the year—as well as on service times and targeted performance measures. With the appropriate use of such demand/ capacity management analytics, the ED operations team is best equipped to answer the following questions: How many physicians, APPs, and