Patient Flow Enewsletter
Volume 2, Issue 1
Thursday, February 3, 2005
Having worked in both private and non-profit hospitals, as well as for HMOs, and as a practicing physician, Robert Wise, M.D., brings unique and multiple perspectives to the Joint Commission on Accreditation of Healthcare Organizations, where he has worked for the past six years. Currently the Joint Commission's vice president of the Division of Standards and Survey Methods, Dr. Wise is responsible for the development of standards and survey methods for all current programs and for new product development.
Those standards include JCAHO's new Leadership Standard, "Managing Patient Flow." The new standard became effective on Jan. 5, 2005, which means that institutions surveyed by JCAHO for accreditation will henceforth be evaluated on adherence to the standard.
Introduced as a draft in 2003, the final standard was released early last year after being significantly modified to reflect comments received from hospitals during the public review period. Most hospitals have devoted considerable resources during the past year to diagnose and cure inefficiencies that contribute to patient crowding, which in turn leads to patient safety and quality concerns.
Dr. Wise recognizes that there are both systemic and relationship barriers that many hospitals have to overcome in order to implement the standard. He is confident, however, that hospitals that successfully meet the standard reap benefits that extend far beyond alleviating crowding.
Interview: Robert A. Wise, MD; Vice President, Joint Commission
Q. Can you briefly explain the background and purpose of the new standard?
In a nutshell, "Managing Patient Flow" puts an obligation on hospital leadership to develop plans to maximize efficient patient flow throughout the hospital. I have documents on this topic in my files that show that JCAHO was discussing this as early as 1991, so this is nothing new. But discussions began in earnest in 2001 as we increasingly saw in the field that there were serious problems of overcrowding in emergency rooms. JCAHO realizes, of course, that there are public policy issues at play here that go way beyond what the hospital or the Joint Commission can influence, in terms of local saturation of primary care providers and increased numbers of uninsured patients. But at the same time, we recognized that there are things that we could look at that would partly contribute to solutions. The new standard reflects that.
Q. Originally this standard was entitled "Emergency Department Overcrowding" and the name was later changed to "Patient Flow." Can you elaborate on this?
The name change reflects an evolution in JCAHO's thinking about the extent of the problem. Originally we looked at the emergency department as the place that is closest to this issue and I think many people perceived that this was largely an ED problem. But thanks to discussions through JCAHO's roundtables and a lot of public comments, we recognized that efficient hospitals do not just monitor and manage the flow of patients through the parts of the hospital that are most vulnerable to crowding, such as the ED. It became clear that while the ED is very visible as a point where patient crowding begins, actually moving the flow depends on a lot more than what the ED controls and involves all other parts of the hospital. We also received a lot of feedback that showed EDs were concerned that the finger would be pointed at them to fix "their problem." That's exactly not what we wanted to happen.
Q. Why did JCAHO feel that this standard should be written specifically for hospital leadership?
It's very important that this is a Leadership Standard and that it focuses ultimate accountability for this standard precisely on the hospital leaders. In our discussions, one of the things we discovered is that internal impediments to patient flow can only be effectively mitigated by the involvement of the organization's top leaders. To meet this particular standard, hospital leaders have to provide the resources and expectation to make it happen. They need to provide the necessary manpower, funding and time to collect data about the extent of the problem at their facility, analyze the data, and coordinate the hospital's resources across the board. It is vital that they view addressing this issue as one of the critical responsibilities that they need to manage. During the vetting process, a number of people commented that hospital leaders needed to get involved in order to address this problem, or said things like 'we're overloaded and not being heard by others.' I think placing responsibility on the top leadership helps give everyone involved a stronger voice.
Q. At the same time, administrative and medical staff needs to share responsibility for managing patient flow processes. Can you comment on that?
It very much is a shared responsibility. What this is really about is having difficult but important discussions - and making decisions - between the ED staff, hospital administration and all other sectors of the hospital. Every hospital has demands on its resources from both elective and non-elective services. The person who ultimately is in charge of admission and discharge of a patient is a physician, and it's difficult for another physician or an administrator to raise discussions about making his or her admission or discharge decisions more systematic or efficient. Or, for example, for medical staff and administrators to even begin discussing changing times and days of elective surgeries in order to maximize hospital efficiency, it requires a very close and trusting relationship between all parties. Everyone is concerned that if you put too many impediments on a physician who wishes to use your hospital for elective surgery, he or she will find somewhere else to go, and that's money out the door. There's already tension between administration, the ED, and surgical staff. These types of discussions potentially further stress relationships that are already stressed, but they nevertheless need to take place in order to help alleviate the underlying problems with patient flow.
Q. It seems that many hospitals have not historically viewed overcrowding as a significant safety threat. How does inadequate patient flow lead to safety concerns in a hospital?
Inefficient patient flow starts a cascading of problems that are significant safety threats. When you have people waiting to get into beds from the ER, people being boarded, people in the hallways, people stacked up in a recovery area, or not getting in or out of the ER, that's a safety threat. When I give presentations, I often ask the audience whether their hospital has people lined up in the hallways on a unit or in the ED. The hands always go way up. It's a serious issue because this is a clear violation of the life safety code. If there's a fire, for example, a person has to be in a location that can be immediately closed off from smoke. If someone is in a corridor, they cannot be isolated and the hospital is in violation. And it's not just a violation of the Joint Commission, but also of CMS and probably their local fire codes, too.
This boarding issue is a particularly difficult one because there are often architectural limitations, particularly in older hospitals, that many facilities don't see how they can overcome. Since they can't put people in the hallway and don't have space for an overflow waiting room, this can be a real challenge. I also think that making the commitment to hiring a "bed czar" for the hospital is tough. That's not a JCAHO requirement, of course, but it is one idea that has proven to be very effective at many hospitals. If a hospital does it, they believe this needs to be a top priority. I know that it is difficult for many hospital leaders to let this issue rise to that level of priority.
Q. What advice do you have for healthcare organizations that may be experiencing difficulties in making progress in improving patient flow?
I think every hospital has to first make a serious effort to understand the root causes that are involved in this problem. They are system-wide and very complicated, and each leader needs to do his or her exploration to determine what is happening in their hospital and what changes can yield the greatest result. It involves a good understanding of the problem and then the courage to implement changes. Of course any issues of safety must be dealt with immediately. And then all the secondary issues must be addressed in a systematic fashion. One looks at the problems and the potential interventions and implements the ones that they think will give them the biggest bang for their buck.
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Elements of Performance for LD.3.15
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Robert Wise, M.D.
Vice President, Division of Standards and Survey Methods
Joint Commission on Accreditation of Healthcare Organizations
Oakbrook Terrace, IL
