To understand one reason why your hospital cares so much about patient throughput and discharging patients before noon, think of tables in a restaurant. A restaurant has a limited number of tables, and the more quickly they serve customers, the sooner they’re able to seat a new party. So by improving their throughput, they can serve more customers and increase profitability without having to add tables.
Of course, the more a restaurant pushes to increase throughput, the more it risks a decrease in the satisfaction of its customers. Too much focus on throughput could annoy customers so much that it puts them out of business (Seinfeld’s Soup Nazi is one notable exception).
Yet hospitals are likely to increase their customers’ satisfaction by improving “front-end” throughput from the ED to the inpatient unit. In fact, CMS added two new core measures (known as inpatient quality reporting, or IQR) that hospitals began reporting on Jan. 1:
- Median time from ED arrival to ED departure for admitted patients, and
- Admit decision time to ED departure for admitted patients.
You already knew about these, right? Although they don’t directly influence Medicare payments to your hospital now, there is a pretty good chance they could become part of the Hospital Value-Based Purchasing program in the future. So expect administrative leaders at your hospital to continue pestering you about ED throughput with even greater intensity.
I confess that improving throughput feels like one of the most difficult things for me to do, and I sweat when in meetings about it. Yet I know intellectually that we can do better. After all, it wasn’t that long ago that a patient could expect to wait hours to see an ED doctor, and shortening the wait seemed an impossible task. But EDs everywhere have done just that, and now lots of them post the current ED wait time (typically less than 10 or 15 minutes!) on the Internet or billboards. So if they can do it, then I’m sure hospitalists can, too.
I wrote about hospital throughput in my April 2009 and May 2010 columns, and included some strategies you might want to try. Here are a few more directed at ED-to-inpatient ward throughput.
The One-Admitter Approach
Most practices have no option other than a single admitter at night, but if your one admitter during daytime hours reliably gets behind, then you should have “rounders” help with admitting duties. While this is stressful for the rounder, and could sometimes delay the rounder’s ability to discharge patients early (more on that later), in most cases, the benefit will be worth the cost. In fact, I think the best arrangement is for all, or nearly all, daytime hospitalists to share admissions every day.
Remember, this approach will eliminate the admitter-to-rounder handoff from Day One to Day Two, resulting in a net increase in efficiency (and probably patient satisfaction). Plus, reduction handoff errors should decrease, because only one doctor, rather than two, will have to get to know the new patient.
Some hospitalists with inefficient work habits have an opportunity to become more efficient at taking a history and reviewing records, along with other steps in the admission process, without risking poor quality. But most are reasonably efficient at those tasks already and shouldn’t make them the focus of throughput efforts.