Patient Flow, Pull and all that

Lean terminology is slowly entering the healthcare vocabulary in particular the terms Flow and Pull.

Our job in healthcare is to enable each individual patient to ‘pull’ themselves through the system and to ensure that our services ‘flow’ to provide exactly what the patient needs exactly when they need it (pulled by the patient) during their journey through our system.

What we actually witness however is reaction:

When pressure is on, to admit medical patients, at the front end of the hospital we see a reaction whereby there is suddenly a huge effort to discharge patients (sometimes unsafely) and if enough patients cannot be discharged, those approaching ‘medically fit status’ are moved to any empty available bed, usually in the wrong specialty ward or worse still into surgical beds. This practice, as we all know, extends LoS, it dismays Clinicians who then have to perform ‘safari ward rounds’ and causes cancellations of, revenue generating, elective procedures.

Even during these pressurised circumstances it sill takes an average of three hours from discharging a patient to the next patient occupying that bed. Which means the front end and the back end are not connected. We know it can be done in 20 minutes or so.

When however the pressure is off to admit medical patients at the front end of the hospital we see another reaction. People involved in the discharge process ’take their foot off the gas’ and breathe a ‘sigh of relief’. Unfortunately this situation is usually followed immediately by a sudden surge of patients turning up at the front end and so the exhausting cycle begins again.

We have learnt that the process must be reversed: Start at the back end

People involved in the discharge process must, all but, ignore what’s happening at the front end and instead constantly focus on their job: discharging small numbers of patients, drip fed throughout the day, which is all that is actually needed to accommodate demand for beds, (and we also know that there is, most definitely, a predictable demand for discharge)

As medical beds become available, priority number one is to repatriate patients who are in the wrong beds.

The wards, in turn, must be scheduling the discharges of their patients, based on the patient’s discharge complexity (planning to discharge a patient that needs special transport, take home drugs and oxygen first thing in the morning, for example, is probably fantasy planning)

This enables the people involved in the discharge process to know who to discharge and when.

In the mean time the front end MAU/Obs Wards must continually update the wards with their patient’s demand for beds by specialty and gender and admit new patients confident in the knowledge that the system can accommodate them.