Practice Management

Relieving Bottlenecks in Patient Flow

Incorporate a multifaceted approach to enhance patient care

A receptionist helping a patient fill out paperwork

Many health care facilities and clinical practices are interested in optimizing patient flow to improve efficiency and increase their revenue. But taking this step isn’t just about the bottom line; in fact, mortality and hospital readmission rates can rise if patient flow hasn’t been enhanced. So what is “patient flow,” and how is it accomplished?

According to NEJM Catalyst, an organization that focuses on health care delivery and includes a council of more than 50 experts in this field, patient flow is defined as the internal systems, medical care, and resources necessary to help patients get from point A (admission) to point B (discharge). Optimizing that flow to meet the demand for care, maintain quality, and keep patients and health care providers satisfied is critical to its success.

Historically, health care administrators would address patient flow by hiring more staff and building additional facilities; however, these are symptoms of the problem. Adding physical resources without balancing the other needs of efficient patient flow obfuscates the root cause.

The 3 Bs: Bottlenecks, Boarding, and Batching

Poor patient flow can lead to bottlenecks, patient “boarding,” and “batching” by health care staff. An example of these three concepts is an urban health care facility with limited resources. As more patients present to that facility’s ED, patient wait times increase.

This bottleneck is compounded when it leads to boarding, which occurs when other departments that are short on beds send patients to the ED while waiting for beds to become available. Bottlenecking and boarding can then lead to batching, which occurs when health care staff wait until a specific time (for instance, the end of their shifts) to complete paperwork or return patients’ phone calls or emails. This batching can then create new bottlenecks or negatively affect patient satisfaction and outcomes because of delays.

Walk in Your Patients’ Shoes

To treat the underlying condition of bottlenecks and boarding beyond simply adding resources, administrators should engage in “flow mapping.”

Flow mapping involves “walking in a patient’s shoes” from the moment he or she enters the door. Observe and note everything about the visit. Look for issues such as inadequate office space, suboptimal customer service, or work duplication. Take note of how long each part of the visit takes (for example, checking in, meeting with a medical technician before seeing a physician). Importantly, ask patients for feedback.

The American Academy of Family Physicians has a helpful worksheet on evaluating your patient flow, taking into consideration where patients go when they enter your office, knowing what information is exchanged or what questions are asked of staff before patients see their physician, and knowing who, if anyone, patients speak to as they exit the facility after their visit (for instance, social workers, navigators, front-desk staff).

Avoid Tunnel Vision

Adam Arabian, PhD, an associate professor at Seattle Pacific University, warns that the flow-mapping approach must be multi-pronged. Arabian teamed up with an ED to research its patient flow, focusing on patient satisfaction and wait times. “There are so many variables in the system that models just don’t have,” he says, so it’s best to map more than just a single department to see how they interact. “For example, if you’re only mapping the ED, you’ll never know how long it will take to get a radiology consult because you don’t have the big picture.”

To help health care facilities incorporate a multifaceted approach, The Joint Commission (TJC) has created standards for improving patient flow. For instance, TJC suggests creating processes that address what happens when a facility is at capacity and cannot admit new patients; how to set, measure, and review goals for efficient patient flow; how to manage boarding (and reduce the duration of boarding when it is necessary); how to better coordinate care by using multidisciplinary teams that include behavioral health specialists; and how to take action when patient flow goals are not met.

Engage Patients

Many health care professionals are also turning to technology to involve patients in improving patient flow. For example, Ya-Ling Liou, DC, a chiropractor based in Seattle, WA, has switched to an automated, online-based scheduling system called AppointmentQuest.

“I’m unwilling to compromise in other areas of patient interactions, so scheduling seemed like the best thing to automate,” she says. She occasionally sees patients who prefer to schedule their appointments by phone, but “even the least tech-savvy patients use email,” she says.

Liou is also keeping pace with shifting demographics and increased levels of computer literacy by developing an online portal, where her patients can learn everyday pain-management techniques. Online programs like hers, which empower patients to take control of their medical needs, can improve patient flow by educating and helping patients prevent an illness from becoming an emergency.

No Single Solution

Because optimizing patient flow involves a multifaceted approach, no single solution exists. Each clinic, health care facility, and department is different; what works for one does not necessarily work for others. Consider testing incremental changes, setting small yet attainable goals, measuring the effects of a single change at a time, and reviewing the impact of those changes as you go. Institution-wide changes on a massive scale aren’t typically successful; rather, research suggests that smaller changes can result in immediate, measurable improvements in patient flow.


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