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By Roberta Fruth, RN, PhD, FAAN
Senior Consultant
Joint Commission Resources
Joint Commission International
Tracing the Bottlenecks of Care that Affect
Patient Safety
The Joint Commission first introduced a leadership standard relating to patient flow in 2005, citing patient safety concerns related to care delays. Not until January 2008, however, was a new patient flow system tracer introduced. The tracer, as noted in the 2008 issue of Joint Commission Perspectives, was developed in part because Joint Commission surveyors were finding that "treatment delays, medical errors, and unsafe practices thrive during times of patient congestion and can lead to sentinel events." Like other tracers, it puts muscle behind a pre-existing standard.
The 2005 Hospital Accreditation Standard LD.3.15 requires hospital leadership "to develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital." The Joint Commission clearly views patient flow as a system-level challenge, as do the Institute of Medicine (IOM), the Institute for Healthcare Improvement (IHI), the American College of Healthcare Executives (ACHE), and a growing consensus of other experts.
Breaking It Down – Four Safety Issues from Bottlenecks
Patient flow bottlenecks affect patient safety and care quality in four ways:
 Access. Access issues usually manifest in terms of ED
overcrowding. Healthcare organizations often address
these issues by expanding the ED or post-anesthesia
care unit (PACU). This is a short-term fix that treats one
symptom of a much larger problem — but exacerbates it
in the long run.
Care delays. The longer someone waits in the ED, the
sicker they get and the more likely they are to need
inpatient care. And what about direct admission patients
whose care is delayed when they're bumped for ED patients?
Comparable care regardless of location. Treating
patients in holding areas not meant for such treatment
isn't safe. ED and PACU nurses aren't trained to conduct
assessments and administer scheduled medications;
they're trained to provide transient care.
Availability of resources for care. Physicians are also
frustrated when they have to hunt for their patients in
holding areas that lack ample space and access to
support services.
Problems in these four areas often lead to closer scrutiny by the Joint Commission, as it warned when it instituted the patient flow system tracer in March 2008: "Patient flow problems stress the hospital's entire system. This stressed environment can lead to staff cutting corners while delivering care, which may cause noncompliance with many Joint Commission standards, core measures, and National Patient Safety Goals."
Head to Bed, Foot to Door
Although the new patient flow tracer ups the ante, the Joint Commission recognizes the scope of the problem and doesn't expect healthcare providers to fix everything overnight. Surveyors are, however, looking for evidence that leaders are accepting responsibility for patient flow issues, evaluating the problems at a system level, identifying problems, and putting plans in place for improvement. Still, many hospitals don't know where to start.
The answer is in the data. The best place to start is with a two-part metric known as "head to bed, foot to door." This refers to the time from when the admission order is entered to when the patient is in a bed, and from when the discharge order is entered to when the patient is out the door. By determining current turnaround times, establishing goal times and holding people accountable, organizations can begin to eliminate the bottlenecks that threaten patient safety and focus their efforts on providing high-quality care.
Dr. Fruth has more than 30 years of experience in healthcare operations and education in hospital, ambulatory and international settings. As a consultant, she brings educational and operational expertise in data management, performance improvement, clinical safety and team development to help organizations achieve their goals. Previously, Dr. Fruth served as chief nurse executive and vice president of patient services at St. Joseph Hospital in Chicago.
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Beginning in January 2008, Joint Commission surveyors began conducting a new patient flow system tracer in hospitals and critical-access hospitals to identify problems with patient flow. The tracer is designed to identify bottlenecks that can affect patient safety, causing treatment delays, medical errors and unsafe practices. Patient flow problems often start in the emergency department, critical care units and surgical areas, but can be found throughout the hospital.
The tracer puts muscle behind a 2005 standard, LD.3.15, which details leadership responsibility for evaluating patient flow, accepting responsibility and making necessary changes to improve throughput. The elements include:
Assessing the impact of patient flow issues on patient safety
and developing a plan to alleviate the impact.
Planning that encompasses the delivery of appropriate care
to admitted patients held in temporary bed locations.
Sharing accountability (leaders and medical staff) to develop
processes to support efficient patient flow.
Planning for delivery of adequate care to non-admitted
patients in overflow locations.
Using indicators that measure the patient flow process,
including bed space, efficiency, safety and support services.
Reporting results to leadership and individuals responsible
for patient flow.
Improving inefficient or unsafe processes essential to the
efficient movement of patients through the organization.
Defining criteria to guide decisions about initiating diversions.
If patient flow issues are identified during the onsite survey, the surveyor will interview hospital leaders about actions they have taken to address the issues that arise from inefficient patient flow.
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