Lewis Blackman didn’t have to die. Eugene Litvak, a Kiev-trained systems engineer, is also convinced that his story illustrates why smoothing patient flow is so important.
Blackman, a 15-year-old academic star, checked into to the hospital on a Thursday morning for surgery to correct a minor congenital defect. But since the post-op beds were full when Blackman came out of the operating room, the teen was sent to a cancer ward to recover.
The oncology residents and nurses were unfamiliar with the side effects of Lewis’ medication. They dismissed his abdominal pain as intestinal gas. A few days later, Blackman died of gastric bleeding caused by a painkiller. “Lewis came into the hospital when resources were stretched,” explained Litvak, who is now the president of the Institute for Healthcare Optimization. The teen, Litvak said, died during a period known as a ‘trough’ when the hospital was inadequately staffed.
If you could scale up one remarkable health care idea, what would it be?
"Smoothing the flow of patients through the health care system is within the immediate reach of health professionals and administrators. Applying systems engineering to streamlining patient flow has proven to significantly improve access to care, quality of care, patient safety and nurse staffing while saving millions of dollars for individual hospitals and billions nationwide."
- Eugene Litvak, Ph.D., President and CEO, Institute for Healthcare Optimization
The poorly managed admissions system was likely one of the factors that led to the fatal medical error. A better system might have saved Blackman. It might also make the hospital admissions process much more efficient, and therefore, less costly. “By leveling out those peaks and valleys, we can save millions of dollars — and lives,” Litvak says.
Litvak’s premise isn’t hard to grasp: by achieving a steady flow of patients, a hospital can optimize the use of operating rooms, imaging facilities and nursing-staff hours. Hotel managers, who also strive for steady occupancy, have used systems analysis to stabilize customer flow for decades. But hospitals have not taken this approach because conventional wisdom dictates that admissions rates are due to unpredictable events — disease outbreaks, natural disasters and heath emergencies — that are beyond human control.
Now Litvak’s research is overturning the assumption that the demands placed on surgeons and staff are, by nature, unpredictable. By collecting data at several major hospitals, he and his colleagues found that the rate of elective admissions varied much more than the rate of emergency department admissions. Their solution: Set up different channels for emergencies and elective procedures.
In the last decade, several major hospitals have tried Litvak’s approach, including the Mayo Clinic of Florida, John’s Hopkins and Cincinnati Children’s Hospital. In 2012-13 the 14-member New Jersey Hospital Association followed suit. The hospitals began by collecting data needed to stratify emergency cases by risk and to project length of stays in both intensive care units and inpatient beds. They used the data to develop operational models that allows a doctor to reserve an operating room the same way he or she would book a seat on an airplane. The approach works, in part, because patients are not a hospital’s customers; surgeons are. The new approach makes their lives easier.
Traditionally, if a gunshot victim needs an operating room that an orthopedic surgeon has booked for a hip replacement, there are two choices. The surgeon can send the hip-replacement patient home or postpone the procedure until the end of the day. With the latter choice, the doctor will be operating at night fueled by coffee and assisted by a staff on overtime. There may be no bed for his patient in the orthopedic unit where nurses are skilled in post-operative care for joint replacements. So the risk of surgical errors, readmissions and mortality increases. In the past, hospitals minimized such situations by expanding facilities to meet peak demand — at an average cost of more than $1 million per bed.
The proposed methodology also helps to triages emergency cases, which are routed to separate, dedicated operating suites.
Hospitals are still fine-tuning the process, but the change is already evident. Cincinnati Children’s increased revenues by 34 percent during the first two years the system was in effect and saved $100 million by canceling a planned expansion. Even as volume increased, patient waiting time fell 30 percent and staff overtime dropped 57 percent.
The New Jersey project was funded by a grant under the Affordable Care Act. After only three months of implementation, the hospitals announced that they were accommodating 11,000 to 17,000 additional patients without adding a single bed. Despite some initial reservations, staff morale is soaring.
“It’s not hard to convince hospitals once you have the data,” Litvak says.