The worst thing to do in a capacity constrained hospital

Hospitals are complex logistical systems. Beware seemingly easy fixes to pervasive problems.

For example, CEOs at the helms of seriously crowded emergency departments constantly receive internal proposals for adding resources. Whether it's for a new building or more staff, a moment of pause is in order before approving such additions. In fact, it's important to recognize that adding resources could unintentionally aggravate an already troublesome situation.

Recently, I met with an executive who was struggling with patient throughput. The problem stemmed from an inability to discharge patients in a timely fashion. When the executive dug into the problem, she discovered that the vast majority of discharges where occurring at shift change (a common problem all over the country).

After a great deal of discussion and brainstorming, the idea of hiring a dedicated discharge nurse surfaced. This was considered a winning proposition for everyone on the unit because:

1. Nurses would be freed from a paper-intensive process to maximize the time they spend providing patient care;
2. Bed management could rely on a person who was accountable for ensuring that the beds where cleared as soon as possible;
3. Nurse management had a more consistent process for moving patients out;
4. Case management got a resource to help coordinate and plan their activities; and
5. Administration would solve one of the biggest challenges facing patient throughput, which would logically lead to even greater throughput.

A discharge nurse was identified and placed in the high-volume 35-bed med/surg unit. But, to everyone's consternation, the average discharge time moved to even LATER in the day. Why?

Previously, this unit averaged seven to ten discharges every day. With a 6:1 patient-to-nurse ratio across a 24-hour period, this meant that each nurse would be accountable for one or two discharges per day…and these discharges most often occurred between approximately 10 a.m. and 8 p.m. In this scenario, many people processed discharges, each independent of the others. Each had her own path to discharge, as illustrated in the chart. Thus, if there were a delay or a problem with Patient B, then Nurse B would have to deal with it. None of the other nurses or patients were impacted.

When the discharge nurse arrived, she was saddled with all seven discharges, and, in theory, she had the capacity to discharge all the patients in a timely manner. What wasn't considered was the fact that all the discharges immediately became interdependent. As such, any delay with any patient would automatically impact the rest of the patients.

This is just one example of how a seemingly good solution can actually create a worse problem. Take time to carefully consider the broad ramifications of changes to the hospital environment.