Managing patient flow and improving efficiencies: the role of technology

Technology to track beds, equipment, staff and patients through a hospital has been used in the USA for years, with positive effect, and now there is growing interest in employing it in the NHS.

I joined a group of NHS leaders to look at how this technology has made a difference to flow and operational management in two different health care organisations in Florida. The results are impressive, although significant transformation is needed to realise the benefits.

The problem

The number of people waiting more than four hours to be seen in an NHS A&E department is growing. By the third quarter of 2016/17, just 82 per cent of patients were seen within the four-hour window – the worst performance since the target was introduced in 2004.

This is, in part, symptomatic of the high occupancy levels many hospitals are facing and their inability to move patients through the system quickly. Short-stay patients (who make up around 90 per cent of all hospital inpatients) need intensive logistical support within a short period of time, for example to prepare a bed and organise admission.

The more patients that require this at any one time, the more difficult it becomes. But for these patients, even small changes in length of stay and bed turnaround time can have a very significant impact on overall flow.

At the same time, there are basic inefficiencies in the system. Data from a 2009 study shows that nurses may spend the equivalent of 40 hours per month searching for equipment. Reducing or eliminating this time means clinicians can spend more time delivering direct patient care.

How technology can help

Tracking technology can facilitate holistic oversight and coordination across a hospital – completely transforming how flow is managed.

Fundamental to this is a manned control centre where clinical and non-clinical staff monitor colour-coded data on admission, occupancy, bed cleaning and portering jobs. They can see when a bed on a ward becomes available and assign a waiting patient to that bed; they can prioritise the cleaning and turnover of beds based on the case-load of patients waiting to be admitted – pushing particular jobs to porters and cleaning teams across the hospital; they can use the data to prioritise discharge expedition efforts; and they can organise transport for patients waiting to be discharged. Ultimately, the data provides a clear view of timeframes for beds becoming available, and the logistical services work together to seamlessly support a better flow of patients through the hospital.

Control centres also display the hospital’s ‘dashboard’ – summary statistics of performance in real time – which can be regularly reviewed by management to spot bottlenecks and improve performance.

The technology underpinning the collection of the data used in the control centre all involves tracking beds, equipment and patients. Real-time location systems (RTLS) that use radio frequency identification (RFID) are a key enabler of many of the products, although hospitals can use as much or as little as they like. Where RTLS are not used, manual data entry, touch screens and pulling data from electronic health records all serve as viable alternatives.

TeleTracking (one provider of tracking technology and the organiser of the trip) has a capacity tracking solution that comprises:

• A pre-admit function that takes clinical information from the electronic health record or patient administration system about patients waiting to be admitted, and uses bed availability data to suggest the most appropriate bed.
• Bed tracking – enabling holistic oversight of occupancy and where cleaning is required.
• A porting module, which assigns jobs based on their location in the hospital and how long the job will take. Porters can use a mobile app to track and manage jobs. When used with other products, transports for discharges can automatically change the status of a bed to ‘dirty’ and send an alert to trigger the cleaning process.
• Patient tracking – an electronic board detailing a range of clinical information. It includes whether the patient has been seen by key clinical staff as part of their discharge planning or when their discharge date is, for example. Information can be pulled from the electronic health record automatically to give an ‘at a glance’ summary of individual patients and the ward case-load.
• Equipment tracking – allowing staff to quickly locate equipment across the hospital.

Any of these modules can be implemented in isolation, although they are most beneficial when used together.

The results

While the technology has not been independently evaluated, internal data collected by the hospitals we visited show positive results.

The first, Health First, is a fully integrated health system in central Florida with 900 beds distributed across four hospitals. Its flagship hospital is Homes Regional Medical Centre, a multi-specialty hospital with 514 beds and a Level II Trauma Centre.

Using lean methodology, it began centralising bed tracking across all four hospitals in 2013. Three years later, emergency department times between admission and inpatient bed occupancy decreased by 37 per cent (Blanchard and Rudin, 2015) and length of stay reduced from 5.75 days to 4.66 days, freeing up 80 additional beds per day.

In 2017, performance to date shows:

• housekeeping total turnaround time is under an hour
• the discharge window (i.e. time between the discharge order and actual discharge) is 2.4 hours, down from 9.25 hours in 2012
• those who left A&E without treatment is down to 1.3 per cent from 4.25 per cent.

The second, Sarasota Memorial Health Care System, is also a fully integrated system. Its main site is an 829-bed acute care hospital, which is the county’s only provider of trauma services.

Sarasota Memorial Hospital started reviewing its patient flow processes in 2015. In 2016 it implemented a control centre, opened a new discharge lounge (known as a departure lounge) and redesigned the discharge process among other things. Like Health First, it employed lean methodology.

Since it started making changes:

• the discharge window has decreased from just under five hours to three hours and 39 minutes
• nearly 40 per cent of all discharges occur before 1pm (up from around 30 per cent)
• time from the emergency care centre sending an admit order to the time the patient is on the nursing unit has reduced from nearly 165 minutes at the highest point to 101 minutes (breaking the stretch target of 113 minutes).

The hospital has also received several awards: it is one of only 2 per cent of hospitals across the USA to earn the federal Centers for Medicare and Medicaid’s top rating for overall quality and safety.

These results are part of the reason why, despite the lack of academic evidence, NHS hospitals are looking to implement tracking solutions. While the hospitals we visited were part of integrated systems, the technology is just as relevant to individual hospitals.

One NHS hospital in the process of implementing the entire suite of TeleTracking products is expecting a wide range of benefits, including whole-hospital ownership of bed pressures and patients being admitted to the right bed first time, reducing moves and the associated risk of harm.

The assumed return on investment is based on a reduction in bed base costs (by increasing patient throughput), reduction in theatre costs (through increased utilisation) and increased efficiency of portering services.

Implementation: Overcoming the barriers

This represents a huge cultural and behavioural change project as opposed to a technology project. It is essential to engage frontline staff from the beginning, particularly as for some it fundamentally changes their roles. For example, allocating beds from the control centre takes away a significant part of a ward manager’s responsibility – which many of the NHS leaders expressed concern about.

One solution is to allow ward managers to prioritise the beds that they would like to be filled first, depending on their existing case-load and workforce configuration. Whatever solution is implemented, it is important not to underestimate the attachment staff feel for their current planning method.

Using the data to engage frontline staff has proved successful (see Blanchard and Rudin, 2015). Collecting baseline data once the technology is implemented, and regularly monitor how it changes, not only provides opportunities for performance improvement, but also helps convince sceptical staff that the technology can offer real benefits to patients.

Structural and logistical changes may also be necessary to support culture change. At Sarasota Memorial Hospital, patients frequently stayed in beds longer than needed after being discharged, due to the lack of adequate facilities to wait for their transport home.

Following consultation with staff, the hospital invested in a new lounge – known as a ‘departure lounge’ – which incorporates a pharmacy, access to food and a nurse who is always on hand. Nurses carry out mini-mobility assessments in the lounge to ensure patients can get to their transport safely. It is now very well used and the average length of stay is 19 minutes, although patients are able to stay all day if required.

Embedding a culture of accountability is also central to success. The data makes performance transparent at a department and individual level. To make the most of the system, executive and frontline managers need to hold both to account – regularly reviewing performance and using the data to resolve any operational problems. Again, this may be a considerable change to someone’s role but it is very important in realising the potential efficiencies.

That said, this must be viewed and presented as an opportunity for the system as a whole to improve. Some staff may feel that the system threatens their personal privacy, particularly where they are monitored by RFID technology. Emphasising the safety benefits monitoring offers – such as enabling staff to trigger an alarm if their personal safety is threatened – may help to improve acceptance.

Several NHS leaders expressed concern about the system overwhelming clinicians and managers with large amounts of data. But the experience of the hospitals we visited is that the ability to run focused, bespoke reports enables managers and departments to use data to focus on what is most important to them. At Health First, performance metrics are posted outside of every department, so that all staff understand performance and how the decisions they make directly impact it.

Finally, the correct workforce needs to be in place to make this work. Sarasota Memorial Hospital found a full-time project manager was essential at the implementation stage. The control room also needs to be effectively staffed. At Sarasota, it comprises:

• Non-clinical patient coordinators who handle admissions and are well-versed on where patients are best treated in the hospital.
• Patient flow coordinators who are registered nurses and keep a clinical eye on where patients are being admitted.
• Hospitality flow coordinators who oversee bed cleaning and portering tasks. They match beds to case-load – e.g. prioritising cleaning cardio beds if there are cardio patients waiting in A&E.
• External transport coordinators who organise transport out of the hospital – e.g. to intermediate care beds.
• Expediters – licensed practical nurses (equivalent to assistant practitioners or nurse associates in the NHS) who address any blockages to timely discharge. For example, if a lack of transport is preventing discharge before 1pm, their job is to arrange transport or understand why transport is unavailable so the problem can be addressed. They use the data to prioritise their work.
• A manager and clinical coordinator – an advanced nurse practitioner.

These can most likely be re-profiled from existing roles. Aside from initial investment in implementation, one NHS trust implementing the full solution is only investing in seven additional staff, who will join a team of four infection control cleaners to create a new ‘bed turnaround team’.

Final reflections

Centrally coordinating patient flow has the potential to create very beneficial results, but they do not come from simply implementing tracking technology. They come from using data to prioritise discharge, bed cleaning and portering efforts; embedding accountability in the system; and monitoring performance to enable continuous improvement. Establishing a control centre that has holistic oversight of the system is a fundamental enabler.

This is not a small undertaking. It requires resource-intensive, transformational change, which at present does not have a robust evidence base to underpin it. Evaluating the technology in a real-world context will be important as NHS organisations begin to use it.

In the meantime, implementing it may be viewed as a risk for the NHS. But given the scale of the potential results, it may be a risk worth taking.

*Sophie Castle-Clarke joined a group of NHS leaders on a trip to Florida on June 19-21 2017. The trip and all associated expenses were funded by Teletracking.