In a corner of downtown Austin in 2011, the emergency department at Brackenridge Hospital was facing a problem common to many older, inner-city hospitals: too many patients in too little space with too little time.
“It wasn’t sized for the number of patients coming through there,” says Kristie Loescher, senior lecturer in management at the McCombs School, who formerly spent 14 years as a hospital administrator.
As a Level 1 trauma center, the department couldn’t turn any patient away. But incoming cases might wait four hours to see a nurse, sometimes spilling over into hallways. Surveys showed that 7 percent left without any treatment, and satisfaction scores were down in the 18th percentile.
Under recent rules from Medicare and Medicaid, low satisfaction ratings could result in financial penalties. So could high rates of readmission, if patients didn’t get proper treatment.
With input from Loescher, the hospital reinvented its ER. In the process, it illustrated a key reform in the business of healthcare: Providers are taking management ideas from unexpected sources of inspiration, such as assembly lines.
Critical chain theory, first published in 1984 by Israeli physicist Eliyahu Goldratt, shows managers how to get the highest levels of production from an assembly line. The advice: Zero in on the tightest bottleneck in the chain. Then adjust the other stages of the process, to make the bottleneck run at top capacity.
“When you’re looking at efficiency in a system, you don’t care about the efficiency of each part of the system,” Loescher explains. “Focus on the scarce resource, and make sure that scarce resource is always working,”
At Brackenridge, a team of doctors and nurses, led by emergency services director Kevin Craven, determined the scarce resource was beds. The team reorganized both procedures and room layouts to ensure that no bed would ever go empty. Staff could migrate from one role to another, depending on need, which inspired the name Flex-Flow.
Under Flex-Flow, a check-in nurse would take vital signs and move a patient to the first available bed in under five minutes. Within 30 minutes, a triage nurse would collect a full medical history and direct a patient to the right room and doctor. After testing, the patient would await results in a newly-created continuing care waiting room. The bed was freed for the next patient in line.
At each stage, a nurse would inform the patient what to expect next, and how long it would take. “Communication goes a long way,” says charge nurse LaTashia Kiel, who worked with Loescher to write up the program’s results. “Even when things are crazy busy, when we try to explain to the patient what is going on, we see their symptoms calm down.”
The program was launched in January 2012. By December, it was showing results. The average door-to-doctor time was cut to under 30 minutes. The percentage of patients who gave up and left was sliced in half, to 3 percent.
Meanwhile, patient satisfaction climbed. December surveys showed 48 percent of patients rated staff as excellent, up from 33 percent a year before. Compared to other hospitals, Brackenridge now scores in the 50th percentile.
Flex-Flow’s ultimate goals are still higher: to lift satisfaction scores into the 75th percentile, and have fewer than 1 percent of patients leave without treatment. In the meantime, Loescher and Kiel hope the program can be a model for other hospitals, as healthcare reform pushes them to become more efficient.
The healthcare industry “thinks it’s so different from other businesses that it often doesn’t pay attention to their lessons,” says Loescher. “Critical chain theory is not new. But it’s new to healthcare.
“Flex-Flow cut through a lot of traditional lines and focused on what was really important. It’s making sure people get the care they need and focusing resources on the people who need it the most. And in the end, it’s also more cost-effective. Doing things right is usually also doing things more cost-effectively.”