Accreditation

Learn how one facility reduced bed turnaround time by 76%

Accreditation Connection, March 1, 2004

At this time last year, hospitals within San Antonio's University Health System (UHS) took an average of two hours to change empty beds. This leisurely pace caused patient unit beds to sit empty while patient boarders piled up in the emergency department (ED).

But after carrying out several "rapid cycle" experiments to determine the best way to approach the problem, UHS not only met the national benchmark of 45 minutes, but surpassed it by an additional five minutes, says David Hnatow, MD, FAAEM, FACEP, ED medical director.

"When you have a 400-bed hospital and you knock off an hour on bed changeovers, that makes a big difference," he says.

About 70,000 people come to Hnatow's ED each year; 25% of them are admitted to patient units (an average hospital has an 11% admission rate, Hnatow says). About 13% of those admissions head directly to the intensive care unit or operating room. This steady flow requires free beds on critical care units.

UHS is working to accommodate this need by participating in Urgent Matters, a $4.6 million project funded by a grant from the Robert Wood Johnson Foundation that aims to free up space in hospital EDs by smoothing patient flow throughout the hospital.

The Urgent Matters initiative is administered by the Center for Health Services Research and Policy at the Washington, DCbased George Washington University Medical Center. It encourages hospitals to test new procedures by using the rapid-cycle quality improvement method. This involves testing small changes in concentrated areas of a hospital for a short amount of time.

Each of the 10 hospitals participating in Urgent Matters receives funding and consulting services to do so.

People don't like to change'
Change isn't easy when you're dealing with 4,000 employees, five different clinics, one large teaching hospital, and a large emergency center.

Short, uncomplicated tests were the perfect way to introduce change to such a large health system, says Hnatow, UHS' primary investigator in the Urgent Matters initiative.

"People don't like to change," he says. "They get used to their way of doing things. The rapid-cycle testing process allows them to do a small change over a short amount of time, then assess the results." If the results are promising, they carry out the test on a wider scale, he adds.

It's also an attractive way to win support from key leaders. "You have to have support from the top," Hnatow says.

Although UHS' administrator, chief executive officer, vice presidents, and chief nursing executive back Hnatow's efforts in the Urgent Matters project, they weren't always receptive to change.

"Leadership hasn't always supported . . . changes because they cost money," he says. However, the Urgent Matters initiative encourages hospitals to look for ways to tweak existing systems without spending a fortune.

Creating a pull system
UHS had never tried rapid-cycle testing when it began using the method to decrease the length of time it took housekeeping to prepare a recently emptied bed for a new patient.

UHS wanted to change from a "push" system that struggled to find empty beds for recently admitted patients being boarded in the ED, to a "pull" system that sought patients to fill empty beds on patient units. This was no easy task.

"You get a little resistance at first," Hnatow says of staff's response to change. "We're not very standardized on the nursing units, but we need to be because that will help us become more efficient. This project showed us that."

Two slips of paper and a jar
UHS launched a simple experiment in July 2003 that helped shave its bed turnaround time from two hours to less than 45 minutes.

How it worked: Because rapid-cycle tests should begin on a small scale, UHS began on just one patient unit. Nursing staff placed two jars at the nurse's station to represent clean and dirty beds.

The minute a patient checked out and a bed was empty, the patient's nurse put a bright-red slip of paper with the room number into the jar. This alerted the unit clerk to inform housekeeping that a bed needed to be changed.

The housekeeping staffer removed the slip once the bed was changed, disinfected, and ready for the next patient. He or she then placed a bright green slip into the second jar. This reminded the unit clerk that there was a free bed on the unit that needed to be filled.

Results: Average inpatient bed turnaround time decreased from 167 minutes to 58 minutes in just three weeks. Today, the average turnaround time is closer to 40 minutes, says Hnatow.

Lessons learned: Once UHS expanded the experiment to other units, it learned more ways to decrease bed turnaround time, including by doing the following: 

Buying more pagers: Nurses soon learned that housekeeping staff are sometimes difficult to track down. UHS nipped that problem in the bud by purchasing extra pagers to ensure that all housekeeping staff can be contacted. 

Speeding up sheet shaking: UHS was still adhering to an outdated policy that prohibited housekeeping staff from removing sheets from a patient's bed. This harkened back to when housekeepers were afraid of accidental pricks from needles left behind in beds. Tie-ups ensued when housekeeping staff had to literally stand around waiting for busy nurses to remove bed linens. 

But fears of such needlesticks are unfounded now that the hospital uses needleless systems, says Hnatow. UHS changed its policy to authorize housekeeping staff to remove soiled bed linens. 

Offering bribes: Obtaining written discharge orders before lunchtime helps nurses speed up a patient's discharge. However, writing orders had never been a top priority for physicians. Last year the hospital's average discharge time was 4 p.m. 

This changed remarkably after Hnatow began offering free lunch gift certificates to physicians who wrote their patients' discharge orders by 10 a.m. 

"Food is a great motivator," he says. So great, in fact, that the average discharge time is now 2:30 p.m. His goal is to have 30% of patients discharged by 11 a.m.

Purchasing a tracking system: The hospital decided to invest in a system that will allow it to track beds throughout each hospital. UHS plans to go live with the system in April.

"We found that we didn't have a way to determine when a bed is clean and ready for the next patient," says Hnatow. "We ended up making multiple phone calls to units to try to arrange beds. It wasted time. A tracking system will help us create more of a pull system." 

Making environmental rounds: Environmental services staff now inspect their designated floors one hour before their shift ends to determine whether any rooms need to be cleaned. If time allows, they add the room to the daily to-do list of housekeeping staff. 

This helped speed bed turnaround time by reducing the number of rooms that are "dumped" onto the next housekeeping shift, Hnatow says. 

It also helps environmental services and nursing staff verify which bed linens are clean and which need to be disinfected and changed.

Staying focused
The Urgent Matters initiative stresses the importance of communicating successes and failures to staff so they feel connected to the project and invested in its success.
To that end, Hnatow sends newsletters to staff each month, posts charts and graphs in work areas that show the results of its rapid-cycle tests, and attends meetings with unit staff, managers, and the board of directors.

"The Urgent Matters project has allowed us to put [the issue of patient flow] on the front burner," he says.

"In the past, there was lip service given to change, but I didn't see a lot of momentum or action on it," he adds.

"Having several brief meetings each week, coming up with ideas for change, looking at the metrics, and determining where we need to focus our changes has forced us to stay focused on it."

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