Bed Management—Decreasing Bed Turn Around Times by 30%

Bed management is a critical “behind the scenes” operation in hospitals. Any patient, physician or associate in contact with in-patients experiences the impact of this operational process. Issues with this process are seen in ED Diversion status, ED Boarding, delays in room assignments for surgical patients and delayed admissions for direct admits. All of these contribute to patient and physician dissatisfaction, community relations issues, associate morale and loss of revenue. This case study highlights the use of lean and six sigma techniques to improve the bed management process of a large hospital. By using this approach in a makeover event style of implementation this hospital was able to reduce the bed turn around times by 30%.

Patients requiring in-patient rooms at this typical hospital were often found to wait a long time until a room was available and ready. The hospital is a 300+ bed facility with a large and busy ED (this ED department has a 35% admit rate). The problem, as for most hospitals, was especially severe for ICU and telemetric beds. This facility was known to periodically be on diversion due to bed shortages in these critical areas. Physicians, patients, and administrators alike were
dissatisfied with the process since it resulted in patient care issues as well as lost revenue. Associates were frustrated with their inability to provide proper beds quickly. The nursing administrator held morning and afternoon bed briefings to discuss staffing and patient needs for a short period of time to manage the room scenario.

The Associate Administrator responsible for nursing knew that most of the room assignment decisions were made by the house supervisor which kept that individual busy and less available to conduct other important functions. A bed tracking software package was being used by the housekeeping department, with the prevailing thought that it was working well, although the units complained that it took to long to clean rooms. Nursing was thought of by many to be the primary cause of bed availability issues due to “bed hoarding” until shift change, supposedly such that nursing would not have to take on more patients during an ongoing shift. The “proof” of theory this was that rooms became available around 7:00 pm each evening which corresponded to the shift change. The Associate Administrator wanted to change the process to decrease the wait time of bed assignment and thus diversion hours. An upgrade to the existing software had been proposed as a possible solution. While she was willing to invest funds if it solved the issue, she decided to use an Extreme Makeover approach and determine if the software upgrade was the appropriate solution or an element thereof.

Working with a team of Lean Six Sigma experts, she assembled an internal team that consisted of a House Supervisor, Patient Access Nurse, Admitting Representative, Unit Nurse, Unit Clerk, and herself. The team went through approximately 6 hours of training in lean six sigma techniques and began by assessing the process from “customer touch to customer touch” with the support and guidance of the lean six sigma team.

The project team gathered data and process times for all process steps. Historic data was also obtained to understand the rate of patient arrivals and departures. The team collaborated over their observations of the process and data analysis and made a number of surprising discoveries: During the observations it was found that housekeeping was getting called by a number of associates such that at times several housekeepers were dispatched to the same room. The room cleaning process was rather fast (30 minutes) once a housekeeper arrived. The house supervisor was extremely busy with her role managing calls coming to her mobile phone and she was constantly checking to determine the best place for each patient. This involved coordination to make sure that staffing levels were adequate in desired units. The data from the detailed analysis showed that it took between 5 and 7 hours from the time a discharge order was written to the time the room was ready for reassignment. Reducing this by 2 hours would effectively free 10 beds during the critical time of day.

Since the team began with a “customer touch to customer touch” view, it decided that the process actually began when a patient was ready to leave versus when a patient was ready for a bed. This led to an inventory management logic for designing the new process. Using this logic the team began the third day by designing the new process using process design tools based on inventory management as well as lean and six sigma principles. The solution elements included: Work management using a visual control system, metrics to measure process performance, decision support tools for bed assignment and a cross functional — high performance work team. The tools provided a full understanding of bed statuses for the entire hospital as well as current and anticipated patient demand. One tool that was developed is a control board that provides both current and future patient needs in one place. The new board provides visibility not only of room status and patient needs, but also a systemic view of operations thus allowing the management of the entire hospital and associated processes more proactively from an overall viewpoint.

Since the nursing units would need to be trained prior to implementation, the process changes could not be implemented immediately as is normally the case. To enable the changeover, the team assembled a complete training and communications package which was rolled out over the next 3 weeks throughout the entire facility. On the designated day the team assembled and completed the final process elements including the physical layout of the area. The new process was launched and 2-hours were cut immediately from the process. The newly co-located high performance work team took calls for patients needing rooms, and once the needs were assessed by access nurses the room assignment was performed if the patient was ready for the room or the need was recorded in the position for future and anticipated demand.

Simultaneously the team was notified immediately as a patient left a room which then allowed housekeeping to dispatch cleaning personnel based on room availability and area of most need within the entire system. This dispatching and prioritization mechanism now prevents the previous problem of multiple housekeepers presenting at the same time ensures that the rooms in units with the highest needs are cleaned first.

The team began using a display board to track the process performance over time. Some of the metrics used were: Average cycle time from the patient being ready to the patient being in a bed for all encounters, the average 5-highest-case cycle times of each day and the percentage of patients discharged prior to 11:00 AM each day. The team instituted a daily performance briefing to find ways to continue to improve the process.

By providing the team with the right skill mix, tools to make decisions consistently, and the visibility of both bed and patient status, it was able to dramatically decrease the amount of time required to provide beds for patients. To further improve the process a board prototype for the nursing units was designed showing potential discharges in a systematic way. Using the boards, the floors can provide more accurate information to the central bed management team. Due to the success of the unit board, it has subsequently been rolled out to all nursing units.

One of the unexpected benefits the team found was that the house supervisors were freed from conducing the bed assignment activity. As a result they are able to address other, often critical, patient needs. Incorporation of access nursing into the function allowed for a rapid and consistent flow of information with respect to patient needs. In addition, decision making on unit assignment was made to optimize both the response time to patients and the level of care required. Finally the new process allowed the twice daily bed briefings to be eliminated. This returned one hour each day to each associate of each nursing unit which allowed for an increase in 17 hours per day

The mission of Healthcare Excellence Institute is to help organizations create safe and efficient healthcare delivery processes by adopting proven world class strategies such as Lean / Toyota Production System to the complexities of healthcare.

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