Care Redesign

What Is Patient Flow?

Article · January 1, 2018

Patient flow is the movement of patients through a healthcare facility. It involves the medical care, physical resources, and internal systems needed to get patients from the point of admission to the point of discharge while maintaining quality and patient/provider satisfaction. Improving patient flow is a critical component of process management in hospitals and other healthcare facilities.

Optimizing patient flow encompasses quickly, efficiently, and effectively meeting the demand for care by moving patients through care pathways while improving coordination of care, patient safety, and health outcomes.  To optimize patient flow, providers seek to successfully match the appropriate amount of resources to each of their admissions.

Patient Flow Problems in Hospitals

Patient flow is primarily associated with hospitals, especially with back-ups and overcrowding in emergency departments and inefficient scheduling in surgical departments. Poorly managed patient flow in hospitals can lead to adverse health outcomes, including increased re-admissions and mortality rates. Even hospitals that are expanding their facilities and hiring additional staff are not immune to issues of overcrowding and poor orchestration of patient admissions, transfers, and discharges.

Inefficient scheduling leads to some patient flow problems. For example, surgical services may schedule the bulk of their elective surgeries earlier in the week, so patients can recover when resources are more readily available. This strategy causes post-operative units to become overcrowded, and staff and support services to become stretched.

Disorganized handoffs — between referring physicians and hospitals, as well as between departments within a hospital — also lead to patient flow problems. Hospitals, therefore, are taking a critical look at their admissions and referral processes in an effort to make improvements.

What Is the Emergency Department’s Role in Patient Flow?

Patient flow issues often originate in the emergency department (ED). An influx of patients can cause EDs to become backed up, especially when non-critical patients use the emergency department as a source of primary care. This over-crowding can lead to long wait times, ambulance diversions to other hospitals, delayed discharges, patients leaving without being seen and patient boarding (admitting patients without beds and leaving them in hallways until beds become available).

Strategies to Improve Patient Flow

3 strategies to improve Patient Flow and accelerate progress: Streamline patient admissions and handoffs; optimize discharges; smooth surgical schedule.

Three areas of focus for improving Patient Flow. Click To Enlarge.

Dr. Eugene Litvak, a noted expert in the field of patient flow, suggests that greater attention to the issue of patient flow would “accelerate progress toward reliable, safe, efficient care.” Among the strategies espoused by Dr. Litvak and other experts to optimize patient flow in hospitals are:

  1. Establish an emergency department “fast-track” process, along with protocols for triage, tests, and treatment to streamline patient handoffs.
  2. Smooth the elective surgical schedule, by spacing elective surgeries throughout the week to help alleviate strain on post-operative units instead of using block scheduling, which can lead to capacity crunches.
  3. Increase the rate of morning discharges. Leaving the hospital early in the day gives patients more time to fill prescriptions and settle in at home, and it opens up beds for incoming patients.
  4. Use patient flow software and telehealth to automate processes and gather data for analysis. One health system has found that using an online portal through which primary care providers can ask questions of specialists helps to reduce the need for face-to-face consultations, which can be hard to schedule for busy specialist practices. Patients who don’t need to be seen are managed with a phone call or chart review, freeing appointment slots for patients who do need to be seen.

Patient Flow Standards and Guidance for Hospitals

The Joint Commission addresses the issue of patient flow in a standard all Joint Commission-accredited hospitals must comply with. The standard requires hospitals to:

  1. Create processes that facilitate good patient flow throughout the hospital.
  2. Address what happens when beds aren’t ready for admitted patients.
  3. Make sure patients in overflow locations receive proper care.
  4. Formalize how ambulance diversion decisions are made and implemented.
  5. Set patient flow goals and measure progress toward those goals.
  6. Manage patient “boarding” and work to reduce the length of time that ED patients are boarded. A cap of four hours is recommended by the Joint Commission.
  7. Review results of flow management initiatives against stated goals and objectives.
  8. Take improvement actions when goals are not achieved.
  9. Work closely with behavioral health providers to better coordinate care.

Additional guidance is available from the Agency for Healthcare Research and Quality, which offers step-by-step instructions that can be used by hospitals in planning and implementing patient flow improvement strategies to ease emergency department crowding. The guide covers everything from how to form a patient flow team, to facilitating changes, anticipating and addressing challenges, and sharing results.

The Institute for Healthcare Improvement offers a White Paper that shares strategies, promising change ideas, and resources to help hospital leaders and improvement teams take on the challenges of achieving hospital-wide patient flow. The report stresses the importance of taking a system-level approach to improving patient flow and building the will to do so throughout the entire organization, from the highest levels of leadership to point-of-care managers and staff. Delivering the right care, in the right place, at the right time, they say, will help hospitals reduce their costs and retain revenue, in addition to improving patient health outcomes.

Patient Flow and Health Outcomes

As hospitals increasingly focus on value-based care instead of fee-for-service care, incentives will likely continue to grow for the operational changes hospitals need to make to improve the flow of patients through their facilities. Hospitals that support those operational changes with relevant cultural changes will be in the best position to improve patient flow.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Kimberly Dennis and David Newton head shots - SunCloud Mental Health Services

Addressing the Lack of Continuity of Care in Mental Health Services

Co-founders of an integrative outpatient treatment center for mental health and addiction discuss the problematic lack of continuity of care between inpatient and outpatient and physical and mental health services.

Epic OB Hemorrhage PPH Risk Assessment Tool and Alerts at PSJH - Preventing Maternal Death

Improving Maternal Safety Through an EMR Risk Assessment

After a mother died of postpartum hemorrhage, Providence St. Joseph Health made organization-wide changes to prevent future maternal deaths and injuries.

Most Health Care Organizations Have Palliative or End-of-Life Care Programs

Survey Snapshot: Challenging the Resistance to “Palliative”

NEJM Catalyst Insights Council members agree that palliative care is gaining traction, but one of many barriers is getting providers over their resistance to the word “palliative.”

The Assessment of Care Tool - Consisting of Six Visual Analog Scales Corresponding with the IOM Six Dimensions of Perfect Care

Real-Time Pursuit of Outcomes That Matter to Patients

A simple and affordable tool to use at the point of care to drive value creation within clinical microsystems.

Many Patients Who Would Benefit from Palliative - End-of-Life Care Do Not Receive It

Care Redesign Survey: The Power of Palliative Care

Our NEJM Catalyst Insights Council survey on palliative care reveals an interesting dichotomy: While the great majority of organizations have a palliative or end-of-life care program, 60% of patients who would benefit from such services don’t receive them.

Heart Safe Motherhood and Way to Health Two-Way Texting for Blood Pressure Monitoring for Postpartum Women with Preeclampsia

Heart Safe Motherhood: Applying Innovation Methodology for Improved Maternal Outcomes

At the Hospital of the University of Pennsylvania, a text message–based blood pressure surveillance program for postpartum women with preeclampsia improved blood pressure management, reduced readmissions, and increased patient and provider satisfaction.

VHA Whole Health System diagram

Finding the Cause of the Crises: Opioids, Pain, Suicide, Obesity, and Other “Epidemics”

Until we redesign our health care system to address our patients’ personal determinants of health, we will continue to inadequately address our multiple chronic disease crises.

Leff06_pullquote home-based medical care for homebound patients

Using Quality to Shine a Light on Homebound Care

How two thought leaders in the fields of home-based medical care, geriatrics, and palliative medicine advanced a quality-of-care agenda for homebound adults.

Charlotte Yeh head shot - hearing aids hearing loss

“You’re Old Without Hearing Aids”— Addressing the Silent Epidemic of Hearing Loss

Hearing loss isn’t a normal consequence of aging. But it is associated with a higher risk of dementia, depression, and falls. The Chief Medical Officer for AARP Services talks about combating this huge but silent epidemic that impacts all ages.

Dentzer01_pullquote - Stone-Age Policies Stifle Modern Virtual Care Solutions

Stone-Age Policies Stifle Modern Solutions

Health care leaders must advocate for regulatory and reimbursement changes to unlock the potential of innovative technology and care team approaches to Parkinson’s and other suitable conditions.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

How a State Advances Whole-Person Health…

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations…

Quality Management

178 Articles

Addressing the Lack of Continuity of…

Co-founders of an integrative outpatient treatment center for mental health and addiction discuss the problematic…

Design Thinking

18 Articles

Heart Safe Motherhood: Applying Innovation Methodology…

At the Hospital of the University of Pennsylvania, a text message–based blood pressure surveillance program…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now