Optimizing

Patient Flow
Advanced Strategies for Managing Variability
to Enhance Access, Quality, and Safety

Edited by Eugene Litvak, PhD

Foreword by Harvey V. Fineberg, MD, PhD
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Acknowledgments
Senior Editor: Jennifer K. Ahearn, MA
Project Manager: Lisa M. King
Associate Director, Publications: Helen M. Fry, MA
Associate Director, Production and Meeting Support: Johanna Harris
Executive Director, Global Publishing: Catherine Chopp Hinckley, MA, PhD

Reviewers
Joint Commission Division of Healthcare Improvement
Karen Pennington, MS, BSN, RN, Field Representative, Hospital Accreditation Program
Joint Commission Division of Healthcare Quality Evaluation
Lynn Bergero, MHSA, Project Director, Department of Standards and Survey Methods;
Stephen Schmaltz, MS, MPH, PhD, Senior Biostatistician and Associate Director, Department
of Quality Measurement
The Joint Commission Center for Transforming Healthcare
Anne Marie Benedicto, MPP, MPH, Vice President; David Grazman, PhD, MPP,
Engagement Director

ii
 Contents

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Foreword by Harvey V. Fineberg, MD, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Introduction by Eugene Litvak, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

Prologue: Lewis Blackman: Lessons Learned from a Ninth Grader

by Ellis “Mac” Knight, MD, MBA, FACP, FACHE, FHM . . . . . . . . . . . . . . . . . . . . . xiii

Part I: CEO Perspectives: Committing to Optimized Patient Flow . . . . . . . . . . . . . . 1

Chapter 1: How We Improved Care and Added Millions to the Bottom Line:
An Outsider’s Perspectives by James M. Anderson, JD, Hon. DSc . . . . . . . . . . . . . . 3

Chapter 2: Using Operations Management to Reduce Variability

in Surgical Demand by Jack Kitts, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Chapter 3: A Proactive Initiative to Improve OR Scheduling by William C. Rupp, MD . . . 17

Chapter 4: Using Science and Design to Improve Patient Flow

by John B. Chessare, MD, MPH, FACHE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Part II: The Mechanics of Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter 5: Reduction and Management of Variability in Health Care Delivery

by Julia L. Krol, RN, BSN, MBA and Michael C. Long, MD . . . . . . . . . . . . . . . . . . . 29

Chapter 6: Using Variability Methodology to Improve Patient Flow:

Three Projects Offering Tangible Results by Julia L. Krol, RN, BSN, MBA
and Michael C. Long, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Chapter 7: Variability Methodology: Tools & Techniques by Cheri Ward, MPH, DPT
and Kristy Zhou, BSc, BComm, MM in Operations Research . . . . . . . . . . . . . . . . . 67

iii
Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety

Part III: How We Did It: The Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Chapter 8: Right Focus, Right Solution: How Reducing Variability in Admission

and Discharge Improves Hospital Capacity and Flow by Peter Viccellio, MD, FACEP;
Katherine Ardalan Hochman, MD, FHM; Peter P. Semczuk, DDS, MPH;
Carolyn Santora, MS, RN, NEA-BC, CSHA, CPHQ . . . . . . . . . . . . . . . . . . . . . . . 97

Chapter 9: New Jersey’s Collaborative on Patient Throughput by Mary A. Ditri, DHA,

MA, CHCC; Aline M. Holmes, DNP, MSN, RN; Patricia A. McNamee, RN, MS;
Robert G. Lahita, MD, PhD, FACP, MACR, FRCP; and Elizabeth Ryan, JD . . . . . . . . . . 113

Chapter 10: Rightsizing Inpatient Medical Units: Developing Telemetry

ADT Criteria by Robert G. Lahita, MD, PhD, FACP, MACR, FRCP and
Jennifer Crist-Muñoz, APN-C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127

Chapter 11: Standardizing Admission, Transfer, and Discharge Processes to Reduce

Artificial and Clinical Variability by Daniel J. Beckett, FRCP, MBChB (Hons),
MSc, BSc (Hons); David A. McDonald, ProfD, BSc (Hons), MCSP; Patrick Rafferty, BN;
and Martin Hopkins, MA (Cantab.), MBA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Part IV: Whole System Flow: Beyond the Hospital Setting . . . . . . . . . . . . . . . . . 157

Chapter 12: Bottlenecks in Flow to Post-Acute Care by Alan Forster, MD, FRCPC, MSc;
Renate Ilse, RN, DHA; Daniel Kobewka, MD, MSc; and Kednapa Thavorn, PhD . . . . . . 159

Chapter 13: Pulling Out All the Stops: Delivering Whole System Flow
by David Fillingham, MA (Cantab.), MBA, CBE; Bryan Jones, PhD; and
Penny Pereira, MA (Cantab.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

iv
 Acknowledgments

I am very grateful to the authors for their valuable Peter P. Semczuk, Kednapa Thavorn, Peter Viccellio,
contributions and for their patience with my multiple Cheri Ward, Kristy Zhou.
requests and suggestions, which I thought were crucial
I am also grateful to Catherine Chopp Hinckley, the
and they likely believed were annoying. I am indebted
Executive Director, Global Publishing at JCR, and Helen
to Dr. Harvey Fineberg for the foreword to this book
Fry, Associate Director, Publications at JCR, for their
but even more for his early recognition of the effect of
helpful comments and suggestions. My special thanks go
optimizing patient flow on quality of care and its cost,
to Jennifer Ahearn, JCR Senior Editor. Her contributions
and for his strong support of this field in his capacities as
made this book a significantly better one.
Harvard University Dean and Provost, and as the past
President of the Institute of Medicine (currently National And finally, my very special thanks go to Helen Haskell
Academy of Medicine). for her contributions to the prologue, for her commitment
to improving patient safety, for her leadership in curbing
I wish to extend my appreciation to the contributing
incidents of patient flow failures (similar to what happened
authors of this book: James M. Anderson, Daniel J.
to her son Lewis Blackman), and for her inspiration to me
Beckett, John B. Chessare, Jennifer Crist-Muñoz,
and many others in my field.
Mary A. Ditri, David Fillingham, Alan Forster, Katherine
Ardalan Hochman, Aline M. Holmes, Martin Hopkins,
Renate Ilse, Bryan Jones, Hakmeng Kang, Jack Kitts,
Ellis “Mac” Knight, Daniel Kobewka, Julia L. Krol,
Robert G. Lahita, Michael C. Long, David A. McDonald,
Patricia A. McNamee, Penny Pereira, Patrick Rafferty, Eugene Litvak, PhD
William C. Rupp, Elizabeth Ryan, Carolyn Santora, President, Institute for Healthcare Optimization

v
Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety

vi
 Foreword
by Harvey V. Fineberg, MD, PhD
President, Gordon and Betty Moore Foundation
Former President of Institute of Medicine
Former Dean of the Harvard School of Public Health

You can always count on the Americans to

do the right thing—after they have exhausted all the other possibilities.
ATTRIBUTED TO WINSTON S. CHURCHILL

A recent news report brought a startling announcement management, gathering and analyzing the right data,
from Jeff Bezos of Amazon, Warren Buffett of Berkshire and putting in place the teams that can implement l­asting
Hathaway, and Jamie Dimon of JPMorgan Chase: improvements in the way patient flow is managed, you
They were taking the health care of their employees can reap the benefits of better patient experience and
into their own hands. If they are serious, I thought, and outcomes, cost savings, and higher job s­ atisfaction
­surely they are, one of the first people they should call is among your professional employees. If this sounds
Eugene Litvak. Here, in this handbook, you can learn what too good to be true, I urge you to read on about the
Dr. Litvak and his colleagues would teach them, how to approaches and successes documented by the authors
apply the principles of operations research and m­ anaging in these chapters. There is no reason their success
the flow of patients to improve both the quality and ­cannot be attained by every institution and system that
­efficiency of medical care. I suspect the concept of flow delivers health care.
management is familiar to Amazon.
This book does not cover every useful tool and technique
If you are a health care executive or clinical leader, there to improve efficiency in the delivery of care, nor does it
is no need for you to wait for the titans of American aspire alone to be a comprehensive guide to managing
business to reweave the fabric of America’s health care. the flow of patients. It is, however, an enlightening, inspir-
You can disrupt your own health care institution, in the ing, and deeply practical introduction to the principles and
best possible way, and start right away. Through exerting methods of managing patient flow that will reward anyone
your own leadership, adopting the principles of operations determined to improve medical care.

vii
Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety

viii
 Introduction
by Eugene Litvak, PhD
President, Institute for Healthcare Optimization

When hospitals suffer from overcrowding, quality of care their peers. Four hospital CEOs tell their stories in
becomes far from satisfactory, infections and readmission separate chapters of this book about how to navigate the
rates increase, and clinicians burn out as they struggle unchartered waters of changing hospital culture while
to support a required level of patient safety. All this takes defining patient safety and quality of care as an ultimate
place in an environment of increasing health care costs. goal of health care. This book also provides physicians,
nurses, other clinicians, and managers with practical
In 2010 Joint Commission Resources published Managing
ways to improve patient safety in their work environment.
Patient Flow in Hospitals: Strategies and Solutions,
Decision support experts will also benefit from this book
Second Edition. This book introduced the concept of
and can use it as a step-by-step manual on optimizing
streamlining hospital patient flow. Ten years later, there
patient flow at their institutions.
is a growing demand for a systematic, scientific, and
practically proven approach to not only streamlining but This book covers both US and international case studies
also optimizing patient flow to improve care and reduce on implementing modern principles in managing patient
costs. My colleagues and I at the Institute for Healthcare flow and is therefore useful for health care workers
Optimization are frequently approached by clinicians, around the world. While this book is a significant step
hospital executives, and managers who need help in forward in optimizing patient flow and hospital operations,
improving efficiency at their hospitals. This grave situ- the aforementioned Managing Patient Flow, Second
ation requires expeditious and methodical actions to Edition, remains an essential guide to patient flow as it
move beyond the status quo. It also provides the primary affects nurse staffing and quality of care. This earlier
motivation for this new book, Optimizing Patient Flow: book also contains important statistical analyses of
Advanced Strategies for Managing Variability to Enhance patient demand and a very educative case study from
Access, Quality, and Safety. This new book offers rigor- Cincinnati Children’s Hospital. Therefore, the earlier book
ous and structured guidance for optimizing patient flow. is frequently referenced throughout this book. For some-
It also provides a practical road map to implementing and one who wants to become an expert in patient flow, these
complying with Joint Commission Leadership Standard two books combined provide the key knowledge for
LD.04.03.11, which requires a systematic, hospitalwide achieving this goal.
approach to patient flow.
One important issue addressed in this current book,
The intended audience for this book is varied. Hospital Optimizing Patient Flow, is managing health care system
executives and board members, who are struggling to flow. A hospital’s inability to discharge patients who are
comply with quality of care measures while improving ready to go home or to a subacute facility (rehabilitation,
hospital margins, have the chance here to learn from skilled nursing facility) is a contributing factor when it

ix
Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety

comes to overcrowding. Indeed, if there is no place PART I

to which to discharge a patient, he or she then unneces-
sarily occupies a hospital bed, which in turn prevents
CEO Perspectives—
admission of an acutely ill patient to that bed, thereby
creating a patient flow bottleneck. For some hospitals,
Committing to Optimized
this bottleneck could be a problem of significant magni- Patient Flow
tude. While this book provides an extensive and detailed
Chapters 1–4. Anyone in hospital management will con-
methodology for improving hospital patient flow, this
firm that it is impossible to implement any complex hos-
approach can and has been successfully applied in
pital project (particularly optimizing patient flow) without
outpatient settings as well.
the strong support of the hospital CEO. However, as most
I would recommend viewing this book as a menu with CEOs have learned, it is challenging to assume the role
selections for different health care professionals. For of a real leader tasked with changing hospital culture.
example, Chapters 1–4 are very important for hospital The first four chapters detail the different experiences
executives who are deciding whether to undertake a of four hospital CEOs who have succeeded in stream-
large-scale patient flow project. Read the stories of CEOs lining patient flow. These are former CEO of Cincinnati
who grappled with the same challenges. Those who are Children’s Hospital Medical Center, James M. Anderson,
leading hands-on patient flow redesign efforts would JD, Hon. DSc; CEO and President of The Ottawa Hospital
greatly benefit from Chapters 5–7. Those who are still (Canada), Jack Kitts, MD; former CEO of Mayo Clinic
deciding whether it’s worthwhile to undertake patient (Florida), William C. Rupp, MD; and President, CEO, and
flow redesign, given its technically and organizationally Director of Greater Baltimore Medical Center, John B.
complex nature, should read the case studies in Chessare, MD, MPH, FACHE.
Chapters 8–11. Finally, for those who look beyond
hospital walls to improve patient flow, Chapters 12 and
13 will be of great importance. PART II

The book consists of a prologue and 13 chapters divided

into 4 parts.
The Mechanics of Flow
Chapters 5 and 6. Optimizing patient flow is a very
The prologue illustrates the reality in health care today challenging task that requires management, data analysis,
and advocates for the need for properly managed patient and clinical expertise. Chapters 5 and 6 provide a step-
flow. Powerful and passionate, a well-known leader in by-step course of actions necessary for “smoothing”
quality of care and hospital operations, Ellis Knight, MD, surgical and medical patient flow These chapters were
makes a very strong and convincing case for optimizing written by Julia L. Krol, RN, BSN, MBA, and Michael C.
patient flow for quality of care and patient safety. He tells Long, MD, both of whom have many years of clinical and
the heartbreaking story of Lewis Blackman, a talented consulting experience in streamlining hospital patient flow
young boy who died due in part to mismanaged hospital in different settings. Chapter 5 focuses on the theory of
patient flow. What makes this case genuine and variability in health care, while Chapter 6 outlines three
emotional is the contribution by Helen Haskell, MA, specific projects that can be used to reduce and manage
a prominent patient safety advocate and the mother variability in the hospital setting.
of Lewis Blackman.
Chapter 7. This chapter, written by operations research-
ers Cheri Ward, MPH, DPT, and Kristy Zhou, BSc, BComm,
MM in Operations Research, provides practical appli-
cations of IHO’s Variability Methodology® described in

x
  Introduction

Chapters 5 and 6 as well as the metrics for patient flow s­ uccess is a valuable lesson for other state hospital asso-
assessment. Variability Methodology is a scientific, prac- ciations, hospital networks, and countries intent on under­
tically proven approach to reducing and eliminating man- taking a systemwide change at multiple hospitals at once.
made artificial swings in patient demand and to cohorting
Chapter 10. The most valued hospital resources are mon-
patients in order to improve effectiveness and efficiency
itored beds, intensive care unit (ICU) beds, and telemetry
of their care. Ward and Zhou provide guidance on how
beds. Proper utilization of these beds is extremely import-
to conduct a quantitative analysis of patient flow, how to
ant for any hospital, and a lack of these beds is a frequent
evaluate fundamental patient flow management strategies
cause of ED overcrowding. In this chapter, Robert G.
using operation management techniques, and how to
Lahita, MD, PhD, FACP, MACR, FRCP, and Jennifer Crist-
apply these strategies and techniques in the context of
Muñoz, APN-C, describe how their hospital optimized the
Variability Methodology. They also give detailed instruc-
use of telemetry beds, thereby improving patient safety,
tions on patient flow assessment, performance metrics,
saving more than $10 million annually, and significantly
and other technical tools, such as queueing theory and
reducing average length of stay and ED boarding time for
simulation, which are helpful in implementing the
telemetry beds.
concepts described in chapters 5–7.
Chapter 11. Are the solutions described in the Chapters
5–7 applicable beyond the United States? The answer is
PART III a confident “yes” from Daniel J. Beckett, FRCP, MBChB
(Hons), MSc, BSc (Hons), and his colleagues. Chapter 11
How We Did It: describes their very successful experience in applying

The Case Studies these methods through the National Health Service
(NHS) Scotland at the Forth Valley Royal Hospital. They
Chapter 8. It is well-known that an overcrowded emer- achieved real results in better access to care and bed
gency department (ED) is symptomatic of hospital over- availability—in part, through earlier median discharge
crowding and obstructed patient flow, two disturbing times, a reduction in length of stay of up to 20.3%, and
events that usually take place at the same time. These potential annualized savings of > 3,000 bed days.
two indicators of poor management endanger patients,
demoralize staff, and reduce hospital revenue. Four
authors of this chapter, Peter Viccellio, MD, FACEP; PART IV
Katherine Ardalan Hochman, MD, FHM; Peter P. Semczuk,
DDS, MPH; and Carolyn Santora, MS, RN, NEA-BC, CSHA, Patient Flow Beyond
CPHQ, are national leaders in implementing full capacity
protocol, as well as early and weekend hospital discharg-
the Hospital Setting
es. The authors have implemented their ideas very suc- Chapter 12. One of the main obstacles to smooth-
cessfully at their institutions and have described the solu- ing patient flow is a hospital’s inability to discharge its
tions in this chapter. These interventions have both patients to a post-acute care facility (for example, reha-
national and international applications. bilitation or skilled nursing). Thus, the hospital’s outgoing
patient flow is obstructed. This is a major problem both
Chapter 9. Optimizing patient flow at one hospital is
domestically and internationally as it hampers a hospital’s
challenging. Doing so simultaneously at several hospitals
capacity to provide adequate, timely, and high-quality
is even more difficult. Can it be done? In this chapter,
patient care. In this chapter, Alan Forster, MD, MSc, and
Mary A. Ditri, DHA, MA, CHCC, and her colleagues
his colleagues in Ontario, Canada, provide a compre­
describe their success with 14 hospitals under the leader-
hensive analysis of the problem, the effects on hospital
ship of the New Jersey Hospital Association in a CMS-
performance, obstacles to addressing this challenge, and
sponsored program, Partnership for Patients. Their
the solutions for managing these issues.

xi
Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety

Chapter 13. This chapter discusses patient flow beyond However, this book, along with Managing Patient Flow,
the confines of the hospital setting. As many of us already Second Edition, will educate you to successfully
know, patient care does not end at the acute or even ­implement a patient flow redesign at your institution.
sub-acute facility. An optimal health care system extends The concepts and tools in both books were tested
to social care services as well. Social care service is a and successfully applied not only in hospitals but also
provision of social work, personal care, protection, or in outpatient settings, testing laboratories, and other
social support services for children or adults in need or nonhospital settings.
at risk. It also pertains to adults with needs arising from
I hope you, the reader, find this book helpful and
illness, disability, old age, or poverty. In this chapter,
important in your efforts to optimize patient flow. I have
David Fillingham, MA (Cantab.), MBA, CBE, and Bryan
no doubt that your patients will greatly benefit from
Jones, PhD, and their colleague discuss the whole system
improved quality of care and patient safety, and your
flow concept, approaches, and related policies inter-
­institutions will benefit from significantly improved
spersed with case highlights and real world applications
­margins. I also hope that you enjoy reading it as much
in the UK NHS.
as all of us enjoyed putting it together. That would be the
Of course, this book cannot include all possible scenarios best reward for all of us who contributed to this book.
and challenges in managing patient flow in your organization.

xii
 Prologue
Lewis Blackman: Lessons
Learned from a Ninth Grader
byEllis “Mac” Knight, MD, MBA, FACP,
FACHE, FHM
Senior Vice President and Chief Medical Officer, The Coker Group

Dr. Knight and Dr. Litvak wish to gratefully acknowledge friends, Lewis was known for a trenchant but understated
the contributions of Helen Haskell, MA, Lewis Blackman’s mother, sense of humor, and to a smaller circle, for his sensitivity
to this prologue. to the vulnerabilities of others. The week before he died,
I came home from work one November day several years a new boy had entered the school. Lewis had reached
ago to find my identical twin daughters in tears. One of out to pull him into the circle of friends he himself had so
their ninth-grade classmates—Lewis Blackman—had just recently joined. A week later Lewis disappeared and did
died unexpectedly after undergoing routine surgery at not return, but the new student never forgot the kindness
the Medical University of South Carolina in Charleston. of his first friend at school.
Little did I realize then that, while his name was unfamiliar The route by which Lewis had ended up in the hospital
to me at the time, the medical community in South that fateful November day was not a straightforward one.
Carolina, where I used to live and work, would forever He had been born with a condition known as pectus
remember Lewis Blackman from that day onward. As excavatum, in which the front of the chest curves inward,
I sat and consoled my daughters that afternoon, I also causing potentially embarrassing disfigurement. Lewis’s
had no idea of how far-reaching the events surrounding pectus condition had little effect on his life and in fact had
his death would become.1 scarcely been visible for most of his childhood. But when
Just over two months earlier, Lewis had transferred, with he hit puberty the indentation had begun to deepen and
a generous merit scholarship, to the private school my by the age of 14 was definitely noticeable.
daughters had attended since kindergarten. An exuberant Lewis’s parents had seen an article in their local paper
and outgoing boy, he fit easily into the small, close-knit featuring a safe, new, minimally invasive surgical pro-
student body and had made many friends in the short cedure to repair pectus excavatum. They asked their
time he had been there. pediatrician to recommend a pediatric surgeon and, after
Lewis was something of a star, even at the age of 15. some deliberation, decided to go ahead with the surgery.
He was a veteran actor who had worked from an early Hopes of a summer surgery were dashed, however, by
age in television and community theater, including the months of delays in the insurance approval process.
South Carolina Shakespeare Company. An academic high Eventually, the pediatric surgery department proposed
achiever, he garnered state honors in math, English, and the date of Monday, October 30. Lewis’s mother asked to
science. He played the saxophone, read widely in history postpone the operation so that Lewis and his sister could
and anthropology, and wrote for the youth section of the celebrate Halloween with their friends. The pediatric sur-
local newspaper. He was an avid soccer player, planning gery department agreed, and Lewis’s surgery was moved
to go out for the varsity team in the spring. Among his to Thursday, November 2.

xiii
Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety

Thus it came about that Lewis entered the hospital and appeared tired and overextended and had few insights to
underwent minimally invasive pectus surgery early on a offer into the situation. By late afternoon, Lewis’s mother
Thursday morning in the first week of the month, just as asked the nurse to call an attending physician. When
the surgery interns began their new rotations. The resi- a young man arrived two hours later, she assumed he
dents who cared for him were general surgery residents was the attending she had requested. He was, however,
with little prior background in pediatrics, while many of another resident, and he reflexively confirmed the diag­
the nurses were recent nursing school graduates who, nosis of opioid-induced ileus. The traveling nurse who
their supervisors said, often had a preference for the was on duty did not call the doctor again when Lewis’s
pediatric units. temperature continued to drop and his heart rate rose
into the 140s during the night.
After the operation, Lewis’s surgeon told his parents
that the surgery had gone well. In the recovery room, When the hospital sprang to life on Monday morning,
Lewis seemed in good spirits. Then it was realized that the return to full staffing did not ameliorate the situation
he was not urinating. Postanesthesia staff replaced his for Lewis because his doctors were fully occupied in the
Foley catheter, to no avail. After several hours, Lewis was surgical suite and did not come onto the patient floors.
discharged from postanesthesia care, still with no urine Then the vital signs technician, rounding at 8:00 a.m.,
output. Due to a high census and a lack of beds on the could not detect a blood pressure. In the assumption that
surgical unit, he was admitted to the pediatric oncology the problem lay with the equipment, the intern and nurses
unit. Pectus surgery patients were not routinely placed on spent the morning searching the hospital for different
this unit, and the oncology staff were unfamiliar with their blood pressure machines and cuffs. All told, they took his
specialized pain regimens. blood pressure 12 times with seven different cuffs and
machines without getting a reading.
Lewis finally began to produce urine late the next
day, after a nurse and pharmacist teamed up to get his At noon on Monday, while having blood tests that had
intravenous fluids increased. But he continued to have been delayed from Sunday night, Lewis went into cardiac
unremitting nausea and his pain remained poorly arrest and could not be revived. An autopsy the next day
­controlled, in spite of high doses of opioid narcotics revealed a large perforated duodenal ulcer, a known side
and regular injections of the intravenous nonsteroidal effect of the intravenous NSAID Lewis had been taking.
anti-inflammatory drug (NSAID) ketorolac. On Friday, In addition, the autopsy showed 2.8 liters of blood and
the surgeon went home for the weekend, leaving Lewis in gastric secretions in his peritoneal cavity.2
the care of an on-call attending physician. His day-to-day
To her credit, Lewis’s mother, after the loss of her son,
care was provided by weekend staff consisting of a
fought to try to prevent something similar from happening
general surgery intern and nurses from the nursing pool
to others. The Lewis Blackman Hospital Patient Safety
or floating from other departments.
Act now stands in South Carolina as a testament to her
Early on Sunday morning, Lewis’s condition took a sudden work in that regard.3 This statute requires that all clinical
turn for the worse with an abrupt onset of severe epigas- staff in South Carolina hospitals, including students and
tric pain. Frantically, he said this was a new pain, quite residents, wear badges that identify their names, depart-
distinct from his surgical pain, and characterized it as ments, jobs, or titles. This was a response to the family’s
“5 out of 5” on the pediatric pain scale. His nurses, confusion over the roles of hospital personnel, in particu-
­initially alarmed, concluded that he must have an opioid- lar Lewis’s mother’s misidentification of the resident who
induced ileus and recommended that he walk the halls to examined Lewis, which she believed had stopped the
alleviate the pain. family from seeking further help.

As Sunday wore on, Lewis’s pain did not dissipate. He The Lewis Blackman Act also states that any time a
grew progressively weaker and his vital signs began to patient or family member requests to speak to the
deteriorate. The on-call attending had not rounded since patient’s attending physician, the nurse must allow them
early Saturday and the only member of Lewis’s medical to talk to the doctor directly, to prevent miscommunication
team present in the hospital was the intern, who of the family’s concerns as happened in Lewis’s case.
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 Prologue  | Lewis Blackman: Lessons Learned from a Ninth Grader

Finally, the law requires that all South Carolina hospitals open beds and perhaps less knowledgeable or inexperi-
have an emergency “mechanism”—an unspecified rapid enced staff. (Note: Lewis was admitted to the cancer unit
response system—that families can call if they feel a as opposed to the surgery unit.)
patient is deteriorating without adequate clinical
The dangers of peaks in flow are well-documented in the
response. This was the first large-scale effort in the
medical literature.6,7 Hospitalists, who care for patients
United States to create a patient-activated emergency
only in the inpatient setting, when surveyed for a Johns
response system in hospitals, a concept that gained
Hopkins patient safety study, reported that they were
widespread currency after The Joint Commission’s 2009
routinely put into situations where having to care for large
National Patient Safety Goal stating that emergency
numbers of patients significantly increased their risks of
response systems should be available to staff, patients
making errors and doing harm.8
and families.3,4
If variability in patient flow is the problem, and a signifi-
I want to make it clear that I think it was quite understand-
cant cause of that variability comes from the admission
able and even commendable for Lewis’s mother and her
of many elective surgical cases during the first part of the
legislative sponsors to work tirelessly to pass the Lewis
week, then why isn’t this being addressed?
Blackman Patient Safety Act. There were other factors
involved in the death of Lewis Blackman, however. It is There are many reasons. First, other solutions for the
my contention that the authors of this statute should have many problems that result from variability in patient flow
further directed their attention toward the single most are much easier to understand. For instance, a standard
important underlying cause of this tragedy: variability in response to overcrowding in the emergency department
patient flow. (ED) is to expand capacity in the ED9 or to hire more staff.
Other frequently deployed solutions include changing the
Variability in patient flow through modern hospitals is
ED triage system and improving or shortening other ED
a very dangerous matter.5 Variability is manifest in the
processes, such as bedside registration.10 None of these
waves of patient admissions that flood into hospitals on
solutions has been shown to be superior to the removal
certain days of the week. These peaks in patient demand
of what is known as access block to inpatient beds.
overwhelm the ability of caregivers of all types to provide
Smoothing the admission of elective surgery patients
care safely to these frequently very ill people. The reason
throughout the week, however, has been shown to
this flow is variable emanates from the way that work
improve throughput, even in areas remote from the
happens in most hospitals where providers, particularly
operating room such as the ED, and other patient flow–
surgeons, do their cases in the first part of the week,
related issues such as quality of care and patient safety,
thereby overcrowding hospitals in the second part.
as well as hospital bottom lines.11
(Note: Lewis’s case was on a Thursday morning.)
Second, other solutions are much easier and less costly
Hospitals also tend to function in much less than full-
to implement. It is much simpler to hire patient experience
service mode over the weekend. Elective surgeries are
consultants, who suggest that health care systems join
not scheduled on Saturdays or Sundays. Case schedules
the “experience economy,”12 than to try to persuade the
are shorter on Fridays and Mondays. On-call personnel
hospital’s surgeons, upon whom the hospital depends for
or residents make patient rounds on the weekends, and
precious revenues, to change their operative schedules.
nursing and other clinical staff levels (such as ancillary
Likewise, many hospital administrators believe that when
services) drop significantly by the end of the week. (Note:
the physicians take the weekends off, other clinical staff
Lewis’s surgeon left for the weekend, and Lewis was left
(including nurses, rehab staff, laboratory workers, and
in the care of a team of residents and an on-call surgeon.)
respiratory therapists) should staff down as well. The
Most hospitals rely on surgical procedures to generate rationale seems to be that when there are no doctors
much-needed profits. Thus, when beds on the postsurgi- around to operate or admit new cases, hospitals do not
cal units are fully occupied, rather than canceling surger- need to run a truly full-service operation, despite studies
ies, patients are diverted to other inpatient care units with that have shown this practice to be quite risky.13

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Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety

Although the effect of the Lewis Blackman Patient Safety 5. Baker DR, et al. Patient flow variability and unplanned
Act has not been rigorously studied, the case of Lewis readmissions to an intensive care unit. Crit Care Med.
Blackman has been widely used in education both of 2009 Nov;37(11):2882–2887.
nurses and medical professionals and has served as 6. Aiken LH, et al. Hospital nurse staffing and patient mor-
an inspiration in the implementation of rapid response tality, nurse burnout, and job dissatisfaction. JAMA. 2002
systems.14–17 Nevertheless, if patient flow were rational- Oct 23–30;288(16):1987–1993.
ized, there might be fewer precipitating conditions for 7. Needleman J, et al. Nurse staffing and inpatient hospital
postoperative emergencies and less need for rapid mortality. N Engl J Med. 2011 Mar 17;364(11):1037–1045.
response calls overall. I find it intolerable to think that the 8. Michtalik HJ, et al. Impact of attending physician workload
health care profession has failed to implement effective on patient care: A survey of hospitalists. JAMA Intern Med.
solutions despite the growing body of knowledge and 2013 Mar 11;173(5):375–377.
understanding that smoothing patient flow can save lives 9. Richardson DB, Mountain D. Myths versus facts in emer-
and prevent harm. I am burdened with the knowledge gency department overcrowding and hospital access block.
that a few simple changes in Lewis’s care could have Med J Aust. 2009 Apr 6;190(7):369–374.
saved his life and the lives of others like him, who have 10. Takakuwa KM, Shofer FS, Abbuhl SB. Strategies for deal-
fallen victim to the health care system’s reluctance to ing with emergency department overcrowding: A one-year
work on eliminating or reducing variability in patient flow. study on how bedside registration affects patient through-
put times. J Emerg Med. 2007 May;32(4):337–342.
If Lewis Blackman’s surgery had been performed on a
11. Litvak E, Fineberg HV. Smoothing the way to high
Monday morning, rather than a Thursday morning, he
quality, safety, and economy. N Engl J Med. 2013 Oct
might be alive today.18 He might, like both of his parents,
24;369(17):1581–1583.
have a degree or two from Duke. With his abilities in math
12. Pine BJ 2nd, Gilmore JH. Welcome to the experience
and science, he might even be a young physician by now.
economy. It’s no longer just about healing: Patients want
This thought is especially haunting, for knowing what I
a personal transformation. Health Forum J. 2001 Sep–
know now about his short life and his inner character, I am
Oct;44(5):10–16.
sure he would be unable to tolerate a system that refused
13. Schilling PL, et al. A comparison of in-hospital mortality
to do the right thing and institute the corrective changes
risk conferred by high hospital occupancy, differences in
needed to save patient lives.
nurse staffing levels, weekend admission, and seasonal
We who genuinely consider ourselves caregivers influenza. Med Care. 2010 Mar;48(3):224–232.
should not rest until this resistance is overcome. 14. Raymond J, et al. South Carolina patient safety legislation:
Otherwise, we will fall far short of honoring the real The impact of the Lewis Blackman Hospital Patient Safety
legacy of Lewis Blackman. Act on a large teaching hospital. J S C Med Assoc. 2009
Feb;105(1):12–15.
15. Transparent Health. The Faces of Medical Error . . . From
» References Tears to Transparency: The Story of Lewis Blackman.
1. Raymond J. Lewis Blackman Hospital Patient Safety Act. J DVD. Chicago: Transparent Health, 2009.
S C Med Assoc. 2009 Oct;105(6):207. 16. QSEN Institute. The Lewis Blackman Story. Haskell H.
2. Monk J. How a hospital failed a boy who didn’t have to die. 2009. Acessed Mar 8, 2018. http://qsen.org/publications
The State. 2002 Jun 16;Sec. A8–9: A1. /videos/the-lewis-blackman-story/.
3. South Carolina Legislature. South Carolina Code of Laws 17. American Nurse Today. Family Initiated Rapid Response
Unannotated: Lewis Blackman Hospital Patient Safety Act. Team. Ehrig S, et al. Aug 11, 2013. Accessed Mar 8, 2018.
Section 44-7-3410 et seq. Accessed Mar 8, 2018. https:// https://www.americannursetoday.com/family
www.scstatehouse.gov/code/t44c007.php. -initiated-rapid-response-team/.
4. The Joint Commission. National Patient Safety Goals. 2009 18. Litvak E. Don’t get your operation on a Thursday. The Wall
Comprehensive Accreditation Manual for Hospitals: The Street Journal. 2013 Dec 2:A17.
Official Handbook. Oak Brook, IL: Joint Commission
Resources, 2008.
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