IHI.org asked Flow faculty expert Kirk Jensen to address some of the challenges to improving hospital flow from his perspective. Here's what he had to say:

Many hospitals are trying to run at or near 100 percent capacity. We also see a significant amount of variation in flow within the different hospital microsystems and variation in utilization of services. The challenge is to focus on achieving an 85 to 90 percent utilization rate so we can optimize patient service and patient safety.

Tell us a little bit about what IHI does know about answers to some of those challenges.

We know that most admissions come in through either the emergency department or the operating room. In the ER you're dealing with unexpected events that do not appear predictable, but if you look at these events from a level of 10,000 feet there's a certain amount of predictability. Another interesting fact is that the surgical schedule is also highly predictable. We know from queuing theory that if you can operate at an 85 to 90 percent utilization rate you maximize service and allow for natural variation. So the challenge and the opportunity are, how can we use this knowledge to optimize utilization in the pursuit of service and patient flow?

So what should a hospital do to improve its flow?

On the tactical level, a hospital should study its demand, and then develop a predictive model for what demand is going to be in the near future. This allows the hospital to try and either match capacity to demand, or at least try and approximate what demand is going to be and build in resources accordingly. On the strategic level, IHI has a lot of pieces in place (tools, resources, and suggested strategies) and we certainly know a lot about optimizing patient flow within any individual microsystem. However, there's still work to be done to finalize the model.

What is an example of a microsystem?

A microsystem is a self-contained unit in the hospital, such as the emergency department, the operating room, or the ICU. These service units are made up of people, processes, and supplies that are largely self-contained. They have their own set of operating principles, they have their own culture, and in many respects they are self-sufficient. That said, there are multiple interdependencies, and that's where cracking patient flow on a hospital-wide basis is both fascinating and challenging.

And why is improving hospital-wide flow so challenging?

A hospital is a great example of a complex adaptive system. You have a -number of people who are making day-by-day, even minute-by-minute, decisions that impact hospital wide patient flow and they are making these decisions without access to information about what is going on in the rest of the hospital. So they may be optimizing flow within their microsystem just within their own individual field of play.

To improve this, the overarching administrative system can do two things. First, an administrative system can enable someone to look at hospital flow and exert some control. Instead of playing on the playground, you can climb up to the top of the jungle gym and you're able to look around and direct the field of play.

The other thing a hospital can do is push information out to the people who really need it. You may have a nurse manager on the floor trying to decide whether to accept an admission from the emergency department manager or discharge two patients in front of her. If she has access to the hospital bed status, then she can make the best decision for all of the individuals involved. To facilitate this, you can have somebody — the officer of the day or the captain of the ship — who can look at hospital flow and facilitate the integration of all the different patient streams and of the various microsystems.

WellSpan Health in Pennsylvania has developed a grid for both evaluating and managing patient flow. They can define a condition as green, yellow, orange, or red, with descriptive parameters to match and alerts built in for dealing with those situations. Other hospitals are working on a hospital-wide computerized tracking system that pushes the information out to other people. There's an abundance of experience with both paper and computerized tracking systems within each of the individual microsystems that make a compelling case for how one can optimize patient flow within a microsystem if one has an effective tracking tool.

How can IHI.org accelerate improvement in hospital-wide patient flow?

IHI.org is cataloging, publicizing, and pushing outward the work that we've already done in the area of improving flow. We have a fairly well-defined change package for improving hospital-wide patient flow. We haven't cracked the code entirely, but we're well on the way. IHI.org can serve as a hunting-and-gathering role for finding and disseminating what hospitals are doing in hospital-wide patient flow.

IHI.org might be a good place to try and build that model. Most of us don't have time to sit down and think creatively about solving a problem that hasn't been solved before. It's much easier to know that St. John's did this and it fixed the problem I have, so let me just do what St. John's did. And then one degree of separation from that is, St. John's did this and it solves my problem, and four other hospitals tried that and here are the unique ways they implemented it in their hospital, so I'm sure one of these ways will work for me. This is much easier than sitting down with a piece of paper and saying, "Hey, let's figure out how to do this." You aren't writing the recipe from scratch, you can just follow or modify someone else's favorite.