Uncorking Bottlenecks

Oct. 1, 2008

A multi-hospital system transforms its culture and processes to optimize patient flow.

Moses Cone Health System is the primary healthcare provider in the Piedmont region of North Carolina, with four hospitals, physician practices, behavioral health centers and other treatment centers to provide the complete continuum of care. The system’s flagship hospital is the 520-bed Moses Cone Memorial Hospital, the largest medical center in the four-county region.

A multi-hospital system transforms its culture and processes to optimize patient flow.

Moses Cone Health System is the primary healthcare provider in the Piedmont region of North Carolina, with four hospitals, physician practices, behavioral health centers and other treatment centers to provide the complete continuum of care. The system’s flagship hospital is the 520-bed Moses Cone Memorial Hospital, the largest medical center in the four-county region.


In today’s high-demand environment, nearly every hospital struggles with patient flow challenges, and Moses Cone was no exception. Our symptoms were typical: patient flow bottlenecks in high-demand areas such as the post-anesthesia care unit (PACU) and the emergency department (ED) stretched wait times for patients waiting to be placed. Incoming patients from physician practices and other hospitals experienced lengthy delays during the patient placement process, which hindered patient and physician satisfaction. Step-down had notoriously long waits for patient placement, which we suspected was due to inappropriate admissions to the unit.

The underlying problem was that most departments operated in silos, and as a health system, we didn’t effectively work together to expedite patient flow. Departments didn’t always communicate well, which contributed to improper bed utilization and delays. However, we lacked the needed data to show how and when these delays happened.

This “silo mentality” also fostered an environment somewhat resistant to change. Early in the project we met with key stakeholders who would undergo major process changes and utilize the new technology. One meeting was with Wesley Long’s bed control associate who had been working in her role for 30 years. She was currently using a pad of paper, a circular file and her telephone to place patients. We told her, “You’ll be able to have all the information right in front of you; no one can tell you they don’t have a ready bed. It’ll make your life so much easier.” She just peered at us over the top of her glasses and said, “Oh, really.” It painted a picture of how far we needed to come, and set the stage for our strategic plan.


We initiated a patient flow improvement project at Moses Cone Memorial, as well as Wesley Long Memorial (a 170-bed hospital and regional cancer center), guided by a multi-disciplinary team of clinicians, nurse managers, executives and support supervisors who designed and implemented a three-pronged approach that would ultimately achieve results at departmental and systemwide levels.

Process Redesign — Using best practices to fuel compliance: For process redesign, we applied Lean Principles and the Institute of Healthcare Improvement’s flow design process. We mapped the ideal patient flow for key departments such as Patient Placement, ED, PACU and Step-down, and determined when and where hand-offs had been neither quick nor consistent, such as communicating “room empty/bed dirty” statuses from nursing to environmental services (EVS). We also created compliance standards that mapped to the new processes. With bed turnover, for example, a nurse was in compliance if she entered “room empty/bed dirty” as the discharged patient was being rolled out of the room. If no status was entered at this point, the room sat dirty until EVS discovered it needed cleaning. These compliance standards set the stage for automating workflow through technology.

Patient Flow Technology — Putting automation behind new processes: Our competitive bid process led us to evaluate four vendors — three in the patient flow space, and one large hospital information systems company. A major criterion was the technology’s ability to conform to our processes, not the other way around, since we were creating cutting edge “best practice” processes with specific compliance goals. Other criteria included end-user ease of use, reporting and metrics, real-time tracking and the ability to incorporate key clinical data.

For more information on
Premise Patient Flow solutions

We selected the Premise Patient Flow Platform because it supported our unique workflow; we didn’t have to re-work our processes around the technology. We used it to support the new workflows with real-time status updates, prompts about tasks to be fulfilled, and trend reports to show non-compliant areas. With aggressive goals such as 90 percent bed turnover compliance and transfers within a half hour from ED and PACU, tracking and metrics were critical.

Culture Change — End-user accountability: When you’re working with conscientious professionals in a high demand environment, reward is always a better tactic than punishment. We had already met with some resistance, so we did as much as we could to excite the team about the new technology and processes.

First, we were strategic with our timing. We began an October implementation for a November go-live, with the idea that we’d be ready for our census peak from January through March. The Moses Cone team knew that our busy time was right around the corner, so everyone had an incentive to learn the new platform right away. Additionally, because it wasn’t our busiest time of year or a typical vacation time, it was easier to get everyone’s attention.

Second, the patient flow committee developed a slogan and successfully marketed it: “The key to throughput is you” was preached daily at the morning bed huddles. We stocked an office from floor-to-ceiling with candy, and during bed huddles we publicly rewarded the units who made their 90 percent goal with bags of sweets. For units that didn’t achieve the goal, we donned locksmith vests decorated with keys, and rounded those units after bed huddle. We placed them in “lockdown,” held them accountable for the previous 24 hours during which they had been non-compliant, and immediately provided them with the training they needed to succeed. Eventually, units that didn’t receive their bags of candy each morning became “upset” and soon they were holding each other accountable. It was a great way to affect cultural change in a positive manner. After just 90 days, the Lockdown Team disbanded — we had achieved our goals.

In addition to the up-front changes, we also instituted several key ongoing process changes based on the new level of transparency and data analysis that came with implementing patient flow technology:

Centralizing Patient Placement: Originally, each hospital had its own patient placement department that fell under Admissions and reported to Accounting; therefore, we didn’t have clinical experts monitoring placement. Patient Placement now reports to Nursing and is a centralized department serving both hospitals. This allows for proactive demand planning as well as accurate, first-time placements.

Nurse Triage for the Step-Down Unit: The step-down unit was receiving inappropriate admissions; for instance, patients from the ED who would then need to be transferred to the ICU, or patients who weren’t acute enough to be monitored in the step-down unit. By creating a nurse triage system that collaborated with patient placement, the step-down unit gained the authority to push back if admissions weren’t appropriate.

Progression Nursing: A new role to Moses Cone, the progression nurse is an eight-hour-a-day consistent staff member whose job is to decrease length of stay (LOS) and reduce delays on a case-by-case basis. Previously, if a physician ordered a test the patient might not receive it that day, and would then need to stay another night. Now, however, the progression nurse reviews reports, speaks with clinicians and intervenes early to ensure a timely discharge.

Implementation and Training

Process redesign, which we began in February 2006, was the substantial part of the project. Later that year, in August, we implemented Premise Bed Turnover, which took 45 days. Following that, in November, we implemented Premise Bed Management. Because processes around bed management are more clinically focused and complex, our implementation time for Bed Management was two months. We trained all of the patient flow committee members to be super-users, and in turn they conducted classroom training for our end users and provided the units with additional one-on-one training.

Connecting with the end users on a regular basis, rather than just relying on formal training, was a major factor in our success.


We saw major quantifiable and non-quantifiable improvements within 90 days. In step-down, the average time from an ED request to bed assignment dropped from 4.5 to 2.5 hours. In addition, inappropriate admissions in this unit decreased by 40 percent. We also decreased ED wait times by 50 percent, which is helping improve patient satisfaction.

Our efforts to create hospitalwide change were also rewarded. In just 90 days, we had increased the number of early discharges (defined as discharges which occur between 8:00 a.m. and 10:00 a.m.) by 2.5 percent. This gave us 12 additional beds earlier in the day. We also decreased late discharges by 50 percent, which gave us another 15 beds earlier in the day. As a result, our LOS decreased from approximately 6.0 to 5.3.

We haven’t quantified all of the cost savings from better resource utilization, but we know we’ve made great strides in this area as well. A prime example is our elimination of the daily bed huddles. Based on nurse staffing for the 30 minute meeting, we’ll save $324,000 this year alone. The process is so efficient that bed huddles are no longer needed.

Aside from creating a better patient experience, the reaction of the Moses Cone team has probably been the most rewarding benefit.

We work better cross-departmentally, as well. Recently, ED experienced an extremely busy day boarding telemetry patients. During that time Patient Placement visited PACU and asked how ED was doing. Once apprised of ED’s status, they told us to take care of the ED first. Prior to our successful process redesign, and the implementation of the workflow management system, that would not have happened. The global perspective has changed and we now think as a system, rather than as individual units, which has made a world of difference for the communities we serve.

Debbie Grant RN, BSN, MSN, is VP of nursing; and David Wilcox RN, BSN, MHA, formerly patient placement manager for Moses Cone Health System, is now a clinical strategist consultant. Contact them at [email protected] and [email protected]