Hospital capacity, productivity, and patient safety--it all flows together.

In this issue of Frontiers, three articles address a significant determinant of hospital productivity: the management of patients in transition through the acute inpatient setting. With the common theme appropriately termed "patient flow," the authors analyze and describe their perspectives of and experiences with activities or sites in the inpatient experience. THE PERSPECTIVE: A COMMON PROBLEM Haraden and Resar provide an overview of the Institute for Healthcare Improvement's (IHI) vision of patient flow analysis and process improvement, and Suzanne Horton at Baptist Memorial Hospital in Memphis, Tennessee, and Diana Henderson and her colleagues at St. John's Hospital in Springfield, Missouri, provide examples of analysis and implementation using the IHI methods at their large healthcare facilities. Both hospitals' stories acknowledge that these new activities were implemented in the midst of ongoing efforts to raise the level of quality and service beyond "our already established performance improvement program" (Henderson, Dempsey, and Appleby) and after having "pursued flow initiatives for more than five years" (Horton). Such details are early clues to the pervasiveness and challenges in managing patient flow. These institutions recognized the need for further improvement and voiced similar concerns regarding factors that seemed to limit capacity and productivity: hospital bed constraints, length of stay, and emergency department (ED) volume. The case studies also show that while specific areas were initially picked as a central focus for flow improvement, subsequent analyses of patient flow determinants led to expanded targets for improvement, illustrating how dynamic and interdependent the flow processes are. Furthermore, the noticeable similarity of the additional areas highlighted (surgery, intensive care unit [ICU]) confirms that these hospitals share common problems. This can be viewed at a systems level, where the problems are a consequence of conventional and historical healthcare processes that need to be revised, and is reflective of a large-scale dilemma affecting many acute care institutions and the industry as a whole. All three articles present examples of problems, such as ED diversion and delays in surgery, within the context of driving the need for change. However, the reader quickly notices the repetitive theme that problems initially misconstrued as an apparent limitation of capacity are instead caused by inefficiencies in clinical hospital operations. Therefore, increasing beds or staffing levels is not necessarily the best fix. THE NEED FOR INTEGRATED CHANCE AND ALIGNMENT What is made most obvious by these authors is the clear interrelationship among multiple hospital staffs and units as patients move through the system. In simple terms, this interrelationship implies that the total efficiency of a process can be constrained by the efficiency of the processes preceding or following it. Thus, the end of one patient's stay has a definite impact on the beginning of the next patient's stay, and movement of a patient out of one location determines when the next patient can enter that environment to receive the necessary care. This interrelationship must be respected, as change should not occur in isolation. Although many healthcare and business leaders understand the significance of "strategic alignment" within their organizations at a macro level, they may be less likely to see the similar application for clinical aspects of hospital operations at the micro (unit) level. In applying the strategic alignment concept to the site of service in the acute care setting, the guiding vision even at the unit level should be getting the patient efficiently through the system, not getting the patient efficiently through one step or area. Presented with the problem of long ED waiting room times or overcrowding, a rapid triage and treatment solution in the ED has limited benefit if patients are made ready for admission more quickly but no beds are available. …