A key step on the road to health equity: improving patient flow

Earlier this year, the National Academies reported that more than 20 percent of all donated organs are wasted, despite the fact that “on average, 17 people die every day from the lack of available organs for transplant.” The major cause of this waste was a lack of available surgeons to perform surgery at the time needed to harvest and transplant donated organs. 

If you are in line for a donated organ, you are less likely to lose out if your place happens to be near the head of the queue than if you are further back. Such unlucky placement is just one example of harm to patients due to avoidable inefficiencies and inequity in how care is delivered.

Health care in America has inequities in many forms, on several bases: race, language, age, gender, disabilities, location and insurance status — the list is long. America’s racial reckoning of the last few years and the COVID-19 pandemic have put a spotlight on equity issues in healthcare, and virtually every organization has efforts underway to identify and reduce inequities.

Since inequities are typically mediated by a shortage of resources (funding, staffing, equipment, facilities, etc.) our first instinct is to put more funding in the system. But the U.S. already spends an inordinate share of its economy on health care with results that are, compared to other wealthy countries, mediocre. And much of the U.S. health expenditure serves no useful purpose: in 2009, The National Academy of Medicine (formerly the Institute of Medicine) report “Best Care at Lower Cost estimated health care waste was in excess of $700 billion annually.

Adding resources is sometimes necessary to reduce inequities in health care. At the same time, if we could eliminate just one source of this waste — mismanaging patient flow — we would experience a 4 to 5 percent ($150 -$180 billion annually) reduction in the country’s health care costs while improving the quality of care, enhancing patient safety and addressing equity.

This requires a single management intervention — streamlining patient flow by scheduling admissions, discharges and visits in a way that alleviates manmade peaks in demand. Such steps can be particularly important in safety net institutions, which are historically under-resourced and hit hard by COVID. 

Streamlining patient flow has been tested and proven to work in several places:

1. Newark Beth Israel Hospital — the main safety net hospital in New Jersey. By streamlining patient flow, in a few months, it reduced its emergency department waiting time for telemetry (monitored) beds from 15 hours on average to 3 hours for 90 percent of patients. This saved lives, reduced the length of stay in that unit, cut costs by more than $10 million annually in the department and freed up nine nurses — a particularly important step during the COVID pandemic’s staffing shortage. In this case, streamlining patient flow required developing a consensus on criteria for admitting and discharging patients from the telemetry unit.
2. Boston Medical Center — the main safety net hospital in Massachusetts. Streamlining surgical flow by evening-out scheduled surgeries across all weekdays practically eliminated delays in elective surgeries while dramatically reducing life-threatening wait times for patients in the emergency department.
3. St. Thomas Community Health Center — the safety net outpatient clinic in New Orleans, a safeguard for the underserved population during Hurricane Katrina and the COVID pandemic. Systematically separating the pools for scheduled versus walk-in patients dramatically increased their access to care and margin by over $20 million per year. More importantly, many more uninsured people are provided with timely, quality care.

Streamlining patient flow by smoothing surgical schedules can increase access to organ transplants and reduce patient mortality. It can alleviate emergency department and hospital overcrowding, as well as stress on front-line workers, improve nurse retention, increase clinicians’ satisfaction and yield multi-million dollar improvements in hospital margins.

The practice has been dramatically proven to work during the COVID pandemic. Dr. Shaf Keshavjee is chief of surgery at the University Health Networks in Toronto (its Toronto General Hospital is ranked fourth among Newsweek’s World’s Best Hospitals 2022) and past president of the American Association for Thoracic Surgery. He recently stated: “It is the silver bullet in that we’re doing more than we’ve ever done with less, more efficiently. We’ve created capacity to do more. So we are working at 105, 110 percent.” He said the hospital’s backlog went from “4300 down to 3200” and it cleared “about 1,000 cases.” Now, with a new omicron variant on the horizon, “doing more with less” is more important than ever.

The COVID pandemic has revealed and exacerbated inequities in health care and produced disproportionate deaths among people of color. It has stretched hospital staffing to the breaking point. In such times of stress, improving health care equity requires more than noble intentions or even money. It requires something more difficult — commitment and practical steps to increase efficiency by overcoming impediments of habit and traditional ways of doing things. 

If hospitals open their eyes to the advantages of smoothing patient flow, and CMS applies financial incentives to end organ waste and improve access to care across the U.S. via this intervention, the benefits for patients and society will reverberate long after the COVID pandemic has subsided. Our commitment to fairness in health care deserves no less.

Eugene Litvak, Ph.D., is president and CEO of the nonprofit Institute for Healthcare Optimization and an adjunct professor at the Harvard School of Public Health. Mark D. Smith MD, MBA, is a clinical professor of Medicine at the University of California San Francisco. Harvey V. Fineberg, MD, Ph.D., is the president of the Gordon and Betty Moore Foundation.