1) What benefits can be drawn from the introduction of a Bed Bureau to the healthcare supply chain?
2) What suggestions can you make for improving the patient pathway in a hospital’s emergency department?
The nature of emergency medicine has changed dramatically in recent years with the introduction of new treatment options and the availability of modern medical technology. Nevertheless, patients presenting to the ED with conditions today are considered time critical. The ED is often seen as the ‘safety net’ for patients, and many experts have noted that the ED is really the ‘gateway to the rest of the hospital’. If, at this early stage of the supply chain, problems arise in the ED, they have the potential to affect the rest of the hospital’s supply chain processes.
The healthcare supply chain is characteristically complex. One is not just dealing with products and services, but also dealing with real people and their health and wellbeing. Additional complexities include the involvement of GPs, government, insurance companies and regulatory agencies. Each part of the supply chain often works independently, which prevents it from working as an interrelated and interconnected system. Patient flow through the ED is a multifaceted supply chain, starting with the patient who may arrive at the ED on the recommendation of their GP.
The purpose of this case study is to review the introduction of a single point of contact, known as ‘the Bed Bureau’, and how it offers options for the GP and for patients to avoid poor outcomes, poor patient experience times and spending extended periods of time on a trolley awaiting an inpatient bed.
Currently, if a patient is unwell, they can attend the ED either by self-presenting or by calling the ambulance service. Alternatively, several patients attend their GP who in turn refers them to the ED, and it is this cohort of patients that are referred to in the case study. Overcrowding is often blamed on patients attending for ‘minor illness’, but most patients with minor illness prefer not to be in the ED at all. Nevertheless, overcrowding in the ED is a regular phenomenon and causes negative reputational damage to the organization. The hospital group under review for this case study makes regular media headlines in terms of the number of patients awaiting treatment in the ED and patients spending time on trolleys.
The hospital group comprises six clinical sites functioning collectively as a single hospital system. This group, known as the UL Hospital Group (ULHG), provides a range of acute inpatient and day-care services to a relatively largely populated area in the mid-west region of Ireland. University Hospital Limerick (UHL) is the only hospital in the group that provides major surgery, cancer treatment and care, and a range of other medical, diagnostic and therapy services, and has the busiest ED in Ireland, providing the only 24/7 emergency services in the group. The rest of the group is made up of specialty hospitals providing, for example, obstetric, neonatal, medical assessment units, local injuries units and day surgeries.
The GPs in the region, through their GP Forum, have advised that they are unable to access services in the local hospitals and therefore often use the ED as a default option. The patient pathway through the ED at the hospital is viewed as a very complex and challenging supply chain path. There are regular issues over patients waiting for a bed and therefore patients spend excessive time on trolleys. This then results in a very poor experience for the patient and often leads to a breakdown in trust with the patients who are the ‘customers’. Prior to the introduction of the Bed Bureau at the hospital, there were several steps taken by the GP to get their patient treated appropriately. Medical assessment units (MAUs) are located across the area within the six clinical sites and they serve the main hospital. Each MAU functions as an independent unit, requiring separate phone calls to book appointments. The GPs have stated that they must wait too long for outpatient appointments to the units and viewed the steps noted below as too complex:
- Patient is seen by the GP and a hospital assessment is determined.
- The GP establishes what hospital assessment unit is suitable for the patient’s needs.
- A call is made to the appropriate MAU.
- If there is a medical assessment appointment available, the patient can attend on the day and time appointed.
- If there is no appointment available for the patient, the patient is sent directly to the ED.
What is a Bed Bureau?
The Bed Bureau facilitates a highly efficient and more structured supply chain process to deal with patients accessing the ED. The Bed Bureau introduces a single point of contact for the GPs, offering options for the patients for applicable care other than the ED. This single point of contact required the establishment of a centralized Bed Bureau at UHL. This was staged by competent staff using a carefully designed computer system for receiving and processing referrals based on a single criterion for the patient to access a relevant MAU as opposed to going to the ED directly. Communication with all the players/stakeholders in the pathway was critical and their buy-in to the process was imperative. The partakers of interest included the chief executive officer (CEO) and the chief operations officer (COO) of the hospital group, the executive management team and clinicians, as well as the communication manager, GP Forum, clinical directors, bed managers, patient flow staff, ED staff and the staff at the MAUs at the clinical sites.
With a newfound focus on the patient pathway, this supply chain improvement process gave rise to an increasing championing of the Bed Bureau. While approaches may differ from hospital to hospital nationally and indeed globally, the common drive for this Bed Bureau from the stakeholders was a need for the patient to have a better experience and reduce the number of patients attending the ED. This common goal has led to all agreeing that the healthcare supply chain for patient pathways needed to be more efficient and provide a better service for all.
Implementing the Bed Bureau
The setting up of the Bed Bureau for the hospital group was a new and innovative way to improve access for the GPs and in turn improve the patience experience. Unscheduled care and the flow of patients through the hospital system is the brief of the COO. It is the responsibility of this post holder to manage and mitigate the associated risks of poor patient experiences and poor patient outcomes. Keeping these metrics in mind, there was clear support to introduce a Bed Bureau. With the support and operations of key stakeholders, noted previously, software was developed by a lead clinician and an external information technology (IT) company to produce a database system that would now be known as the ‘Bed Bureau’. In summary for this case study, several activities took place:
- A room to host the Bed Bureau was identified and desks, computers and headphones were installed.
- Staff were recruited through the nursing and Human Resource (HR) department.
- A paramedic coordinated the transfer of patients from UHL to other hospitals or returned the patient home.
- An administrator redeployed to work with the team became the superuser of the IT system and provided training to the Bed Bureau staff and to the staff on all the other sites.
- The governance of the Bed Bureau was provided by the Bed Manager and her office was near the staff answering the phones.
Initially 30 GPs were contacted to test the concept. Communication to the MAUs was also imperative as their work lists would now be generated by the Bed Bureau staff. The staff at the clinical sites would no longer take calls from their local GPs and book the patients in. There would now be a group-wide approach and the sites would no longer work in isolation. Each site agreed a number of slots every day that the staff in the Bed Bureau could populate. The staff in the Bed Bureau travelled to each of the sites, met the local staff and discussed the criteria and number of slots allocated. Each site had visibility of the other sites and agreed to use the criteria set up on the software system.
In addition, when the Bed Bureau commenced, the ED was very busy and it was decided that patients attending the ED with a GP letter and who met the criteria for MAUs at UHL would be transferred there once booked in through the Bed Bureau booking system. The ED staff in this instance rang the Bed Bureau and booked the patient in. This alleviated the pressure in the ED and ensured the other MAUs were populated first with appropriate patients.
The Bed Bureau was set up on a phased basis initially, with the key aim to formalize the interaction between the referring doctor in primary care and the acute hospital and to ensure patients are streamed to the most appropriate clinical site within the hospital group that has the appropriate environment to deal with the patient’s problem in an effective and timely manner. The steps now taken by the GP are identified as follows:
- Patient is seen by the GP and a hospital assessment is determined.
- The GP telephones a dedicated phone line for the Bed Bureau.
- The GP is offered an appointment for one of the relevant assessment units or referred to the ED as appropriate.
Over the period of design and implementation of the Bed Bureau, a collection of data using both quantitative and qualitative methods was obtained, reviewed and analyzed. Surveys were carried out and interviews undertaken with relevant staff, and the Planning, Performance and Business Intelligence Unit at the hospital and the Bed Bureau software program extrapolated certain data criteria for review. This also coincided with pre and post the implementation of the Bed Bureau. Data measured included:
- The number of attendances to the ED in the four months preceding the introduction of the Bed Bureau and the same information for the four months after the introduction of the Bed Bureau.
- These data were also used to establish the age profile of the patients attending, the total number of hours spent in the ED, the number of patients on trolleys and the total number of admissions to the hospital group.
- Attendances at the MAUs on all sites were measured pre and post implementation of the Bed Bureau.
- In addition, data from the Bed Bureau IT system were obtained to establish the number of calls made by the GPs and the number of slots filled in each MAU as well as the numbers of patients who attended their appointments and those who did not attend.
- Furthermore, the numbers of admissions and the number of patients discharged from the MAUs were identified.
- Additional information available included:
- Identifying the number of times GPs used the Bed Bureau to access the system and alternatively identify the number of GPs who don’t use the Bed Bureau and continue to refer their patients to the ED.
During this period the satisfaction rate of the GPs was continuously monitored.
Analysis of Bed Bureau data
The data generated by the Bed Bureau for the period January to April 2017 were analysed post implementation and noted as follows:
- The total number of GP referrals processed by the Bed Bureau for a four-month period = 6,042 referrals.
- The average number of GP referrals per month processed by the Bed Bureau for this period = 1,510 referrals.
- The highest number of referrals by a single GP per month for this period = 15 referrals.
- The average number of referrals by a single GP per month for this period = 5 referrals.
- The lowest number of referrals by a single GP per month for this period = 0 referrals.
- The total number of referrals to one of the MAU sites per month for this period is 184 GP referrals.
- Patient experience times and outcomes
- Patient flow through the ED is a complex supply chain, and overcrowding results in poor outcomes and poor patient experience. The introduction of the Bed Bureau simplified the supply chain for patients who attended their GP and required further medical assessment. Prior to the Bed Bureau, these patients were often referred to the ED because accessing an appointment in the MAUs was so complex, with each MAU having a different criterion and a different contact number. The Bed Bureau introduced a single point of contact for GPs across the whole region, offering options other than the ED for patients. This reduced the number of GP-referred patients going to the ED, as these patients avoided the ED altogether and were more appropriately assessed, diagnosed and treated in the MAUs, which previously were resourced but underutilized.
- In setting up the Bed Bureau, the GPs were considered to be key players in managing the major queues that occur in the ED, and their feedback, although mainly informal and through a short survey, was given due consideration. The setting up of the Bed Bureau in UL hospitals was a new and innovative idea to improve access for GPs and to improve the patient experience. Communication on the sites was also very important, as their work lists would now be generated by the Bed Bureau staff and the staff on the sites would no longer take calls from their local GPs and book patients in.
- The Bed Bureau facilitates a group-wide approach and the sites no longer work in isolation. Each site agrees on a number of slots every day that the staff in the Bed Bureau can populate and each site has visibility of the other sites. This ensures that all available slots on all sites are utilized. When the Bed Bureau commenced, the ED was very busy, and it was decided that patients attending the ED with a GP letter who met the criteria for the acute MAU in the UHL would be transferred there. Once they were booked in through the Bed Bureau booking system, they avoided the bottlenecks in ED. The ED staff in this instance ring the Bed Bureau and book the patient in. This alleviates the pressure in the ED and ensures the other MAUs are populated first with appropriate patients, as the available slots on the UHL site are prioritized for ED. Eventually, it is anticipated that these patients will be referred directly to the Bed Bureau by their GPs. The Bed Bureau is now available 24/7, so that out-of-hours GPs can also use this resource.
- Benefits of the Bed Bureau
- The Bed Bureau was set up and introduced on a phased basis and its impact to date has resulted in a number of benefits for GPs and in turn patients. The benefits include:
- GP referrals are triaged at a central point: the Bed Bureau.
- GP referrals admitted via the MAU remove that cohort of patients out of the ED, which in turn reduces the number of patients that contribute to the overcrowding.
- The Bed Bureau generates data to evaluate referral patterns for GPs over time.
- The Bed Bureau creates a database for oversight of bed availability across the hospital.
- The Bed Bureau process standardizes referral/admission criteria against which to audit for compliance.
- The Bed Bureau addresses the inefficiencies of the previous process, reducing the patient pathway to three key steps as opposed to five complex steps. This is now a lean process that addresses the risk of variation in the system.
- The Bed Bureau facilitates a more efficient bed utilization of bed capacity in the hospital.
The Bed Bureau has facilitated a single point of contact for GPs and has improved the experience of suitable patients who can be referred directly for a medical assessment in the MAUs across all the hospitals in the group. These patients avoid the ED altogether and the resources available are utilized in a much more efficient way. The process for referring the patient has been refined to reduce the many steps that were previously used by the GP to refer patients to the MAUs. This leaner process has reduced the variation that existed by standardizing the process for all MAUs in the region.
Managing patient flow and pathways in healthcare is a complex supply chain and the introduction of the Bed Bureau has addressed the requirements for one group of patients, namely those referred by GPs.
The approach of managing GP referrals to reduce overcrowding in the ED at ULHG is pioneering work; nevertheless, we do appreciate that the Bed Bureau may not or cannot address the overall overcrowding issues that arise in EDs nationally or indeed globally. It is widely recognized that there are many other issues contributing to overcrowding. Examples include a lack of acute bed capacity, difficulty in attracting consultants to work (specifically in this case) in the Irish health system and a lack of development and expansion of services in the community, to name but a few. These are major challenges facing hospital supply chains. For those patients who are referred via the Bed Bureau directly, the patient experience time and the patient’s outcome are much improved. Access to the MAUs is much less cumbersome for GPs and the revised pathway through the Bed Bureau is efficient. This allows GPs to give the patient their appointment date and time before they leave their GP surgery. The entire process can take less than a three-minute conversation on the telephone now.