The Lehigh Valley Hospital and Health Network (LVHHN) operates in Allentown and Bethlehem, PA, with its three locations having more than 47,000 admitted patients, 119,000 emergency department (ED) visits and tens of thousands of outpatients each year.

By the late 1990s, LVHHN staff and administrators found themselves experiencing a challenge common to many hospitals across the country - inefficiency in turnover of patient beds. Discharge notification to the patient placement office was delayed 74 minutes on average, and room turn-around was averaging 210 minutes - or three-and-a-half hours.

"A big part of the problem was that we shared information verbally," said Lisa Romano, RN, MSN, administrator of Patient Logistics/Access, LVHHN. "When a patient was discharged, the unit called to notify housekeeping that the room was now empty. These calls were placed when the staff found the time. Sometimes it took awhile because staff members with many responsibilities would either forget to notify housekeeping or just get delayed in calling. We found that notifications of a bed's availability and room cleaning were not happening quickly, and the slow turnover was having a hospital-wide impact."

Phase I: Implementing Capacity Management Software

In an effort to solve this problem, LVHHN embarked on an institution-wide performance improvement process called Growing Organizational Capacity, which focused on people, process and physical space. Recommendations from the capacity team led to the formation and implementation of a Patient Logistics command center. The command center and its newly designed processes were enhanced by the use of software to fully automate bed turnover and bed assignment functions.

Key to the new system is the time stamping feature that is part of the TeleTracking Technologies, Inc. capacity management solution. Through time stamping, staff now knows:

• Exactly when a room is vacated
• Exactly when an inpatient bed was requested
• Exactly when a room was assigned to a new patient
• Exactly when the room became clean, and
• Exactly when it is ready for a new patient.

The transport tracking system automatically pages housekeeping as soon as a bed becomes empty, and the time stamping allows inpatient unit staff to track exactly when the bed can be filled. The system also provides real-time interface between the transport, housekeeping and the bed board, so that there is immediate notification when a patient has been discharged and immediate dispatch of the cleaning job to housekeeping.

See computer screenshot with time stamping feature.

Gains in efficiency were realized almost immediately, so Romano and her colleagues began recognizing staff achievements and accomplishments with small tokens of recognition. About a year into the program, however, it became obvious to senior managers that the impressive gains were not going to be maintained long-term without additional intervention.

Phase II: Implementing a Pay-For-Performance Approach

"You need to recognize people who are doing a good job, and we tried to have fun with that," said Romano. "I became the reigning queen of cookies and fruit baskets, but staff aren't going to keep it up forever for just a candy bar. They will keep it up if it's set up as an expectation - knowing that it's part of their job and that they will be held accountable."

LVHHN senior management realized that the success of the Patient Logistics system was dependent upon staff compliance, and thus decided to incorporate a goal around capacity into the already-existing performance evaluation plan based on merit. In order to fully engage staff and keep them compliant, management recognized that they would have to hardwire the concept of compliance into the organization's culture. Incorporating a capacity goal into the merit-based incentive plan, however, ensured there were no longer any abstract goals without concrete meaning for individual staff members.

Mark Holtz, senior vice president of operations, points out, "Not all hospitals are alike." Since the late 90s, LVHHN had supported incentive programs, which was definitely a contributing factor in the success of process improvements that drove patient logistics changes. The organization already had a culture of merit-based pay, a shared success plan and incentive compensation for middle and upper management - allowing the team to seamlessly incorporate capacity goals and focus everybody on the big picture for the local community and the organization.

"Making every area or department of the hospital establish department-specific, achievable and attainable goals against which they would be evaluated brought the approach to life," said Romano. "The capacity goals for the housekeeping department, for example, were different from those for the clinical units, as was the patient transport goal."

In 2004, LVHHN rolled out the capacity goal addition for all staff - from senior managers to housekeepers - with clearly defined measurements or metrics for throughput success. Whether or not staff met their targets became part of their annual review, with performance data actually shared in a very visible manner, typically during monthly unit meetings and bulletin board postings, as well as on the unit budget scorecard. The capacity goal also included patient satisfaction targets to ensure that gains in patient flow maintained patient satisfaction.

click here to view a larger image

"The cultural change is that this is no longer a 'feel good' process or approach," said Romano. "It doesn't feel good to be part of the unit that is going to be publicly revealed as the lowest performer."

A Look at Housekeeping

Even though housekeeping at LVHHN is contracted out, as it is in many hospitals nationwide, the new Patient Logistics system has measurements in place that allows individual housekeepers - who are members of the newly created Discharge Bed Swat Team (DBST), fully dedicated to the cleaning of discharge and transfer beds - to receive monthly bonuses.

DBST housekeepers are evaluated by how many beds they clean per day on average over a one-month period, which is easily tracked under the new Patient Logistics software system. In order to be rewarded under the incentive system, an individual must clean 14 or more beds per day on average while maintaining a quality score of greater than 93 percent. If someone is only doing eight or nine per day, for example, he or she will receive no bonuses and may be removed from DBST back to general housekeeping.

Discharge Bed Swat Team Incentive Plan 14 cleans with a quality score > 93 receives $50 per month 15 cleans with a quality score > 93 receives $150 per month 16 cleans with a quality score > 93 receives $250 per month

See Bed Tracking Statistics.

Experienced, high-performing housekeepers can clean an average of 15 beds per day. If they meet that target, they receive a month-end bonus of $150. On the other hand, a 16-per-day average - which carries an award of $250 - has become a nearly unobtainable goal. Quality is also tracked through this system, and system administrators have seen that even LVHHN's best housekeepers usually cannot maintain their quality score at such a fast pace.

Those who are in managerial roles at LVHHN - nursing directors, for example - are largely graded on the performance of their staff. "The expectation is that directors, supervisors and managers will 'steer the ship,' so to speak," said Romano. "In other words, if your staff members perform to or beyond their target, it is because of your leadership."

See examples of Clinical Services Directors' targets.

Though some may find it surprising, the addition of a capacity management goal to the merit-based performance evaluation program has been cost neutral for LVHHN to introduce - other than the costs of the 2003 software investment in the Patient Logistics system that actually allows such performance measures to be tracked closely.

Results and Lessons Learned

In fiscal year 2005, LVHHN had an 8.4 percent growth in admissions, without increasing the number of beds. While such growth could not be achieved if LVHHN was not a quality institution with well-trained staff who provide excellent patient care, senior managers also believe the growth would not have been achieved without the LVHHN capacity management initiative.

This incentive-based approach to capacity management is not possible without the software in place to constantly measure and evaluate employee targets. LVHHN believes that the purchase and installation of the software is money well spent for any hospital or health system. The out-of-pocket costs for a fully integrated TeleTracking Technologies, Inc. capacity management suite with bed board, transport and bed tracking is approximately $13,000 to $14,000 per month for a hospital system similar to LVHHN's system of approximately 850 beds. This license fee would of course vary for larger or smaller institutions.

To put the cost in perspective, LVHHN estimates that the loss of just one patient - perhaps someone who leaves because the wait in the ED for an inpatient bed is too long - amounts to about $5,000 in lost revenue. Dissatisfied patients may also share their negative experience and steer future patients away from LVHHN, weakening referral patterns and impacting admission volumes.

"You cannot just make the decision based on the upfront software costs. Beyond the monthly costs, there are internal intangible costs too, but you have to think of this from a return-on-investment perspective. What's the cost of not doing anything?" said Romano. "With the growth rate of admissions we've achieved in the first year, it has paid for itself 10 times over."

See PowerPoint presentation on LVHHN's Patient Flow system.

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Lisa Romano, M.S.N., R.N.
Administrator of Patient Logistics/Access
Lehigh Valley Hospital and Health Network
Allentown, PA