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The Joint Commission's New Patient Flow Standards
The Joint Commission accredits about 82% of the hospitals in the United States. Any hospital accredited by the Joint Commission must be in compliance with all of their standards. The Joint Commission has standards on patient flow to prevent crowding and boarding of patients in the emergency department (ED) and in other temporary locations.
The Joint Commission first implemented patient flow standards in 2005. These standards have been amended and the new changes will go into effect January 1, 2013. However, element of performance six and nine will not go into effect until January 1, 2014 (see below). Many practitioners applaud the efforts of the Joint Commission to continue their efforts to address this important issue.
Revisions addressing patient flow through the ED include hospital leadership’s use of data and measures to identify, mitigate and manage patient flow issues as well as management of ED throughput as a system wide issue. Additional revisions include safety for boarded patients and leadership communication with behavioral health providers to ensure coordinated care. Boarding of psychiatric patients has increased and has been especially problematic in EDs.
Crowding has been a problem in US hospitals for many years.. In fact, a recent study found that ED crowding is growing twice as fast as visits, rising to unsustainable proportions.1
The Joint Commission patient flow standard is located in the Leadership Chapter. The patient flow standard and tracer is based on hospital leadership’s responsibility to evaluate patient flow and its authority to take actions to improve patient flow. 2 Information on the Joint Commission patient flow tracer can be obtained at no cost from the Emergency Medicine Patient Safety website at www.empsf.org under the patient safety briefings.
Boarding increases waiting times, diversions, length of stay, medical errors, sentinel events, financial losses, malpractice claims, mortality and other related issues, leading to crowding. Patient flow is an issue that needs to be solved by hospital leadership. The revised standards recognize that the causes may be multifactorial and stem from other areas in the hospital, not just the ED.
The Patient Flow standard (officially known as LD.04.03.11) has nine elements of performance (EP). Elements of performance are the sections that the hospital must ensure compliance in order to meet the standard. These elements are outlined below.
EP1 states the hospital has a process that supports the flow of patients throughout the hospital. Many hospitals have policies such as, no direct admissions to the emergency department. Some hospitals go on diversion when there is a critical shortage of critical care or other beds. Processes may include a stat clean of the room by environmental services for a patient who is waiting in the ED for the bed to be ready. A process may include opening an overflow unit. One hospital had a revised process in which each of the departments accepted one overflow patient. The thought being it was easier for a department to take care of one additional patient then to have 12 boarded patients in the ED. The hospital found that the patients didn’t wait long on each unit as it expedited their admission. Some hospitals require that daily rounds be made by a specified time so current patients are discharged home timely freeing up beds for patients who are being boarded. Others have ensured that adequate services are available on the weekend so surgeons will not just schedule elective cases on Monday or Tuesday but can space elective cases throughout the entire week.
EP2 addresses the need for the hospital to plan and care for the patients who are admitted and whose bed is not ready or unavailable. The patient may be placed in a temporary overflow area such as the Post-Anesthesia Care Unit (PACU) or in the ED.
EP3 address the need for the hospital to plan the care for patients who are placed in an overflow location. Patients must receive the appropriate care for their condition and diagnosis no matter what area of the hospital they are currently located.
EP4 states that criteria guide decisions to initiate ambulance diversion. Recently, one state passed a law forbidding ambulance diversion. Hospitals should have a policy and procedure on diversion. Hospitals should not divert when there is adequate staffing and available beds and the patient’s condition is one that they are adequately able to care for. Occasionally the issue of diversion has come up in cases related to the federal EMTALA law (Emergency Medical Treatment and Labor Act).
EP5 requires the hospital to measure and set goals for the components of the patient flow process, which is new for 2013. Hospital leaders will need to use data and metrics in a more systematic process. It is imperative for hospital leaders to monitor and manage the patient flow process throughout the entire organization.
This includes the available supply of patient beds, access to support services such as case management and social work, and the safety of areas where patients receive care and treatment. It also includes the throughput of areas where patients receive care which could include inpatient units, lab, PACU, telemetry, radiology, and telemetry. Hospitals must also measure and set goals for the efficiency of non-clinical services that support patient care such as transportation and housekeeping.
EP 6 does not go into effect until January 1, 2014. The hospital must measure and set goals for mitigating and managing the boarding of emergency department patients. Boarding can be an indicator that the hospital has more systematic problems. Boarding is a significant risk management and patient safety issue. The four-hour window is new and has led to a lot of discussion in the emergency care community. Some fear this could result in a four-hour delay for admitted patients. It is important to note that this time frame is not a requirement and patient acuity and best practices must be followed.
The Joint Commission now defines boarding as:
“The practice of holding patients in the ED or a temporary location after a decision to admit or transfer is made. The hospital should set its goals with attention to patient acuity and best practice: it is recommended that boarding timeframes not exceed 4 hours in the interest of patient safety and quality of care.”
EP 7 was also revised to require the staffs or individuals who manage the patient flow processes to review the measurement results. This is done to assess if the goals made were achieved.
EP8 requires leaders to take action to improve patient flow when goals are not achieved. Leaders who must take action include the board, medical staff, along with the CEO and senior leadership. PI.03.01.01, EP 4, also states that the hospital take action when it does not achieve or sustain planned improvements. Delays in patient assessment, blood draws, radiology studies, handoff communication and reporting, and delays in the getting patients to the operating room can signal that patient flow problems exist.
The last element of performance, EP 9 goes into effect January 1, 2014 addressing the boarding risk for behavioral health emergencies. (See also EP 24 at PC.01.01.01 regarding the safe ED care of behavioral health patients.) Hospital leaders must communicate with the behavioral health providers to improve coordination of care. Patient flow problems pose a significant and persistent risk to the quality and safety of behavioral health patients.
In summary, hospitals and staff should be aware that the Joint Commission has standards that apply to patient flow in hospitals. The Joint Commission has made changes in their standards in an effort to reduce overcrowding and boarding in emergency departments and other temporary holding areas. Hospitals should conduct an assessment and implement processes in place to keep behavioral health patients safe until a bed opens up. Hospital should implement evidenced based guidelines and recommendations that the evidenced based literature has shown has been effective in reduction overcrowding and boarding.
To obtain a copy of the revised Joint Commission Patient Flow Standards Here
Are you improving patient flow in your hospital? Email a short description of your innovation to firstname.lastname@example.org to be included in our toolkit available as a resource to your fellow ED stakeholders.
Sue Dill Calloway RN MSN JD CPHRM, Chief Learning Officer, Emergency Medicine Patient Safety Foundation
1. Pitts SR, Pines JM, Handrigan MT, Kellermann AL. National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity. Ann Emerg Med. 2012 Jun 20. [Epub ahead of print]
2. Leadership; Tools to Prepare Your Leaders for Joint Commission Survey, Second Edition, Sue Dill Calloway, HCPro, 2009, page 109.