To some extent, the throughput of your healthcare facility can be measured based on “bodies on beds.” As in hotel operations, if you’re seeing low occupancy of your beds, you may not be pulling in the required revenue to cover your fixed operating costs.
Given that consideration, one of the key efforts that you may need to pursue to improve operational performance is to get a new patient into a bed or room as quickly as possible after the prior patient is able to be discharged. This process is known as patient room turnover.
While turnover speed is important, it must be balanced with quality. All health care processes require special focus to ensure cleanliness and prevent infection. Rushing through room turnover at the risk of neglecting appropriate cleaning and sanitation can cause problems for your patients, in both satisfaction and potential infection, leading to greater financial problems for your facility.
What is involved in improving patient turnover?
As with your other improvement efforts, you’ll want to start with an assessment of current state. When you conduct a value stream analysis of patient flow through your facility, you may find low bed occupancy and backlogs simply because beds are not ready to be occupied. If this is evident, patient room turnover is likely to be an improvement target. To start, determine what is involved with patient room turnover in your facility. Measure how long the process and its individual steps take and establish standards of quality.
From a timing perspective, be sure to consider the front and back ends of the process. From an overall perspective, turnover includes more than just the time from one patient being wheeled out and the next being wheeled in. As soon as a patient is well enough to be discharged, the turnover clock starts ticking. When the health care team makes that determination official, the clock keeps ticking. When a patient is dressed and anxious to leave, but waiting for a transport staff member, the clock is still ticking (probably to the annoyance of the patient). When the patient leaves and the cleaning staff complete their work in the room, the clock is still ticking. The clock doesn’t stop until the new patient is settled in a bed.
Once the patient leaves the room, within the turnover process are items such as cleaning, checking equipment and supplies, and changing out damaged or soiled materials. Much of this work may be done by the facility’s environmental services department (EVS) or contract cleaning staff. As noted, this team must be charged with achieving both speed and quality of the process.
Just what should a patient room turnover look like?
Patient room turnover should include a standard for cleanliness and a standard for turnover time. Be aware that faster isn’t always better. Before establishing goals for the team, check internal and external benchmarks. In 2009, the Association for Healthcare Environment (AHE) published recommended guidelines for environmental cleaning in healthcare. AHE suggests effective patient room cleaning upon discharge should take about 40 to 45 minutes.
However, AHE cautions that room size, degree of isolation, number of surfaces, and other factors can increase this time. While a cleaning company might offer to clean rooms in 15, 20, or 25 minutes vs. current in-house levels that are much higher, this rapid process might not allow enough time for adequate cleaning. Look at internal benchmarks as well as external. Do certain teams have significantly higher or lower numbers than others while maintaining quality standards?
When using benchmarks, be sure you’re measuring the same activities as the benchmarked organization. The AHE recommendation is for cleaning only and does not include all the steps noted above in the overall process.
Starting tips to improve patient room turnover
One key to improving patient room turnover is effective communication and collaboration among staff, especially the nursing, environmental services, and transport teams. When these teams don’t work together well, long patient turnover times can occur simply because roles and responsibilities are muddy or there is no handoff when processes finish.
When these teams come together to address the opportunities through a structured operational excellence approach, they will not only enhance their teamwork, but also use their process knowledge to generate improvement ideas. As they work through the value stream map and identify issues, they will utilize problem-solving and root cause analysis to generate and implement improvement activities such as these.
Implement an early “target checkout time.” Hotels have fixed morning checkout times so that they can have rooms empty and ready for cleaning at a predictable time. They then match cleaning needs with appropriate higher staffing level. This system also gives predictability of room availability for guest placement. This concept can be applied in healthcare facilities. (See the related article on patient placement.)
- Establish a predicted discharge time as part of patient placement and make it visible to staff throughout the patient stay with updates as needed.
- Provide physician incentives for morning discharge.
- Communicate requirements for discharge to patients so last minute visitors, showers, getting dressed, or other patient activities don’t slow down discharge.
- Once patient is expected to be dischargeable, move into a discharge standardized process.
- Utilize a bed tracking system. Knowing the availability of beds can have a huge impact on predictability in the patient placement process, reducing wait times and backlogs and influencing a positive patient experience.
- Whether you use a bed board, a technology-enabled system, or simply a red/green room readiness cards, ensure that bed availability is anticipated and announced for all relevant team members.
- Build in a "pull" system. As soon as a bed is available, it should be flagged to patient placement so that a match to an incoming patient is sought.
Create a standard operating procedure for room cleaning. The CDC reported 722,000 overall health-care associated infections (HAI) and 75,000 related deaths in 2011, some of these probably related to patient room cleanliness. While the speed of patient room turnover is important, quality of cleanliness is vital.
- Provide specific cleaning instructions and required supplies and equipment.
- Use quality tools such as checklists, kitting, and standard work in a SMED experience to make the time needed for room inspection, cleaning, and re-equipping as short as possible.
- Utilize a visual approach to remind employees of exact requirements.
- Provide standardized training, possibly enhanced with video instruction.
- Incorporate new developments and technology as recommended by CDC or other expert agencies.
- Monitor HAI performance by unit along with speed of room turnover.
Address transport opportunities. Clearly, transport personnel must be part of the improvement team. Look for ideas to get the dischargeable patient out of the room as quickly as possible.
- Host the patient outside the room once discharge is permitted and patient is waiting for outside transportation, possibly in a floor waiting area to sign papers, await prescriptions, etc.
- Ensure transport personnel are trained in hazardous materials and infections, so that they are not spreading disease as they travel around parts of the hospital.
Starting and continuing the journey
It’s likely that patient room turnover will be part of your overall healthcare facility improvement efforts. Utilize a beginning assessment to start on this important, but often overlooked, part of the patient flow.
Even after patient room turnover goals have been achieved, maintain a cross-functional process improvement team, monitor performance, continue to gather ideas, incorporate new technologies, and recognize the team for ongoing turnover performance in both speed and quality.