A Genius In Our Midst
I am reading the wonderful biography of Leonardo da Vinci by Walter Isaacson. I was struck by his description of how carefully Leonardo observed and described processes in the natural world — the flow of water through streams and rivers, the beating of birds wings, etc. It made me think of another genius, who thankfully is alive and working today and his incredible observations and measurements of how patients flow through hospitals and other healthcare settings.
The genius I am referring to is Eugene Litvak, Ph.D.,the President and CEO of the Institute for Healthcare Optimization in Boston. Dr. Litvak, who is a mathematician by training, emigrated to the US in the early 80’s just as the AIDS epidemic was exploding. His initial work on HIV testing was transformational and led to his looking further into healthcare operations in this country.
His most incredible observation, which was totally unrecognized prior to his work in this area was that the variability in patient flow in almost every hospital is greater through an elective surgical service than it is through the emergency department (ED). This seems counterintuitive since most of us think that there’s no way to predict the day-to-day variability of how many patients will seek services in an ED. After all, the number of emergency cases naturally varies according to factors such as whether or not it's flu season, or whether or not there is bad weather which has led to an increase in motor vehicle accidents. In the case of an elective surgical service, case number variation is solely due to the number of cases scheduled on any particular day. We, of course, have more control over this artificial type of variation and one might expect these numbers to remain fairly consistent and predictable. Dr. Litvak however, showed that they vary tremendously from one day to the next and even from one week to the next. There are a number of reasons for this, most particularly there is the fact that most surgeons like to operate in the middle of the week and eschew operating on Mondays, Fridays and certainly don’t like to schedule cases on the weekends. Surgeons in most hospitals also enjoy what is known as block time, i.e. OR time that is exclusively reserved for their use only. Most hospitals claim to have a “use it or lose it policy” regarding block time but the truth of the matter is that most of these facilities are less than eager to reprimand a surgeon who brings them a lot of lucrative business for not notifying them when he or she is going to be on vacation or otherwise unable to fill up their block time. Therefore, in most hospitals, you see case volume curves for the OR that look like jagged mountain ranges with peaks in volume during the middle of the week and the morning hours and valleys in the curves from Friday to Monday.
Why are Dr. Litvak’s observations so important? Well, study after study has shown that peak times of patient flow through a hospital, correlate closely with peak times for errors and patient harm events, peak times for bottlenecks in patient flow ( with lots of patients having to be held in the ED), and peak times for additional costs to be incurred by hospitals who have to call in staff or ask staff to work overtime. So, variability in patient flow can lead to increased rates of mortality and morbidity, increased numbers of dissatisfied patients and staff, and increased costs. These are things that all hospitals would like to avoid.
Dr. Litvak was also smart enough to come up with a solution to the above, but unfortunately, very few hospitals throughout the country have instituted this cure. This solution involves separating emergent from non-emergent/elective cases in the OR, smoothing out the day to variability in elective cases at least Monday through Friday, and booking elective cases back to back with protection from being bumped by emergent cases (see step one above).
The recent Covid-19 pandemic has shown how important it is for hospitals to maintain important services, e.g. elective surgeries, during times of peak demand such as we’ve seen during times when pandemic cases have surged. It is now time that more hospitals listen to the genius of Dr. Litvak and make the operational changes that will keep things moving smoothly during and after the pandemic.
