When “More Space” Becomes “Too Much”

July 17, 2014  |  Kristyna Culp, MBA

Give a gas more space, and it will expand to fill that space. The same goes for people — and this tendency offers some important lessons for emergency department planners.

When an ED has too much treatment space, it can actually slow down the process.

Finding the right balance

When I’m on a project consulting with an ED, my primary roles are to determine what the current processes are, help the client create more efficient processes so they can focus on the real work: taking care of patients. I do this by analyzing data and building computer simulation models to help clients quantify the effect of improving processes for patients, staff and physical capacity. The models help the team determine how many spaces they need now — whether for waiting, subwaiting, treatment, or radiology/imaging — and how many they might need in various future scenarios.

My colleagues and I almost always find that clients need fewer beds than they think they do. This is not to say that they don’t have good reasons for their thinking. If the last time your ED was renovated was 15 to 20 years ago, it’s not hard to understand why you would want to squeeze as many new rooms as you can into your new space. But that doesn’t mean it’s the most effective approach for your department.

It seems counterintuitive, but your ED staff can be more efficient operating in fewer treatment spaces.

Of course, this approach requires a thoughtful layout of treatment spaces, with enough room for patients, family members, and the right supplies. You may also need to implement some process improvements. But I guarantee that your staff can work more efficiently and move the patients through faster — and therefore, require less treatment space.

Another consideration is that of staffing ratios. Most ED professionals have found that a staffing ratio of four beds to one nurse works better than other ratios. This means that even if you could put five beds in your fast track area, for example, you might find out that four would have worked better — because the fifth one is simply hard to staff for. Granted, your additional bed would allow the staff to pull in more patients, and doing so might empty out the waiting room. That’s good, but even though the patients have been seen and treatment has begun, with nobody waiting, you’ve also reduced or eliminated the sense of urgency. That’s when things tend to slow down in the treatment rooms.

Like many processes that happen along a continuum, there’s generally a “sweet spot” of utilization where things work at their optimum level of efficiency. In my experience with clients, most departments find the sweet spot when they’re turning beds over with about 70 to 80% utilization. If they get much busier, they feel like they’re rushing around, and the quality of care may suffer. At lower rates, they feel like they’re twiddling their thumbs.

This issue isn’t unique to the ED, or even the healthcare industry. We all see it in our everyday lives. When an entire day stretches out in front of us with nothing to do, we tend to waste it. But if we have a lot of specific tasks and organize them well, we can get a lot of things done.

If these questions of time and space management interest you, you might want to check out the book Scarcity by Sendhil Mullainathan and Eldar Shafir. The authors discuss some cutting-edge research about how the dynamic of scarcity affects many aspects of our lives, both professional and personal. They even share a healthcare-related case study of a very busy surgery center. Operating at nearly 100% capacity during normal business hours, the facility got to the point where they often had to postpone elective surgeries. The book explains the surprising recommendation they received from a consultant.

Seeing the bigger picture

I’ve found that the only way to know how many rooms your ED really needs is to do a fairly in-depth review. You need to look at your processes, your data, and then build a simulation model of how many spaces of what type you’ll need, given constraints such as type of patient, when patients arrive, patient volume, acuity and your staffing model — and most importantly, how they all work together.

Once you have a workable simulation model, you can test it with different variables and scenarios, such as 10% more volume, 20% lower acuity, etc., and make sure the space configuration you’re creating works. Otherwise, you’re just guessing. The goal should be to find that perfect balance — just enough space to get the work done efficiently, but not so much that the work actually slows down.

 ABOUT THE AUTHOR    Kristyna Culp MBA
Kristyna creates workflow mapping and computer simulation model frameworks to validate, test, and quantify various scenarios to help clients make informed decisions about both operational and physical design improvements.



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