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					Patient Flow
Collaborative




Angela Peluso - Clinical Lead
Ian Jackson - Presenter
Eastern Health – Maroondah Hospital

Department of Human Services
Summarise Organisational
Constraint areas

• Bed Management
  - Admission delays for elective surgery
 - Admission delays from ED
• Acute/Sub Acute
  - Delayed access to Rehab & NH beds
• Theatre Utilization
  - High HIP rate
Summarise Priority Constraint
Area 2

• Acute to Sub Acute
  -Delayed access to NH Beds
  -Delayed access to Rehab beds
Diagnostic work
• Ward sample data repeated
 -Confirmed previously identified constraints
• Brainstorming session
 -Included all stakeholders – NUM‟s, Allied
 Health, Medical Rep (Geriatrician), Reps from
 off-site rehab facilities
 -Confirmed process issues and recommended
 these be mapped
• Process Mapping session
 -Identified key constraints in transition
 process
Diagnostic work cont.

• Staff reactions
 -Committed to “doing something” to improve
 things
 - Enthusiastic about possibilities
 - Acknowledgement that even small changes
 could have big effects
 - “Lets do it!”
 Improvement Plan

• Establish clinical area team
  - Identify clinical area team leader
 - Include key stakeholders
        -Medical representative – Geriatrician
        - Rep from PJC
        - NUM‟s from GEM, ortho & medical
             wards
        - Allied health – social worker & physio
        - Aged care nurse consultant
Improvement Plan Cont.

• Investigate the following six key areas
  identified as contributing to delays
  1.   Referral process to allied health
  2.   Organising OT home visits
  3.   ACAS referral process
  4.   Refusal of rehab bed by patient/family
  5.   Delays in discharge summary documentation
  6.   Out of hours communication with central booking
       office
Progress

Implementing the following changes
1. Faxing allied health referrals
2. NUM generated ACAS referrals
3. Improved communication channels with
   centralized bookings office
Lessons learnt

• Need for all key stake holders to be
  involved
 -delivers better more sustainable outcomes
• Select “right person” for “right job”
 -need to be motivated & outcome focused
• “Rome wasn‟t built in a day”
 -be patient
Desired Impact

• Reduce LOS
• Reduce 12 hour waits in Ed
• Better more effective communication
  channels between sites
• Improved patient care
Next Steps

• Review and update relevant policies &
  procedures
• Review admission/discharge criteria for
  hospital GEM ward
Questions
Patient Flow
Collaborative




             Janine Rogers,
             CHIP Manager

   Calvary Health Care ACT
Department of Human Services
Summarise Organisational
Constraint areas

• Allied Health (AH) referral process-
  inappropriate & not timely
• Radiology-timeliness & accessibility
• Nursing Paperwork-duplicative & excessive
• VMO Rounds-disjointed & not well managed
  from
• ACAT Services-limited appointments &
  difficulties with rebooking
Summarise Priority Constraint
Area 1

• AH Issues

  – Inappropriateness of referral
  – Timeliness of referral
  – Referral process
Diagnostic work
• Brainstorming
   – Ad hoc referral arrangements
   – Timing issues
   – Communication issues
• Consumer
   – Not seen in ED
• Determine what is process now
• Tick and flick exercise in ED and Medical for
   –   Response times
   –   Relevance of referral
   –   Who is making referral
   –   Process effectiveness.
Improvement Plan

• AH referral indicators
  – Determine indicators
  – Pilot in two areas, then
  – Specific to each service area
• Refine process
  – Determine time intervals from referral to
    assessment and then set optimum goal
  – Structured flow for referral
• Facilitate communication between parties
  – Streamline process
  – Ease of access to contact # and names
Progress
• AH referral audit underway
• Referral process set into flow diagram
• Specific AH Indicators for pilot accepted
  – AH and nursing input
• Evaluation audit on pilot to be
  completed
Lessons learnt

• Managing detractors and concerned
  staff
• Getting everyone in the right place at
  the right time
• Reliance on senior 3rd party to share
  project information
• Don‟t do this during accreditation
Desired Impact

• Timeliness
   – Patients requiring AH intervention to be seen
     within …?…. (optimal time frame)
• Appropriateness
   – All AH referrals to have a clear rationale for
     assessment
• Knowledge
   – Increase knowledge across hospital on referral
     indicators
• Communication
   – % of referrals that follow correct communication
     process
Next Steps

• Radiology mapping
• Revise nursing assessment
  – Standardise across hospital
  – Standardise risk assessments
  – Include expectation management
• Increase efficiency of VMO rounds
• ACAT service
Questions
Team Presentations



Melanie Hendrata and Kim Moyes
5TH October 2004




Department of Human Services
Concurrent Session 1
Team Presentations

Bellarine Room 3
  – Northeast Health - Wangaratta
  – Bendigo Healthcare Group
  – Southern Health – Dandenong Hospital
  – Peninsula Health
  – Box Hill Hospital
Patient Flow
Collaborative




                Christine Giles
          Northeast Health Wangaratta


Department of Human Services
Rigorous Diagnostics

• Poor communication pathways both
  verbal and written- Inadequate or
  incorrect documentation of patients‟
  social & medical history.
• Inconsistencies with quality of
  admission data from GP‟s and
  referring agencies.
Rigorous Diagnostics

• Patients being asked the same questions
  repeatedly by different personnel.
• Organisation duplication of paperwork.
• Discharge dependant on timing of medical
  rounds, availability of bed elsewhere, family.
• Delays in radiology.
Organisational Constraint Areas

1. Communication and Information
   Transfer.
2. Emergency Department-time taken
   between decision to admit and
   admission to ward.
3. Medical ward LOS-activities affecting
   discharge, transfer & readmissions.
Implementation Phase-
Plan, do, study, act.
• Team members further brainstormed the
  constraint areas.
  –   Communication between ED and Medical unit
  –   INR monitoring and warfarin therapy
  –   Nurse initiated clinical guidelines
  –   Discharge-time and trends in the Medical unit
  –   Quality of admission data
  –   Delays in ED-causes and effect
  –   Form review by Medical Records.
• Consensus reached on plan, do, study act
  initiatives.
Implementation Phase-
Diagnostic work

Tools
Desk top audits, tally sheets, staff interviews both
structured and unstructured, questionnaires, existing
hospital data.

Who was involved?
Health information manager, ED, medical unit, nursing
staff and clerical staff, ward nurses, executive, junior
and senior medical staff, director of pharmacy, director
of radiology, under graduate student. Patients and
relatives.
Implementation Phase-
Diagnostic work
What data/information was really useful/not useful?
Anecdotal, face to face staff interviews, audits,
previous studies, patient comments.

1. Face to Face Radiology delays as an issue debunked.
New filmless system being implemented. Delays in the
request for and actioning pathology results highlighted-
INR-therapeutic range and warfarin dose.
2. INR Clinical Indicator Variance Analysis 2003
This data supports anticoagulation management as one
 of our perceived causes of medical ward prolonged
LOS affecting discharge, transfer & readmission.
Implementation Phase-
Diagnostic work

3. Desktop audit indicated excellent compliance by
NHW with discharge summaries but raised some
questions about the quality of information
accompanying patients on arrival to our hospital.

Identified some evidence of GP admitted patients
having increased LOS for certain patient types.

4. Tally sheets!!-poor compliance, hostility,
paperwork fatigue led to insufficient data.
Implementation Phase-
Diagnostic work

                 Staff reactions-
                 • Anger.
                 • Disinterest.
                 • Passive resistance.
                 • Frustration.
                 • Ability to see what
                   needs to be done but
                   negative about means
                   to achieve change.
                 • Powerlessness.
                 • Blame culture.
Improvement and Progress

1. Medical ward and ED identified as the most
   pressing communication issue. Positive
   channels of communication to be established
   and shared goals initiated
-  Reduce duplication in history taking, trial
   innovations to ease the burden of the admission to
   ward process.
-  Explore MAPU to improve patient flow.
-  Established a forum for both groups to have
   dialogue and understand each other‟s issues.
Improvement and Progress

2. Communication with Medical staff group
  to establish key responsibilities for
  investigating identified constraints
- Engage GPs-review admission process, LOS.
- Exploration of nurse initiated activities to expedite
  the discharge/transfer process i.e.pathology
  requests, referrals to allied health, medication.
- Identification of the use of evidence based care,
  clinical practice guidelines, beginning with anti-
  coagulation therapy.
Lessons learnt
1.   Separate fact from opinion.

2. Distil the problem from the symptoms.
3.   Examine data quality carefully and adapt
     diagnostic tools to be contextually appropriate-
     “you can’t weigh something with a tape measure”
4.   Accept that change is painful but good leadership
     can transform negative energy into a positive
     outcome.
5. Harness the energy of the organisation champions.
Next Steps

1. Trial MAPU.
2.   Develop education plan for Medical ward and ED
     nursing staff re history taking, referral, pathology
     and pharmaceuticals skills.

3.   Develop an education plan for admission clerical
     staff and external referral agencies re accuracy of
     patient information.

4.   Engage junior medical staff in a culture of
     teamwork and evidence based practice, clinical
     practice guidelines.
Questions
Patient Flow
Collaborative




June Dyson
Bendigo Health Care Group

Department of Human Services
BHCG Organisational
Constraint areas

• Variation in patient management
  practices by doctors and nursing staff
  for Stroke patients. Impacts on quality
  of care and length of stay
• Limited availability of acute, rehab and
  aged care beds
BHCG Organisational
Constraint areas


• Availability of registrars to assess
  potential admissions in the Emergency
  Department (ED)
• Repetitive documentation, assessment
  and data capture for patients
Priority Constraint
Variation in patient management for
Stroke

• Stroke is a discrete and important area
  across the continuum.
• There is some evidence that:
  – Stroke care and treatment could be improved in
    the ED
  – Stroke care and treatment could be improved in
    the acute phase
  – Stroke patients spend time additional time in acute
    beds when they are ready for discharge
  – Follow-up for TIA and Stroke patients in the
    community could be improved.
Diagnostic work
• Stroke patient journey times
  – A data collection tool was developed to better
    understand the timing of the patient journey.
  – Developed by the Executive team in collaboration
    with ED, acute and rehab staff.
  – Difficulty in reaching consensus on tool - the tool
    was drafted at least six times.
  – Consumers were not involved at this point.
  – The data collection is in progress (it took six weeks
    to reach agreement on the tool and manner of
    data collection)
Diagnostic work: Data collection tool
Diagnostic work
• Stroke residential care patients
   – A SPC analysis of stroke length of stay (2001-004) identified
     a number of „special causes‟
   – We reviewed the patient histories of „special causes‟ to
     determine the reasons for long lengths of stay
   – Particularly we looked at the time frames between acute
     admission, Aged Care Assessment team assessment,
     placement on residential care waiting list
   – This was compared to existing data looking at Stroke referral
     time to rehabilitation and residential care.
Diagnostic work: SPC of
Stroke LOS
                                              SPC chart of variation in Stroke length of stay: 2001-2004

                                                                     Length of stay        Average        LCL        UCL2

                            100

                            90
                            80
    Length of stay (Days)




                            70
                            60

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                            10
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                            22 200
                                  20

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                            22

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                            22
                                                                                   Admission date

                     The chart shows the length of stay of 627 stroke patients between June 2000 and June 2004. The upper and lower control (LCL) limits
                     represent two standard deviations above and below the log (ln) length of stay (since the LOS data are skewed). Patients admitted with
                     Stroke can expect acute lengths of stay between 0 and 44 days, with an average length of stay of 10 days. 10 'special causes' were
                     identified: that is, patients whose length of stay exceeded the upper control limit.
Diagnostic work: Potential
causes of Stroke long LOS
                     Average time course for long stay Stroke patients (N=15)



           Acute admit to 1st
            Rehab assess.

          Rehab to 1st ACAS
               assess.


     ACAS assess to NH wait


       NH wait to NH bed (or
           deceased)

                              0.0         10.0         20.0         30.0        40.0         50.0         60.0

                                                           Days post admission

     The graph shows the average time course for Stroke patients with very long lengths of stay. The bars on
     the graph show how long (in days) the average patient can spend in acute care, until assessment and
     transfer to nursing home. The graph shows that approximately half of these patients LOS is taken up
     waiting for residential care.
Diagnostic work: Potential
causes of Stroke long LOS
                 60


                                                                19
                 50                                                                 19




                 40                                             6




                 30
                                                                29                  29
                                                                13

                                                                                    13
                                                                                    6
                 20
                                          6                                         28
                                          38                                        24


                 10
       Days




                  0
                    N=                  46                    46                  46

                               Referral to w aitlist   Referral to Admit   Waitlist to Admit


                      Period

         The boxplots above are based on data collected on 46 patient journeys between August
         2003 and January 2004. The boxplots above show that 50% of patients placed on a
         waiting list for rehabilitation within 8 days of referral, and admitted to rehab within 12
         days of referral. A number of patients are ‘outliers’ – with considerably longer than
         normal waiting times.
Diagnostic work: Long LOS
• The data was consistent with staff‟s beliefs
  about the difficulty in finding residential care
  placements.
• A small subset of cases for Stroke LOS
  identified data collection problems
• There is a „weariness‟ about the difficulties in
  finding residential care placement. It is „out
  of our hands‟.
• The data did not provide clues to how to
  improve patient flow.
Improvement Plan

• Two clinical teams have been
  established.
  – The first clinical team is looking at the problem of
    variation and patient management.
  – A second clinical team is building on the work of
    an existing working group to investigate options
    for patients waiting in acute care for residential
    placement.
  – Establishment of an emergency department clinical
    team is contingent on the results of the data
    collection.
Progress

• Documentation clinical team established
• Nursing Home working party-implementation
  of Entry to Nursing Home process.
• Elective surgery peer group working party
  established
  – theatre utilisation
  – how patients are put on the waiting list
  – using patient hotel accommodation to encourage
    day of stay admission
• Further data collection strategies in place
Lessons learnt

• It has been challenging garnering
  enthusiasm from clinical staff.
• Change is slower than we would have
  liked but is progressing.
Lessons learnt

• The executive team meetings have, for
  some time, been engaging in both
  executive team and clinical team
  activities and discussion.
• Communication has been an issue as
  not all of the team are fully conversant
  with the PFC process.
Lessons learnt

• Need to have senior members of the
  executive team active and on board early.
• Need to establish clinical teams as soon as
  the problem is identified
• Need to find a way to better engage clinicians
  – Overcome the „not another project‟ feeling
  – Communicate the goals of the project uncritically
  – Deal with realistic and unrealistic expectations of
    impact of the PFC on workload
Desired Impact

• Reduce repetitive patient and clinician
  documentation (for Stroke cases)
• Improve consistency of care (Patient X
  receives the same care irrespective of
  treatment by Doctor A, B or C)
• Reduce delays for Rehabilitation and
  Residential care placement.
Next Steps

• Collect and analyse patient journey
  timings.
• Establish ED clinical team, if necessary
• Complete review of documentation.
  Trial this new documentation and
  reassess patient journey times
• Evaluate outcomes of nursing home
  clinical team and further development
  of new strategies.
Questions
Patient Flow
Collaborative



Ms. Maggie Emmerton

Pharmacy Site Manager
Dandenong Hospital
Southern Health
Department of Human Services
Summarise Priority Constraint
Area 1
Discharge - Pharmacy

  •   Information / data needs
  •   Script Accuracy
  •   Communication
  •   Discharge planning/priorities
  •   Week end – resources, hours
Diagnostic work
• Diagnostic exercises:
   – Table top issue exploration x2
   – Discharge pharmacy flow
   – Pharmacy audits

• Participants: ED manager, ward pharmacists, clinician,
  Nurse managers, Chief pharmacist, project facilitator

• Reactions: gained new understanding of complexity of
  pharmacy issues and requirements

• Useful information: Internal pharmacy audits, ward
  experiences
Improvement Plan
• Data:
 - Liaise with Admission clerks re data requirements
 - Liaise with Ward Clerks re data verification

• Script Accuracy:
 - RMO to verify script with 2nd person before
   submission to pharmacy
 - Feedback through Pharmacy Intervention / Incident
   Reporting Database

• Communication:
  – Designated ward staff member as central
    communication point between ward staff and
    pharmacist
  – Reduce interruptions through utilisation of LAN page
Progress
• Progress:
 -Liaisonwith Snr Health Information Mgr re Admission Clerk
  responsibilities.
  Incorporation into training schedule.

 -Trialling of measures on designated ward
     -ward clerk monitoring patient data
     -designated central contact b/n ward & pharmacy
     -utilise LAN page in preference to phone to reduce
      interruptions
     -encourage RMO‟s to verify discharge script before
      processing
Progress - Outcomes

Ward 4 trials:-
-open communication b/n ward clerk and pharmacist re missing
 data
-need to identify incorrect data
-snapshot of actual data issues to be compiled for feedback to
 Admissions

-designated central contact effective. Some fine tuning of process
 required.
-LAN page system well utilised

-Medical staff – little response to verbal communication.
     Request audit of specific issues with scripts.
Desired Impact

 The expected impact from the improvement
 measures undertaken is to reduce discharge
 delays related to barriers to the pharmacy
 process.

   -Increase the accuracy of patient
   demographic data for SH.

   -Increase accuracy of prescribing.
Next Steps
• Next Steps:
 -evaluate current trials

 -implement other actions to enhance script accuracy.
    -RMO induction / orientation package – repeat session
    -unit meeting agenda – reinforce accuracy
    -pharmacy tutes – schedule meeting b/n ward
     pharmacist and RMO, provide script writing assistance
    -re audit local ward scripts – provide feedback
Patient Flow
Collaborative



  Ms. Joanne Burns

  Director Patient Access and
  Demand Strategy
  Southern Health
Department of Human Services
Summarise Organisational
Constraint areas

1. Bed Bureau – operations and functions
   inconsistent across sites of SH.
  •   Resources
  •   Communication
  •   Trust
  •   Protocols
  •   KRA‟s
Summarise Organisational
Constraint areas

2. Discharge Pharmacy
  •   Information / data needs
  •   Ward stock / requirements
  •   Week ends
  •   Communication
  •   Script accuracy
  •   Discharge planning / priorities
Summarise Priority Constraint
Area 1

Bed Bureau
  • Inconsistent service
  • Communication ad hoc
  • Trust
  • Defined responsibilities
  • Bed allocation prioritisation
  • KRA‟s
Diagnostic work
• Diagnostics:
  – x2 patient journeys
  – x4 table top sessions
  – Involving nursing, ward management, medical, heads of unit, ED,
    Bed Bureau, orderlies, administrative and OT personnel

• Reactions:
 - overall positive vibe with recognition of difficulties involved, but
 general sentiment that most problems were caused by others. A need
 to take ownership of issues and work collaboratively to resolve.

• Useful data:
 -‟ED time from bed request to bed allocation‟
 -‟ED time from bed request to transfer to ward‟
 - Patient journey time through ED – although would be helpful
   to map entire medical patient journey – identifying and
   understanding component parts to create better flow.
Improvement Plan
• Increase resources and service hours

• Establish communication procedures

• Establish bed allocation prioritisation principles

• Establish consistency of operation and function across
  sites

• Collect and collate activity data

• Develop Inpatient Access Manager role

• Report Bed Bureau activities to site exec
 Progress
• Access Working Group sub group – Bed Bureau-
  established

• Resource costing profile

• Communication strategy / process documented &
  endorsed by site executive

• Policy requirements identified

• Development : elective capacity predictor tool
Progress


• Communication channels trialled and showed
  an improvement in time from bed request to
  bed allocation.

• Daily bed meetings and utilisation of Predictor
  tool provide an accurate count of daily acute
  capacity.
Outcomes
• Regular meeting of Access working group sub group

• Daily Bed Management meeting – bed census, border
  information

• Changes to formal communication processes include
  LAN paging, Homer and email utilisation
Lessons learnt

• All participants found to have
  frustrations often with no channels for
  resolution

• Important to prevent information /
  problem overload. Tailor information to
  individuals that is pertinent and
  relevant to their sphere of interaction.
Desired Impact
Looking forward we expect:

-better management of the elective and emergency
 demand balance

-accurate prediction and accommodation of elective
 surgical demand and a reduction in episodes of HIP

-reduced time for patient journey through the ED and
 admission to an in patient bed

-a decrease in time „Ready for discharge patients‟ wait
 for a subacute bed
Next Steps

• Continue developing the work

• Improve discharge end of journey to
  enhance interface with subacute linking
  with RASP services
Questions
Patient Flow
Collaborative



Dr Susan Sdrinis

 Manager – Medical Operations
Peninsula Health

Department of Human Services
Summarise Organisational
Constraint areas
Guiding Principles of Peninsula Health PFC

•   Patient focussed
•   Improved patient outcomes
•   Right patient, place, resource, time and clinician
•   Prompt access
•   Optimal flow
•   Efficiency
•   Enhance professional networks and relationships
Summarise Organisational
Constraint areas
Priority Areas

• Optimise patient flow from the Emergency
  Department

• Eliminate delays for patients awaiting surgery

• Optimise bed utilisation across all sites

• Facilitate consistent systems and processes across
  Peninsula Health
Summarise Priority Constraint
Area 1



• To improve patient flow between Emergency
  Department and Radiology Department

• To improve the service provided to Emergency
  Department patients associated with Radiology
  procedures
Diagnostic work

  • Process mapping

  • Brainstorming

  • Tick charts

  • Time measurements
Diagnostic work

 Who was involved?
 – Patients
 – Frontline staff
 – Departmental Managers


 Reactions?
 – Have done it before
 – Good, let‟s get this right
Diagnostic work

                  Time Request is Faxed to PSA Contacted for Patient Transport

            250

            200
  Minutes




            150

            100

             50

              0
              55

              05

              50

              30

              40

              10

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            20

            21
                                        Time Faxed to PSA Contacted
                                                            Minutes
                                08




                                                  10
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                                                                      30
                                                                           35
                                                                                40
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                                          0
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                                                                                                                                                    Diagnostic work




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                                                                                               Time PSA Contacted and PT Transported to Radiology




                                     11
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                                     33
                                17
                                     50
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                                     33
                                19
                                     00
                                21
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                                21
                                     23
Time Transported to Radiology
Diagnostic work
                                    Time PSA Contacted to PT Transport From Radiology to ED

            16

            14

            12

            10
  Minutes




             8

             6

             4

             2

             0
              30


                     33


                            15


                                    43


                                           26


                                                  10


                                                         45


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                                                                       20


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            08


                   09


                          10


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                                                                                                                                    22
                                 Time PSA contacted for transport back to ED       Time PSA Contacted to Time Transported to ED
Improvement Plan
    Critical to               Innovation                      Actions             Achieved
     Quality
Requests delivered       Using Fax Machine and        Speed dial formatted –      Yes
timely                   speed dial                   Memory test on fax OK

Better communication     Doctor goes to specialty     Leong to educate at
if specialised           modality technician during   registrars meeting and
resources required       hours and speaks with MIT    through Memo
                         on duty afterhours
ED electronic            Need to discuss further      Richard to organise
whiteboard in            and bring in IT              meeting and invite Leong,
Radiology                representative               Wendy, & Eric to progress
Timely transport of      To be discussed further.     Wendy to implement single
pt‟s to radiology when   Start with implementing      point of contact
contacted                single point of contact

Timely transport of      Radiology to contact PSA     Radiology agree to change
pt‟s back to ED when     for all pt returns           practice. Bert to
contacted                                             implement in Radiology.
                                                      Wendy to implement in ED
Improvement Plan
     Critical to                Innovation                      Actions              Achieved
      Quality
 Notification of patient   ED will ensure staff direct   This information to be
 in Radiology Waiting      pt‟s to notify Radiology      placed on fax sheet.
 Room                      of their presence             Wendy & Leong to
                                                         implement.
 Report process            Radiology to prioritise all   Bert to develop memo
 streamlined (A)           in hours ED radiological      and confirm with Leong
                           procedures as priority 1      - Trial Period to be
                           for reporting                 implemented – All
                                                         portable procedures are
                                                         to go straight back to ED
                                                         consultant others to
                                                         Radiologist as priority 1
 Report process            Place interim reports on      Richard to organise
 streamlined (B)           Orion.                        meeting and invite
                                                         Susan, Shamala, & Bob
                                                         Ribbons
Progress

• Describe progress so far?
• What was the outcome?
• What was trialled?
• How many patients were involved?
• What staff were involved?
Lessons learned


• Process mapping / data motivated and guided group

• Focussing on patient need rather than department /
  staff need

• Ownership of problem by both departments
Lessons learned


• Having an independent facilitator

• Informal regular meetings encouraged brainstorming
  of solutions

• Involvement of frontline staff earlier
Lessons learned
NHS Sustainability Model
• Lowest scores were items 4 & 5
   – 4 - Staff involvement and training to sustain the process
   – 5 – Staff attitudes towards sustaining the improved process

• Areas to focus on to increase the sustainability of the
  process were:
   –   Involve staff through pressure testings
   –   Team meetings
   –   Include staff in Membership of the project group
   –   Involve staff in the development and/or agreeance of tools
   –   Involve staff in the decision making process
   –   Provide regular feedback
   –   Celebrate wins
Desired Impact


• To support patients receive a customer focussed,
  time efficient, and accurate diagnostic process as a
  result of presenting to the emergency department for
  care of their injury or illness.
Desired Impact

• 100% of pts are transported to Radiology within
  12mins of contact

• 100% of pts are returned to ED within 10 mins of
  contact

• Radiology reporting streamlined to prioritise all in
  hours Emergency Department radiological procedures
  as priority 1 for reporting
Next Steps


• Continue to develop innovations to address all critical
  to quality items

• Involve more frontline staff in process

• Post implementation data analysis
Patient Flow
Collaborative




Kate MacRae

Director of Occupational Therapy
Peninsula Health

Department of Human Services
Summarise Organisational
Constraint areas

Priority Areas

• Optimise patient flow from the Emergency
  Department

• Eliminate delays for patients awaiting surgery

• Optimise bed utilisation across all sites

• Facilitate consistent systems and processes across
  Peninsula Health
Summarise Priority Constraint
Area 3 – Bed optimisation – Transport
delays

• Poor systems of access to pool cars for
  clinical use
• System of „first in best dressed‟
  previously adopted across the network.
• The issue of increased incidence of
  manual handling of equipment by
  therapists was also raised as an OH&S
  issue.
Diagnostic work

• An analysis of number of delays in conducting
  home assessments, prior to discharge, was
  conducted over a 2 week period.
• The impact on increased LOS and subsequent
  delayed discharge was measured.
• All inpatient occupational therapists were
  involved.
Diagnostic work


• Staff viewed this activity positively.
• The number of home assessments
  conducted per ward was also measured.
• The number and usage of each pool car
  across the network was also plotted.
Improvement Plan




• The need for a car (station wagon) to
  be „quarantined‟ at each site, which was
  prioritised for clinical use, was
  identified.
Progress

• A revised car booking system was
  trialled for 2 weeks, and then
  implemented as policy
• The additional car was purchased
  following executive discussion and
  approval.
• The increased through put and reduced
  LOS had impacted on the clinical need
  for access to pool cars.
Lessons learnt


• Quick wins are important!

• An analysis of one problem often identifies
  other issues, which will need to be addressed.
Desired Impact

• Since the review of the car pool system
  there have been no documented
  occurrences of home assessments not
  being able to be conducted due to lack
  of transport.
• Manual handling of equipment has been
  rationalised.
Next Steps

• The project is now completed.
Questions
Patient Flow
Collaborative




     CARMEL BROWNE
     BOX HILL HOSPITAL


Department of Human Services
SUMMARY OF CONSTRAINT

• Identifying issues of workload and
  capacity for the medical units to
  manage this number of patients.
• Balancing this with other pressure on
  bed access - psychiatric patients waiting
  for admission to adult or aged
  psychiatric services- elective surgical -
  medical imaging admissions.
Diagnostic work
• Utilising data we determined how many patients
  were allocated to each medical unit and where those
  patients were placed within the hospital.
• How many patients were waiting in ED to access a
  acute bed.
• How many patients were on the elective surgical list
  needing admission that day.
• How many patients were booked as elective
  imaging,of which some will require admission.
• How many psychiatric patients were in ED waiting
  admission to adult, adolescent or aged psychiatric
  services.
Improvement Plan

• Carmel Browne worked with key stakeholders to
  identify a more reasonable workload.
• An agreement was made to review medical rosters,
  patient numbers and to share patient allocation
  amongst registrars who may be quieter.
• A daily data summary sheet is emailed to key staff
  using the daily whole system data.
• A key facilitator in medical administration
  communicates with medical units to share the
  workload.
Progress

• This was trialed across all general
  medical units.
• A cross section view of all patients by
  ward - unit- or specialty revealed where
  constraints could be.
• The medical administration assistant
  then negotiated allocation of patients
  with all medical units.
Progress

 •The improvement monitored the
 patient flow and resulted in a more
 manageable workload for medical
 units.
 •Patients benefits were reduced wait
 time in ED, and being seen more
 promptly by medical staff.
Lessons learnt

• This process is currently person
  dependant.
• The data analysis and creation of the
  daily sheet is time consuming.
DAILY REPORT SAMPLE
ED had about x7 waiting for beds
x2 of these are psych patients who have been there coming up to 4 and 5 days
respectively.

Hospital full
A1     x25 patients    x7 wards
A2     x16     "       x5 "
B1     x10     "       x3 "
B2     x30     "       x7 "
Oncol x14      "       x3 "
Haem x13       "       x2 "
CCU    x8
Neuro x10      "       x2 "
Spec x12       "

Surgical x77 of 94 beds
There is a lot of nursing sick leave in the operating theatre today.
Usual agency had not been able to supply staff.
If not all avenues have been exhausted and some afternoon cases will have to
be cancelled.
Desired Impact

• Improved access to a bed and medical
  consultation for the patient.
• Improved collaboration amongst
  medical registrars.
Next Steps

• Development of an automated program
  will assist with the long term progress
  and sustainability of this trial
Questions
Team Presentations



Tony Snell and Prue Beams
5TH October 2004




Department of Human Services
Concurrent Session 1
Team Presentations

Bellarine Room 4
  – LaTrobe Regional Hospital
  – St Vincents Health
  – Northern Health
  – Angliss Hospital
Patient Flow
Collaborative




Peter Wright - ED Director
Latrobe Regional Hospital



Department of Human Services
Summarise Organisational
Constraint areas

1.    Bed availability (ED Acute, Acute Sub-Acute)
2.    Awaiting ACAS assessment
3.    Delay in Allied Health Assessments
4.    Reluctance to call Inpatient Referral
5.    Medical rounds done too late in day
6.    Awaiting Inpatient Team assessment in ED
7.    Awaiting clinical investigations
8.    HMO decision making delays
9.    Delay in CT results & ultrasound
10.   No Radiology between 10pm - 8:30am
Priority Constraint
1. Bed Allocation

• Hourly patient tracking in ED has highlighted
  patients waiting 3 to 6 hours from time of bed
  allocation to actual time of admission.

• Goal to have all ED patients admitted to the
  hospital within one hour of the decision to
  admit.
Hourly Tracking Analysis
                      3-12 hour waits in ED

 12
 11
 10
  9
  8
  7
  6
  5
  4
  3
  2
  1
  0

        R      P        W      BW          BA      I       C        E
 3hrs   4hrs   5hrs   6hrs   7hrs   8hrs    9hrs   10hrs   11hrs   12hrs+

R = Radiology                       BA=Bed allocated waiting ward t/fer
P = Pathology                       I = Inpatient Review
       W= Waiting to be seen               C = Communication Delay
        BW = Waiting bed allocation        E = ED Treating
Diagnostic work
• Hourly ED tracking undertaken to identify major
  flow constraints
• Refinement of data tracking to better reflect bed
  allocation issues, including ward, system, ED &
  clinical constraints
• ED AUM‟s and ED Manager involved in data
  collection
• Hourly data tracking well received by staff,
  however busy times impact on data collection
• Relatives or carers were not involved
Diagnostic work continued ...
Refinement of hourly data tracking included breaking
down codes for Bed Allocation constraints;
• BAF bed allocated, but bed not empty (this includes verbal
      allocation for expected discharge)
• BAC bed allocated, but needs cleaning
• BAS bed allocated, awaiting staff pick up, ie Ward Nurses or
      Hospital Attendants
• BAT bed allocated, treatment in ED before can be transferred,
      ie: clinically unstable, IV medications etc
• BAP bed allocated, paperwork holding up transfer, ie doctors
      notes, admission notes, etc.
Improvement Plan

• Refined data collection will identify
  improvement areas.
• Possible improvement areas;
  – Ward meal breaks and stable patient transfer, no
    ward staff available to do immediate admission
  – Patient paperwork in order prior to bed allocation
  – Staff availability for physical patient transfer
  – Bed Clean procedure performed on discharge, not
    admission request
Progress
• We‟re working on patient flow constraints in
  reverse to free beds for patient entry points
  such as ED. These initiatives include;
    –   Community Bed Register
    –   Bed Manager Role
    –   Social Worker Unification including GEM triage
    –   Functional Mobility Program for GEM patients
    –   Multi Disciplinary Admission / Discharge Summary
    –   Bed Manager focus on Short Stay Unit utilisation
    –   Alert system for 8 hour ED stays
Progress cont ….
• Positive impacts to date;
   – 3% decrease in ED journey & average stay time.
   – 23% increase in utilisation of Short Stay Unit
                                  Utilisation of Short Stay Unit (LRH)

                    90
                    85
                    80
                    75
                    70
                    65
                    60
      Occupancy %




                    55
                    50
                    45
                    40
                    35
                    30
                    25
                    20
                    15
                    10
                     5
                     0
                         May 04           June 04           July 04      Aug 04
Progress cont ...

• We expect to see more significant
  improvement as initiatives settle in.
• ED AUM‟s, Management and all ED patients
  over 3 months were involved in the hourly
  data collection.
Lessons learnt

• What worked well;
  – Hourly tracking
    • Simple and well accepted, if not liked
    • Highly visible
    • Highlighted key constraints
• What would you now do differently and
  why?
  – Start data collections earlier with better
    tracking tools (initial tools inadequate)
Desired Impact

Our expected impact will be;

• All patients admitted within an hour of
  bed allocation
• 12 hour stays in ED brought within
  target levels
• Utilisation of Short Stay Unit over 100%
• Reduced Acute LOS
Next Steps
• Further work on Bed Waiting and Bed
  Allocation
• Implementation of the GEM Functional
  Mobility Program late September should
  impact on Acute LOS and impact on
  available beds for ED admissions.
• Refinement of hourly patient tracking
  will determine new action plans.
Questions
Contacts:
Peter Wright
ED Director
pwright@lrh.com.au

Wen Bezzina
PFC Co-ordinator
wbezzina@lrh.com.au
(03) 5173 8139

				
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