Department of Human Services Patient Flow Collaborative Lee Martin Collaborative Director Welcome...

transcript

Department of Human Services

Patient Flow Collaborative

Lee MartinCollaborative Director

Welcome and overview

House keepingHouse keeping

• Informal – ask lots of questions• Phone/Bleep• Restrooms• Refreshments• Partnership approach• No knows all the answers• Fire alarms

AgendaAgenda

8.45 - 9.00 Welcome and registration

9.00 – 9.30 Overview of day,

9.30 – 10.00 Project Coordinator role and key roles of health service team

10.00 - 10.15 Morning tea

10.15 – 11.30 Introduction to self assessment and questions

Capability building

11.30 – 12.30 Whole system thinking

12.30 – 1.15 Lunch

1.15 – 2.45 What is your behavioural style? What is your learning style?

How do we help others to learn?

2.45 – 3.00 Afternoon tea

3.00 – 4.00 Game: Variation - capacity and demand,

Critical chain project management, reporting/presenting skills

Conference calls, Site visits, Score your team

4.00 – 4.15 Feedback and discussion

AimsAims

• To tackle key constraints in the patient process identified by each health service

• To promote and facilitate the development of service improvement skills within each health service

Patient Flow CollaborativePatient Flow CollaborativeKeyOS Orientation SessionLS Learning SessionC/Call Team Conference Calls

SustainSustain

Patient Flow CollaborativeProject Plan

Feb Apr SeptJulJun

LS25 Oct

LS38-9Feb

LS419-21April

OctMarJan Apr Jun Jul

LS519 July

Diagnostic phaseTest cycles and implementation Action phase:

Enable spread

HealthImprove-

mentSchool

Embed sustainability and mainstreamTrainingphase

Engage HealthServices

LS16 -7July

Celebration

Aug Nov MayJan

Site visitsC/Call

7-11 March

Site visitsC/Call

23-28 May

ActionLearningSession

Site visitsC/Calls

23-27Aug

ActionLearningSession

ActionLearningSession9 Aug

Site VisitsC/Calls3-8 May

Site visitsC/Call 15-

20 Nov

ActionLearningSessionJan 04

ActionLearningSession3rd Dec

Site Visits

Nurse LeadTraining1 April

DataTraining17 Mar

PGMTraining

InnovationAssociates

Training30 Apr

Training29 Oct

ProjectTeam

TrainingDay 1

29 Mar

MainstreamAction Plan

Report

Training29 Apr

ProjectTeam

TrainingDay 227 Apr

ExecutiveTeam

Training31 Mar

Key componentsKey components

• Rigorous diagnostics

• Innovations

• Spread and Sustain

• Mainstream

Learning ProgramLearning Program

• Master classes• Self assessment• Learning sessions• Mentors• Action learning sets• Change package

Partnerships HDM and CIAPartnerships HDM and CIA

Assistance

• Strategic Workforce Planning• Nurse Policy Unit• Planning Group from field• Health Services

Health Service StructureHealth Service Structure

Executive team

Clinical

team Clinical

MethodologyMethodology

• Breakthrough Collaborative

• Whole system improvement

• Constraints theory

• Adult learning principles

Expectations Health serviceExpectations Health service

• Sampling data• Engaging health service at all levels• Report to the website monthly• Learning sessions & Conference calls• Spread and sustainability of innovation• Embed innovations approach within

the organisation

Expectations HDM/CIAExpectations HDM/CIA

• Improvement skills training• Diagnostics• Data – SPC’s• Action learning sets• Master class series education• Networks of innovation• Spread of innovation• Site visits

Internal Communications Internal Communications strategystrategy

• To assist unfreezing

• Spread motivation

• Raise morale

• Increase public confidence

• Increase staff pride

RisksRisks

• NO Executive commitment

• Too big too soon

• Rigorous diagnostics not completed properly

• Human dynamics of change not processed

• No Project Coordination

• Lack of organisational readiness

Questions

Coordinators Role

Coordinators roleCoordinators role

• Discussion around what is the key roles for the project coordinator and your experience of doing this

Partnerships for changePartnerships for change “I think that people are trying to tackle initiatives too low in the organisation .…

you need a damn good project manager, a strong chief executive

and a strong lead clinician” Site visit comment

The partnership of these groups will provide a effective, dynamic team

Team levelTeam level

Executive team

Clinical

team Clinical

Questions

Self assessment

Project coordinator self Project coordinator self assessmentassessment

Learning ProgramLearning Program

• Learning sessions• Action learning sets• Self Assessment• Change Package• Mentors• Master classes

AimsAims

• To tackle key constraints in the patient process identified by each health service

• To promote and facilitate the development of service improvement skills within each health service

Self assessment formsSelf assessment forms

Questions

Capacity and Demand

Lee MartinCollaborative Director

An elephant is like a brush

An elephant is like a rope

An elephant is like a snakeAn elephant is

soft and mushy An elephant is like a tree trunk

GP Acute

Sub acute

Residential

Ambulanceattends

Elective

HomeDeaths

Transfers

HomeDeaths

Transfers

Whole system health care

EquilibriumEquilibrium

EvaporationRiver flows in

River flows outWater level stays the same

Activity

Did Not AttendCancellationsDeaths

Demand

Queue keeps utilisation 100%Queue keeps utilisation 100%

EvaporationRiver flows in

River flows outWater level stays the same

Activity

Did Not AttendCancellationsDeaths

Demand

Variation mismatch = queue

Demand Capacity

Can’t pass unused capacity forward to next week

Sources of variationSources of variation

Demand• numbers of patients presenting• clinical conditionCapacity• number of practitioners• time available• Equipment etc

Moment of truthMoment of truth

• Even if average demand = average capacity

then• variation in demand

– + variation in capacity = queue !

• is system causing queue?

1. Demand > capacity1. Demand > capacity

waiting numbersIf Demand

> Activity or Capacity

Rare situationCommon belief

Effect of variation on flowEffect of variation on flow

1 2 3 4 5

Carve out results in churnCarve out results in churn

Demand

Capacityactivity

Bottleneck

Sick patients do not go away - they get sicker

Capacity carve out: specialisationCapacity carve out: specialisation

Demand

Bottleneck

CapacityHands

Number of specialists432Su

432Phys

Number of appointmenttypes

urgentsoon

routine

urgent soon

Flexi-sig

Colonoscopy

routine

urgent soon

The size of the carve out

xx xxx

xxxxx xx

xxxxx xx xxxx

xx x xxx

73 queues

Carve out: 2 & 3 careCarve out: 2 & 3 care

Clinic

LaserClinic

Research

ClinicTheatre

TheatreAdmin

Paedsclinic

Angios

teaching

SoonRoutine

Follow

SoonRoutine

Follow

SoonRoutine

Follow

Urgent Urgent Urgent Urgent Urgent

SoonRoutine

Follow

Urgent

SoonRoutine

Follow

Urgent

SoonRoutine

Follow

Urgent

SoonRoutine

Monday Tues Friday Sat SunThursWed

Recognising vicious circleRecognising vicious circle

More beds( & staff)

Less frequent ward rounds More

consultants & staff

More variation

More confusion

LessQuality

Length of stay

Number of admissions

More GPvisits How do we

reverse this ?

More readmit’s

Where should we focus change Where should we focus change effort ?effort ?

• ‘smooth’ elective admissions?• ‘smooth’ all discharges?• reduce length of stay ?• reduce test turnaround times?• improve quality to reduce re-

admissions?• more beds?

• if so, how many?

See “today’s” demand See “today’s” demand “today”“today”

• So we never let the queue get out of hand– set the capacity at 80% of the fluctuation in

demand– flex the capacity to meet the demand

• annualised hours

Advanced access

Where do we get ‘extra’ capacity from?Where do we get ‘extra’ capacity from?

• Map process• re-design process• measure bottleneck

– demand/capacity/activity/backlog

• analyse data - reduce variation• continue to measure and analyse• apply Statistical Process Control (SPC)

Improvement ToolsImprovement Tools

• Process map• Understand data• Reduce complexity• Reduce variation• Reduce carve out• Manage patient flows - pull not push• 80% improvements (Pareto)• Maximise capacity• PDSA• Constraints theory• Lean thinking

Whole system improvement Whole system improvement toolstools

• Structures • Process • Patterns

General medical ward round - Monday 28th of April 2003

MAU9.00-9.08 2 patients

Cuckmere ward9.14 - 9.17

1patient

Berwick ward9.17-9.302 patients

Wilmington ward11.23-12.209 patients

Folkington ward10.40-11.156 patients

East Dean ward9.37-10.227 patients

Summary:Duration of ward round = 3 hours and 20 minsWards visited = 6Patients seen = 26

DME post take ward round- Saturday 26th April8.55am MAU

5 patients

10.05am Gardner ward

2patients

10.30am Newington

Ward 1 patient

11.10am CCU

1 Patient

11.00am James Ward

1 patient

10.45am Baird Ward

1 patient

11.20amBenson Ward

1 patient

11.30amMurray ward

1 patient

Back to MAU for 11.50am

Summary:Duration of ward round = 2 hours and 55minutesNumber of patients seen= 13Number of wards visited= 8

% New appointments resulting as DNAs per week April 2001 to February 2003

Week Ending

% New DNAs

Mean =10.8%

UCL =14.9%

LCL =6.6%

Between Apr 01 and Feb 02 Hastings could expect to see between 7% and 15% of new appointments result in a DNA outcome per week with a weekly average of 11%.

From Feb 02 Hastings can expect to see between 6% and 14% of new appointments result in a DNA outcome per week with a weekly average of 10%.

Apr-01 to Jan-02 Feb-02 to Feb-03

Christmas/ New Year 2001

DNA marketing campaignGP surgeries & OPD Feb 2002

Christmas/ New Year 2002

Football World Cup June 2002

Summer holidays

Out Patient services

% Patients waiting over 4 hours in A&E

Week Ending

% Over 4 Hours

Year End Targets

Between 01 April 2002 and 31 March 2003 8% and 30% of patients attending A&E department could expect to wait more than 4 hours.

The average number of patients waiting over 4 hours per week was 19%

Between 01 April 2003 and 31 August 2003 0% and 12% of patients attending A&E department could expect to wait more than 4 hours.

The average number of patients waiting over 4 hours per week was 6%

Changes in process - dramaticreduction in waiting times

Theory of ConstraintsTheory of Constraints

• Step 1 -Identify the constraint• Step 2 -Exploit the bottleneck• Step 3 -Subordinate everything else to

the bottleneck• Step 4 -Elevate constraint - bring in

extra capacity• Step 5 -Once bottleneck solved, look for

the next bottleneck in the system

Case Study MeasuresCase Study Measures- Inpatient- Inpatient

• Total, Emergency and Elective Admissions (Daily/Weekly Multiple Line chart)

• Daily Admissions and Discharges by Elective/Emergency (SPC charts) • Avg Elective and Emergency LOS by Day of Admission (Bar for year

sample) • Average Inpatient Discharges + Deaths (DOW Stacked Bar for year

sample)

Length of Stay (Total) Length of Stay (Total) - Chart- Chart

80% of patients (excluding sameday) at this hospital had a length of stay between 1 and 8 days with the maximum length of stay at 238 days.

Average LOS by Day of AdmissionAverage LOS by Day of Admission- Chart- Chart

y = x2 – b

f = ma?

“attractor”

Tossing a Rock or a Bird?Tossing a Rock or a Bird?

Transfer the change ideas, not the Transfer the change ideas, not the solutionssolutions

Solution / change in healthcare

organisation A

Change idea Change idea

Solution / change in healthcare

organisation B

A range of restructuring, process and systems redesign, and transformation

Improvement model

Act• what changes are to be made?

• next cycle?

Plan• objective• questions and predictions (why)• plan to carry out the cycle (who, what, where, when)

•complete the analysis of the data

•compare data to predictions

•summarise what was learned Do

• carry out the plan• document problems and unexpected observations• begin analysis of the data

What are we trying to accomplish?How will we know that a change is an improvement?What change can we make that will result in improvement?

Bull whip effectBull whip effect

• increasing demand distortion down process– effect on intermediate care ?– effect on sub-acute?– effect on administration staff ?– effect on primary care ?

Adopter CategorisationAdopter Categorisation

Innovators

EarlyAdopters

EarlyMajority

LateMajority ‘Rear guard’

Source: Rogers

2.5% 13.5% 34% 34% 16%

Process complexity and implementation indexProcess complexity and implementation index

Low Medium HighP

Possible

Don’t do

Process Complexity IndexIm

FinancialFinancial improvement matrix improvement matrix

High Medium lowP

asy Key

2nd stage

Cost savingIm

Stories

Primary care – 3 million overspend implemented

one A4 tracking sheet and saved 2,000 per ward per day.

Average older person stay 39 days down to 19 days

Stories

ED – tracking all patients through in 75 minutes average

No category ones, none seen immediately

Staff morale raised, development program in

place covered by Clinical Director

for all staff

Australian Sample Data Surgical Ward

16 days

No clear care plan = 96Awaiting Radiology tests = 53

Not reviewed by home unit = 28No Discharge Plan = 22

Outlier patient not seen by unit yet = 14Late decision to D/C = 10

Awaiting ACAT assessment = 10Awaiting ACAT referral = 9Waiting r/v another unit = 9Waiting for Rehab bed = 9

Behavioural and learning styles

What is your styleWhat is your style

Expressive Amiable

Direct Driver Analytical

ExpressiveExpressive

• Verbal• Motivating• Enthusiastic• Gregarious• Convincing• Generous • Influential• Dramatic• Animated

AmiableAmiable

• Patient• Loyal• Sympathetic• Relaxed• Mature• Considerate• Stable• Trusting• Team person

Direct DriverDirect Driver

• Action oriented• Decisive• Problem solver• Direct• Assertive• Risk taker• Competitive• Independent• Determined

AnalystAnalyst

• Controlled• Orderly• Precise• Disciplined• Deliberate• Cautious• Diplomatic• Accurate• Fact finder• Systematic

ExerciseExercise

• Corners of the room are sign posted• Move to the corner of the room that

reflects your style

Positive and Negative Positive and Negative perceptions of Expressiveperceptions of Expressive

• Verbal inspiring• Ambitious• Energetic• Enthusiastic• Confident• Friendly

• Talkers • Overly dramatic• Impulsive• Undisciplined• Excitable• manipulative

How to work with expressive How to work with expressive people betterpeople better

• Tell who first• Be enthusiastic• Allow for fun• Support their creativity• Talk about people and goals• Handle the details for them• Value feelings• Keep fast paced

Positive and Negative Positive and Negative perceptions of Amiableperceptions of Amiable

• Patient• Respectful• Willing• Agreeable• Dependable• Concerned• relaxed

• Hesitant• Wishy washy• Pliant• Conforming• Dependant• Unsure• Laid back

How to work with amiable How to work with amiable people betterpeople better

• Tell why and who first• Ask instead of telling• Draw out their opinions• Explore personal life• Define expectations• Strive for harmony

Positive and Negative Positive and Negative perceptions of Direct Driverperceptions of Direct Driver

• Decisive• Independent• Practical• Determined• Efficient• Assertive• Risk takers• direct

• Pushy• One man/woman

show• Tough• Demanding• Dominating• Insensitive• Cuts corners

How to work with direct How to work with direct driver people betterdriver people better

• Tell what and when first• Keep fast paced• Don’t waste time• Be business like• Give some freedom• Talk results• Find shortcuts

Positive and Negative Positive and Negative perceptions of Analystperceptions of Analyst

• Accurate • Conscientious• Serious• Persistent• organised

• Critical• Picky• Moralistic• Stuffy• stubborn

How to work with analyst How to work with analyst people betterpeople better

• Tell how first• List pros and cons• Be accurate and logical• Provide evidence• Provide deadlines• Give them time, don’t rush or

surprise

Under stressUnder stress

analytical•will withdraw

driver•will become autocratic

amiable•will submit

expressive•will become offensiveor sarcastic

Fears about changeFears about change

analytical•not enough information•making a wrong decision•being forced to decide

driver•loss of control•failure•lack of purpose

amiable•damaged relationships•confrontations•not being recognised for efforts

expressive•being ignored•being asked for detail•being linked with failure

Change and learningChange and learning

Panic Zone•peopleclose up•they freeze•they don’t learn

Comfort Zone•people stay here•they don’t learn

•they don’t change

Discomfort Zone

Change and learningChange and learning

Comfort Zone

PanicZone

•uncertainty•learning

Change learning and comfort: Change learning and comfort: people respond differentlypeople respond differently

• some feel it’s an adventure and are excited and stimulated

• some feel it is a mission or a duty• some feel it is a forced march and are

fearful and cautious• some feel overwhelmed, depressed and

demotivated

Noer’s Response factor modelNoer’s Response factor model

Entrenched

Overwhelmed BSers

Learners

Comfort with change(learning readiness)

highlow

Noer’s Response factor modelNoer’s Response factor model

Entrenched

Overwhelmed BSers

Learners

Comfort with change(learning readiness)

highlow

Clings to narrow learnings

Learns and grows

Withdraws and avoids

‘Makes it up’high drive but low

substance

Can apply to individuals, groups, Can apply to individuals, groups, departments, directorates or departments, directorates or organisationsorganisations

Entrenched

Overwhelmed BSers

Learners

comfort with change(learning readiness)

(abili

o learn

highlow

Clings to narrow

learnings

Learns and grows

Withdraws and avoids

‘Makes it up’high drive but low substance

Overwhelmed - Overwhelmed - low comfort with low comfort with change, low capacity for changechange, low capacity for change

Withdraws and avoids• avoids confronting real issues• retreats into old patterns that

are perceived as safe• hopes that things get better• engages in passive /

aggressive behaviour• avoids thinking about or

planning for the future

Overwhelmed:Overwhelmed: low comfort with change, low comfort with change, low capacity for changelow capacity for change

How overwhelmed feel• unhappy or depressed• frustrated, anxious, powerless• bruised self esteem• fearful of mistakes and failure• needs approval, reassurance and stability

What is needed• help in coping with stress, fear and frustration• phased transition and success loaded

challenges

Entrenched - Entrenched - low comfort with low comfort with change, high capacity for changechange, high capacity for change

Clings to narrow learning• blames and complains• acknowledges need for

change but resists changing• works harder than ever at

previously successful behaviour

• tries to ride it out until things return to normal

Entrenched:Entrenched: low comfort with low comfort with change, high capacity for changechange, high capacity for change

How entrenched feel• frustrated, anxious, angry• unrealistically confident that past skills are

valid• reluctant to take risks

What is needed• understanding and help in coping with anger

and frustration• phased transition with a bridge from old to

BSer - BSer - high comfort with change, low high comfort with change, low capacity for changecapacity for change

‘Makes it up’ - high drive but no substance

• jockeys for positions of influence• presses for quick solutions and

actions• may initially come across as a

beacon in the darkness - ultimately becomes transparent

• often fools superiors

BSers: BSers: high comfort with change, low high comfort with change, low

capacity for changecapacity for change

How BSers feel• comfortable with need for change• compelled to do something - anything!• frustrated with the ‘confused’ and ‘whining’• confident in ability to function in any situation

What is needed • close supervision and close monitoring• assignments which are safe for the

organisation and push the employee

Learner -Learner - high comfort with change, high comfort with change, high capacity for changehigh capacity for change

Learns and grows• finds silver linings behind

dark clouds• finds humour in difficult

situations• is very aware of both

strengths and weaknesses• expands boundaries of their

comfort zone

Learners:Learners: high comfort with change, high high comfort with change, high

capacity for changecapacity for change

How learners feel• comfortable with need for change • challenged, stretched, optimistic• in control of own destiny / positive thinker• not afraid of short term mistakes and setbacks

What is needed • protection, latitude, air time• developmental roles and assignments with

impact• rewards and reinforcements

How leaders can helpHow leaders can help

Entrenched - find ways to let go of old and comfortable and learn skills

Overwhelmed -provide help and support during neutral zone of their transition

BSers - identification (uninformed optimist and the true hard core) and development

Learners - create an organisation to develop, select and preserve learners

Leading your team

Remember to consider your teams behavioural styles:

•Analytical/processing

•Amiable/supporting

•Expressive/enthusiastic

•Driver/controlling

Variation game

Project management

Critical chain project management

And finally

•Presentations

•Conference calls

•Site visits

•Scoring your team

Team scoring card

Feedback and close

Welcome and overview

Rochelle Condon

Patient Flow Collaborative

House keeping

Mobile phones/Bleeps turn to silent

Rest rooms

Fire Alarms

Equipment on table

Agenda

9.00-9.15 Rigorous Diagnostics – How are we going?

10.15-10.30 Morning Tea

10.30-12.00 Working with groups

Project Plans

Constraints Theory

Prioritising Innovations

12.00-12.30 Lunch

Aim of the rigorous diagnostic phase

Overall aims• Identify constraints across the patient journey• Engage key staff in the process ready to

implement change• Find any myths

Rigorous Diagnostic phase

Elements of the diagnostic Elements of the diagnostic packpack

• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative

involvement tools• Innovation intensive tool

Program Measures Program Measures

• Patient Journey Time in ED (SPC chart)• Percentage and Number of ED Admissions waiting <12 hrs (SPC chart)• Percentage of ED Throughput <6hrs (SPC chart)• Patient Journey Time on Waiting List (SPC chart)• Patient Waiting Times for Admitted Patients from Waiting List (Pareto

chart)• Hospital Initiated Postponements per 100 Admissions (Line chart)• Average Admissions & Discharges by day of week (Bar chart)• Length of Stay – Medical/Surgical/Other (Pareto chart)• Number of Unplanned Readmissions within 28 days by day (SPC chart)

Patient Patient Journey Time in ED Journey Time in ED - All Presentations Chart (mth)- All Presentations Chart (mth)

Within the month of Nov03 patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 1287mins with an average of 356mins.

Percentage of ED Admissions waiting <12 hours Percentage of ED Admissions waiting <12 hours - Chart- Chart

For the period Jul03 to Feb04 between 59% and 86% of ED patients waiting for admission to a ward could expect to wait less than 12hrs.

The average number of patients admitted within 12hrs per week was 73%, with a target of 95%.

Number of ED Admissions waiting <12 hours Number of ED Admissions waiting <12 hours - Chart- Chart

For the period Jul03 to Feb04 between 134 and 252 of ED patients waiting for admission to a ward could expect to wait less than 12hrs.

The average number of patients admitted within 12hrs per week was 193.

Percentage of ED Throughput <6hrs Percentage of ED Throughput <6hrs - Chart- Chart

For the period Jul03 to Feb04 between 59% and 76% of ED patients waiting (I.e. from Arrival datetime to Departure datetime) could expect to wait less than 6hrs.

The average number of patients waiting less than 6hrs per week was 76%, with a goal of 100%.

Patient Journey Time for Admitted Patients Patient Journey Time for Admitted Patients on Waiting Liston Waiting List

- Chart (Cat1)- Chart (Cat1)

Within the month of Jul03 Category 1 Patients admitted from the waiting list could expect to have a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 52days with an average of 19days. Note: Median waiting time would be 13days.

Within the month of Jul03 Category 2 Patients admitted from the waiting list could expect to have a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 300days with an average of 86days.

Within the month of Jul03 Category 3 Patients admitted from the waiting list could expect to have a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 883days with an average of 229days.

Patient Waiting Times for Admitted Patients Patient Waiting Times for Admitted Patients from Waiting Listfrom Waiting List

- Chart- Chart

80% of admitted patients from the waiting list for the 02-03 financial year had a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 103 days with a maximum waiting time of 1504 days.

HHospital Initiated Postponementsospital Initiated Postponements per 100 Admissions per 100 Admissions - Chart- Chart

Hospital Initiated Postponements reporting methodology = The number of cumulated postponements over the entire patient waiting time, reported on the month of admission.

Average Admissions & Discharges by DOW Average Admissions & Discharges by DOW

- Chart- Chart

The highest average admissions for Multiday patients occur on Mon (79), and the highest average discharges occur on Fri (83). The lowest average admissions and discharges very clearly occur on the weekend. These numbers exclude Sameday admissions and discharges.

Length of Stay (Total) Length of Stay (Total) - Chart- Chart

Length of Stay (Medical) Length of Stay (Medical) - Chart- Chart

Length of Stay (Surgical) Length of Stay (Surgical) - Chart- Chart

Length of Stay (Other)Length of Stay (Other)- Chart- Chart

Number of Unplanned Readmissions within Number of Unplanned Readmissions within 28 days28 days- Chart - Chart

For the period Jul03 to Feb04 we could expect to see between 0 and 39 unplanned readmissions within 28days of discharge.

The average number of patients with an unplanned readmission within 28days is 18

Percentage of ED Admissions waiting <12 hours Percentage of ED Admissions waiting <12 hours - Chart- Chart

For the period Jul03 to Feb04 between 59% and 86% of ED patients waiting for admission to a ward could expect to wait less than 12hrs.

The average number of patients admitted within 12hrs per week was 73%, with a target of 95%.

Sampling toolSampling tool

• Two clinical areas minimum• Request staff to identify key delays• Chart delays for each patient each day• Total at end of time period

ExampleExamplePILOT EXAMPLE Example of creation and process of delay tally chart

Surgical ward identified delays total numbers – Example

Day No clear

care plan Awaiting tests: MRI, CT, Bone scans

No planned discharge date

Home unit not reviewed

Boarder- not seen x unit before 0900 bed meeting

Late decision to discharge

Waiting for assessment

Waiting for ACAT referral

Waiting for rehab bed

Waiting for review by other unit

Waiting acute bed at another hospital

No weekend discharge plan so covering RMO says no

Monday 5 1 3 0 0 0 1 1 0 0 1 0 0

Tuesday 3 3 1 0 2 2 2 0 0 0 0 0 0

Wednesday 11 4 2 1 1 1 1 0 0 1 0 0 0

Thursday 6 3 0 0 1 1 2 0 0 1 2 0 0

Friday 9 4 0 0 1 1 1 0 0 1 1 0 0

Sunday 8 1 0 0 2 2 0 0 0 0 1 0 0

Monday 8 5 0 12 2 2 0 1 0 1 3 0 0

Tuesday 4 6 1 12 1 1 0 0 2 1 1 0 0

Wednesday 11 5 2 0 0 0 0 1 2 0 0 0 0

Thursday 10 2 3 3 1 1 1 1 2 0 0 0 0

Friday 1 3 0 0 0 0 0 1 2 1 0 0 0

Saturday 0 1 0 0 0 0 0 2 1 1 0 0 0

Sunday 6 4 3 0 0 0 0 2 0 0 0 0 0

Monday 2 4 4 0 2 2 1 1 0 1 0 0 0

Tuesday 9 7 3 0 1 1 1 0 0 1 0 0 0

Total 93 53 22 28 14 14 10 10 9 9 9 0 0

Brainstorm toolBrainstorm tool

• Brainstorm the delays that effect your patients

Brainstorming toolBrainstorming toolBrainstorm Whole system constraints tool

Order of

constraint

Description of constraint

Effect on majority or

minority of total points

Key Minority – small number of patients affected Majority – majority of patients affected

Process mapping toolProcess mapping tool

Map minimum of two whole system patient journeys

Elective Admission to DischargeEmergency Admission to Discharge

Surgical Process Map Surgical Process Map Fractured Neck of FemurFractured Neck of Femur

85 yr old woman lives aloneDaughter & Son

Home HelpMeals Services

Diabetic (Public patient)

Found by Home Helpin the bathroom

on the floor

Supervisor travelsto the home

location

Ambulance rungby Supervisor

Home HelpContact Supervisor

Ambulance Arrives

Triage•Ambulatory Services•Information to Nurses•Assign Category

* Issue

Ambulance flowdirection

Patient transferred intothe ambulance

HospitalEmergency Dept.

Clerical Registrationfrom RELS / PT / AMB running sheet/transfer letter

History & labelsgenerated

History & Labels transported to the cubicle area

Nurses / CC contactrelatives (or patientliaison nurse)

Patient moves toa cubicle

Handover Ambulance Cubicle Nurse Staff

Patient moved from trolley cubicle bed

AMB/ Nurse/ PAC

Medical staffpick up patient

care fromcomputer system

Medical Officerassigned and Nursingcare commenced

RIV by ED DR& assess – physical

Transported to X-Ray

Bed Managerallocates a bed – contact wardupdated HAS

HAS Request for a bed lodged

Patient have X-RayTaken in Plain Film

X-RayFill in slips

X-Ray slip -manualWalk to slot to queue

Radiographerprioritises requests andassigns categories

Patient transportedBack to ED cubicle

Interim Rx Plan Written

Analgesia andGen. Nurse Careand Relatives in.

Nurse Initiated Analgesia

Commenced IV cann.ECG / Bloods

RIV by careCo-coordinatorNurse Risk assessment

Ward rings Bed Manager.Notifying Bed

available

Ward contact time negotiated to transfer the patient to theward

Referral to receiving Orthopaedic UnitRegistrar

Paged by ED DR

Wait for response

ED DRR/V’s X-Rays

Diagnosisconfirmed# NOF

Control Clerk calls for EDA totransport patientX-Ray

Bloods sent to labsvia centraldistribution area(shute)

BloodsFill in slips

Basic protocol forcare commenced

* Radiographer ring ED/page/loud speaker requestTransport of patient

Policy &Procedures Myths

3½-4 hrs

* myth

ED + /

Theatre process

Patient still waitingFor

Ortho UnitRIV

Clinical Co-coordinator

Arranges EDN to transport patient

Ortho RIVUndertaken

Clinical Co-coordinatorHandovers viaPhone to ward

Exit ChecklistDone by Nurse

Checked byCl. Co-coordinator

Patient R/V’dBy medical

Arrives to wardAnd transferred

To bed

Patient preparedFor transferto the ward.

Patient moved to The ward

Notes/X-Ray/ Exit Checklist Ortho Unit

Contact TheatreTo make a booking

Rx Plan written

Histories

Filing

Investigation

Check IV(EDA/NurseTransport)

By who Ward Documentation

And ExpectedL.O.S.

AssessmentNursing•Obs•Anal•Risks

Medical RegistrationAuto. RIV’s

Ortho patients

8-10 hrs

48 hrs

52 hrs

Patient transferredto ward

Anaesthetist RIV’spatient night prior

Patient has furthermedical investigations

done to her

Patient consented for theatre

Patient transferredto theatre

Further medicalinvestigations ordered and

Ward round every day

Patient waitingtill theatre time

Patient medically fit

Post op care per Care Plan

Discharge planX 2 weekly reviews

Referral sits inTrack officefor Triage

Aged CareRehab

Consultantsdecide

Care Plan

Patient StandbyPhysio

and O.T.

Electronic Referral

To rehab. ByDr.

3-4 days waiting Ref/RIV)

(Rest waits for a bed)

Discharged To Rehab

days – 2

Theatre

Patient,carer and relative Patient,carer and relative involvementinvolvement

• Small test cycles to gain consumer input

• Use the tools one to one with patients

Intensive innovation toolIntensive innovation tool

• Pre-plan 6 weeks in advance• One day event for individual health

service• Book early!• Not needed for completing the rigorous

diagnostic phase

Completion of diagnostic Completion of diagnostic phase phase

• Review all of the 5 tools together and priorities the constraints that are causing the most disruption to the larges patient group.

• Identify the clinical area team that is needed to carry forward the innovations from the diagnostics

Review meetingReview meeting

• Collaborative team wish to be involved • Feedback at the first learning session

Handy hintsHandy hints

• Share the work • Gain as many views as you can• Use this phase to find the constraints

and test assumptions• Enjoy the focus on patient process• Have fun

How are you going?Questions?

Morning Tea

Working with GroupsWorking with GroupsAims of the sessionAims of the session

• To help to prepare for group meetings

• Be aware of what facilitation skills to use and when

• Examine your own communication style, and understand personal communication preferences

Think of a group you enjoyed Think of a group you enjoyed and did not enjoyand did not enjoy

A group you enjoyed

What made you enjoy it?

What made you not enjoy it

A group you did not enjoy

In an effective groupIn an effective group

• Clarity• Informal• Everyone participates• Everyone listens• Free expression• Free disagreement• Decisions - consensus

In an in-effective groupIn an in-effective group

• Dominated by few• Never hear ideas, comments• Real agenda lost• No follow up actions

Stages for group Stages for group developmentdevelopment

Forming Storming Norming Performing Adjourning

FORMINGFORMING

• Effort in defining goals• Sizing up• Keep feelings to themselves• Very polite• Aware of boundaries and hierarchies

STORMINGSTORMING

• Questions – who is responsible for what, leadership, goals, directions

• Jockeying for position• Withdrawal – if values not aligned

NORMINGNORMING

• Acceptance• Ground rules are set• Difference is valued• Everyone belongs

PerformingPerforming

• Effective• Efficient• Learning – collective and individual• “Less me – more we”

AdjourningAdjourning

• End of project• Well defined• Mainstreaming plans set• Sustainability of efforts• Mourning/ celebration

FacilitatingFacilitating

EXPLORE ACTION

learning agreementsperspectives decisionsoptionsexperience

What facilitation style?What facilitation style?

• doing nothing

Gentle • silence

Intervention • support

Supportive • questions to clarify

• questions to move

• suggesting choices

Persuasive • suggesting paths

Forceful • sharing ideas

Intervention • suggesting actions Directive • guidance

• choosing for the group • directing

Communication StylesCommunication Styles

• Adapt and flex your style• What is your style?• Over to you!

SummarySummary

• A snapshot of working with groups• Key players • Be aware of human dimensions• Future Learning Sessions &

communications

Project Plans 5-11

Apr12-18Apr

19-25Apr

26-2Apr/May

3-9May

10-16May

17-23May

24-30May

31-6Jun

7-13Jun

14-20Jun

21-27Jun

Process mapping

Sample data

Patient carer involvement

Brainstorm session

Review program measures

Book site visit with CIA team

Display for Learning session 6/7 July 2004

Presentation for Learning Session 6/7 July 2004

Organisational Rigorous Organisational Rigorous DiagnosticsDiagnostics

Step 1

Step 2

Step 3

Step 5

Case Study – constraint data

Clinical area- diagnostics and innovation

Back to the Beginning

Organisational wide- diagnostics

Clinical Stream data

Step 4

Process complexity and implementation indexProcess complexity and implementation index

Low Medium HighP

Possible

Don’t do

Process Complexity IndexIm

FinancialFinancial improvement matrix improvement matrix

High Medium lowP

asy Key

2nd stage

Cost savingIm

Theory of ConstraintsTheory of Constraints

• Step 1 -Identify the constraint• Step 2 -Exploit the bottleneck• Step 3 -Subordinate everything else

to the bottleneck• Step 4 -Elevate constraint - bring in

extra capacity• Step 5 -Once bottleneck solved, look

for the next bottleneck in the system

Model for ImprovementModel for Improvement

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is improvement?

What change can we make that will result in

improvement?

Adopter CategorisationAdopter Categorisation

Innovators

EarlyAdopters

EarlyMajority

LateMajority ‘Rear guard’

Source: Rogers

2.5% 13.5% 34% 34% 16%

Questions?

Department of Human Services Patient Flow Collaborative Lee Martin Collaborative Director Welcome...

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