als3_jan19_pres.ppt

Department of Human Services

Patient Flow CollaborativeAction Learning Session No 3

January 19th , 2005Western Hospital

Chair for the day – Jannie Selvidge

WelcomeWelcome

Today is an opportunity for further;• Sharing of ideas and discussion

• Networking

• Challenging yourselves and each other

• Support to keep going

HousekeepingHousekeeping

• Phones and pagers

• Delegate packs

• Lunch will be served (12:00 – 12:45)

• Rest rooms

AgendaAgenda

9.45 – 10.15 Western Health Megan Bumpstead

Scheduling elective patients

10.15 – 10.45 Southern Health Lesley Dwyer and Elective surgery planning Shannon Wight

10.45 – 11.00 Morning Tea

11.00 – 12.00 Discussion Time Lee Martin and - Access Toolkits

- LOS Hot topic callsRochelle Condon

AgendaAgenda12.00 – 12.45 Lunch

12.45 – 13.15 Maroondah Hospital Dominique Leyden

Ward realignment

13.15 – 13.45 Emergency Department Lee Martin and Data analysis Prue Beams

13.45 – 14.15 Melbourne Health Marcus Kennedy Pilot site update

14.15 – 14.45 Melbourne Health David Smallwood

Improving Communication

AgendaAgenda14.45 – 15.00 Afternoon Tea

15.00 – 16.00 Team Clusters PFC Leads

- Learning Session 3 Agenda

16.00 Close


Western HealthScheduling Elective Patients

Meg BumpsteadDivision of SurgeryWestern Health

Waiting List SchedulingWaiting List Scheduling

Current Issues• Duplication of work• No knowledge transfer• Missed equipment/ prosthesis needs• Difficult to pull pts in waiting order• Difficult to fully utilise lists• Patients booked minimal consultation


Interim Improvement Plan• Microsoft Outlook Diaries

– Off site access to schedule for Surgeons– Access from NUM to theatre schedule– Still duplication

Waiting List Scheduling Waiting List Scheduling


Long term solutions• DHS secondment – Simon Jolly • Development of IT based scheduling

tool


ImprovementsImprovements

• New Schedule will “talk” to PAS• Upper level schedule for Theatres• Individual Surgeon lists available off site• Ready reckoner for Equipment/

Prosthesis requirements

Booking ProcessesBooking Processes

Improvements to Date• Minimal Cancellation• No booking without unit consultation• Development new RFA – endoscopy• Development new RFA - theatre

Questions

?


Southern HealthElective surgery planning

Lesley DwyerAndShannon WightSouthern Health

QUEUING EQUITY PROJECTQUEUING EQUITY PROJECT

ESSENTIAL CRITERIA1. To reduce the average waiting time for Category 2 Pt’s on MMC,

Clayton Waiting List. Actual 192 days KPI 173 days.2. To treat the tail-ending patients – queuing equity.3. In order to address a Waiting List Strategy – we need to start the ball

rolling from “somewhere”

PROCESS1. Based on the volume of Theatre sessions and number of Category 2

Tail-ending patients.2. Even distribution across Weekly Theatre Schedule.3. Pre-Admission Clinic Collaboration4. Clear communication with Surgical Registrars & support from

Surgical Heads of Unit.5. Awareness in Bed Bureau/Access Unit of Patient Urgency as to pt

identification on Elective Admission List.

QUEUING EQUITY PROJECTQUEUING EQUITY PROJECT

MEASURES

1. Access to Acute Bed2. Cancellation Rate (HIP)3. Visible reduction in average waiting time for Category 2 Patients.4. Patient Satisfaction5. Sustainable change to Monash Medical Centre. 05/06 Financial Year.

Elective Theatre Access Elective Theatre Access Management – List ConstructionManagement – List Construction

• Problem “living within our means”

Emergency WIES close to target BUT Elective WIES ahead of target in both waiting list electives and non-waiting list (other).MMC has the following profile:

70% Emergency30% Elective

10% waiting list20% other eg Gastroenterology


• Proposal• Develop Strategies that reduce WIES but still

deliver waiting list targets!• Ambitious target• Start date NOW!

• List Construction Project• GO LIVE FEBRUARY• What are the elements of this project?


• Key elements of Project• Resource appropriately – form a “can-do” group• Look for and incorporate “levers” eg ESAS non

conformers, capacity at other sites.• Remain true to objective – don’t cut across other

initiatives rather use them to ensure outcomes are met eg Queuing Equity Project


• Develop a rationale – quasi but importantFormula:

Emergency WIES + Cat 1 + Maternity = XLess

Target = YAvailable Cat 2’s, Cat 3’s, Non W/L Z•Z is calculated and distributed equitably

across surgical units cognisant of demand pressures and waiting list targets


• What might this look like?– Typical list

• Cat 1 and/or Emergency• Long Wait Cat 2’s – tails• Long Wait Cat 3

• How do we support clinicians?– Develop guidelines for booking – work with

their special needs– Give information – Monitor progress and report back regularly


• Why are we “picking on” surgical units when they are only a small part of the problem?

• We are not - similar strategies will be developed for “other”

Morning Tea Morning Tea –meet us back –meet us back here at 11amhere at 11am


Discussion Access Toolkits and LOS Innovations

Lee MartinManager, CIACollaborative Director

Access ToolkitAccess Toolkit

• System wide Toolkit

• LOS Innovations – access toolkit

Lunch Lunch –meet us back here at 12.45–meet us back here at 12.45


Maroondah Hospital Ward realignment

Dominique LeydenPatient Flow Coordinator


Maroondah Hospital

Dominique Leyden – Project FacilitatorInnovations to Improve Patient Flow in the Area of Bed Management

Background Background – Why Bed – Why Bed Management?Management?

Rigorous diagnostics in phase 1 of patient flow collaborative identified our top three organisational constraints to be;

1. Theatre utilization - high HIP rate2. Ward bed availability ( bed management)

- Admission delays for elective surgery, - Admission delays from ED

(Unable to meet 12 hour targets)

3. Acute/Sub Acute transition - Delayed access to NH and rehab beds

MethodologyMethodology

• Repeat ward sample data collection

Include all 5 acute ward areas

• Conduct a brainstorming session• Map a medical unit ward round• Map the bed manager for a day

Results: Results: Ward Sample DataWard Sample Data

REASONS FOR DELAYS TO A PATIENT JOURNEY THROUGH WARDS

Ward sample data collected August 9th to 22nd on all five acute wards at Maroondah Hospital Number Reason for delay Number of

occurrences

1 Waiting for N/H or interim care bed 101

2 Waiting for Rehab bed 84

3 Waiting for medical review 75

4. Waiting for Allied Health review 32

5. Waiting for medical staff to write up discharge summaries and medications

27

6. Waiting for ACAS 15

7. No clear plan of care 14

ResultsResults – Brainstorming – Brainstorming SessionSession

Set up to look at two key areas:

• Delays caused by waiting for medical staff to review patients and do discharge paperwork

• Delays associated with waiting for allied health review

Results; Results; BrainstormingBrainstorming

Multi disciplinary team identified that;

• Medicine functions independently of and separate to nursing and allied health,

• Little consultation between disciplines

OutcomeOutcome

An identified need within the organisation to change the current bed allocation process and move towards developing a ward based medical and allied health structure

Current Bed Allocation Current Bed Allocation ModelModel

1 NORTH25 beds

1 SOUTH30 beds

2 SOUTH30 beds

2 NORTH25 beds

1EAST

24 beds

3 EAST

30 bedsMed 1 1 4 3 9

o Endocrinology Med 2 1 4 4 2 8

o Oncology 1 1 4 1 o Haematology Med 3 1 2 1 2 4

o Cardiology 3 1 o Respiratory 1 2 Med 4 1 2 4 7

o Gastro o Infectious Diseases ACE Unit 1 9 1

Surg Unit 1 7 6 o Thoracic 1

Surg Unit 2 1 7 9 Orthopaedic Unit 17 6 Plastics 1 5 Urology 2 GEM 24 Estimated Medical Staff involved in patient care(Excludes Consultants & referrals)

24

22

23

16

2

14

Projected BenefitsProjected Benefits

•Reduced LOS

•Reduced 12 hour stays in ED

• Improved median discharge time

Proposed ModelProposed Model

1 SOUTH30

Beds

1 NORTH24

Beds

2 NORTH32

Beds

2 SOUTH30

Beds

1 EAST 23 BEDS

3 EAST25

Beds

Medical Unit 1 GEM Unit Medical Unit 4 Medical Unit 4 Surgical Unit 1

Orthopaedic Unit

Endocrinology Gastro Medical Unit 2 ThoracicSurgery

ACE Unit Medical Unit 3 Oncology Surgical Unit 2

Cardiology Haematology Plastics

Respiratory Urology

Estimated Medical Staff involved in patient care (Excludes Consultants & referrals)

5

2

6

7

9

5

Typical day – Current model of allocation – medical staff numbers (Excludes Consultants & referrals)

3 East 14

GEM 2

2 North 16

2 South 23

1 South

22

1 North 24

Project OutlineProject Outline

• Communication and consultation process Nov 4 – 25 2004

• Ward moves Dec 30 – 31st 2004

Phase OnePhase One

1 SOUTH30

Beds

1 NORTH25

Beds

2 NORTH32 Beds

2 SOUTH30 Beds

1 EAST 23 BEDS

3 EAST24

Beds

Medical Unit 1 Orthopaedic Unit

Medical Unit 4 Medical Unit 4 Surgical Unit 1

GEM




Respiratory Urology

Transit Lounge.


5

5

6

7

9

2


3 East 14

1 North 24

2 North 16

2 South 23

1 South

22

GEM - 2

Phase TwoPhase Two

1 SOUTH30

Beds

1 NORTH24

Beds

2 NORTH32 Beds

2 SOUTH30 Beds

1 EAST 23 BEDS

3 EAST25

Beds

Medical Unit 1 GEM Medical Unit 4 Medical Unit 4 Surgical Unit 1

Orthopaedic




Respiratory Urology

Transit Lounge.


5

2

6

7

9

5


3 East 14

Gem - 2

2 North 16

2 South 23

1 South

22

1 North 24

SuccessesSuccesses

• Hospital maintained capacity• 12 hour ED targets met• Emergency surgery continued• No patient/relatives complained!

Questions?Questions?

?


Emergency DepartmentData Analysis

Lee MartinDirector Patient Flow Collaborative&Prue BeamsData Consultant

Clinical StreamsClinical StreamsTriage Cat1 (Resuscitation)Triage Cat1 (Resuscitation)

Patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 1228mins with a mean of 88mins.

Clinical StreamsClinical Streams - Triage Cat2 (Emergency)- Triage Cat2 (Emergency)


Clinical StreamsClinical Streams - Triage Cat3 (Urgent)- Triage Cat3 (Urgent)


Clinical StreamsClinical Streams - Triage Cat4 (Semi Urgent)- Triage Cat4 (Semi Urgent)


Clinical StreamsClinical Streams - Triage Cat5 (Non Urgent)- Triage Cat5 (Non Urgent)


Patient Journey Times in ED by Triage CatPatient Journey Times in ED by Triage Cat- Summary table- Summary table

Patient Journey Times in ED by Triage CatPatient Journey Times in ED by Triage Cat- Summary table- Summary table

ED Presentations by Diagnosis (Top 25)ED Presentations by Diagnosis (Top 25)

* Complete list available on request

ED Presentations by Diagnosis (Top 25)ED Presentations by Diagnosis (Top 25)- Only patients > Upper Limit (1,007mins)- Only patients > Upper Limit (1,007mins)

* Complete list available on request

Time of Presentation to ED by Hour of ArrivalTime of Presentation to ED by Hour of Arrival

ED Median/Mean Length of StayED Median/Mean Length of Stay- Admitted v Discharged streams- Admitted v Discharged streams

ED Median Length of StayED Median Length of Stay- Admitted v Discharged streams- Admitted v Discharged streams

ED Length of Stay SummaryED Length of Stay Summary- Time bands- Time bands


Melbourne HealthPilot Site Update

Marcus KennedyClinical Lead, Patient Flow Collaborative

Bed availability coordination Bed availability coordination groupgroup

• Bed management has been organizationally restructured within the operational stream, and work is advanced in development of an electronic bed management and patient tracking system.

• The organizational admission and access policy has been redrafted and is under executive review. This process clarifies and streamlines access routes and their management.

Clinician communication Clinician communication coordination groupcoordination group

• This group has actively engaged clinical staff at all levels.

• Specific work has occurred in relation to: – time of day of discharge,– investigation services prioritization of access for

discharge patients, – improved electronic referral and rostering

systems, – weekly review and – audit of discharge practices.

Operating Theatre coordination Operating Theatre coordination groupgroup

• This group has developed – an online emergency booking system, and – improved systems of flow within the OR to reduce

delays in start times. – A number of recovery room strategies to minimize

exit block from recovery have been implemented. • Melbourne Health has recently made

available an emergency operating theatre, and

• Opened day procedural facilities that increase capacity.

Subacute and rehab coordination Subacute and rehab coordination groupgroup

• This work group has performed major work to redefine the model of care in subacute services.

• Major changes have occurred with implementation of– an improved bed management and access

system, – improved relationships and patient flow systems

between the acute and subacute campuses, and – improvements to patient length of stay.

Radiology coordination groupRadiology coordination group

• Specific process improvements have occurred in this area with regard to weekend transport issue for patients requiring medical imaging. This has impacted length of stay for many patients.

• Improved reporting systems have meant availability of reports in a more timely fashion.

• Improvement opportunities for patient access, queue management and flow systems remain in this area.

Emergency Flow GroupEmergency Flow Group

• A web based patient status tracking system has been developed which is viewed on wards and other areas, to encourage pull strategies for patient movement out of ED.

• This is linked to action cards and supported by the access policy (under revision).

• ED processes of care have been reviewed, and innovative streaming systems are being implemented.

Impact of Changes at Melbourne Impact of Changes at Melbourne HealthHealth

• Through December 2004 and January 2005, objective evidence of impacts is starting to be realised.

• Length of stay in subacute areas has decreased significantly

• Elective surgery access has been maintained, and activity increased in December

• Cancellations of elective work due to bed unavailable have decreased

Ambulance bypass rates have Ambulance bypass rates have decreased dramaticallydecreased dramatically

Ambulance Bypass

1120

9 612 14

4 27 7 5

13

41

19

40

27

6 20

1020304050

Patient flow through emergency Patient flow through emergency has improved dramaticallyhas improved dramatically

% Emergency Patients Admitted < 12 hours

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Upper Control Limit (+3SD)

Lower Control Limit (-3SD)

Mean

?Sustainability?Sustainability

• The improvements in these measures (over several measurement periods) suggest that the gains may be sustainable.

• The quantum of the change in particular in the “% admitted less than 12 hours” indicator is suggestive of major and fundamental system change. – In this measure, the performance has crossed the

upper control limit in the statistical process control chart for the parameter.


Melbourne HealthImproving Clinical Communication

Dr David Smallwood

Clinical Communication Working PartyClinical Communication Working Party

BackgroundBackground• The rigorous diagnostics phase identified

constraints in patient flow due to:– Poor communication within and between units– Inconsistent admission and discharge

processes– Ward round practices (senior and junior staff)– Problematic staff rosters (updated list)– Units being unavailable for referrals


Key ActionsKey Actions

•Clinician communication survey

•Discharge ward rounds


Clinical Communication SurveyClinical Communication Survey

Audit of all Unit heads, Nurse Unit Managers and Senior Registrars with the aim:

• Establish an awareness of PFC• Establish an understanding of existing

processes.• Identify problematic areas.• Gain feedback from participants.


Clinical Communication SurveyClinical Communication Survey

• Key Findings:

- Irregular timing of ward rounds.- No communication process to notify timing of ward rounds.- Inconsistent after hour/weekend processes.- Varied methods of communication between senior and

junior staff.- Minimal nurse & allied health attendance on ward rounds.- Varied patient decision making processes.- Lack of understanding/existence of admission policy.


RecommendationsRecommendations

WARD ROUNDS• Published schedule • Additional consultant input on weekend ward

rounds. • Multidisciplinary attendance. • Time efficiency eg. pre-ward round debriefs. • Criteria initiated discharge.

– Less reliance on consultant review.– Nurse initiated.



DISCHARGE PLANNING• Educate junior doctors about day prior discharge

planning and re-enforce the benefits of this discharge process to senior doctors.

• Prioritize patients who could potentially be discharged and assess them earlier so that discharge processes can begin as soon as possible e.g. clerical duties

• Priority X-rays and bloods in am



ROSTER AVAILABILITY• An up-to-date medical roster which is accessible to all staff

at all times. WEB BASEDRegistrar availability for emergency contact.

REFERRAL PROCESSES• Develop project dimensions and strengthen work towards

the establishment of an ‘e-referral’ system.

• Discharge reviews:– 51% (53) reviewed Monday discharges out of

103 patients over two weeks.– Median discharge time of reviewed patient

histories: 1500 hours– Median discharge times of all patients

discharged on these two days: 1430 hours


Discharge Ward RoundsDischarge Ward Rounds



Discharge times

0

2

4

6

8

10

12

14

1 2 3 7 9 10 11 12 13 14 15 16 17 18 19 20



• Weekly ward round• Varied wards,• Helpful ‘Magic Wand’ approach• Participants include:– Senior Doctor (rotate between Gen Med, Surgery & ED)– Registrar – PFC coordinator– Bed Management– Occasional Executive representative



Key reasons for delays:

• Time of notification of patient transfer.• Time of/ waiting for ward round review.• Waiting on transport.• Inadequate documentation (e.g.discharge summary).• Waiting on results.• Delay in specialist unit review.• Transit lounge- use & availability• Boarders• Discharge time entry (electronic)• Poor communication eg family


Positive ImpactsPositive Impacts

• Increased awareness.• Clarification of existing processes.• Increased Patient Flow Collaborative profile.• Encourages input from staff re improvements.• Communication between clinical staff.• More timely discharges• Nursing initiated action sheets


Positive ImpactsPositive Impacts

0

2

4

6

8

10

12

14

08 09 10 11 12 13 14 15 16 17 18 19 20 21

25/10/2004 08/11/2004 07/12/2004 15/12/2004

Median discharge time for October 1300 hoursMedian discharge time for 15th Dec 1200Avg discharges are 50 - 60 per day

Discussion and challengesDiscussion and challenges

• Engagement of senior medical staff• Maintaining momentum/awareness

•All clinicians• Creating new processes that do not rely in any one person

Afternoon Tea Afternoon Tea –meet us back –meet us back here at 3pmhere at 3pm


Team Clusters

Lee Martin and PFC Leads

ClustersClusters

• LS3 Agenda and preparation

• Involving your team

– Who do you want to network with at LS3?

– Who do people in your team need to meet at LS3?

• Communication plans

– How are you using your communication strategy?

• Future events- newsletter

• Evaluation forms

SummarySummary

• Registrations for LS3 due 17th January

• Keep marketing your achievements- present to your CEO where possible

• Continue to engage and influence widely

• Keep Going…..

Have a safe trip home

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