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Perfecting Healthcare Delivery The Maggie Program It’s time for a better system Delivering High Quality Patient Care March 2004
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Perfecting Healthcare Delivery
The Maggie Program
It’s time for a better system
Delivering High Quality Patient Care
March 2004
The Maggie Program
About Hunter Health
• Provides public health services in Hunter region, NSW
– Hospital and community based services
– Population health and research
– Businesses provide pathology, imaging & catering services
• 550,000 people, 11 local council areas, 25,000sq km.
• Largest employer in region – over 9,000 staff
• Major referral centre for Northern NSW
– only children’s hospital, child and adolescent mental health unit and neonatal intensive care unit outside Sydney,
– busiest emergency department and trauma centre in NSW
– Major cancer, cardiothoracic and renal service in northern NSW
The Maggie Program
What is PHD? – “The Maggie Program”
• A program of major change – commenced May 2002
• A philosophy/approach to providing care – rather than a series of projects
• Patient perspective paramount
• Simplify systems – remove complexity and duplication
• Has full support of Hunter Health Board
The Maggie Program
Let me tell you a story about a woman called Maggie
• 87 yr old Italian widow• Fell in a hostel after angina attack. Broke hip.• Long wait in Emergency - 15 hours.
• Multiple complications not diagnosed quickly.
• Spent time in Emergency Dept and 6 wards. 2 trips to the operating theatre, treated by 7 specialist teams.
• Orthopaedic Team not advised of deterioration or transfers. Geriatric Team introduced late.
• Home after 53 days
There has to be a better system!
The Maggie Program
How will we achieve our Vision?
• Walk Maggie through major systems
– from leaving home to returning home
– including interfaces between hospital, GP, community, health support at home
• Redesign systems - make them simple
• Ask questions of all our services - frontline clinical, support, and administrative:– What do we need to change to make the experience better
for the patient and their family/carer?– What do we need to change to make work more satisfying
for staff?
The Maggie Program
PHD projects comprise six main stages, and may span from 4 to 20 weeks
Communication and Change Management
Program Management
Project Timeline
Phase 2: Rollout
Operations
Review Processes
Reengineering
Organisation Redesign
Dev. Imp.
Plan
Re-align Infrastructure
17 Mar17 Feb
14 Apr 12 May 4 July9 June
Sta
rt-up
1
1 2 3 4
5
6
Phase1: Business Diagnostic & Conceptual DesignPhase1: Business Diagnostic & Conceptual Design INDICATIVE
Project Approach
The Maggie Program
Systemic Dependencies
Common Symptoms
• High wait times – grid lock
• Delays in Ambulance offload
• Access block/ bypass
• Fragmented roles
• Low patient / staff satisfaction
• Bad press
3. Access Block (% Not Admitted within 8 Hours of Being Seen by a Doctor)
0
10
20
30
40
50
Per
cen
t n
ot
adm
itte
d w
ith
in 8
hrs
The Maggie Program
Systemic Dependencies
EmergencyDept
Front Door Inpatients Community
Pre AdmitClinic
Self Presents
SpecialistRooms
GP
CommHealth
Ambulance
FRONT DOOR PROBLEMS
• 15-25% of patients could be seen by GP
• Lack of after hour services• Frequent Flyers• District hospital patients at
tertiary
The Maggie Program
Systemic Dependencies
EmergencyDept
Front Door Inpatients Community
Pre AdmitClinic
Self Presents
SpecialistRooms
GP
CommHealth
Ambulance
AdmitOffice
Day Proc
OperatingTheatre
Intensive Care
Clinical Support – Allied Health, Pharmacy
Diagnostic Support – Pathology, Imaging, etc
Hotel Services – Housekeeping, Food Services
Inpatient Wards
ED / WARD HANDOVER PROBLEMS
• Unclear admit protocols • Slow response - Inpatient clinical teams• Lack of a house-wide bed management• Bed outliers
ON THE WARD PROBLEMS
• Delays in assigning preliminary dates of discharge
• Complex patients - narrowly defined specialities
• Lack of coordinated discharge planning
• Poor coordination with diagnostic, pharmacy, allied health
The Maggie Program
Systemic Dependencies
EmergencyDept
Self Presents
SpecialistRooms
GP
CommHealth
Ambulance
Front Door
AdmitOffice
Pre AdmitClinic
Day Proc
OperatingTheatre
Intensive Care
Inpatient Wards
Clinical Support – Allied Health, Pharmacy
Diagnostic Support – Pathology, Imaging, etc
Hotel Services – Housekeeping, Food Services
Inpatients Community
PatientDies
Patient Referred
PatientHome
Rehab
SpecialistRooms
GP
CommHealth
OutpatientClinic
NursingHome
BACK DOOR PROBLEMS • Lack of nursing home,
rehab, home care services
• Uncoordinated community services
• Lack of coordination acute to community
The Maggie Program
Typical problems – Process and organisation fragmentation
Medical ClericalNursing/ Wardspersons/
Housekeeping AmbulanceMedical ClericalNursing/ Wardspersons/
Housekeeping Ambulance
• Narrowly defined roles
• Separate handovers
• Separate care plans
• Ad hoc coordination with wardsmen delayed patient admission
• Clerical staff felt isolated
• Professional silos driving “us and them” environment
• Point of management integration at service manager level
• No role looking after overall patient flows
ProcessingProcessing
Management and rosteringClerical Staff
Handover Care deliveryHandover Patient Transport Care delivery
Management and rosteringAmbulance Officers
Handover Care planning Care deliveryHandover Care planning
Management and rosteringMedical Staff
Handover Care deliveryHandover Care planning Care delivery
Management and rosteringNursing Staff
Handover Prioritisation Multiple TasksHandover Prioritisation
Management and rosteringWardsmen
ProcessingProcessing
Management and rosteringClerical Staff
Handover Care deliveryHandover Patient Transport Care delivery
Management and rosteringAmbulance Officers
Handover Care planning Care deliveryHandover Care planning
Management and rosteringMedical Staff
Handover Care deliveryHandover Care planning Care delivery
Management and rosteringNursing Staff
Handover Prioritisation Multiple TasksHandover Prioritisation
Management and rosteringWardsmen
The Maggie Program
• Often success at getting beds is based more on "who you know" than following procedures - - A&E Registrar
• “We’re in crisis mode everyday. It’s reactive. There is no bed management”
- Process Mapping Workshop
• Often success at getting beds is based more on "who you know" than following procedures - - A&E Registrar
• “We’re in crisis mode everyday. It’s reactive. There is no bed management”
- Process Mapping Workshop
Division of Medicine
Mismatch of responsibility & accountability for bed management and turnover
UnitUnit
WardWard
Bed Manager
Ward staff not accountable for bed management efficiency
The Bed Manager has full responsibility but no authority to place patients in a bed
Medical staff responsible for admission / discharge, but not accountable for bed management
Division of Surgery
OutliersInliers
Inliers vs Outliers2,4 (Jul ’01 – Jun ’02)
86%
37% 74%68%
26%
14%
63%
26%32%
74%
Cardiology (CCU, G3C)
General Medicine
(J3M)
Gastro- enterology
(H3GA)
Neurology (G2M)
Immunology2 (F2I)
1,769
1,066
595655
58%
42%
Respiratory (F2R)
822
346
Average Length of Stay:
J3 General Medicine
Other Wards
7.8 days
10.9 days
Difference 3.1 days
Typical Problem – Fragmented Bed Management Organisation
The Maggie Program
General Medicine – J3
General Medicine – J3• Improves patient care for
elderly/complex patients
• Reduces outliers and length of stay
• Medical teams are less frustrated more efficient during ward rounds
• Centralised, more collaborative work environment
• Lots of running around
• Different units, different layouts, different nursing teams
• Higher probability of disconnects
• High levels of staff frustration
From: Dispersed Patient Population
To: Greater Co-location and Clinical Focus
Proposed solution – Reaggregation of bed space to reduce outliers
The Maggie Program From: a disorganised process where people & activities ‘collide’…
To: a co-ordinated, more collaborative approach.
Care DeliveryCare Delivery
Testing9:00am
Breakfast
Physio referral
Medications
Patient Observations
Registrar’s ward round
• Shared plan and schedule across professions
• Common work practices
• Multidisciplinary care coordination and discharge planning
• Adjustment of Medical rosters
• Different schedules for different professions
• Variability in ward rounds
• Contention for diagnostic and allied health services
8:00am 5:00pm12:30pm
Patient Care Activities:
Medical Activities
Allied Health Activities
Multi-disciplinary, Care Co-ordination Meeting
New Patient Assessment Round
Teaching
Inter Specialty, Medical Consults
Pathology & Radiology Test Ordering
Pathology, Radiology Testing & results reporting
Morning Medical Handover
Working Medical Round
Nursing Activities
Medical Activities
Alignment of Nursing Activities
Afternoon Medical Handover
8:00am 5:00pm12:30pm
Patient Care Activities:
Medical Activities
Allied Health Activities
Multi-disciplinary, Care Co-ordination Meeting
New Patient Assessment Round
Teaching
Inter Specialty, Medical Consults
Pathology & Radiology Test Ordering
Pathology, Radiology Testing & results reporting
Morning Medical Handover
Working Medical Round
Nursing Activities
Medical Activities
Alignment of Nursing Activities
Afternoon Medical Handover
Proposed solution – Coordination of ward based work practices
The Maggie Program
Typical Problem – Large Number of Uncoordinated services
There are 450 public services and 50 private services under 32 major categories of services in the Hunter
Source: (1) Commonwealth Carelink Centre
Community Spinal Service
Friendship Groups
Domestic Assistance
HACC
DVA
HES
DADHC
COP
ACATACARS
CACP’s
OTPhysio
Psychology
CounsellingSocial Work
Nursing
Carelink
Rehab
Community Transport
Retirement VillagesSupported Accommodation
Church Groups
Pharmacy
Hostels
Boarding HousesNursing Homes
Respite
Crisis Relief
PADP
GP’s
EACH Meals on Wheels
Personal Care
Day Care
Home Care
Group Houses
Geriatric Medicine
Rehabilitation Medicine
Enablement
Welfare
Disability ServicesPrivate Case Management
Coordinated Care Trials
Chronic Disease ProjectSpastic Centre
Spinal Unit Home Modifications
Palliative Care
D&A
Advocacy
Patient Transport
Community Spinal Service
Friendship Groups
Domestic Assistance
HACC
DVA
HES
DADHC
COP
ACATACARS
CACP’s
OTPhysio
Psychology
CounsellingSocial Work
Nursing
Carelink
Rehab
Community Transport
Retirement VillagesSupported Accommodation
Church Groups
Pharmacy
Hostels
Boarding HousesNursing Homes
Respite
Crisis Relief
PADP
GP’s
EACH Meals on Wheels
Personal Care
Day Care
Home Care
Group Houses
Geriatric Medicine
Rehabilitation Medicine
Enablement
Welfare
Disability ServicesPrivate Case Management
Coordinated Care Trials
Chronic Disease ProjectSpastic Centre
Spinal Unit Home Modifications
Palliative Care
D&A
Advocacy
Patient Transport
Case manager
Co-ordinator
Nursing
Occupational Therapy
Physiotherapy
Podiatry/Footcare
Speech Pathology
Other Allied Health
Other Clinicians
Total
0
1
34
20
22
4
4
7
4
96
2
4
11
7
2
0
10
1
0
37
Discipline General
AssessmentSpecialised Assessment
2
5
45
27
24
4
14
8
4
133
Total
Case manager
Co-ordinator
Nursing
Occupational Therapy
Physiotherapy
Podiatry/Footcare
Speech Pathology
Other Allied Health
Other Clinicians
Total
0
1
34
20
22
4
4
7
4
96
2
4
11
7
2
0
10
1
0
37
Discipline General
AssessmentSpecialised Assessment
2
5
45
27
24
4
14
8
4
133
Total
Indicative Sample of Tools From File Audit
“We are serving the community, yet making empires. We make people go through 57 assessments to get 4 services.”
- Process Mapping
What Staff are Saying
The Maggie Program
Typical Problem – Exit Block – Nursing Home and Rehab
Summary of Findings 1Audit of Discharges from JHH
Date of audit
Wards audited at JHH
Medicine
Surgery
Total number of discharges
Number of delayed discharges
Delayed discharges as proportion of all discharges audited
Total days delayed
117
27
23%
118 days
Waiting for Rehabilitation bed
Cause of Delay Number Discharges Affected
Total Days Delayed
Proportion of Total Delays
13 71
3 42.5
3 1.29
1 1
1
1
3
1
1 1 1
36%
1.1%
0.84%
0.51%
0.42%
60%
F1, G1
F2, G2, J3
7th-14th April 2003
Lack of discharge planning
Other (patient wandering)
Waiting for ambulance
Waiting for discharge summary
0.84%
Waiting for Nursing Home/Hostel bed
Waiting for Specialist consult
The Maggie Program
Patient Flow
Rapid Assessment• Triage first point of contact• Rapid Assessment Personnel
(RAP) Team facilitate early injury management
Care Coordination• Multidisciplinary care teams• Care plans drive consistency
and continuity of care• Effective partnerships
Timely Discharge• Discharged after 12 days • Continuous relationships• Electronic discharge
summaries provided immediately
Proactive Treatment• Needs are anticipated • Early identification of risk
factors• Early involvement of specialist
care providers• Evidence based practice
Patient / Family Education• All interactions are explained
to Maggie• Italian interpreter assists
education• Post-discharge education
arranged
Information Sharing• Improved communication• Efficient information flow• Information captured once
only• Non paper-based system
Patient Flow
Patient Flow
Rapid Assessment• Triage first point of contact• Rapid Assessment Personnel
(RAP) Team facilitate early injury management
Care Coordination• Multidisciplinary care teams• Care plans drive consistency
and continuity of care• Effective partnerships
Timely Discharge• Discharged after 12 days • Continuous relationships• Electronic discharge
summaries provided immediately
Proactive Treatment• Needs are anticipated • Early identification of risk
factors• Early involvement of specialist
care providers• Evidence based practice
Patient / Family Education• All interactions are explained
to Maggie• Italian interpreter assists
education• Post-discharge education
arranged
Information Sharing• Improved communication• Efficient information flow• Information captured once
only• Non paper-based system
Rapid Assessment• Triage first point of contact• Rapid Assessment Personnel
(RAP) Team facilitate early injury management
Care Coordination• Multidisciplinary care teams• Care plans drive consistency
and continuity of care• Effective partnerships
Timely Discharge• Discharged after 12 days • Continuous relationships• Electronic discharge
summaries provided immediately
Proactive Treatment• Needs are anticipated • Early identification of risk
factors• Early involvement of specialist
care providers• Evidence based practice
Patient / Family Education• All interactions are explained
to Maggie• Italian interpreter assists
education• Post-discharge education
arranged
Information Sharing• Improved communication• Efficient information flow• Information captured once
only• Non paper-based system
Fragmented Reactive Poor information sharing Multiple complications
ED OT Relapse ICU OT GEM Recovery DischargeRecovery 53 Days
Original Maggie Story
ED OT DischargeRecovery 12 Days
New Maggie Story
Maggie’s Story
The Maggie Program
ED John Hunter
ICP - General Medicine JHHPhase 1 - Resp, Card, ImmPhase 2 - Gastro, Renal, Neuro
Mater Inpatient Care
Maitland ED
PHD Rural - Denman
Ambulatory Care
Access BlockService Config. / Pt Logistics
ED to IP Handover
Surgical
Belmont ED / Inpatient Care
Community Health
Mater ED
Management Development
PROGRAM Legend
MAY 2002 - MARCH 2004 Planning phase Diagnostic & Design Implementation
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
2002 2003 2004
> 90% of solutions
implemented in
timeframes!
The Maggie Program
Consumer involvement (~195)
• Program Management:
– Visioning Workshop (4)
– Consultative Forum (1)
– Core/Lead Team (1)
– Planning Workshop (2)
• Projects:
– Reference Group (10)
– Core Project Teams (4)
– Working parties (25)
– Tag-alongs (28)
– Project specific patient survey (100)
– Press Ganey patient satisfaction survey
– Consumer interviews (20)
– Complaint feedback from JHH Patient Advisor
Consumer input / patient experience are critical to guide analysis of problems and help direct solution development:
The Maggie Program
Inpatient Care KPIs
Access Block (% Not Admitted within 8 Hours of Being Seen by a Doctor)
0%
20%
40%
60%
80%
PHD begins
PHD begins
PHD beginsPHD extended
The Maggie Program
Improved Access to Care
John Hunter Access Block Performance
0%
10%
20%
30%
40%
50%
60%
Jan
-02
Fe
b-0
2
Ma
r-0
2
Ap
r-0
2
Ma
y-0
2
Jun
-02
Jul-0
2
Au
g-0
2
Se
p-0
2
Oct
-02
No
v-0
2
De
c-0
2
Jan
-03
Fe
b-0
3
Ma
r-0
3
Ap
r-0
3
Ma
y-0
3
Jun
-03
Jul-0
3
Au
g-0
3
Se
p-0
3
Oct
-03
No
v-0
3
De
c-0
3
Jan
-04
Month
Per
cent
not
adm
itetd
with
in 8
hou
rs
Actual Mean Target
33%
42%
29%
A 12% improvement in access block achieved despite 789 (11%) more Emergency Department admissions over the past seven months
PHD Access project
Comparative Access Block: Percent Not Admitted Within Eight Hours
37 3842 41
36
4338
36
4144 44
4851
54
0
10
20
30
40
50
60
John
Hun
ter
Roy
al N
orth
Sho
re
Wes
tmea
d
St.
Geo
rge
Roy
alP
rince
Alfr
ed
Pen
rith-
Nep
ean
Con
cord
Principal Referral Hospital
Per
cen
t n
ot
adm
itte
d w
ith
in 8
hrs 2002
2003 The result in January was the best for 25 months and is against the trend at a number of peer hospitals
The Maggie Program
Cultural awareness
Rating of PHD Program Success by Staff Level of Awareness
80%
20%
7%
17%
65%
20%
3%
16%
74%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Low awareness (n=716) Medium awareness(n=498)
High awareness (n=618)
Level of awareness
Per
cen
t to
tal
Low success rating Medium success rating High success rating
Source: 2003 Staff Opinion Survey
The Maggie Program
Improved Patient Satisfaction
• John Hunter Emergency Department – patient satisfaction rating improved from being in the bottom 10% to top 25% of Australian peer hospitals.
• Satisfaction score increased 6 points (8%)
Source: 2002 and 2003 Press Ganey Patient Satisfaction Survey
Note: General Medicine patients currently being surveyed
•“Could not fault anything, very compassionate staff”•“Treatment was caring and thorough. I felt I was in a competent atmosphere.”•“Could not do enough to make me comfortable and treat my cause. Above and beyond their line of duty.”•“If anyone I know needs to attend hospital I would recommend the John
Hunter Hospital - the care I received was excellent.”•“The service was very good, as it was Melbourne Cup Day and very busy.”
The Maggie Program
Executive Summary – Why We Want To Continue Doing This
• Our current health system is not delivering the outcomes we expect in terms of:
• patient service - poor communication, delays and difficulties in access,
• staff satisfaction - frustration with system, overworked, paperwork, fear of litigation, old and poorly designed buildings
• quality of care – adverse events, and
• efficient use of community resources
• The problems are deep seeded and systemic – our analysis has highlighted the interconnected nature of the problems. Historically, point specific or incremental solutions have not delivered sustainable benefits.
• We believe only through a broad based transformation program can we properly address these systemic issues and deliver better outcomes to our patients, staff and the community
• So far the results of the PHD program have been encouraging, especially the reorientation of work practice around patient journeys and the extensive participation of staff.
• PHD may have benefits that extend beyond Hunter Health to NSW Health and Australian healthcare, in general
The Maggie Program
DESIRED OUTCOMESPATIENT JOURNEYS
Executive Summary – Integration With Other Programs
• PHD seeks to realign health service delivery around specific ‘patient journeys’ through the system & is the overall framework for most major change programs within Hunter Health
• Other strategies will be aligned with PHD to ensure appropriate direction and use of resources
• Benefits will be tracked within the Balanced Scorecard framework
VISION: Hunter Health is the leader in creating healthier communities
MISSION: To improve the health of the people of the Hunter and those referred to us
Goals:1. Effectively promote good
health and prevent disease
2. Deliver high quality patient care
3. Ensure sustainability
PHD
PHD
Management Development
Leadership Strategy
ITStrategy
NewcastleStrategy
Clinical Risk Management
PHD
Emergency
Ambulatory Care
Surgical
Medical
Community Health
Obstetrics
Health Promotion
HH
BALANCED
SCORECARD
The Maggie Program
Vision, Leadership and Management
Overall Plan
Program and Change ManagementEvaluation & Benefits Realisation
Patient Journeys – Design, Pilot & Rollout
Area Wide Planning
2002 2003 2004Q3 Q4 Q1 Q3 Q4 Q1 Q2 Q3 Q4
Confirm IT Strategy
PHD Funding Strategy
Management Review
HR Strategy
Newcastle Strategy Alignment
Community Based
Pilot Rollout
Surgical Inpatient
Pilot Rollout
Ambulatory/Outpatient
Pilot Rollout
Pilot
Medical Inpatient
Rollout
Pilot Rollout
ED
Access Block
Q2Q2
The Maggie Program
Executive Summary - Benefits Recap
This will result in the following outcomes over three years…
1. Reduced Length Of Stay (LOS)
• 10-15% reduction across 6 major hospitals
2. Improved access to care
• 50-100% reduction in access and exit blocks– Improved clinical integration– Increased services in hospital and
community
3. Improved patient satisfaction
• Increase from 87 to 95%• 20-40% reduction in ED wait times
4. Improved patient safety
• Reduction in bed days due to adverse events 30-60%
5. Improved staff satisfaction
• 45% improvement in overall staffsatisfaction to best in class levels
The Maggie Program
In conclusion
• We are making real progress – still have a long way to go
• 15 projects and 3 associated projects in various stages
• Over 2000 people directly involved in PHD activity across the geographic spread of Hunter Health
• Fascinating journey of discovery
• Building sustainable delivery models
• Courage to listen to the data and make adjustments
• Building confidence and new capabilities in management
• Truly rewarding experience for all involved
