My Job?
South African Triage Scale and Acute and Emergency Case Load
Management Policy Implementation Officer
Triage?
• First come, first served• “eye-ball”• To the Letter (“inappropriate”)• “Love thy Neighbour”• Dr G Special
SATS used correctly
• ↓Waiting times• ↓Emergency Centre Length of stay• ↑Patient flow• ↑Patient and staff satisfaction• ↓Mortality (2% to 0.7%)
SATS Performance Indicator
CTS priority Target time to treat Performance indicator threshold
Red Immediate 95%
Orange 10 minutes 80%
Yellow 60 minutes 75%
Green 240 minutes 70%
Seen by Doctor
• 0% Orange patients seen in under 10mins after SATS assigned
• Orange and Yellow patients are seen by doctor on average 2 hours after arrival (about 50 minutes after triage) – this is in a system where Green patients are streamed elsewhere.
Time waiting in EC
• 71% of admissions spend over 8 hours in the EC (from arrival)
• Average is 12,5 hours from arrival to ward bed
• Average wait from time seen by specialist to time to ward is 7hours.
Overcrowding
If your hospital is >90% full
OR
Over 10% of the patients in the Emergency Centre have been waiting over 8hrs from arrival to
admission
THEN...
INPATIENT MORTALITY IS INCREASED BY 30%!
Mortality risk ratio is 1.1 for each hour spent waiting in the Emergency Centre
Mortality risk ratio is 1.2 for each hour spent waiting for a doctor
Overcrowding causes• Increased patient mortality • Ambulance diversion• Increased inhospital lengths of stay�• Patients not being placed on the appropriate ward• Medical errors�• Poor infection control• Poor hospital processes• Financial losses to hospital and physician�• Medical negligence claims�• Increased staff burnout and decreased morale
No matter how few resources we havethere is always hidden capacity in the systems
Use our limited resources more effectivelyIncrease efficiencies, reduce duplication, reduce waste
Patients want:• the right treatment• without mistakes• without waiting
“Work smart not hard”
Systems Improvement
Front Door Issues – Entry Portal
GFJ:
• 20% of CHC referrals are “inappropriate”
• 40% GP referrals “inappropriate”
EC EfficiencyNursing Staff
• 44% of time is non-value added work – giving directions– pushing trolleys– answering phones– finding stock
• ie Employ 10 nurses and you will get 5,6 nurses’ worth
• ?Quality of the 56% nursing care done under pressurised and distracting conditions
• Doctors only slightly more productive...
Ward check
• Ward 1: 0 Beds , 5 discharges pending• Ward 2: 4 Beds, 5 discharges pending• Ward 3: 5 Beds, 3 discharges pending• Ward 4: 3 Beds, 0 discharges pending
Back Door Issues - Discharge planning
• Patients admitted on Thursdays have longer lengths of stay than those admitted on Mondays
• Patients often only leave beds at 17h00 on the day of discharge
Discharge Process
Discharge summary written and handed to nurse
Folder to pharmacy
Transport arranged
OPD appointments made
Home-based care forms filled
Patient waits in bed until medications or transport, whichever comes last
This often only happens at 12h00
or 15h00...
With Discharge Planning
Day before• Contact transport (heads
up)• OPD appointments• Home-based care forms• Intern to prepare discharge
forms for next day
On the Day• Discharge round first thing
in the morning• Transport confirmed• Patient to discharge lounge
as soon as transport confirmed
With discharge planning, discharge rounds and discharge lounge
Total length of stay shortened
Every bed hour saved:
• Reduces mortality and morbidity of patients awaiting beds
• Reduces Cost to the Hospital
DMAIC
• Define the Problem and its impact on the Organization• Measure the Current Performance
• Analyze the Performance to identify Causes of this Performance• Improve the Problem by attacking its Causes
• Control the Improved Process to Maintain the Gains.
Finding ideas for change
• people providing the service• patients• guidelines (eg AECLMP and SATS policies!)• change ideas/concepts (eg lean, 6-sigma)• mapping the system• identifying underlying problem (root cause
analysis) • novel ideas (creativity) eg brain storming• best practice - sharing ideas
What Change can we make that will result in an improvement?
Types of waste
Muri (overburden) – unreasonable work imposed because of poor organisation – pushing person or machine beyond natural limits. Improvement comes at the level of proactive planning.
Types of waste
Mura (uneveness): Problems inherent in systemdesign or implementation. Improvement is in smoothing out the process
Types of Waste• Muda (non-value added work): waste that becomes
apparent once system implemented– Transportation: moving products that are not actually
required to perform the processing– Inventory: all components, work-in-progress, finished
product not being processed– Motion: people or equipment moving/walking more than
is required to perform the process– Waiting: for the next step in the production– Overproduction: ahead of demand– Over processing due to poor tool or product design,
creating activity– Defects (mistakes, re-work)
VALUE STREAM MAPPING
10 min
30 min1 Hour
6 min
2 hour
12 min
10 min
2 min
3 hours
24 min 6 hours 40 min
Porters’ Lodge
X-ray
Ward 4 Ward 1
Ward 2
Ward 3
Emergency Centre
Ward3 to X-rays
EC to Ward2
X-ray to EC
Ward 2 to Ward 3
EC to X-ray
Porters’ Lodge
X-ray
Ward 4 Ward 1
Ward 2
Ward 3
Emergency Centre
Ward3 to X-rays
EC to Ward2
X-ray to EC
Ward 2 to Ward 3
EC to X-ray
Some other processes impacting flow
• Stock availability and placement• Pharmacy throughput• Laboratory turnaround time• Enquiries setup• Time to folder – place for bedside admission?• Statistics collection and acting on Escalation
Policies
Rapid Cycle Change
What can we change that will result in an improvement?
How will we know that a change is an improvement?
What are we trying to accomplish?