Post on 24-Dec-2015
Department of Human Services
Team Presentations
Felicity Topp and Rochelle Condon
5TH October 2004
Concurrent Session 1Concurrent Session 1Team PresentationsTeam Presentations
Bellarine Room 1– Ballarat Health Service– Goulburn Valley Health– Western Health– Royal Children's Hospital
Department of Human Services
Patient Flow Collaborative
Fiona Brew Phil Catterson Jill O’Flynn
Operating Suite Emergency Department PDU
Ballarat Health Services- ‘The Stream Team’
Summarise Organisational Summarise Organisational Constraint areasConstraint areas
BHS Constraint Background• Culture
• Stable workforce• Education level• Flexibility
• History• Medically driven organisation• VMO mentality
• Public v Private
• Opportunity• Current practice - ? Good / Bad / Ugly • Cascade effect - isolation / up and downstream impact
Summarise Priority Constraint Area 1 Summarise Priority Constraint Area 1
System Approach - Access to Theatre
• Timing of cases• am vs pm - length of stay
• Session allocation• emergency• elective
• Delays• entry• exit
Diagnostic workDiagnostic work
• Process
• Staff Involved – Nursing, Medical, Support
• Staff Reaction – Keen, positive
• Useful data – Tally charts
Improvement PlanImprovement Plan• Action Plan
– tally chart presentation– champion selection
• Strategies developed
– Identify Culture • Paddle own canoe • Going with the flow • Aiming for improved stream?
– Communication
– Work practices• Roles• Most work in daylight hours• Utilise DOSA unit
ProgressProgress• Communication
– Centralised distribution
• Culture – Patient focus – Team approach - New skills– Planning
• Work practices– Roles – Day surgery focus
Lessons learntLessons learnt
• Success– Communication– Culture
• avoid isolation– Work processes / practices
• strategies embedded in culture
• Future Improvements • Education• Frequency• One size does not fit all
Desired ImpactDesired Impact
• Recognition of cascade effect– impact on patient flow– global view
• Action – purposeful– innovative– positive - up and
downstream validation prior
• Evaluation– patient perspective
Next StepsNext Steps
• Consolidation
• Increased medical ‘buy in’
• Feedback
• Further development of strategies – outcomes related to measures
Questions
?
Department of Human Services
Patient Flow Collaborative
Kim ReadGoulburn Valley Health
Summarise Organisational Summarise Organisational Constraint areasConstraint areas
• Of the 5 Major constraints @ GVH, 2 constraint areas were prioritised due to the current internal efforts/projects being undertaken to improve patient flow:
- 1. Major Bowel Surgery Admissions- 2. Discharge Planning/Communication
Summarise Priority Summarise Priority Constraint Constraint Area 1Area 1
• Bed Availability.• Major Bowel Surgery Admissions on day
prior.• What works for us and OUR PATIENTS.
Diagnostic workDiagnostic work
• Day of Surgery Admission (DOSA)rates• Patient Interviews• Staff Interviews• Process Mapping
DOSADOSA
General Surgery DOSA Ratio
0
10
20
30
40
50
60
70
80
90
100
Jan-
03
Mar
-03
May
-03
Jul-0
3
Sep
-03
Nov
-03
Jan-
04
Mar
-04
May
-04
Jul-0
4
Sep
-04
Nov
-04
General surgery DOSA Ratio (%)
Patient InterviewsPatient Interviews
• First Patient• Noted what seemed to be a long wait to be seen by specialist after referral.• Had support of wife and daughter when making decision to go ahead with surgery. Glad of their presence
during discussions.• Noted the effort to get surgery done in short period of time once decision made.• Had bowel preparation in hospital but would have been happy to have this in his own home
environment.• Pain relief post operatively was good.• Felt he started solids too soon after – vomiting and subsequent naso-gastric tube.• All went well after discharge and for follow up.
• Second Patient • Felt that all went quickly in relation to being seen and being booked for surgery.• Was distressed and horrified with diagnosis and need for subsequent surgery.• Younger female patient who requested to have bowel preparation at home.• Discussed at pre-admission clinic her desire to be at home with her husband pre-operatively.
Wanted to be in the comfort of her own home, and in her own bed. Although she had nausea with the bowel preparation, she would not change her mind about having the prep at home.
• Discussed problems with pain relief post-operatively.• Had problems after discharge with nausea and became dehydrated. • Required representation to Emergency Department for re-hydration and issues related to the drain tube.
Process MapProcess Map
Current Major Bowel Surgery Admission Process Map
Appointment with GPReferral to VMO Private
Rooms or Outpatient ClinicPlaced on to waiting list and
notification to patientPatient Health
Questionnaire completed
Commence bowelpreparation at 1500
hoursFleet / Golightly
Admit day prior tosurgery
Stomal Therapistappointment
Pre-Admission ClinicFBE, U&E
Theatre booking andnotification.
Diet instructions
Commence IVtherapy/fluids at
2400 hours
Fast from 2400 hoursor 0700 hours
Prepared andtransported to
Theatre
Improvement PlanImprovement Plan
• Research bowel preparation options.• Surgeon Involvement.• Research processes at other
institutions.• Relationship with private hospital.
ProgressProgress
• Proposed process map.• Commenced clinical guideline.• Motel Accommodation guideline.
Lessons learntLessons learnt
• One bite at a time.• Involve the key players.• Has to make a positive difference for all.
Desired ImpactDesired Impact
• Satisfactory preparation.• Patient’s needs met.• Bed availability (HIPs).• DOSA rates comparable.
Summarise Priority Summarise Priority Constraint Constraint Area 2Area 2
• Discharge Planning/Communication- potential improvement option- Poor performance of discharge planning
& communication linked to lack of bed availability
- potential increased unplanned re-admission rates
• Satisfaction Surveys/Medical File Audits (R1)• Patients/Service Providers/Clinical Staff (R2)• Staff lack understanding of effective discharge
planning and further hindered by lack of appropriate risk assessment tools+lengthy & complicated referral forms/systems.
• Random Patient Satisfaction Survey (R3)• Patient thoughts/feelings/perception of self-care
needs.• Patient lack of understanding & misconception about
current day healthcare environment (e.g > LOS)
Diagnostic workDiagnostic work
Improvement PlanImprovement Plan
• Review & re-development of pre-admission/emergency admission documentation
• Implementation of streamlined internal referral.• Review & re-development of discharge
summary (R4)• Development of decision support tools-D/P(R5)• Development of Clinical Practice Guidelines-
Admission & Discharge
ProgressProgress
• Improvement strategies gathering momentum
• Improved awareness of the importance of discharge planning at day 1 of admission to support clinical outcomes (R5.2)
• New Referral System + Discharge Summary dissemination system (R6)
- Included patients admitted from March 2004• Included all clinical staff (acute/sub-acute &
ED)
LOS ComparisonsLOS Comparisons
Complex Care Patients - Average Length of Stay
0
5
10
15
20
25
30
Chr ObstructAirw ay
Disease WCat/Sev CC
Chr ObstructAirw ay DisNo Cat/Sev
CC
Heart Failure& Shock W
CatastrophicCC
Heart Failure& Shock noCatastrophic
CC
Diabetic Foot Diabetes WCatastrophicor Severe CC
Diabetes W/OCatastrophicor Severe CC
E65A E65B F62A F62B K01Z K60A K60B
Ave
rag
e L
eng
th o
f S
tay
01/07/01 - 30/06/02 01/07/02 - 30/06/03 01/07/03 - 30/06/04
Lessons learntLessons learnt
• System change alone will fail unless supported by culture change, which in turn is supported by effective education and communication support strategies.
• Referral system development- would repeat consultation process.
• Development of new admission/assessment documentation taking longer that envisaged due to complicated consultation process and variety of internal/external influences
• Discharge Summary review-would include internal satisfaction review and corresponding time with GP satisfaction review
Desired ImpactDesired Impact
• Improved patient and carer satisfaction with the discharge process and health outcomes.
• Services will be integrated across the continuum of care.
• Length of stay will be comparable to industry benchmarks.
• Reduction in rate of unplanned readmissions within 28 days of initial separation.
• Improved processes of transition across the acute, sub-acute and community interfaces
Next StepsNext Steps
• Continue development of streamlined admission,health assessment & risk screen documentation to improve patient assessment consistency and early identification/intervention
• Ongoing education and support for staff regarding D/P- empower ALL STAFF to be skilled in D/P to improve patient journey thru healthcare continuum
Questions
?
Department of Human Services
Patient Flow Collaborative
General Internal Medicine UnitWestern Hospital, FootscrayG. Lane, Head of UnitH. Hasanoglu, NUM
OrganisationOrganisation
Background: Background: General Internal Medicine UnitGeneral Internal Medicine UnitPatient Mix Patient Mix
• Daily average of 45 inpatients (range 25 to 90)
• Average age 79 years
• Varied ethnic backgrounds
• Several acute medical problems
• Scarcity of community support or supportive accommodation
Background: Background: General Internal Medicine Unit. General Internal Medicine Unit. Common ProblemsCommon Problems
• Cardiac failure• Ischaemic heart disease• Cognitive impairment• Falls• Urinary tract sepsis • Septicaemia• Pneumonia• Unstable diabetes
• Acute and chronic renal impairment
• Polypharmacy problems• Syncope • Obstructive lung disease • Psychiatric diagnoses• Self-harm• Accommodation and
community support problems
Diagnostic work: ADiagnostic work: A
* 2 week period of reporting by all junior medical and daytime nursing staff of processes which possibly delayed patient flow
* Recorded daily at nursing and medical handover
* Staff reactions:* Nursing: cautious enthusiasm* Medical: cautious cynicism
Diagnostic work: B Diagnostic work: B
• Patient Flow Profile • 3 patients tracked and interviewed throughout their
admission• Most interactions with health personnel recorded,
including process delays Patients’ opinions sought about:• Being told what was wrong• Being told about my treatment
• Going home • Being followed up• Felt to be less useful than “A”
Organisational Constraint Organisational Constraint areasareas
General Internal Medicine Sample Data DHS Patient Flow Collaborative May 2004
0
10
20
30
40
50
60
70
80
90
100
Type of Delay
Nu
mb
er
of
Oc
cu
rre
nc
es
of
De
lay
3 EAST Sample Data for Patient Flow Collaborative on LOS delays May 2004
0
10
20
30
40
50
60
70
80
90
100
Type of Delay
Nu
mb
er
occu
rren
ces o
f d
elay
Organisational Constraint Organisational Constraint areasareas
Delay in patients being seen for consultations and procedures was the 2nd highest rating process
Desired ImpactDesired Impact
50% reduction in:• mean time • range waiting for consultations and
procedures
? Significant reduction in length of stay
Measures reflecting the effect of Measures reflecting the effect of the constraint on the organisation the constraint on the organisation before and after test cyclesbefore and after test cycles
a) Time to see patient by registrar
b) Time to see patient by consultant
Pre-interventionPre-intervention
• Days to see patient: Registrar Pre (n=27) n 18 Range 0-7 Median 0 Mean 1.2 SD 1.93 Variance 3.7
Pre-interventionPre-intervention
• Days to see patient: Consultant Pre (n=27) n 14 Range 0-6 Median 2 Mean 1.9 SD 1.89 Variance 3.6
How Improvement How Improvement Strategies were derived and Strategies were derived and implementedimplemented
• Discussion with General Internal Medicine Unit staff (junior and senior) about reasons for delays in consultations and procedures
• Consensus on the most practical intervention strategy
Improvement StrategyImprovement Strategy
Change to referral process:If registrar of other unit had not seen the
patient by the next day, the parent unit consultant would contact the consultant of the other unit
OutcomesOutcomes• Days to see patient: Registrar Pre (n=27) Post (n=24)n 18 19Range 0-7 0-4Median 0 0Mean 1.2 0.68SD 1.93 1.06Variance 3.7 1.1Not seen 9 5 by reg
OutcomesOutcomes• Days to see patient: Consultant Pre (n=27) Post (n=24)n 14 9Range 0-6 0-7Median 2 2Mean 1.9 2.2SD 1.89 1.92Variance 3.6 3.7Not seen 13 15 by cons
Lessons learntLessons learnt
* Time intensive
* The challenges of frequent changes in junior staff
* ?Hawthorne effect
* Procedures often escaped reporting
* Difficult to record exact times
* Too short a study time to assess whether intervention would affect overall length of stay
What would you now do differently?What would you now do differently?
• Focus on delay to procedures rather than
consultations
• Devise an electronic collection process of data by
Unit’s registrars
• Weekly audit of delayed procedures and
consultations at Unit’s Safety and Quality meeting
• Display recording sheets on all wards
Next StepsNext Steps
• Repeat cycle within Unit, with better mechanisms to capture all procedures
• Ongoing frequent reminders to Unit medical staff• Longer study period• Remeasure LOS• Involvement of all heads of units in the development
of an Organisational policy on consultations and procedures
• Extend throughout Network• Ongoing audit, and resources to facilitate this
Questions
?
Department of Human Services
Patient Flow Collaborative
Mr. Mark BaldwinPlastic Surgeon Western Health
BackgroundBackground
● Plastic hand and maxillofacial surgery unit.
● 7 part time consultants.● 2 registrars, 3 residents and 1 fellow.● 2 campuses.● Approx 2400 cases/year.● Approx 50% hand surgery.
● Brainstorming sessions– Two sessions, surgeons and other staff
● Data measurement– Over two weeks, 4 areas collected data
● Review of Programme Measures such as LOS● Process Maps
– 10 patients, showed extreme variation in flow through the system
Diagnostic workDiagnostic work
Sample Data ResultSample Data Result
Constraint Issue
Patient Presents to ED
Patient DischargedTheatre
Discharged Home for Clinic. Appt
Admitted
Discharged home to wait surgery
Ward
Short Stay Unit
DPU
Out Patient follow up
Wait for Registrar review
Registrar calls: theatre, admissions, bed manager, and patient.
Inconsistent management plans
X-ray, medical record not available.
Registrar may not be on campus
Surgeon/ Theatre session availability
Opening hours may not allow recovery time Overbooked clinic
unable to make appointment
Goal settingGoal setting
● Reduce patient time in ED● Reduce plastics registrar organisational workload● Reduce unnecessary after hours calls to registrar● Improve reliability and utility of communications● Reduce need for multi day bed● Reduce delayed outpatient appointment bookings● Simplify referral to Hand therapy
Improvement Plan Improvement Plan
● Develop clinical pathway for consistent ED management– Protocol for discharge whilst awaiting theatre– Protocol for booking outpatient appointments
● Adopt SMS text service– Protocol for when to contact and what to include
● Implement regular 'twilight' emergency lists– DPU open to support these lists
● Op note sticker for Hand therapy referral● 'One stop' theatre bookings
What's in it for plastics?What's in it for plastics?
● Fewer 2am phone calls from ED about a cut finger.● Less time spent on the phone.
– Organising theatre– Waiting for ED staff to get information– Explaining standard procedures to ED staff
● Less late night/ after hours operating.
Downside.● More patients clogging the corridors of outpatient
clinic and/ or more clinic sessions.
What's in it for the ED?What's in it for the ED?
● Uniform, simple, teachable procedure to follow = less mistakes.
● Fewer hours spent waiting to get plastics registrar opinion.
● Less time spent on the phone.– Tracking down which registrar is oncall– Answering registrar's questions
● Easy access to outpatients clinics bookings.
Downside.
● Possible de-skilling of ED staff.– No account taken of individual's skills or abilities– Need to overcall rather than undercall diagnosis
What's in it for the patients?What's in it for the patients?
● Uniform, simple teachable protocol = less medical mistakes.
● Less time waiting in hospital.– In ED– Prior to theatre
● Fewer theatre cancellations.● Fewer unnecessary outpatient appointments..
Downside.● None
ProgressProgress
Team met after hours every fortnight.● Session 1
– Review Diagnostics & Planning innovation● Session 2
– Review work to date (pathway)– Identify further action points
● Session 3– Team refinements (mainly via e-mail)
● Session 4– Final agreement for drafts and trial
Team MembersTeam Members
● Surgeons● ED Physicians● Nursing ED, Theatre, DPU, Ward/ SSU● Allied Health● After Hours Management● Site Management● Division of Surgery Executive
Team WorkTeam Work
ProgressProgress
● Beta- testing pathway ● Start date for twilight lists● Start date for extra outpatient sessions● Installation of SMS software
ProgressProgress
● How to trial the pathway?● Upper limb only● Sunshine only● Paper form and phone contact
Lessons learntLessons learnt
● It’s amazing what you can achieve with a great team
● Some things take longer than the 12 weeks implementation time
● If it's not worth doing properly, it's not worth doing at all.
Next StepsNext Steps
● Complete beta testing of– Pathway from clinical point of view– Pathway from logistics point of view– SMS service
● Evaluation● HTML based pathway in ED?
Desired ImpactDesired Impact
● Happy patients● Happy staff
Questions
?
Department of Human Services
Patient Flow Collaborative
Trevor RixonPatient Resource ManagerThe Royal Children’s Hospital
The Royal Children’s Hospital The Royal Children’s Hospital Broad Broad Constraint Constraint AAreasreas
• RCH operational context
• Complexity of RCH admissions process
• Communication & information gaps
• Waiting list management systems
• Re-active bed management
Constraint Area 1Constraint Area 1Admissions ProcessAdmissions Process
• Process mapping
• Multidisciplinary group & follow up meetings
• Trialling revised ‘Admissions Form’
• Develop ‘RCH Admissions Process’ - policy & work practice
• Admission & discharge - times & days of week
• Hospital Demand Management
Constraint Constraint Area Area 22ConsentConsent
• 64% of patients admitted with no written consent
• Patient flow affected by multiple entry points and surgeon availability
• New booking pack and consent process developed
• Auditing to follow
Constraint Constraint Area Area 33Pre-Admission TriagePre-Admission Triage
• Process mapping completed
• Surgical team engagement
• Developing multi-faceted solutions:
•Pre-admission triage criteria
•Pre-admission phone calls to parents/carers
•Parent/carer-completed health questionnaire
•Review of RMO work practice
•Introduction of pre-admission clinic
Priority ConstraintPriority ConstraintBed ManagementBed Management
• No clear senior clinical involvement
• Communication gaps that impact on timely decision-making
• Minimal ‘real time’ knowledge of available bed stock & staffing resources
• Delays for patients in accessing beds
• Balancing staffing requirements & bed allocation
• Patient Resource Manager appointed (EFT 1.0)
• Determined current bed management process & practice and service gaps
• Met with key stakeholders
• Commenced daily bed management meeting
• Developed & implemented IT-based tool which illustrates the variation of bed management activity on a periodic basis
Diagnostic WorkDiagnostic Work
Improvement PlanImprovement Plan
• Review bed management policy & practice
• Interpret admissions & discharge data around times and by specialty
• Develop an ‘on-line’ bed management system
• Interpret and trend HR data: e.g., nursing sick leave patterns; rostering practices
ProgressProgress
• Trial of IT-based bed management template
• Very positive feedback - >95% daily attendance by ward nursing staff
• Dealing with bed management issues in group forum allows time to identify & resolve issues
• Enhanced communication between RCH and Royal Bank
Date:
Expected 'Admissions'
Anticipated Beds
Required Emergency Electives O.T. ICU Green Go < 85%
Time: 0930 hours 0 YellowEarly
Caution > 85%
Occupancy 0600 hours
ED Actual 2003 Orange
Late Caution > 95%
Red Stop 100% or >
Ward/UnitTotal Bed Capacity
Beds Open
Current Census
(Actual pts. in beds)
Expected Discharges
Expected Admissions
Anticipated Transfers
IN
Anticipated Transfers
OUT Beds
Variance Iso. BedsUnstaffed
Beds
PM Staffing
Variances
ND Staffing
Variances Capacity
8 West 10 0 10 #DIV/0!7 West 23 0 23 #DIV/0!6 West 23 0 23 #DIV/0!6 East 16 0 16 #DIV/0!5 West 24 0 24 #DIV/0!5 East 24 0 24 #DIV/0!4 Main 32 0 32 #DIV/0!4 North 19 0 19 #DIV/0!3 East 22 0 22 #DIV/0!SSU 12 0 n/a 12 #DIV/0!
Medihotel 3 0 n/a 3 #DIV/0!
PICU 17 0 0 n/a 17 #DIV/0!NNU 22 0 n/a 22 #DIV/0!
EmergencyO.T.
RecoveryPSC/DMU
DSUHITH
TOTAL 247 0 0 0 0 0 0 0 0 247 0 0 #DIV/0!
ED Admissions Actual '03Actual
'04 Var. DischargesExpected
'04 Actual '04 Var.
0 0-Jan-00 0
Unexpected Admissions Actual '04
0-Jan-00
Bed Management TemplateBed Management Template
Lessons Lessons LLearntearnt
• Systems & tools enable better understanding of resource requirements by all participants
• Information presented in a structured format ensures an agreed understanding of data & minimises disputation of the data
• Important to acknowledge and celebrate progress
Desired ImpactDesired Impact
• Ensure timely access to hospital for patients & families
• Staff development - access to mentors & champions
• Identify & remove blocks to good bed management practice
• Increase nursing staffing efficiencies
• Provide data to assist in managing elective & emergency demand
Next StepsNext Steps
• Bed Meeting – one venue, twice daily 7 days/week
• Integrate process into culture & context by seeking involvement of key medical and allied health staff
• Determine if allocation of beds by specialty meets demand by specialty
• Determine discharge profile
Questions
?trevor.rixon@rch.org.au
justin.king@rch.org.au
sean.spencer@rch.org.au
Second Concurrent Session12.45 – 2.00 How to encourage a culture of innovation Cathy Balding and
Mary Mitchelhill
Outpatient Department Toolkit Veronica Strachan and Kim Moyes
Communication Strategies Julian Murphy and Sharon Neal
Advanced Project Management Ruth Smith and Claire Mackinlay
Managing Variation, Elective & Emergency Lee Martin and Bernadette McDonald and Marcus Kennedy
LunchLunch
• Meet us in the next Concurrent Session at 12.45
Department of Human Services
Team Presentations
David Langton and Mary Mitchelhill
5TH October 2004
Concurrent Session 1Concurrent Session 1Team PresentationsTeam Presentations
Bellarine Room 2– Royal Women’s Hospital – Southern Health – Monash Medical Centre– Peter MacCallum Cancer Centre– Maroondah Hospital– Calvary Health Care
Department of Human Services
Patient Flow Collaborative
Tanya Farrell & Rosemary BurrellThe Royal Women’s Hospital
‘‘Operation Caesar’Operation Caesar’
Tanya Farrell
Maternity Care Program Manager
Summarise Organisational Summarise Organisational Constraint areasConstraint areas
• Operation Caesar– Variety of disciplines and locations for one
process (including off site services)
• Wait watchers– Lack of data to monitor attendances and
FTAs
– Resources, resources, resourcesResources, resources, resources..
Summarise Priority Constraint Summarise Priority Constraint
• Operation Caesar
– Pre Admission Clinic (Midwife PAC & Anaesthetic PAC)
– Theatre booking
• Operation Caesar
– Further Process mapping,– Documentation review, – Review template and capacity for all Pre
Admission clinic appointments,– Consumer Advisory Committee
representative – walk through
Diagnostic workDiagnostic work
Improvement PlanImprovement Plan
• Operation Caesar– Provide a guideline and revise pathway for
the C/S process– Revise documentation– Streamline patient instructions and
information provided
– Find capacity for Anaesthetic pre op review
ProgressProgress
• Operation Caesar
– Trial revised pathway and theatre booking form
– Revised Pre Admission templates – “AAC”– Ceased midwife pre admission role– Patient instructions; content updated and
source of distribution centralised.
Desired ImpactDesired Impact
• Operation Caesar
– Improved access to service for patients and staff
– Decrease in incident reporting– Better use of resources
Next StepsNext Steps
• Operation Caesar
– Complete Pathway for rest of patient journey
– Patient information, update using consumer input
‘‘Wait watchers….’Wait watchers….’
Rosemary BurrellRosemary Burrell
Well Women’s Program ManagerWell Women’s Program Manager
Summarise priority Summarise priority constraintconstraint
• Wait watchers
– Appointment /Booking System– Access to ultrasound results in clinic– Medical staff availability
Diagnostic workDiagnostic work
• Wait watchers
– Process mapping, – Restructure of clinic templates, – Trial FTA process, – Trial Overbooking Policy, – FTA audit– Consumer Advisory Committee
representative – walk through
Improvement PlanImprovement Plan
• Wait watchers– Appointment of a Gynae Clinic Coordinator– Revision of gynae clinic appointment
templates– Confirm a FTA process and develop policy– Implement an Overbooking policy– Liaison with
clinic/ultrasound/ultrasonographers– FTA audit
ProgressProgress
• Wait watchers
– Internal reporting available in Oct 04– Gynae Clinic Coordinator appointed– Information from FTA audit– Ultrasound Results access
Desired impactDesired impact
• Wait watchers
– Improved access to service, better use of resources
– Reduction in variation
Next stepsNext steps
• Wait watchers
– Consider implementing partial booking system and reminder call service
Lessons learntLessons learnt
• Worked well– Multidisciplinary approach– Engaging medical staff– Whole system approach
• What would we do differently– 1 constraint only– FTA audit completed during the diagnostic
phase
Questions
?
Department of Human Services
Patient Flow Collaborative
Andrew Driver & Wendy Jupp
SouthernHealth – Monash Medical Centre
Summarise Organisational Summarise Organisational Constraint areasConstraint areas
1. Workload – continues to rise by approximately 2% per month over 20% per annum.– Paediatric & Respiratory sessions.
2. Equipment– Understocked stable of endoscopes.– No replacement plan – by 2005 current stock will be severely stressed.– Limited physical space.
3. Workforce– No extra nursing staff, medical staff administrative staff. – Non availability of anaesthetics for certain sessions.
4. Access
Summary Priority Constraint Summary Priority Constraint
• Gastrointestinal bleeding is the most common emergency in the gastroenterology field.
• Early recognition is the primary component of treatment.
• Facilitation of urgent access to endoscopic is a priority.
• Various levels of staff skill exist, affecting clinical decision making.
• Clear pathways facilitating decision making to improve care.
• Improved care and timely endoscopic access reduces length of stay.
• Diagnostics:– x2 patient journeys– Involving nursing, ward management, medical, ED, Bed Bureau,
administrative.
• Reactions:- Variable response to the process, but recognition of difficulties involved. Overall sentiment was that the problems were caused by others no directly associated to the work.- A need to work collaboratively to further identify issues and move towards a resolution.
• Useful data:- identification of where the delay was.- time of request to transfer to endoscopy- Patient journey time through medical stay – it would be helpful to map entire medical patient journey – identifying and understanding component parts to create better flow.
Diagnostic workDiagnostic work
Improvement PlanImprovement Plan
• Increase resources and service hours
• Provide decision making pathway
• Identify the need for intervention
• Establish communication procedures
• Establish bed allocation prioritisation principles
• Continue to Collect and collate activity data
Improvement PlanImprovement Plan
Injec t with adren aline
Variceal Bleed
END OSCOPY
Poss ible surg ery for over sewof bleeding vessel or partial gastrectom y
Out patient repeatvariceal banding
Await brownb owel ac tion
discharge
Repeat out patient scope toch eck ulcer healing + or -H. Py lori eradicat ion
Res tore haemodynam ics tabilityEndocopy,cons ider TIP SBalloon tam penad e
Haemodynamically stable
Fluid resus unt il blood availablecons ider haem accel, N saline or coloidsTransfuse if Hb < 80 or if clinically unwellGastro med reg notify U pper GI surg reg
No rebleed Rebleed No re bleed
continue bleeding
Bleeding DU or GUMallory Weiss Tear
Presentation to ED withsignificant GI bleed
Haemodynamically unstable
Await brow nbowel action
discharge
ACUTE UPPER GASTROINTESTINAL BLEEDING ALGORITHM
PR -ve Hb stab leGas M ed reg review ? discharge
Await brownbowel ac tionD ischarge
Res tore haemodynam ic s tabilityRepeat endoscopy
Aspirin,warfarin, clopidogril
Diatherm y to bleeding vessel and orInjec t with adrenalineCont inue IV Om eprazoleGastro Med not ify Upper GI surgCom mence oral Omeprazole
THESE ARE TREATMENTGUIDELINES AND DO NOT REPLACE CLINICAL JUDGEMENT
A
ED assesm ent notify Gastro Med Reg im ediat ly IV access x 2U&E FBE clott ing LF T group and hold 4 unitsR BCRecord pos tural BP P R temp & Sao2Perform PRECGConsider C VC & IDCComm ence Om eprazole and or OctreotideCorrec t clott ing w ith FFP, platelets or Vit KAscertain risk fac tors - ETOH , NSAID, antigoagulationAspirin, W arfarinC lopidogrel
Poss ible trans fer to ward
No re bleedContinues bleedingor Re bleeds
R arely surgery
Continues bleedingor re bleeds
Variceal bandingC ont inue octreot ide 48-72 hrsOral Propranolol
ProgressProgress
• Communication strategy / process documented & endorsed Medicine & Nursing
• If deemed the avenue to follow undertake a Resource costing profile
• Policy Priority requirements identified
• Continued Development : Decision tree & predictor tool
OutcomesOutcomes
• Development and introduction of decision tree.
• Daily Medical / Nursing Unit Management meeting – patients, demand information etc..
• Changes to formal communication processes include LAN paging, endoscopy bookings etc..
Lessons learntLessons learnt
• Important to prevent information / problem overload.
• Tailor information to individuals that is relevant and timely to their sphere of control.
• All participants found to have frustrations often with no channels for resolution
Desired ImpactDesired Impact
Looking forward we expect:
- Better understanding of endoscopic management of the elective & emergency demand balance
- Accurate prediction and accommodation for acute endoscopic demand
- Reduced time for patient medical journey with incorporated discharge planning.
- Reduction in confusion as to decision making responsibility resulting in appropriate care
Next StepsNext Steps
• Small Steps – frequently.• Reconfirm buy in to process• Continue developing the work• Improve the entire gastro medical
journey.• To enhance interface and actions with
other Units
Questions
?
Department of Human Services
Patient Flow Collaborative
Skin / Melanoma Service
Peter MacCallum Cancer Centre
Summarise Organisational Summarise Organisational Constraint areasConstraint areas
• High volume clinical load
• Long waiting list time to theatre
• Perceived patient delays in clinic as well as late clinic finish time
• Multiple attendance before treatment plan established
• Limited resources to treat malignant lesions within the cancer tertiary centre due to the high number of patients with benign lesions
Summarise Priority Constraint Summarise Priority Constraint Area 1 – Area 1 – High Vol Clinic LoadHigh Vol Clinic Load
• Improve and systematise the initial visit to the clinic.
• Re allocate the human resource to meet the demand.
• Decrease the number of patients with benign presentations accessing the clinic, and increase resource allocation to the patients with malignant conditions.
1. Audit of New Patient Presentations• Timeframe May, June and July • Review assessment & treatment outcomes
2. Audit referral source• General Practice
3. Who Participated• Clinic staff i.e. Medical, nursing and clerical staff.• Finance and Statistics staff
4. Staff Reactions• All members of the team were happy to participate as they felt it was a positive move towards
organising a better system
5. Useful data• Analysis of assessment outcomes demonstrated high numbers of patients proceeding to
surgery• Large numbers of patients were undergoing biopsy in clinic
Diagnostic workDiagnostic work
Treatment options for New Patients. May - JulyTotal Number of Patients 100
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Biopsy 15.7% Surgery 57.8% Dermatology1%
Cryotherapy6.9 %
Topical Rx2.0%
Review 3.9 % Ref Back toGP 3.9 %
No Further Rx8.8%
Percentage
Improvement PlanImprovement Plan
1. GP Education Program• Biopsy the patient prior to initial visit to the hospital
2. Human Resources• Reorganise this in order to facilitate the high number of patients going
to theatre and post operative care.
3. Patient’s who proceeded to biopsy. • Benign result -> Develop a standard form letter to be sent to the
patient and referring GP.• Malignant result - > Patient to be called personally. Patient to be
triaged to the appropriate clinic.
4. Develop standards treatment pathways.• Including follow up: Currently no NHMRC guidelines for this group of
patients
ProgressProgress 1. GP Education
– Found that over a 12 month period, 1383 new patient presentations from 800 different referrers.– Gap in Data: We were not able to allocate the 800 into practitioner groups.– Initial Standard Draft letter has been written and is currently under review by all involved
consultantsOutcome: Initial strategy would be onerous and cost inefficient. Therefore this option was not pursued
2. Human Resources – One clerical support person allocated to the pre operative work up process. – Two nurses allocated to post operative wound care in a separate area adjacent to the main
consulting rooms
3. Patient Assessment & Monitoring• Both the Consultant Surgeons and the Registrar are attending both Review and New Patients. • Results in an increase in the number of patients being discharged.
4. Clinic Templates• The clinics regularly finish on time.• Still experiencing some delay for patients• Need to review and further refine Clinic Template booking form.
How many patients were involved? - > All patients presenting to the clinic form August onwardsWhat staff were involved? - > Medical, Nursing, Clerical and Statistics Staff
Lessons learntLessons learnt
• Absolutely essential to have good data collection
• Need to Audit on a regular basis in order to reallocate resources with better outcomes
• Need to design the audit carefully. For example, a breakdown of the outcome of patients going to theatre. ie. Benign versus malignant
• Need more regular team meetings, including Consultants, with data in order to influence practise change
• Include a patient satisfaction survey
• Need to develop an internal web site, including audit material to disseminate information easily and include as many people in the process as possible
Desired ImpactDesired Impact
• Reduce the amount of time that patients wait to be seen in the clinic
• Reduce the number of visits to the hospital
• Concentrate scarce resources into the appropriate area as we are a tertiary referral centre
• Increase staff moral and satisfaction
• Develop a greater awareness of the importance of accurate data collection and regular review of work practise
• Alter the concept of change from negative to positive
• Develop standard guidelines that are evidence based
Next StepsNext Steps
• Undertake further auditing to assess the waiting times and patient satisfaction.
• Develop the standard letters and implement this system
• Liaise with another group within the hospital to begin some work on reducing the number of DNA’s.
• Audit the number of post operative wound care time allocations to possibly move toward Nurse Led Clinics
Questions
?
Department of Human Services
Patient Flow Collaborative
Christine Fisch – Patient Access Manager.Eastern Health – Maroondah Hospital
Summarise Organisational Summarise Organisational Constraint areasConstraint areas
• Bed Management– Admission delays elective surgery– Admission delays from ED
• Unable to meet 12 hour targets.
• Acute/Sub Acute– Delayed access to Rehab and NH Beds.
• Theatre Utilization– High rate of HIPS.
Summarise Priority Constraint Summarise Priority Constraint Area 1Area 1
• BED MANAGEMENT
– Delayed Access to Beds.– Lack of structure - bed allocation– Inequitable distribution of workload.
• Sample data – 5 Acute areas– (3 Areas repeat data)
• Brain Storming – 2 hour session with lunch provided.
– Multidisciplinary team including• Patient Flow Collaborative - Facilitator• Patient Access Manager• Nurse Managers• Allied Health• Pharmacist• (No medical representation)
Diagnostic workDiagnostic work
Diagnostic Work (Con’d)Diagnostic Work (Con’d)
• Staff reactions
– Committed to aim of session– Honest – Frustrated– Seeking solutions– Feeling of deja vu
Areas HighlightedAreas Highlighted
• HR Management• Communication• Collaboration & Team Building• Organisation• E-Support• VMO’s• Organizational Structure.
Areas highlighted (Con’d)Areas highlighted (Con’d)
• Care Planning• Communication• HR.• Service model
OutcomesOutcomes
• Identification for the need to change the current bed allocation processes within the organisation.– Development of a strategy to implement a
Unit based patient allocation process.– Medical, Nursing and Allied Health teams
to support this structure.
Expected BenefitsExpected Benefits
• Reduced LOS• Reduced 12 hour stays in the
Emergency Department• Improved median discharge time of
patients (Currently 1300 – 1400 hours)
• Improved patient care• Improved staff morale
Improvement PlanImprovement Plan
• Establish a clinical working team.– Clinical Lead – Patient Access Manager– Nurse Manager – Surgery– Nurse Manager – Medical– Allied Health Representation (Social Work)– Medical Registrar/Intern– Patient Flow Collaborative - Facilitator
Improvement Plan (Con’d)Improvement Plan (Con’d)
• Map a Medical Unit ward round to use as a baseline.
• Process Map the Patient Access Manager for 1 day
• Review current Bed Management Policies and update as necessary
ProgressProgress
• Clinical Working Team established and first meeting held Monday 13th September.
• Lee Martin & Rochelle invited to attended.– Guided group
Next stepsNext steps
• Establish Organisational Capacity & Demand over 3 months– Retrospective data to be used.
• Appoint Clinical Leader• Establish designated bed numbers for each
Medical Unit.• Establish Formal Medical Handover each morning
• Stage introduction of patient allocation to designated wards.
Lessons learntLessons learnt
• Get everyone involved– Management Executive Team– Medical – Nursing – Allied Health– Hotel Services
• Good communication at all times as project progresses
• Research – experiences of other similar sized organizations.
Desired ImpactDesired Impact
• Timely change to Unit Based Patient Allocation
• Success measured– Improved LOS– Reduction in 12 hour stays in ED– Improved patient care– Improved staff moral
• Retention• Sick leave
• Equitable workloads (Medical Units)
Next StepsNext Steps
• Ensure the current motivation across all disciplines continues.
• Ongoing commitment of the Clinical Working Team.