A systems approach to improving patient flow
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Transcript of A systems approach to improving patient flow
Improving Patient Flow John Ash
Director of Patient Flow
www.qualitysummit.ca
#QS14
Faculty/Presenter DisclosureFaculty: [John Ash ]
Relationships with commercial interest: • Not Applicable
Disclosure of Commercial SupportPotential for Conflict(s) of Interest: • Allscripts Patient Flow will be discussed as a part of this presentation.
Allscripts Patient Flow was purchased by E-Health Saskatchewan, and is being implemented by multiple regions across the province as directed by the province.
Mitigating Potential Bias• The approach discussed was established based on literature review and best
practice.
• The approach discussed has been adopted by the provincial Hoshin on ED waits and Flow.
Regina Qu'Appelle Health Region
Under the medium growth scenario the City of Regina would grow at a rate of 2,500 people per year exceeding 226,500 in 2020 and 258,000 in 2035.
In the last 14 years the overall population that RQHR serves has grown 2.7 per. However people 85 years old and older have doubled.
2009 to 20013 Saskatchewan's population grew more than 80,000
1. Regina Qu'Appelle Health Region, Health Status Report, 2010 POPULATION, EMPLOYMENT AND ECONOMIC ANALYSIS OF REGINA June 2010
The Problem : Population Growth +
242,827 245,784
246,877
243,767
246,889
252,366 253,809
266,386
230000
235000
240000
245000
250000
255000
260000
265000
270000
2003 2004 2005 2006 2007 2008 2009 2010
Co
ve
re
d P
op
ula
tio
n
Regina Qu'Appelle Health Region Covered Population
2003-2010
The Problem : Unhealthy Population +
High saturated fat & high sugar diets, smoking, recreational drug use, alcohol use, lack of exercise are pre cursors for chronic disease
• 35% of 18y/o over population overweight (BMI 25% or greater)
• 21.5% of 18y/o over population obese (BMI > 30) *70% of the burden of illness and injury is attributable to chronic disease.
1.2010 RQHR Health Status Report
The Problem : Increasing Demand =
RQHR ER visits have increased 15.1% and admissions from the ER have increased 13.9% over past 5 years
RQHR EMS transports to ER have risen 15% over the past 5 years
Demand for urban LTC, Convalescence beds and Homecare spaces and support has increased
= Poor Patient FlowSummary 2012/13
Regina Qu'Appelle Health Region: Occupancy 120-130% Admitted ED patients awaiting IP bed
Pasqua and Regina General combined norm: 20-25 Peak 60+
Use of overflow ER space 2012-2013: monthly occurrence Use of hallways for inpatient care: 9 designated spots ED Admission decision to placement in IP bed (Wave Time):
30+ hours
Effective patient flow is achieved by providing safe quality care to the patient without delays or waste.
Environmental scan highlighted leading practices: IHI, Advisory Board International, and other health jurisdictions including Fraser Health, Australia, UK, Germany.
….Finding A Solution
Primary Care
Acute Care
Community Care
RQHR: First Steps
Dedicating patient flow as area of focus: Resources/Structure Centralized bed management supported by clear business workflows,
policies, and integrated technology Allscripts Patient Flow Software implementation & business process
redesign Real Time Demand Capacity Management (RTDC)
Governance structure, standard work, and accountability framework for patient flow: Everyone's responsibility
Develop a Long-term strategy based on best practice
From – To
Primary Care
Acute Care
Community Care
Making a Long Term Plan to Long Term Problem
• Understanding and identifying opportunities through data & value stream mapping
• Initial focus - in hospital - to improve ER overcrowding, achieve surgical targets & reduce over-capacity
• Long term – full patient journey
The Solution = A Strategic Approach to Patient Flow
Care Planning
Patients are involved with care team and contribute to the development and delivery of their care plan/timeline
Care plans and discharge planning are considered standard work & patients are well informed / prepared for discharge
Short Term Initiatives: RQHR RPIW’s: Physician communication of Target Discharge Date (TDD) and
Care Plan; Multidisciplinary rounds Provincial RPIW: Repatriation Clinical Pathway development: RQHR and Province
Governance
Standard work for leaders at all levels specific to patient flow – respond quickly & effectively to patient flow issues
Short Term Initiatives: Establish Department of Patient Flow Establish Patient Flow Senior Leadership Steering Committee (medical /
administrative), Operational Leadership Team (Service Line Dyads and KOTs) Defined Roles and Accountabilities for Senior Leaders and Managers Implement Real Time Demand Capacity (RTDC) roles & responsibilities for:
• AM/PM unit huddles• Bed meetings• Multidisciplinary rounds
Standard Work
Standard work is imbedded in the organization & leaders hold themselves & teams accountable
Core business clearly understood by staff and quality standards for each service line
Short Term Initiatives: Finalize standard work for:
• Multidisciplinary team meetings• Unit huddles / bed meetings• Bed management
Revise policy / procedure for use of OCP beds Develop system level capacity response framework
to replace OCP
Load Leveling
System demand is leveled where possible – surgical & clinic (i.e. Endo) targets are achieved with increased throughput while limiting overall system disruption
Operating room case complexity is factored into booking process
Short Term Initiatives: Surgery Slate Leveling Assessment of Outpatient Clinic Admission Patterns LOS targets
Demand & Capacity Planning
System Capacity Response Framework with adjustments made to address recurring capacity demand mismatches
Short Term Initiatives: Establish capacity response framework based on unit level escalation
triggers Develop tools to predict demand a week in advance – for frontline unit
managers / charge nurses Create additional bed spaces through bed reallocation; short stay surgical
and medical units; convalescent beds
Escalation
Negative capacity identified and mitigated ahead of time to limit impact.
Unpredicted demand managed through interim plans at unit level.
Short Term Initiatives: Implement RTDC standard work including:
• Unit level capacity plans to manage demand capacity mismatches in conjunction with physician & physician leaders
• Review of unit level plans to identify system barriers• System response to address system barriers
Implement unit level demand capacity plans linked to system capacity response framework
Quality and Safety
Patient, staff safety and quality patient care at the core of every decision. Zero defects. Zero unplanned readmissions.
Patient, Staff and Physician engagement are supported by patient outcomes to drive system change.
Short Term Initiatives: Current Lean activity – Mistake Proofing & RPIWs Improve bed management processes to limit patient movement through:
• Allscripts Patient Flow Software• Bed management/allocation process review
A best practice and literature review has highlighted a “systems approach” will result in sustainable improvement to overall patient flow
RQHR has integrated the findings of best practice into the development and implementation of its patient flow strategic framework
Annual work plan Integration with lean activity
Summary
Reduced Admit No Bed #’s: Combined norm 10-16 Periods of zero ANB
Reduce System Wide Occupancy 92%-98% norm Improved Wave Time: 6-8 hours All 9 IP hallway beds permanently closed Infrequent use of ED overflow space ER Overcrowding: Seen as system issue Cooperative culture to managing occupancy Improved accountability and visibility
Outcomes
Framework adopted by the provincial Hoshin : ED Waits and Flow.
Outcomes
Questions
Questions?Contact Me:
John Ash Regina Qu'Appelle Health Region,
Director of Patient Flow [email protected]
www.qualitysummit.ca
#QS14