Department of Human Services Patient Flow Collaborative Dr Alison Dwyer, Fellow in Medical...

Department of Human Services

Patient Flow Collaborative

Dr Alison Dwyer, Fellow in Medical Management

St Vincent’s Health

Organisational Constraint Organisational Constraint area at SVHarea at SVH

• Acute bed access • 12-hour wait targets in Emergency

Department: potential to improve the time to ward admission from emergency

12 hour waits12 hour waits

• On review of August data there is a potential to improve

% patients admitted to ward bed by 12 hours August 2004

0

20

40

60

80

100

% admitted by 12 hours from EDTarget

Priority Constraint Priority Constraint Area 1 – timely access to ward bedsArea 1 – timely access to ward beds

• Significant constraint in timely access to ward beds identified from audit

Emergency

0

20

40

60

80

100

120

140

Ward

bed n

ot

availa

ble

No d

ecis

ion

made to

adm

it/d

ischarg

e

Test re

sults n

ot

ready

Aw

aitin

g

Psych/A

llied

Health S

taff

revie

w

Medic

al re

vie

w

not availa

ble

Oth

er

transport

issues

Type of Delay (1 week period)

To

tal

Specif ic bed not available

Allocated bed not ready

Priority Constraint Priority Constraint Area 1 – timely access to ward bedsArea 1 – timely access to ward beds

• Policy of discharge by 10am not occurring in reality

• anecdotal issues with waiting for – discharge medication– documentation to be completed– transport

1. Tally Charts – Emergency department– Surgical ward (5W)– Operating Theatre complex

• These were refined to focus more precisely on the significant delay revealed with each surveyed period

• Bed access and discharge issues highlighted by tally chart process

Diagnostic work – why aren’t Diagnostic work – why aren’t patient discharged by 10am?patient discharged by 10am?

Tally chart of surgical ward Tally chart of surgical ward delays in dischargedelays in discharge

Surgical Ward

048

121620242832364044

Dis

charg

e

Sum

mary

not

done

Medic

ation

not

availa

ble

OP

D

Appoin

tment

not

availa

ble

Am

bula

nce

transfe

rs

Medic

al

revie

w n

ot

availa

ble

Bed a

t oth

er

hospital not

availa

ble

Oth

er

transport

issues

Type of Delay (1 week period)

To

tal

Pharmacy

Script not written

Coincided with MAS industrial action

2. Process maps: • Emergency department care streams

– ie. short stay patients >12 hours but not admitted patientsEmergency Medical Unit (EMU)Emergency Observation Unit (EOU) patients

• General Medical Patients • Pharmacy discharge medication process• Surgical resident’s day

Diagnostic workDiagnostic work

3. Charts for discharges1. Time of day of discharges – bar chart and SPC2. % patients discharged by 10am

• For medical ward• For surgical ward• Baseline information


3. Time of day of discharges on 9E (medical)


9 East Discharges (August)

0

5

10

15

20

25

30

35

00

:00

01

:00

02

:00

03

:00

04

:00

05

:00

06

:00

07

:00

08

:00

09

:00

10

:00

11

:00

12

:00

13

:00

14

:00

15

:00

16

:00

17

:00

18

:00

19

:00

20

:00

21

:00

22

:00

23

:00

Hour of the Day

Average 14:05Median 14:07

NB: Data may be inflated due to time Ward Clerks are able to d/c patient from system

3. Time of day of discharges on 5W (surgical)


5 West Discharges (August)

0

5

10

15

20

25

30

35

40

00:0

0

01:0

0

02:0

0

03:0

0

04:0

0

05:0

0

06:0

0

07:0

0

08:0

0

09:0

0

10:0

0

11:0

0

12:0

0

13:0

0

14:0

0

15:0

0

16:0

0

17:0

0

18:0

0

19:0

0

20:0

0

21:0

0

22:0

0

23:0

0

Hour of the Day

Average 12:24Median 12:08

NB: Data may be inflated due to time Ward Clerks are able to d/c patient from system

3. Statistical process charts – Time of day of discharges 9E – August 2004


0:00

4:48

9:36

14:24

19:12

0:00

Subsample number

Up/down runs Above/below runs Reset color

Average time = 14:05

3. Statistical process charts – Time of day of discharge from 5W – Aug 04


0:00

4:48

9:36

14:24

19:12

0:00

Subsample number

Up/down runs Above/below runs Reset color

Average time = 12:24

3. Audit of Medical ward• To identify patients ready for discharge, and analyse

acuity level of patients– Patients ready for discharge today

– Patient could go home or to site of regular accommodation but discharge has not been identified for today

– Patient is over the acute illness requiring acute treatment but deemed appropriate for rehabilitation or GEM admission and is waitlisted but a bed is not currently available

– Patient requires or appears to require long term supported accommodation in either a residential care facility or in Supported Residential Services but is unable to go to such facility today

– This patient at no stage in this admission required acute nursing care but was admitted primarily for social reasons



• Results of medical audit in 9E Ready for discharge but delay due to...

0246

81012

tran

spor

t(f

amily

)

tran

spor

t(a

mbu

lanc

e)

Med

ical

revi

ew

Inve

stig

atio

nre

sults

Inve

stig

atio

nto

be

done

Delays

freq

uen

cy

• Bed management meeting: – observed by DHS representative

• Capacity-Demand analysis: – quarterly figures for admissions and discharges

compiled via Patient Administration System per unit


Diagnostic work – identifying Diagnostic work – identifying emergency demand per unitemergency demand per unit

Medicine & Emergency Services - Average Discharges

0.00

1.00

2.00

3.00

4.00

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

DERMATOLOGY EMERGENCY CARE EMERGENCY MEDICAL EMERGENCY OBSERVAT'N

ENDOCRINE & DIABETES GEN. MEDICINE/STROKE GENERAL MEDICINE A GENERAL MEDICINE B

GENERAL MEDICINE C HAEMATOLOGY INFECTIOUS DISEASE NEPHROLOGY

NEUROLOGY NEUROSURGERY ONCOLOGY RHEUMATOLOGY

Neurosurgery – can predict that the unit will need 3 emergency beds on weekdays, 1 on weekends


Specialist & Critical Care Services - Average Admissions

0.00

1.00

2.00

3.00

4.00

5.00


BREAST &ENDOCRINE SG CARDIOLOGY CARDIOTHORACIC

COLO RECTAL GASTROENTEROLOGY HEPATOBILARY/UPPERGI

RENAL LITHOTRIPSY RESPIRATORY MEDICINE UROLOGY

Cardiology – can predict that the unit will need 4 emergency beds Mon-Thurs, 2 on Friday and , 1 on weekends


Surgery & Surgical Services - Average Admissions

0.00

1.00

2.00

3.00

4.00


E.N.T. HEAD & NECK ESAS ORTHOPAEDICS ESAS UROLOGY ORTHOPAEDIC PLASTIC SURGERY VASCULAR

Vascular – may only need 1 emergency beds Mon-Friday and no dedicated bed on weekends

– NUMs/ ANUMs – in-charge nursing staff– Pharmacy department– Doctors– Patient/consumers

• Emergency department• Operating Theatre• Wards (medical and surgical)• Pharmacy

Who was involvedWho was involved

• What were staff reactions: – generally understanding;

– aware that this was important for improvement of care and safety of hospital;

– that SVH under pressure for beds;

– aware that their department was ‘part of the hospital’ and that they needed to participate

– overall extremely positive


• What data/ information was really useful1. Emergency department tally chart – clearly

highlighted bed access issue

2. Statistical Process Charts – to identify exactly what sort of problem we had with discharge times

3. Pharmacy process map – demonstrated duplication of work processes

4. Medical ward audit – demonstrated areas of ‘block’ requiring review

5. Surgical ward tally chart – demonstrated need to review medical work processes


Improvement PlanImprovement Plan

• Overall Aim:– To ensure 95% of patients at St

Vincent’s emergency department are admitted to a ward bed within 12 hours

• Sub-aims:– To achieve 75% of patients in

St Vincent’s Health discharged by 10am


• Whole of hospital approach:– Areas we are tackling within this project

1. Medical wards – event driven discharge2. Surgical wards – work process of junior medical staff3. Pharmacy department – work processes of pharmacy

staff (listed in orange)

– Areas we have identified that are beyond the initial scope of the project1. EMU/EOU review2. Consideration of transit lounge3. Consideration of bed management process review4. Medihotel review (listed in green)

Admissions from the Emergency Department

Emergency Department

Emergency Medical Unit

Emergency Observations

Unit

Medical Ward

Surgical Ward

Transport

Transit Lounge

Subacute Facility

Intensive Care Unit

Beyond scope of

initial project

Beyond scope of

initial project

Bed Management Processes

Pharmacy

Beyond scope of

initial project

Beyond scope of

initial project

1. EVENT DRIVEN DISCHARGE

2. JMO TO THEATRE

AFTER DISCHARGE COMPLETED

3. PHARMACIST COMMENCE 0745 HOURS

Bed capacity

affected by ward bed

status

Medical wards – Medical wards – Event driven dischargeEvent driven discharge

• Aim: Streamlining discharge process to facilitate discharge prior to 10am

• Medical staff identify patients potentially ready for discharge in next 24 hours

• Medical staff identify key criteria for patient’s discharge – – eg if respiratory patient afebrile and O2sats >95% patient

can be discharged by nursing staff without medical review

• Discharge script written and dispensed day prior

• Transport organised day prior etc

Surgical wards –Surgical wards –Commence theatre after discharge Commence theatre after discharge completecomplete

• Initial discussions with consultants of units on surgical ward (5W)

• Resident staff to complete all discharge summaries/ medications prior to going to theatre

Pharmacy departmentPharmacy department

• Discussions with pharmacy department to consider commencing at 0745 hrs

• To prepare medications for discharge• Will monitor –

– Number of discharge scripts written by 0745 hrs

– Number of interventions required

ProgressProgress

• Medical wards keen to commence Event driven discharge

• Surgical wards keen for surgical residents start in theatre after completion of discharge

•

• Pharmacy department will trial early commencement for two weeks and review

• Consideration of best use of Capacity-demand analysis

Lessons learntLessons learnt

• Root cause of delays need to be identified before any meaningful intervention is tackled

• Systems and processes need to be considered from different perspectives– Eg commencement times of surgical resident in

theatre– Medical review prior to discharge– Pharmacy commencement times

Desired Impact 1Desired Impact 1

• Medical ward - Event driven discharge

– improve effectiveness of discharge process– Pharmacy receive scripts the day before– Transport booked the day before– All home supports organised the day before– Patient able to be discharged by nursing staff on

day of discharge as per medical staff parameters

• Ultimately, patient discharged by 10am


• Surgical ward – improve effectiveness of discharge process– Pharmacy receive scripts the day before or early

on day of discharge– Medical staff complete discharge summary early in

morning of day of discharge– Improve ‘quality’ of discharge ie complete

discharge summary on day of discharge to send to GP



• Pharmacy hours – Pharmacy department able to collect and prepare

discharge scripts early– Pharmacy able to educate patients early on day of

discharge


Overall Desired ImpactOverall Desired Impact

• The combination of all three interventions:– Will increase the number of patients discharged by

10am– Will decrease the time of day that patients are

being discharged– Will free-up ward beds for admissions from the

emergency department– And will ensure that 95% of patients in the

emergency department are admitted to a ward bed by 12 hours

Next StepsNext Steps

• Evaluate effectiveness of pharmacy opening hours following 2 week trial

• Trial Event driven discharge for 4 weeks and evaluate

• Trial surgical residents commencing in theatre after discharges complete

• Consider implications of capacity-demand data

Questions?

[email protected]

[email protected]

[email protected]

mailto:[email protected]





The Northern Hospital

Edwina Harding

Organisational Constraints Organisational Constraints

• Discharge processes / timeliness of consultation

• Family Issues

• Referral Processes / timeliness of consultation

• Access to external resources

• Access to internal and external diagnostic investigations

Priority ConstraintPriority Constraint

Discharge Processes

•Notification of discharge

•Discharge letters / summaries

•Scripts

•Discharge medications

•Family issues

Post discharge medical record audit:

Identify documentation of a discharge date a

day or more in advance of the day of

discharge

Result - 46%

DiagnosticsDiagnostics

Timed the steps of the discharge process

• Communication of discharge decision

• Discharge documentation (script, letter etc.)

• Discharge medications

• Discharge assessments

• Family (notification, pickup etc.)


Medical results• approximately 58% of scripts written at time of

discharge decision (approximately 3hrs post discharge decision for the remainder)

• up to 4 hours for discharge medications• up to 4 hours for the family to collect patient

Surgical results• most discharge scripts and letters were written at

time of discharge decision.• up to 1.5 hours for discharge medications


Discharge medication delays

Scripts• Incorrect, incomplete, required clarification• Missing patient data – concession card, DVA card,

pensioner details, safety net card or destination

Results• 180 occasions pharmacists had to liaise with medical

staff• 188 occasions pharmacists had to find additional patient

data• 44 occasions of ‘waiting’



• Implement an additional medical unit to improve medical consultation and workload

• Document proposed day of discharge in medical record• Map process steps for patient data collection • Implement additional patient data collection on admission

(concession cards etc)• Enable transfer of electronic data between ‘systems’ i.e.

PMS – STOCCA• Update the patient information brochure• Develop an admission checklist• Review process for scripts to be written the day

prior to discharge

ProgressProgress• Process mapping

• Admission checklist

• Participation in the HealthSmart project

• Upgrading of pharmacy software for PBS

• Patient brochure reviewed and updated

• Prompt sheets to assist with the collection of concession card

data • Education of medical staff re: documentation of proposed

discharge date

ProgressProgressPartial implementation of additional medical unit

• Fixed receiving days• Post ‘take’ ward rounds

Require funding for full implementation• New Consultant positions• Increase consultant hours in other units

Results (compared to the same time 2003)

• Reduced LOS for July & August 2004• Reduced 12 hour waits for July & August 2004 • Fewer patients per unit

Desired ImpactDesired ImpactMinutes and hours

Organisation • Reduction in multi-day stay Length of Stay• Reduction in 12 hour waits• Reduction in Category 2 and 3 elective

waiting list

Next StepsNext Steps• Source additional funding

• Revise the Registrar handbook

• Continue education and feedback

• Implement writing of scripts day prior to discharge

• Measure• Post discharge medical record audit

• Repeat pharmacy audit

• Evaluate

Questions

?



Colin Pearson Emergency Department Physician – Angliss Hospital

Summarise Organisational Summarise Organisational Constraint areasConstraint areas

• Patient length of stay in ED longer than 8 hours

• Transfer process between ED and Wards

• Waiting list Category 2 patients and Hospital Initiated Postponements.

Summarise Priority Constraint Summarise Priority Constraint Area 1Area 1

• To identify constraints to patient flow within the ED for admissions to inpatient beds.

Diagnostic exercisesDiagnostic exercises

• Examining two years of data from an existing database of reasons for ED LOS>12 hours collected by the nursing coordinators.

• Collation and analysis of data on time from presentation to bed request and the distribution of these requests over the day.

Diagnostic exercises (2)Diagnostic exercises (2)

• Collection and evaluation of data on time from bed allocation to transfer to ward with comparisons between wards and time of day.

• Review and analysis of medical records for reasons causing delays identified in the above data.

Diagnostic exercises (3)Diagnostic exercises (3)

• Development and introduction of a proforma to collect real time data on ED LOS >8 hours prior to admission

• Analyse medical decision-making processes within the ED

Who was involvedWho was involved

• Clinical project/area team comprisedBed managerED nurseED doctorMedical ward nurseSurgical ward nurseIT manager

staffs reactions/ cultural staffs reactions/ cultural aspectsaspects

• Several incidents had contributed to disharmony over the ED/ward patient handover process. Staff wanted an improvement and ready to embrace change viewed as improvement.

• ED staff keen to prove perception that access block a major contributor to LOS

staffs reactions/ cultural staffs reactions/ cultural aspects (2)aspects (2)

• Communication of goals of project at relevant forums

• Representatives of each involved area to drive project

• Promotion of project at meetings, posters, prizes

• Encouragement of feedback• Prompt attention to issues

data/ information that was data/ information that was really usefulreally useful

0

10

20

30

40

50

60

No. of incidences

Unable totransfer

Delay in CT

No bed

Delay incontactingspecialistChange inclinical state

Unable totransfer

Delay in US

data/ information was really data/ information was really useful (2)useful (2)

• Feedback from staff and a freehand section on the proforma suggested the patient transfer process contributed to LOS

Total Time Differences: Arrival - Transfer

0

300

600

900

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug AV

Available/Transfer

Allocated/Available

Request/Allocation

Arrival/Request

Times from presentation to Times from presentation to bed requestbed request

Arrival/Request

0

50

100

150

200

250

300

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Adjuncts to decision-making Adjuncts to decision-making processes (1)processes (1)

• Active supervision by senior ED medical staff

• Availability of senior ED medical staff to discuss issues

• Nursing staff encouraged to raise management plan issues

• Regular patient rounds

Adjuncts to decision-making Adjuncts to decision-making processes (2)processes (2)

• Computer system alert to bed manager activated by extended LOS

• Junior doctors handover patients to a more senior doctor

• Improved documentation of management plans within the ED medical record, checked through periodic audits

data/ information that did not data/ information that did not helphelp

• Proforma data potential for collection bias Seasonal factors contributed to access

block

data/ information that did not data/ information that did not help (2)help (2)

• Limited value in retrospective analysis, real-time provides better information

• Nursing coordinators database overly complex and poorly utilised


• Reduce LOS by tackling the constraints identified

• Improve decision-making processes within the ED

• Improve understanding between ED and the wards with each appreciating the others workloads and priorities

• Revamp nursing coordinators data collection

progress so farprogress so far

• Introduction of proforma, promotion via flyers, presentations; collection and analysis of data

• Reduced conflict over the ED/ward handover process

What was trialledWhat was trialled

• ED nursing staff escort patients to ward – well accepted in first 2 weeks and to continue

• Bed coordinators database reviewed and now free text field

Graph of median time from bed Graph of median time from bed availability to transfer before and availability to transfer before and after trialafter trial

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

Pre Post

Hours

Graph of average time from Graph of average time from availability to transfer before and availability to transfer before and after trialafter trial

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Pre Post

Hours


• Most gains from reducing access block which is outside of the ED’s control.

• The dominance of access block as a constraint in this period skewed any interpretation of statistics on time to bed request, time to transfer and their distributions over the day.

• Listen to the staff.

Desired ImpactDesired Impact

• Focus on strategies to increase the availability of inpatient beds


• Foster a culture of cooperation, each unit appreciating the others workload and priorities.

Questions

?

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


Team Presentations

Peter Bradford and Ruth Smith

5TH October 2004

Concurrent Session 1Concurrent Session 1Team PresentationsTeam Presentations

Bellarine Room 5– Royal Victorian Eye and Ear Hospital– Melbourne Health– Barwon Health– Austin Health



Margaret Balla Director Clinical Governance

RVEEH

Organisational Aim: Organisational Aim: OutpatientsOutpatients

• To minimize the impact of disease through timely, accurate, co-ordinated, appropriate and equitable management of episodic care and chronic disease. (VOBG)

4 Critical Success Factors:4 Critical Success Factors: Outpatients Outpatients

• Management of new patient waiting list

• Management of ongoing review patients

• Management of clinical staff

• Management of Failed to Attend

External Constraints: Outside External Constraints: Outside control of Health Servicecontrol of Health Service

1. Distribution and allocation of services

2. Funding policy

3. Different Health Service methods to manage referrals and services

4. Primary care sector management of chronic disease

5. Referral to multiple waiting lists

6. Professional’s view of outpatients

External Constraints: Outside External Constraints: Outside control of Health Servicecontrol of Health Service

Serious impact on management of:

• waiting list

• clinical staff

• Failed to Attend

Organisational Constraint Organisational Constraint AreasAreas

• Outpatients

1. Referral to Outpatients

2. Access to Outpatients

3. Outpatient day of appointment

Organisational Constraints: Organisational Constraints: Within control of Health ServiceWithin control of Health Service

1. Referral to Outpatients

• Appropriateness

• Acknowledgement response time

• Time to appointment


2. Access to Outpatients

• New to review ratio

• Post op visits per specialty

• Pts discharged

• Clinic Utilisation

• Failed to Attend


3. Day of appointment access

• Preparation of history

• Clinic capacity and staff resources


• Manage Failed to Attend – Policy to ensure clinical risk managed

• Manage referral and multiple waiting lists– Through Memorandum of Understanding with

GPDV develop and implement guidelines

• Identify likely non attendance – Telephone contact call with patients– Waiting list audit– Appropriate notification which is through patient

consultation for time of appointment

Progress: 1. Progress: 1. Referral to OutpatientsReferral to Outpatients

External Referral acknowledged:

99% w/in 1 work day

Urgent patient appointment:

100% at next clinic

Patient sent routine appointment letter:

99% w/in 1 work day

Progress: 2. Progress: 2. Access to OutpatientsAccess to Outpatients

Time to next routine appointment:

85% w/in 8 months

New to review ratio: 1 new to 4 review Specialty dependent

Post op cataract consults: reduced from 4 to average 3

New Fail to Attend: reduced from 8.5% to 6.7%

Progress: 3. Progress: 3. Appointment day accessAppointment day access

Time from arrival to end of consult:

Currently being audited

Preparation of history: 95% ready on morning

Clinic capacity and staff resources:

Currently being audited


• Some things outside control of health service

• Internal systems can be improved by team effort

• Sustainability through continuous monitoring of systems

• Patients have high level of tolerance for poor service.


• To influence the appropriate and equitable management of episodic care and chronic disease


• Policy of Failed to Attend

• Reduce delay in clinic start and finish time

• Provision of detailed reports on specific variables to clinical staff

• Monthly meetings between clinical staff and clinical unit heads

• Ensure that medical roster matches demand

Questions

?



Melbourne Health

‘‘Improvement Areas’Improvement Areas’

• Bed Availability

• Acute – Subacute

• Clinician Communication

• Emergency

• Operating Theatre

• Radiology

““Bed Availability”Bed Availability”

• Initially formed to work through issues around discharge and admission processes.

• Found crossing over other groups work therefore rationalised.

• Processes for actual discharge – leaving hospital bed – home, etc not clear

• Bed access for ED blocked• Communication b/w regional hospitals & waiting

for interhospital transfer poor• Boarders – created delayed care • Patient movement through the organisation

delayed due to bed occupancy / availability not communicated.

Issues identifiedIssues identified

Opportunities for Opportunities for improvementimprovement

Following the diagnostic phase it was decided to concentrate on:– Unit / Ward round communication and decision-

making.– Bed availability for admission of patient to ward

bed. Admission & Discharge time mismatch.

Current actions being Current actions being undertakenundertaken

New working group convened to develop:

• specifications and recommendations for ‘real time’ bed occupancy tool.

• Discuss and develop predictive capacity & demand function

• Changes to process requiring potential role redesigns.

“ “Acute Subacute”Acute Subacute”

Diagnostics Undertaken

1. Patient journey mappingGeneral medicine patient from Ed through general medicine and to GEMOrthopaedic patient through to Rehabilitation

2. Preadmission Process mapping

3. Analysis of the acute long stayers that are waiting sub acute.

4. Comparison of LOS in the sub acute to state average LOS

5. Audit of all sub acute patients to ascertain what is keeping them in an inpatient bed

6. TRAC process and KPI’s

7. Process of documentation between each campus

8. The referral admission and bed management process between the acute and the subacute

Issues IdentifiedIssues Identified

• There is no integrated model or clinical plan starting at commencement of acute phase.• Each segment works within its own pod.

• Bed management is not based on a clinical plan, it is a disjointed process between two separate units.

OpportunitiesOpportunities forfor improvementimprovement

• Acute LOS of ‘out of area’ sub acute patients compared

to patients that go to MECRS is 32 days compared to 20 days

• Patients with the greatest LOS have special needs.

Recommendation• 1. Consultant to consultant approach to the sub acute

facilities. • 2. MH residential care to develop plan to

accommodate these patients.

OpportunitiesOpportunities forfor improvementimprovement

• LOS for both GEM and Rehabilitation are both above

state average• Patients admitted from community do not all require

inpatient management.

Recommendation

1. Implement the new model of care when developed

2. Continue the increased Allied Health input

3. Implement a meeting to develop plans for the MECRS long stayers beginning with the 60 day LOS

4. Geriatricians to triage community referrals and home visits when appropriate.

Recommendations Recommendations ImplementedImplemented

•Criteria for admission to the Aged and Rehabilitation wards at MECRS.

•Care Coordinators in emergency can now make Aged care referrals

•Encouragement of early referrals to TRAC for consultation on overall care.

•Discharge date and patient goals to be established and documented within 48 hours of admission to sub acute

Pending implementationPending implementation

•Development of clear communication channels between the acute and sub acute

•Investigations of Admissions on the weekend to sub acute

DesiredDesired ImpactImpact• Model of care for the aged person admitted to

Melbourne Health • Intermediate term

– reduced length of stay in the sub acute – A tailoring of MH residential care facilities to meet

our patients needs – Increased use of sub acute ambulatory services– Transparent communication between the acute

and sub acute– integrated bed management system across the

acute and sub acute

MajorMajor MeasurementsMeasurements

Measurement

Four major measurements 1. Acute LOS for patients needing sub acute care 2. LOS for the Inpatient stay in sub acute 3. LOS for the whole episode of care across the

continuum 4. Quality of care measurement to be developed Process KPI’s will be used to measure new processes


• Need to come back to the basic principles

• Some times there needs to be a whole system change

• Resistance to change is usually based in fear which leads to defensiveness

““Clinician communicationClinician communication””

• Clearly identified as a major problem with almost all initial diagnostics

• Not just between clinicians but also within units

• Hoping to understand how referrals are made and unit expectations

• Establish clear lines of communication

• Intra-unit communication– Access to senior staff, especially VMOs– Timing of ward rounds– Lack of multidisciplinary approach– Discharge planning

• Inter-unit referrals (also from ED)– Accessibility of registrars/consultants– Clear question imperative

IssuesIssues identifiedidentified toto datedate

Issues identified to dateIssues identified to date

• Discharge process after hours/weekends– Sunday discharges, timing on Monday– waiting for services– Lack of senior staff input (review of “sick” patients

only)

• Staff rosters/leave management– Constantly changing, no central (web) data base– HR process of leave notification– Clinician availability

FurtherFurther DiagnosticsDiagnostics

• Medical unit audit of referrals– Preliminary data (37 patients)– Roughly half seen by consultant *Clearly added to LOS

• Mapping of consultant ward rounds– Communication of decisions


• Improving referral processes– Back up procedures

• Ward round communication/coordination

• Sunday discharges

• Accurate rosters, streamlining of notification of leave


• Survey of unit heads, NUM’s and registrars– Process in place for referrals and access to consultants,

expectations etc…– Asking for suggestions

• Interview switch board/HR/IT– Intranet based roster

• Review of Monday discharges– Reason for delay (if there was one)

• Trial of Friday afternoon meeting for the multidisciplinary team to plan weekend discharges

• Change to Surgical registrar role & responsibilities on Sunday.

““Emergency”Emergency”

• Brief – To review internal ED processes, using the rigorous,

multifaceted diagnostics method– To evaluate flow improvement opportunities

• Why– ED is the principal feeder stream of predictable patient

inflow at RMH

• Referral Delays (including time to bed request)

• Matching Staff Resource with clinical demand

• Sub optimal Clinical Area Communication – internal/external, written/verbal

• Excess Waiting Time for Cat 4 and 5 patients

• Unnecessary Triage Enquiries Excess queuing & delays in waiting times

Issues identifiedIssues identified

Referral Delays (including time Referral Delays (including time to bed request)to bed request)

• Service agreement with units• Schedule of registrars• Up to date rosters • Reinforce roles of floor consultant

Matching Staff resource Matching Staff resource with clinical demandwith clinical demand

• Roster review

Sub optimal Clinical Area Sub optimal Clinical Area CommunicationCommunication

• Communication clerk• Patient status viewer• Medical orientation• Organization wide communication

Excess Waiting Time for Excess Waiting Time for Category 4 and 5 patientsCategory 4 and 5 patients

• Extra triage nurse (multi-skilled) train up existing staff

• More information about GP clinics especially after hours

• Triage & fast-track team to include triage nurse, FAN and ED Consultant or Reg

• Forward assessment nurse in afternoons

Unnecessary Triage Enquiries Unnecessary Triage Enquiries Excess queuing & prolonged Excess queuing & prolonged waiting timeswaiting times

• Review physical layout, signage, initiate departmental signage / flow review

““Operating theatre Operating theatre access”access”

• Access to emergency and elective operating identified as a major issue – Emergency patients waiting for emergency

theatre access filling inpatient beds– Intention to improve the flow of emergency

and elective patients to and from the operating theatre

• Major issue is access to theatre for emergency cases• - Mean delays of over 2 days for cholecystectomy and TURP

• Majority of surgical emergency admissions from midday to 10 PM

• Delays due to - Operating room availability- Staff availability

- In hour VMO availability- Nursing

- Recovery room block

Issues identified to dateIssues identified to date


• Twilight operating lists• Improving emergency surgery booking

system - ? on-line system• Unit based care for surgical emergencies

– all day operating lists

• Utilisation of spare time in elective lists• Availability of emergency theatre• Improving utilization of actual session time.


Twilight operating lists Assessment of possible time changes

Emergency booking system

Improvement of current data collection for theatre bookings

Emergency surgery demand

Collection of data of emergency admission timesComputer modeling of emergency theatre requirements according to demand

Unit based care Improving processes for management of patients by appropriate units

Impact of loss of quarantined beds on elective through-put

Comparison of elective admissions with and without quarantined beds

Improving utilization of actual session time

Late startsRecovery room block

““Radiology Coordination Group”Radiology Coordination Group”

Organisational Anecdotes...

• Waiting for radiology examination/results

• Radiology Transport delays

• Radiology booking processes (forms/criteria)

• Communication between wards & radiology

• Delays on weekend/out of hours.

• Total Turn-Around-Time (7 day/ 24 hour data collection)

• In-patient Transport Study

• Outpatient clinic film/ report audit

• Ward audit (patients waiting for radiology)

Diagnostics UndertakenDiagnostics Undertaken

Inpatient Turn-Around-Inpatient Turn-Around-TimeTime

InpatientInvestigations

Receive toExam

Exam toDictation

Dictation toTranscription

Total Turnaround Time

General x-ray(n=119)

3h 30m 5h 55m 16h 31m 31h 14m

Mobile x-ray(n=118)

20m 3h 50m 3h 52m 7h 56m

CT(n=81)

3h 3h 4m 5h 9m 25h 15m

Ultrasound(n=33)

4h 1h 30m 18h 31m 26h 30m

MRI(n=22)

2h 35m 6h 53m 10h 3m 26h 30m

Angio(n=18)

6h 45m 2h 37m 18h 35m 27h 30m

Fluoro(n=17)

6h 34m 19h 1m 26h 48m

(h=hour, m=minutes)


• Radiology patient transport (weekends)

• Decreasing delays between exam and dictation

• Decreasing delays between dictation and transcription

• Decreasing number of unreported films

Current and proposed Current and proposed actions...actions...

ACTION StatusWeekend Radiology CA.Also explore feasibility oftransport nurse

Currently in week 2 of a 6week trial period.

Weekend transcription(remove Monday backlog)

In development

Explore feasibility of 7-dayRadiologist cover(ie. Sunday consultantradiologist reporting)

In discussion

PACS Ongoing discussion

Education for ward nursingstaff re radiology patientpreparation requirements.

Yet to commence

P r e l i m i n a r y R e s u l t sP r e l i m i n a r y R e s u l t sW e e k e n d C A t r a n s p o r tW e e k e n d C A t r a n s p o r t

I n p a t i e n t T r a n s p o r t B e f o r e P F C A f t e r P F CT i m e t a k e n b e t w e e nr e q u e s t f o r e x a ma n d p a t i e n t a r r i v i n gi n r a d i o l o g y( W e e k 2 r e s u l t s )

3 6 . 9 6 m i n( r a n g e 5 – 2 1 0 m i n )

1 5 . 8 m i n( r a n g e 5 – 3 0 m i n )

( W e e k e n d R a d i o l o g y C A t r a n s p o r t e d 2 2 i n p a t i e n t s i n a d d i t i o n t o a s s i s t i n g w i t he m e r g e n c y p a t i e n t t r a n s p o r t )



John MulderExecutive Director OperationsDeputy CEOChairman, Patient Flow Collaborative

Barwon Health

Summarise Organisational Summarise Organisational Constraint areasConstraint areas

PriorityAreas

Process Maps Brainstorming Tally Charts Consumer Interviews

Program Measures

1Medical Officer Assessment ED

Patient waits up to 2 hours for ED MO assess in Ed

MO review delayed Patients LOS in Ed increased. Need r/v to commence Treatment

22% pt wait >1 hr for ED MO assess. 12% wait over 12 hrs

No problem realise lots of people before me, felt like a long time

High variability in Ed wait times for admitted patients

2Pt waiting for Diagnostics MI

ED – MI delayBatching, no priority system, transfer system halted

Delayed patient transferLong delay to call patientCan’t find x-ray

Patients wait up to 90 min for x-ray,

Please Dr wants to find out more. Professionally carried out.

15-32% patient LOS ED > 6 Hrs

3Cardiac Patient Flow

Consultant -discharge readiness. Delay scripts,Test results etc

medication not ready.Pt waits medical review, test reults

Patients discharged after 1500 hrs.

Explanations have been comprehensive

LOS Medical. 80% of pts at this hosp had a LOS b/w 1-7 days.

Summarise Priority Constraint Summarise Priority Constraint Area 1Area 1

1. Medical Officer Capacity – Medical and Surgeons

• Within Barwon Health current systems, the delays in the patient journey depend on the availability and capacity of medical officers.

a. Patients waiting in emergency for assessment by emergency medical officer

b. Patients waiting for outpatient appointmentsc. Patients waiting for theatred. Patients waiting for receiving unit medical officer to

review patients to confirm admission

Process MapProcess Map

Patient arrives in EDTriage – Category 3-4#NOF

Patient allocated to cubicle

Nursing Assessment, IV insertion, bloods taken

MO assesses Patient

Time 30min to 2 hours

MO writes Clinical notes orders Xray and bloods

Patient to X –Ray

30 minute – 3 hours

X Ray review by MODecision to Admit, bed request

Ortho Team Contacted

Bed Allocation

Medica and Ortho Team Review Patient. Policy to expedite pt to ward if >2hr not applied

Admission to inpatient bed

HOURS

Theatre Booking by Ortho team Allocation of Surgical time 1-24 h

Transferred to OR30-90 min Review by Anaesthetist

DelayStaffResourcesProthesis

PACU 30min-2HoursTransferred to Ward

Delay Porter, RN availability

Pathway Level 1.2 obsPhysioOT

Services if required? Rehab in the HomeOT home assessment

Recovery - Wellness

Rehabilitation

Home

Nursing HomeLOS

Wait time Sampling needed





Batching, no priority system, , porter delay, handpassing

Tally SheetTally Sheet

Reasons for patient waiting in Emergency Department July 2004 (one week of data)

132

193

18

0

50

100

150

200

250

Pt to bubicle Nurse avail to assess pt Time to ED MO ini.assess Inpatient review delay Bed Block

Reason for Delay

Tota

l nu

mb

er o

f p

atie

nts

Order tests

Review management plan Liaise Write Pt notes 2- 3 m

inu te

s

Process Map Medical Officer Process Map Medical Officer in Emergency Departmentin Emergency Department

Check list of patients, select patient

Print notes for patient

Take pt history/ Examine

Discuss management with patient, family, and nurse

Discharge

5

min

ute

s

1-40

m

in

Consult with admission team registrar/ consultant

Place sticker in book

Page nurse,Wait for nurse

Tell nurse

Transfer process

Staff ProblemRoster changes not shownWrong dr. on roster,Dr not avail to phone, in theatre, OPD, ward round

Bed not avail.Pt remains in Ed >12 hrsDr interrupted with ongoing management issues

Suturing

22 minutes

Flow interruptions – any point in process up to 5 minutes •Supervision or need for supervision•Patient not in cubicle•Patient not in correct area•Time to get equipment not avail in cubicle•Interrupted with care of patients allocated to others•Interrupted with care issues of patient allocated to self•Setting up for procedures•Whilst doing procedures•Whilst walking to check x-ray•Walking to get equipment•Phone use•Writing up notes

What do doctors do in ED?What do doctors do in ED?

051015202530354045

Han

do

ver

HM

O S

up

ervi

sio

n

6 P

atie

nt A

sses

smen

ts

3 P

atie

nt R

evie

ws

Su

ture

sR

ou

nd

s Tr

iag

e N

seL

iais

e M

O o

ther

Pt i

n in

corr

ect r

oo

m

Join

t ass

ess

HM

OP

ho

ne

Pat

ien

t no

t in

cu

bic

le

Nu

rse

dis

cuss

ion

Dia

gn

ost

ics 45% Pt care

20% Teaching Learning35% interruption

Patient Carers and relative Patient Carers and relative viewsviews

Seeing a medical officer

Checked me up, gonna keep me in, name band on already. (ED) Being assessed by a

Medical officerHe found what I know for myself, he’s alright, checked everything.

Waiting to be seen by MO in ED

Not waiting too long, maybe 5 minutes. I was sent here by GP.

Having a medical officer order test to find out what is wrong

Blood test done on Saturday, X-ray today was planned as outpatient, but GP sent me here today, and they gonna do here.

Being told by the medical officer what was wrong

Will tell me what’s wrong when get results of test, going to check prostate, don’t get bleeding, I had ½ litre before Christmas but low again, have been low all my life. (ED)Can’t recollect what he said, he’s probably broken his arm (mother in ED)

Being told by the MO about my treatment..

Has had x-ray and put in drip, given something for pain, going to talk to the bone surgeon.(mother ED)


Innovation Possible outcome

Problem type

Rate of Difficulty

Cost

Equip in treatment room

+ 6 pt in 24 hrs

Culture – nurse as handmaid

Medium nil

Pt in cubicle (volunteer, alter Ward Clerk Priority)

+ 5 pt in 24 hrs

Wd clerk’s data entry

Small Nil

Diagnostics ready screen

+26 Pt/day

IT, culture,Need big screen

Medium $2,500

Microphone in Fishbowl

+2 pts day

Cultural Small $40.00


• Streaming in Emergency– Site visit to Flinders arranged for October

2004– 24 hour bulk billing GP clinic for the

hospital, to service 38% of presentation to ED that require GP care. Application stalled by the Commonwealth Government, who are providing incentives for local doctors to bulk bill (Geelong News, August 25th).

ProgressProgress

• The Clinical Team is meeting every two weeks to consider the rigorous diagnostics and to oversee the project.

• When the initiative to be undertaken has been agreed the following questions will be answered.– What was the outcome?– What was trialled?– How many patients were involved?– What staff were involved?


• 90% of patient’s journeys through the emergency department will be 6 hours or less when they do not require admission to hospital.

• 95% of patient’s journeys through emergency will be less than 12 hours when they require admission to hospital


• The clinical team will determine which initiative they will undertake

• The team will present their proposal to the steering committee

• The team will undertake the initiative

Area 2Area 2

2. Medical Imaging Delay• Patient experience delays in emergency, outpatient

and inpatient care.a.Patients waiting for diagnostics

Process MapProcess Map

Time and Date stamp on slip by office staff

Request information entered into data base on computer

Plain X-ray from ED

Slips placed in box at front office by ED orderly

ED requests appear like all other requests, all incoming requests placed in this box

U/S or C.T. request sometimes in this box

Patient may require more than one examination eg Nuclear medicine – if this is done first, other exams such as x-ray / ultrasound. Slips in different departments, conflict cannot be detected.

Office staff locate previous films in film bag, bring whole bag to …..??

Office staff walks specialty slipt to specialty areas

Slips placed in box for radiographer, box light put on

Radiographer sees slip in box, looks at x-ray request and places in one of three “pending” boxes 10 metres away

When radiographer has time, picks up slip and rings the ward clerk in ED to notify that patient needs to be transferred to MI for x-ray

Radiographer goes to waiting bay and collects the patient and the x-ray film bag (if present)

Radiographer goes to get a slide sheet

Radiographer calls another radiographer to help position the patient

Radiographer gets the patient changed

Radiographer removes body piercings

Radiographer hands patient back to ED to get changed and remove body piercings

Call ED orderly for transfer

Radiographer waits for the clerk to call an orderly to transfer patient

Patient arrives with ED orderly and the medical record is placed in the “Patient Here” box

ED orderly turns on the patient here light

Radiographer picks up request

If request does not contain adequate clinical notes, radiographer contacts ED MO

4 h o u r d e l a y

Radiographer develops the film in the dark room

Radiographer labels the film and puts their initial on film in dark room

Radiographer enters details into the computer program, may change the examination description entered by the reception

ON the RIS system the radiographer enters the QD film

Print the stickers for film bag

Wheel the patient and film bag back to patient waiting bay

Find film bag15 min

Previous film may be in ED

May have multiple film bags – x-ray, CT, U/S

Slide patient back to trolley5-20 min

Radiographer rings ED and say the patient is ready to be taken back to ED

General x-rays go back with the patientSpecial x-ray eg CT/US/MRI stay in department for reporting

Slip is placed in the box next to the computer

What if:Video surveillance of waiting bay 1Radiographer sees slips in Ed on clips 2ED nurse/clerk sees MI waiting bay, patient is ready for return

Film retrieved by BMI for reporting from the ED outbox in ED by ?????. (Assumed these are finished with)

Slip moved to filing box of unreported slips

Wrong films in bag

Patient has taken x-rays home

?

Tally Tally ED patient journey through Medical Imaging

0:02

0:06

0:09

0:17

0:16

0:03

0:21

0:08

0:00

0:02

0:05

0:08

0:11

0:14

0:17

0:20

0:23

1

Tim

e (h

ou

rs a

nd

min

ute

s

Request to ED Desk Request to radiologist;s page reponse Time to move slip from ED to MI

Time for patient to arrive in MI from call Time from arrival to xray completion Time from x-ray completion to waiting bay

Time ED notified Time for patient collection from WB

Tally Tally ED patient readiness for x-ray

0

20

40

60

80

100

120

140

Patient on slde sheet (57/193 required) Patient in gown (143/198 72% required this) Metal/jewellery removed required by 123/18666%)

Constraints in MIConstraints in MI

1. Conflicting demand between outpatients, inpatients and ED patients

Innovation - Emergency MI Services– Radiographer, PSA, and room suitable for trolleys

with moveable table, auto exposure and CR

2. Patient transport system b/t MI and EDInnovation – Communication system and all ED patients on slide sheet, PSA carry mobile phones, light switch to let ED PSA know patient is ready to go back

Constraints in MI con’tConstraints in MI con’t

3. Quality of equipment– Innovation – replacement room

4. Non- required x-rays– Innovation - Protocol development OR

Order system with traffic lights for authorising x-rays

Patient Carer and Relative’s Patient Carer and Relative’s viewsviews

Having tests to find out what was wrong…

NIL (ED)I was concerned he may have an anaphylactic reaction (ED)

Having a medical officer order test to find out what is wrong…

Blood test done on Saturday, X-ray today was planned as outpatient, but GP sent me here today, and they gonna do here.

Out of Hour Process MapOut of Hour Process MapNO reception

ED MO pages Radiologist for each x-ray

Radiologist in ICU

Radiologist already doing x-ray

Same process for urgent and non-urgent x-rays

ED can wait 5 – 30 minutes for respond phone call

Different paging

process,

defining nature

of call, so

radiologist

knows whether

to stop current

work to ring

back urgently

Sometimes slips batch up in ED and 6 patients are waiting for x-ray

ED orderly takes slips to MI

Radiographer rings ED ward clerk and request patient to be brought to MI

Radiologist requests that the patient be brought to MI

Radiologist looks for previous films

Radiologists puts the request into the database on the computer

An inpatient / GP requested x-ray may take precedence if requested earlier

Processing request may delay patients x-ray

Radiologist may wait for adequate size x-ray room availability before calling for patient

MO from ED may phone and ask radiologist why x-ray not done

Can’t find films

Only 2 radiographers on evening shift

Request from: ICUSpecial care nurseryCTWardTheatrePrivate HospitalGPsGPS

Thea

Per day process

Con’tCon’t

Same process for urgent and non-urgent x-rays

Different

paging process,

defining nature

of call, so

radiologist

knows whether

to stop current

work to ring

back urgently

Sometimes slips batch up in ED and 6 patients are waiting for x-ray

ED orderly takes slips to MI

Radiographer rings ED ward clerk and request patient to be brought to MI

Radiologist requests that the patient be brought to MI

Radiologist looks for previous films

Radiologists puts the request into the database on the computer

An inpatient / GP requested x-ray may take precedence if requested earlier

Processing request may delay patients x-ray

Radiologist may wait for adequate size x-ray room availability before calling for patient

MO from ED may phone and ask radiologist why x-ray not done

Can’t find films

Only 2 radiographers on evening shift

Request from: ICUSpecial care nurseryCTWardTheatrePrivate HospitalGPs

Per day process

Issues identified Issues identified

• There is no Emergency Specific Radiographer.• In hours and out of hours systems are

different, but the clinicians work around the clock and get the systems confused.

• Impact of MI services to other services• Lack of priority system• Patients are not on slide sheets and often

need to be changed and take of jewellery once they get into the x-ray room

Progress Area 2Progress Area 2

• Rigorous Diagnostics have been completed – What was the outcome?– What was trialled?– How many patients were involved?– What staff were involved?


• Describe lessons learnt• Waiting for MI to be ready to participate

has led to a “whole of department” readiness to participate in the collaborative process.

Desired ImpactDesired Impact• To decrease the amount of time ED patients

requiring MI will journey through MI.• Improved communication between ED and MI.

Eg MI participation in the functional plan for ED Dept.

• Red, Yellow and Green system for MI requisitions

• Dev. Of protocols to decrease unnecessary x-rays.


• The Medical Imaging Clinical Team is preparing their summary of diagnostics in readiness for presentation to the steering committee.

• They will propose innovation/s in response to the steering committees comments.

Area 3Area 3

3. Cardiology and Cardiothoracic Patient journeys delayed

a. Patient waiting during inpatient stay for diagnostics, therapeutics and discharge planning.

• The cardiology team have held their first meeting and will embark on their diagnostics over the following 2 weeks.

• This team has put forward a submission for innovation funding to assist them in decreasing length of stay in the units with non-consultant initiated patient transitions.

Cardiology Clinical TeamCardiology Clinical Team

Questions

?



Cameron GoodyearManager – Care Coordination TeamAustin Health

Key constraints identifiedKey constraints identified

Care planning and coordination for medical patients

Outpatient waiting times for new appointment- orthopaedic patients

Elective surgical patient flow – increasing waiting list numbers

Discharge delays

Other Unit consults

Bed management and capacity planning

Patient Flow Collaborative – Austin StructurePatient Flow Collaborative – Austin Structure

Austin health Pt flow collaborative support team

work

stream work

stream

Clinical work

stream

Patient Management Taskforce Executive Committee

Discharge Delay teams9A – orthopedic surgical

14 E – Acute Medical7C – Acute Medical

7D – Medical Assessment & Planning Unit

Ward 11 &12 - Sub acute

Emergency Medical Patient Flow Team

Focus Care planning/ coordination

Elective Surgical Patient Flow team – OrthopaedicFocus Outpatient waiting

times for appt

Patient Flow collaborative Support

Team

New Teams currently being formed

7A & B – Acute Neuro wards discharge delaysCardiology & Aged Care Referral process teamElective Surgical patient team

Key constraint – Emergency Medical Patient Flow Key constraint – Emergency Medical Patient Flow Care Coordination & CommunicationCare Coordination & Communication

Diagnostic work indicated lack of coordinated approach to care planning and communication

Patients not aware of plans for admission or transfer

Staff unsure what the plan is

Increased time in ED

No clear plan for discharge

Multiple plans on different documents

Reviewed current process

Interviewed patients and staff to find issues

Baseline measures LOS in ED Time from bed allocation to transfer to MAPU Number of patients with EDD and discharge

destination documented by medical staff

Further diagnostic workFurther diagnostic work

Improvement Plan - AimsImprovement Plan - Aims

To remove unnecessary delays, transfers and complexity for general medical patients admitted through the ED resulting in: Reduced LOS for medical patients in Austin Health Reduced Journey time in ED for medical patients

( Program Measures)

To improve patient flow from ED through MAPU and general medical wards through the pilot of a multidisciplinary care plan: created within 48 hours of admission used for communicating daily and short term goals to aid discharge

planning

Improvement Plan- TargetsImprovement Plan- Targets

100% of patients will be discharged or transferred from MAPU within 48hrs of admission.

Admitted General medical patient time in ED will be <8hrs

Time from bed allocation in ED to arrival in MAPU for general medical patients will be within 60mins.

100% of patients or carers will be involved in discharge planning discussion.

100% of patients admitted to MAPU will have documented care plans with discharge plan and discharge destination agreed and signed by Registrar within 48hours of admission to MAPU.

Progress- 1st PDSAProgress- 1st PDSA

Aim

To increase number of patients who have documented discharge plan which includes discharge destination within 48hours of admission to MAPU, this is to ensure discharge planning is commenced and communicated to staff and patients.

Progress- 1st PDSAProgress- 1st PDSA

Baseline measure of current performance Agreed timeframe for completion of discharge plan and discharge

destination on transfer summary. Agreed process and responsibility Senior registrar worked with interns to educate re importance of

Transfer documentation of goals and discharge plan Interns did not want to assume responsibility for establishing

estimated date of discharge with multidisciplinary team Interns to document discharge plan and communicate with

patients and families within 48hours of admission to MAPU. Trial for 2 weeks and measure


• Difficult to agree small test of change• Need to look at whole journey but in manageable

parts.• Gaining input of all involved in patient journey

challenging but important.• Review of current process takes time• Need to consider other changes taking place at the

same time• Need to ask what the incentives for change are?


• Review process from ED to MAPU test change to reduce time, involve bed resource manager and registrars

• Review ED stage redesign in line with streaming model and new documentation

• Redesign documentation – add goals and timelines• Start process of Registrar signing discharge plan in

nursing documentation• Working with 3 consultants to raise awareness of

discharge plan with interns ( intern of the month award)

Questions

?

Department of Human Services Patient Flow Collaborative Dr Alison Dwyer, Fellow in Medical...

Documents

Transcript of Department of Human Services Patient Flow Collaborative Dr Alison Dwyer, Fellow in Medical...