PAASPORT TO BETTER OUTCOMES

• Nicola Ryan, Senior Project Officer

• Dr. Gavin Teague, HOD Anaesthesia, Project Lead

• Professor Krishna Boddu, Service Director,

Executive Sponsor

Improving the Patient

Journey

Key Drivers for Change at RPH

• Universal Drivers

• State and National Health Reform & Targets

• Clinical Services Plan

• National accreditation

• Activity Based Funding/ Management

Identify stakeholders

Sub- group: Pre Operative Assessment

Leader: Gavin Teague/Simon Wall/Penny

Toomey

Governance:

Reports to the Elective Patient Journey Task

Force who in turn report to START

KPI’s:

· Cancellations

· DNA’s

· Number of visits pre op

· Number of investigations requested?

· Number of referrals to other specialties?

Desirables:

· Establish multidisciplinary clinic assessment

for high risk pts

· Pathways for referrals

· Review rostering of anaesthetists – buddied to

specialty teams - same anaesthetist in theatre

reviews pt in clinic?

Issues identified from previous

redesign projects

0

10

20

30

40

50

60

Request for WaitlistRegistration

Pre – Admission Journey

Admission Theatre Post – operation care & discharge

Frequency of Issues

Journey Location of Issues

RPH Elective Surgery Patient Issues by Journey Group Mapping from 2009 redesign project

RPH Pre-admission Assessment

Service (PAAS) • Located adjacent to RPH

• Currently assesses all elective surgical patients for

• Orthopaedics

• Plastics

• Urology

• Vascular

• General Surgery

• Booked admissions

• Limited capacity for walk ins

• 2 anaesthetists; 1 clinical nurse; 2 registered nurses; 1

preadmission clerk

• 30 patients a day on average

• Runs a high risk assessment clinic (2 afternoons a week)

Clinic and Pre-operative

Assessment • Inconsistent booking

practices; potential for loss

of documentation

• Complex patients were not

identified early in the

process

• Patients not “Ready for

Care” at end of PAAS

• No triage process

• Short lead in time for

patient assessment and

optimisation

• Poor medication advice

Project Aims

• Patients having a seamless surgical

experience

• Enhanced satisfaction of patients/

families and staff

• Reduction in cancelled cases and

waiting times

• Impart redesign and change

management skills to hospital staff

• Improve data collection practices

• Continuous monitoring of KPIs

Choosing a methodology

Courtesy of Hannah

Moss and Sam Green

DOH Western Australia

How to choose

methodologies when faced

with a choice?

• Suitability of methodology to

problem

• Available resources

• Need for data

Using the DMAIC Process

• Process Mapping

• Voice of the staff

• Voice of the patient

• Voice of the organization

Challenges of Engagement

WE HAVE ALREADY DONE THIS!

NOT MORE FOUR HOUR RULE!

RESOURCES

YOU CAN’T CHANGE THE

CULTURE!

IT WON’T WORK

NOTHING WILL

CHANGE

I THINK WE DO

A GREAT JOB!

I see you are doing the

important work

When

do I find

time to

do

this???

Challenges of Engagement

Defining the problem

We engaged over 100 stakeholders from across

the hospital through participation in:

5 Process Mapping sessions

Numerous 1:1 discussions

2 Root-Cause-Analysis sessions

We logged 89 issues,

10 root causes and delay reasons

We also asked our patients what they

thought of the Pre-Admission process

Define - Process Map for

Preadmission

Themes Arising from Mapping

• PAAS appointments <2 weeks prior to DOS resulted in

increased cancellation rates on DOS

RPH: Time from seen in PAAS to Day of Surgery

Measure - What is the Problem?

This line

represents the 2

week mark

Most patients are falling within

the <2 weeks boundary

Measure- Data Collected from Electronic

Booking System until Aug 2013

Pts on EBS GEN SURG ENT OPHTHALMOLOGY UROLOGY VASCULAR

PTS ON LIST 187 130 469 606 41

NO OF PT CANCELLED

26 (14%) 20 (15%) 93 (20%) 113 (19%) 11 (27%)

CANCELLATIONS 28 (15%) 30 (23%) 130 (27%) 150 (25%) 12 (29%)

KNOWN REFERRAL

184 (98%) 0 (0%) 120 (26%) 59 (10%) 10 (21%)

CONSENTS 178 (95%) 124 (95%) 461 (98%) 573 (95%) 24 (59%)

CAT 3' s CONSENTED

61 (100%) 74 (92%) 346 (98%) 209 (97%) 4 (44%)

What is the Problem?

You told us that a lack of management of anti-coagulants cause day

of surgery cancellations…

PATIENT UNFIT - In ED PreOP

- High INR

- High potassium/ renal

review

- Fluid overload

- Didn’t stop Warfarin

- Didn’t stop Clopidogrel

- UTI

- For LA needs – needs

GA

- Ankle swollen

In the month of September 2 patients did not

stop taking their anti-coagulant medication

and their surgery was cancelled on the day

Measure - What is the

Problem?

Pre-admission Patient Journey - Junior Doctor Consult Times

08:15 08:30 08:45 09:00 09:15 09:30 09:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 11:45 12:00 12:15 12:30 12:45 13:00 13:15 13:30 13:45 14:00

JMO

JMO

JMO

JMO

JMO

JMO

JMO

JMO

JMO

JMO

JMO

JMO

JMO

Note that while clinic appointments begin

from 8:00am, most Junior Doctors are

unable to attend the clinic until after

10:30am due to work on wards

Measure - What is the Problem?

RPH: Control Chart for time from arrival to

departure pre-admission clinic

• VOP – patients complained about wait times (the average

patient waits at least 165 minutes)

• VOS – staff complained about wait times

• VOO – inefficient use of resources

Measure- PAAS Activity 2012/13

What is the Problem?

Patient did not report (DNR) to Pre-admission appointment…

This means a

loss of clinicians

time due to

waiting for

patients who do

not arrive.

There is great variation

in DNRs across specialty

It is not clear

at this stage

why patients

DNR

Data Fair

Data Fair

• Outcomes:

– Voice of Registrar

– Social Work

– Pathology

– Breast Clinic

– Displays

• Anaesthesia

• Theatre

• Pre-admission

Analyse- Root Causes

1. Why do we have limited patient info prior to pre-

admission?

• No state-wide consent process for release of patient

information

• No minimum data set for referrals

• Lack of standardised process for distribution of Health

Questionnaire

2. Why do we only use 76% of our pre-admission

capacity?

• Low activity days

• No centralised allocation for use of sessions

• No formal process for filling cancellations

• Some sessions left empty due to unpredictable

Analyse- Root Causes

3. Why is patient wait in pre-admission 165mins?

• Pre-admission often includes 3 different

appointments

• Conflicting role demands: Junior Doctors

• Lack of processes to accommodate variation in

workload and staffing

4. Why can’t clinicians see if patients have

attended pre-admission?

• Pre-admission appointment only recorded in EBS

for approx 50% patients

• Use of recording systems (TOPAS)

• Lack of formal data entry processes

• Insufficient training in relevant programs

Solution Generation

• Early distribution of Patient

Health Questionnaire

• Triage Nurse

• Removal of surgical JMO and

replacement with nurse case

managers

• Pharmacist

• Physiotherapist

• Walk in model of care – 50/50

• Patient PAASport

• Standardized pre-op

investigations by specialty

• Inclusion of GP

• Telephone screening

Templates for standardised

letters to GP

Pre-admission PAASport

Developed by

Professor Krishna Boddu

• System of checklists

• Must be checked off at each

point of the patient journey

before the patient can move

onto the next step.

• Ensures efficiency and provides

a system for accountability.

• A coded medical record

document remains in the

patient notes

Theatre Management System

• Electronic capture of the pre-

anaesthetic assessment

• Improves communication

between anaesthetists

• Improved legibility

• Electronic capture of

anaesthetic Hx.

• Potential for communication

across sites

Telephone Screening

• Development of a screening tool

• Reduction in number of patients requiring a face to

face preadmission assessment

• More efficient use of existing resources

The project timeline has been extended to accommodate

successful embedment of solutions

Excellence

“We are what we repeatedly do

Excellence, therefore is not

an act but a habit”

- Aristotle

Questions?

Contact us

Nicola.Ryan@health.wa.gov.au

Gavin.Teague@health.wa.gov.au

Krishna.Boddu@health.wa.gov.au