Patient Flow Collaborative

1
Patient Flow Collaborative
Dr Alison Dwyer, Fellow in Medical
ManagementSt Vincents Health
2
Organisational Constraint area at SVH

• Acute bed access
• 12-hour wait targets in Emergency Department
  potential to improve the time to ward admission
  from emergency

3
12 hour waits

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

4
Priority Constraint Area 1 timely access to
ward beds

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

5
Priority Constraint Area 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

6
Diagnostic work why arent patient discharged
by 10am?

• 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

7
Tally chart of surgical ward delays in discharge
8
Diagnostic work

• 2. Process maps
• Emergency department care streams
• ie. short stay patients
• gt12 hours but not admitted patients
• Emergency Medical Unit (EMU)
• Emergency Observation Unit (EOU) patients
• General Medical Patients
• Pharmacy discharge medication process
• Surgical residents day

9
Diagnostic work

• 3. Charts for discharges
• Time of day of discharges bar chart and SPC
• patients discharged by 10am
• For medical ward
• For surgical ward
• Baseline information

10
Diagnostic work

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

NB Data may be inflated due to time Ward Clerks
are able to d/c patient from system
11
Diagnostic work

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

NB Data may be inflated due to time Ward Clerks
are able to d/c patient from system
12
Diagnostic work

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

Average time 1405
13
Diagnostic work

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

Average time 1224
14
Diagnostic work

• 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

15
Diagnostic work

• Results of medical audit in 9E

16
Diagnostic work

• Bed management meeting
• observed by DHS representative 
• Capacity-Demand analysis
• quarterly figures for admissions and discharges
  compiled via Patient Administration System per
  unit

17
Diagnostic work identifying emergency demand
per unit

Neurosurgery can predict that the unit will
need 3 emergency beds on weekdays, 1 on weekends
18
Diagnostic work identifying emergency demand
per unit

Cardiology can predict that the unit will need
4 emergency beds Mon-Thurs, 2 on Friday and , 1
on weekends
19
Diagnostic work identifying emergency demand
per unit

Vascular may only need 1 emergency beds
Mon-Friday and no dedicated bed on weekends
20
Who was involved

• NUMs/ ANUMs
• in-charge nursing staff
• Pharmacy department
• Doctors
• Patient/consumers
• Emergency department
• Operating Theatre
• Wards (medical and surgical)
• Pharmacy

21
Diagnostic work

• 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

22
Diagnostic work

• What data/ information was really useful
• Emergency department tally chart clearly
  highlighted bed access issue
• Statistical Process Charts to identify exactly
  what sort of problem we had with discharge times
• Pharmacy process map demonstrated duplication
  of work processes
• Medical ward audit demonstrated areas of
  block requiring review
• Surgical ward tally chart demonstrated need to
  review medical work processes

23
Improvement Plan

• Overall Aim
• To ensure 95 of patients at St Vincents
  emergency department are admitted to a ward bed
  within 12 hours
• Sub-aims
• To achieve 75 of patients in St Vincents
  Health discharged by 10am

24
Improvement Plan

• Whole of hospital approach
• Areas we are tackling within this project
• Medical wards event driven discharge
• Surgical wards work process of junior medical
  staff
• Pharmacy department work processes of pharmacy
  staff (listed in orange)
• Areas we have identified that are beyond the
  initial scope of the project
• EMU/EOU review
• Consideration of transit lounge
• Consideration of bed management process review
• Medihotel review (listed in green)

25

26
Medical wards Event 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 patients
  discharge
• eg if respiratory patient afebrile and O2sats
  gt95 patient can be discharged by nursing staff
  without medical review
• Discharge script written and dispensed day prior
• Transport organised day prior etc

27
Surgical wards Commence theatre after discharge
complete

• Initial discussions with consultants of units on
  surgical ward (5W)
• Resident staff to complete all discharge
  summaries/ medications prior to going to theatre

28
Pharmacy 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

29
Progress

• 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

30
Lessons 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

31
Desired 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

32
Desired Impact 2

• 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
• Ultimately, patient discharged by 10am

33
Desired Impact 3

• Pharmacy hours
• Pharmacy department able to collect and prepare
  discharge scripts early
• Pharmacy able to educate patients early on day of
  discharge
• Ultimately, patient discharged by 10am

34
Overall 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

35
Next 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

36

• Questions?

?
Alison.dwyer_at_svhm.org.au Kathryn.bailey_at_svhm.org.
au Michael.langley_at_svhm.org.au
37
Patient Flow Collaborative
The Northern Hospital Edwina Harding
38
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

39
Priority Constraint

• Discharge Processes
• Notification of discharge
• Discharge letters / summaries
• Scripts
• Discharge medications
• Family issues

40
Diagnostics

• Post discharge medical record audit
• Identify documentation of a discharge date a
  day or more in advance of the day of discharge
• Result - 46

41
Diagnostics

• Timed the steps of the discharge process
• Communication of discharge decision
• Discharge documentation (script, letter etc.)
• Discharge medications
• Discharge assessments
• Family (notification, pickup etc.)

42
Diagnostics

• 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

43
Diagnostics

• 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

44
Improvement Plan

• 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

45
Progress

• 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

46
Progress

• Partial 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

47
Desired Impact

• Minutes 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

48
Next 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

49

• Questions

?
50
Patient Flow Collaborative
Colin Pearson Emergency Department Physician
Angliss Hospital
51
Summarise Organisational Constraint 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.

52
Summarise Priority Constraint Area 1

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

53
Diagnostic exercises

• Examining two years of data from an existing
  database of reasons for ED LOSgt12 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.

54
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.

55
Diagnostic exercises (3)

• Development and introduction of a proforma to
  collect real time data on ED LOS gt8 hours prior
  to admission
• Analyse medical decision-making processes within
  the ED

56
Who was involved

• Clinical project/area team comprised
• Bed manager
• ED nurse
• ED doctor
• Medical ward nurse
• Surgical ward nurse
• IT manager

57
staffs reactions/ cultural aspects

• 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

58
staffs reactions/ cultural 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

59
data/ information that was really useful
60
data/ information was really useful (2)

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

61
(No Transcript)
62
Times from presentation to bed request
63
Adjuncts to decision-making 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

64
Adjuncts to decision-making 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

65
data/ information that did not help

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

66
data/ information that did not help (2)

• Limited value in retrospective analysis,
  real-time provides better information
• Nursing coordinators database overly complex and
  poorly utilised

67
Improvement Plan

• 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

68
progress so far

• Introduction of proforma, promotion via flyers,
  presentations collection and analysis of data
• Reduced conflict over the ED/ward handover process

69
What 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

70
Graph of median time from bed availability to
transfer before and after trial
71
Graph of average time from availability to
transfer before and after trial
72
Lessons learnt

• Most gains from reducing access block which is
  outside of the EDs 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.

73
Desired Impact

• Focus on strategies to increase the availability
  of inpatient beds

74
Next Steps

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

75

• Questions

?
76
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

77
Lunch

• Meet us in the next Concurrent Session at 12.45

78
Team Presentations
Peter Bradford and Ruth Smith 5TH October 2004
79
Concurrent Session 1Team Presentations

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

80
Patient Flow Collaborative
Margaret Balla Director Clinical Governance
RVEEH
81
Organisational Aim Outpatients

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

82
4 Critical Success Factors Outpatients

• Management of new patient waiting list
• Management of ongoing review patients
• Management of clinical staff
• Management of Failed to Attend

83
External Constraints Outside control of Health
Service

• 1. Distribution and allocation of services
• Funding policy
• Different Health Service methods to manage
  referrals and services
• Primary care sector management of chronic disease
• 5. Referral to multiple waiting lists
• 6. Professionals view of outpatients

84
External Constraints Outside control of Health
Service

• Serious impact on management of
• waiting list
• clinical staff
• Failed to Attend

85
Organisational Constraint Areas

• Outpatients
• Referral to Outpatients
• Access to Outpatients
• 3. Outpatient day of appointment

86
Organisational Constraints Within control of
Health Service

• Referral to Outpatients
• Appropriateness
• Acknowledgement response time
• Time to appointment

87
Organisational Constraints Within control of
Health Service

• Access to Outpatients
• New to review ratio
• Post op visits per specialty
• Pts discharged
• Clinic Utilisation
• Failed to Attend

88
Organisational Constraints Within control of
Health Service

• Day of appointment access
• Preparation of history
• Clinic capacity and staff resources

89
Improvement Plan

• 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

90
Progress 1. Referral 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

91
Progress 2. Access 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

92
Progress 3. Appointment 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

93
Lessons learnt

• 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.

94
Desired Impact

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

95
Next Steps

• 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

96

• Questions

?
97
Patient Flow Collaborative
Melbourne Health
98
Improvement Areas

• Bed Availability
• Acute Subacute
• Clinician Communication
• Emergency
• Operating Theatre
• Radiology

99
Bed Availability

• Initially formed to work through issues around
  discharge and admission processes.
• Found crossing over other groups work therefore
  rationalised.

100
Issues identified

• 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.

101
Opportunities for improvement

• 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.

102
Current actions being undertaken

• 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.

103
Acute Subacute

104
Issues 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.

105
Opportunities for improvement

• 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.

106
Opportunities for improvement

• 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.

107
Recommendations Implemented

• 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 implementation
• Development of clear communication channels
  between the acute and sub acute
• Investigations of Admissions on the weekend to
  sub acute

108
Desired Impact

• 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

109
Major Measurements

110
Lessons learnt

• 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

111
Clinician 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

112
Issues identified to date

• 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

113
Issues 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

114
Further Diagnostics

• 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

115
Opportunities for improvement

• Improving referral processes
• Back up procedures
• Ward round communication/coordination
• Sunday discharges
• Accurate rosters, streamlining of notification of
  leave

116
Current actions being undertaken

• Survey of unit heads, NUMs 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.

117
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

118
Issues identified

• 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

119
Referral Delays (including time to bed request)

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

120
Matching Staff resource with clinical demand

• Roster review

121
Sub optimal Clinical Area Communication

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

122
Excess Waiting Time for Category 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

123
Unnecessary Triage Enquiries ? Excess queuing
prolonged waiting times

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

124
Operating theatre 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

125
Issues identified to date

• 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

126
Opportunities for improvement

• 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.

127
Current actions being undertaken
128
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.

129
Diagnostics Undertaken

• 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)

130
Inpatient Turn-Around-Time
131
Opportunities for improvement

• Radiology patient transport (weekends)
• Decreasing delays between exam and dictation
• Decreasing delays between dictation and
  transcription
• Decreasing number of unreported films

132
Current and proposed actions...
133
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134
Patient Flow Collaborative
John MulderExecutive Director OperationsDeputy
CEOChairman, Patient Flow CollaborativeBarwon
Health
135
Summarise Organisational Constraint areas
136
Summarise Priority Constraint Area 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.
• Patients waiting in emergency for assessment by
  emergency medical officer
• Patients waiting for outpatient appointments
• Patients waiting for theatre
• Patients waiting for receiving unit medical
  officer to review patients to confirm admission

137
Process Map
138
Tally Sheet
139
Process Map Medical Officer in Emergency
Department

• Bed not avail.
• Pt remains in Ed gt12 hrs
• Dr interrupted with ongoing management issues

• 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

• Staff Problem
• Roster changes not shown
• Wrong dr. on roster,
• Dr not avail to phone, in theatre, OPD, ward round

5 minutes
140
What do doctors do in ED?
45 Pt care 20 Teaching Learning 35 interruption
141
Patient Carers and relative views
142
Improvement Plan
143
Improvement Plan

• 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).

144
Progress

• 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?

145
Desired Impact

• 90 of patients journeys through the emergency
  department will be 6 hours or less when they do
  not require admission to hospital.
• 95 of patients journeys through emergency will
  be less than 12 hours when they require admission
  to hospital

146
Next Steps

• 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

147
Area 2

• 2. Medical Imaging Delay
• Patient experience delays in emergency,
  outpatient and inpatient care.
• Patients waiting for diagnostics

148
Process Map
149
(No Transcript)
150
Tally
ED patient journey through Medical Imaging
023
021
020
017
017
016
014
Time (hours and minutes
011
009
008
008
006
005
003
002
002
000
1
Request to ED Desk
Request to radiologists 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
151
Tally
ED patient readiness for x-ray
140
120
100
80
60
40
20
0
Patient on slde sheet (57/193 required)
Patient in gown (143/198 72 required this)
Metal/jewellery removed required by 123/186
66)
152
Constraints in MI

• 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
• Patient transport system b/t MI and ED
• Innovation 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

153
Constraints in MI cont

• Quality of equipment
• Innovation replacement room
• Non- required x-rays
• Innovation - Protocol development OR Order system
  with traffic lights for authorising x-rays

154
Patient Carer and Relatives views
155
Out of Hour Process Map
156
Cont
157
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

158
Progress Area 2

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

159
Lessons learnt

• 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.

160
Desired 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.

161
Next Steps

• 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.

162
Area 3

• 3.  Cardiology and Cardiothoracic Patient
  journeys delayed
• Patient waiting during inpatient stay for
  diagnostics, therapeutics and discharge planning.

163
Cardiology Clinical Team

• 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.

164

• Questions

?
165
Patient Flow Collaborative
Cameron GoodyearManager Care Coordination
TeamAustin Health
166
Key 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

167
Patient Flow Collaborative Austin Structure
Patient Management Taskforce Executive Committee


Austin health Pt flow collaborative support team

Patient Flow collaborative Support Team
Discharge Delay teams 9A orthopedic surgical 14
E Acute Medical 7C Acute Medical 7D Medical
Assessment Planning Unit Ward 11 12 - Sub
acute
Clinical


work
work
stream

stream


Elective Surgical Patient Flow team
Orthopaedic Focus Outpatient waiting times for
appt
Emergency Medical Patient Flow Team Focus Care
planning/ coordination
work
stream

• New Teams currently being formed
• 7A B Acute Neuro wards discharge delays
• Cardiology Aged Care Referral process team
• Elective Surgical patient team

168
Key constraint Emergency Medical Patient Flow
Care 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

169
Further diagnostic work

• 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

170
Improvement 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
•  

171
Improvement 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 lt8hrs
• 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.
•  

172
Progress- 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.
•   

173
Progress- 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
•   

174
Lessons learnt

• 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?

175
Next Steps

• 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)

176

• Questions

?