Reengineering patient flow: Directions for a system wide approach

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Re-engineering patient flow Directions for a
system wide approach

• ACHSE CONFERENCE
• APRIL 8
• Dr Tony OConnell

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The problem to be solved. Worsening access
block Worsening off-stretcher times Rising
occupancy rates Inefficiencies in patient
flow Falling capacity to perform elective surgery
with rising waiting lists
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Understanding the current situation - Demand.
Who are the customers?
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Extra 100,000 older people within 7 yrs.
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Hunter data
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The older the patient, the more likely a delay in
ED
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Mental Health
We frequently have Mental Health patients for
days - ED
Workshop Takes up to a week to get a consult
- Inpatient Workshop
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Sustainable Access Plan 563 beds
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Front Door
Inpatients
Community
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A New Vision Integrating Management
Workforce / Professions
IMT
Funding
Facilities
Community Services
Consumer Involvement
Management
Hospital Services
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The Access Block Improvement Program..
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A new approach.

• Increased bed capacity
• Clinical Service Redesign Program
• Patient Flow Units
• Integrated Aged Care Service
• Emergency Dept Demand Mgt
• Predictable Surgery Program
• Partnership for Performance

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Each Unit will proactively manage patient flow.

• Data to be monitored
• Unit will use Bed Board to monitor status of
  patient flow data and early warning signs. Data
  monitored includes
• Predict Patient Flow based on Historical Trends
• Predicted admissions
• Predict discharges
• Demand data
• ED data (number of presentations, waiting for
  bed)
• Planned surgery lists
• Type of patients (eg number of elderly, etc)
• Supply data
• Detailed bed data ( open, closed, occupancy)2
• Staff availability trends (eg Medical officer
  leave, school holiday leave, sick leave, etc)
• Key Patient Flow data / Early Warning Signs3
• Access Block
• Number of inter-hospital transfer patients
• Number of patients waiting on diagnostic tests /
  key interventions (eg Cardiac Catheterisation)
• Estimated Day of Discharge information
• Estimation of long stay patients
• Demand for nursing home and rehabilitation beds

Each Unit will use a Bed Board1
Notes 1 In the short term, a simple Microsoft
Excel dashboard could be established until the
advanced version is built and tested. 2
Accurate data, particularly data regarding bed
availability is required. This will be
facilitated via PiMS (or equivalent) 3 Some
data collection will need to be manually
collected (e.g. via daily bed meetings, etc)
before it is entered into the Bed Board. Early
warning signs will need to be identified and
customised by each site, and may need to be
limited in their number (eg 5 data sources)
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Actions will be specific to each early warning
sign.
Early Warning Sign Activated
Potential Responses
Hospital Bed Board

• Implement communications via usual management
  processes
• Use flex beds to accommodate extra patients
• Pre-organise extra staff member(s) to care for
  extra patients
• Move some patients to other hospitals (if
  appropriate)
• Delay non-urgent inter-hospital transfers
• Notify Surgeons and attempt to prioritise
  operating list

Surgery1
DOSA admissions this day
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DOSA admissions tomorrow
DOSA admissions in 7 days
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• Implement communications via usual management
  processes
• Move some patients to sub-acute or private
  hospitals (if appropriate) (via service
  agreement)
• Activate contracts with some GPs (selective) to
  help manage some patients

Delays in Discharge
Number of long stay patients
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Waits for nursing home bed
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Waits for rehabilitation bed
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• Notes
• In some hospitals, capping daily DOSA admissions
  has proven to be an effective method of managing
  overall hospital load.
• Need to ensure early warning signs are reviewed
  at a defined time to ensure preventative measures
  can be made (review of early warning signs at 8am
  is too late)

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The bottom lineKey Performance Indicators

• Access Block
• Off-Stretcher Time
• Elective Surgery waiting lists

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Factors for success

• Success across ten/eleven sites was variable
• By project and hospital
• Sometimes cultural and mindset change did not
  equal impact on KPIs
• Important Factors
• Clinician engagement
• Executive sponsorship/commitment
• Capacity (beds, resources)
• Metrics (performance driven management)

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Synergies for success
Executive drive
Capacity
Transformational Change!
Clinician engagement
Flow Visibility of KPIs
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Clinical Service Redesign Program

• Business Process Redesign in all AHSs
• Three year program
• Teams with external facilitator assistance in
  every AHS

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Clinical Service Redesign Program

• Engaging clinicians and front line staff
• Patients and staff working together to identify
  issues
• Expert external assistance to facilitate and
  effect skills transfer
• Clinicians prioritising and redesigning processes
• Management support for implementation

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Clinical Service Redesign Program

• Clinical Redesign units in each Area Health
  Service
• Core positions and project positions for projects
  to address priority issues
• Backfill for clinicians to redesign processes and
  lead implementation

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What do we want.. Facilities that work
efficiently Patients that are satisfied Staff
that are satisfied Value for money Quality
practice Smooth patient flow through services