Department of Human Services Patient Flow Collaborative Angela Peluso - Clinical Lead Ian Jackson -...

Department of Human Services

Patient Flow Collaborative

Angela Peluso - Clinical Lead Ian Jackson - PresenterEastern Health – Maroondah Hospital

Summarise Organisational Summarise Organisational Constraint areasConstraint areas

• Bed Management- Admission delays for elective surgery

- Admission delays from ED

• Acute/Sub Acute- Delayed access to Rehab & NH beds

• Theatre Utilization- High HIP rate

Summarise Priority Constraint Summarise Priority Constraint Area 2Area 2

• Acute to Sub Acute-Delayed access to NH Beds

-Delayed access to Rehab beds

• Ward sample data repeated-Confirmed previously identified constraints

• Brainstorming session-Included all stakeholders – NUM’s, Allied Health, Medical Rep (Geriatrician), Reps from off-site rehab facilities -Confirmed process issues and recommended these be mapped

• Process Mapping session-Identified key constraints in transition process

Diagnostic workDiagnostic work

Diagnostic work cont.Diagnostic work cont.

• Staff reactions-Committed to “doing something” to improve things- Enthusiastic about possibilities- Acknowledgement that even small changes could have big effects- “Lets do it!”

Improvement PlanImprovement Plan

• Establish clinical area team- Identify clinical area team leader- Include key stakeholders

-Medical representative – Geriatrician- Rep from PJC - NUM’s from GEM, ortho & medical

wards- Allied health – social worker & physio- Aged care nurse consultant

Improvement Plan Cont.Improvement Plan Cont.

• Investigate the following six key areas identified as contributing to delays

1. Referral process to allied health2. Organising OT home visits3. ACAS referral process4. Refusal of rehab bed by patient/family5. Delays in discharge summary documentation6. Out of hours communication with central booking

office

ProgressProgress

Implementing the following changes1. Faxing allied health referrals2. NUM generated ACAS referrals3. Improved communication channels with

centralized bookings office

Lessons learntLessons learnt

• Need for all key stake holders to be involved-delivers better more sustainable outcomes

• Select “right person” for “right job”-need to be motivated & outcome focused

• “Rome wasn’t built in a day”-be patient

Desired ImpactDesired Impact

• Reduce LOS• Reduce 12 hour waits in Ed• Better more effective communication

channels between sites• Improved patient care

Next StepsNext Steps

• Review and update relevant policies & procedures

• Review admission/discharge criteria for hospital GEM ward

Questions

Janine Rogers, CHIP Manager

Calvary Health Care ACT

• Allied Health (AH) referral process- inappropriate & not timely

• Radiology-timeliness & accessibility• Nursing Paperwork-duplicative & excessive• VMO Rounds-disjointed & not well managed

from • ACAT Services-limited appointments &

difficulties with rebooking

• AH Issues

– Inappropriateness of referral – Timeliness of referral – Referral process

• Brainstorming – Ad hoc referral arrangements – Timing issues – Communication issues

• Consumer – Not seen in ED

• Determine what is process now• Tick and flick exercise in ED and Medical for

– Response times – Relevance of referral – Who is making referral – Process effectiveness.

• AH referral indicators– Determine indicators – Pilot in two areas, then– Specific to each service area

• Refine process– Determine time intervals from referral to

assessment and then set optimum goal– Structured flow for referral

• Facilitate communication between parties– Streamline process– Ease of access to contact # and names

ProgressProgress

• AH referral audit underway• Referral process set into flow diagram• Specific AH Indicators for pilot accepted

– AH and nursing input

• Evaluation audit on pilot to be completed

• Managing detractors and concerned staff

• Getting everyone in the right place at the right time

• Reliance on senior 3rd party to share project information

• Don’t do this during accreditation

• Timeliness – Patients requiring AH intervention to be seen within

…?…. (optimal time frame) • Appropriateness

– All AH referrals to have a clear rationale for assessment

• Knowledge – Increase knowledge across hospital on referral

indicators• Communication

– % of referrals that follow correct communication process

• Radiology mapping• Revise nursing assessment

– Standardise across hospital– Standardise risk assessments – Include expectation management

• Increase efficiency of VMO rounds• ACAT service

Questions

Team Presentations

Melanie Hendrata and Kim Moyes

5TH October 2004

Concurrent Session 1Concurrent Session 1Team PresentationsTeam Presentations

Bellarine Room 3– Northeast Health - Wangaratta – Bendigo Healthcare Group– Southern Health – Dandenong Hospital– Peninsula Health– Box Hill Hospital

Christine Giles Northeast Health Wangaratta

Rigorous DiagnosticsRigorous Diagnostics

• Poor communication pathways both verbal and written- Inadequate or incorrect documentation of patients’ social & medical history.

• Inconsistencies with quality of admission data from GP’s and referring agencies.

Rigorous DiagnosticsRigorous Diagnostics

• Patients being asked the same questions repeatedly by different personnel.

• Organisation duplication of paperwork.• Discharge dependant on timing of medical

rounds, availability of bed elsewhere, family.• Delays in radiology.

Organisational Constraint AreasOrganisational Constraint Areas

1. Communication and Information Transfer.

2. Emergency Department-time taken between decision to admit and admission to ward.

3. Medical ward LOS-activities affecting discharge, transfer & readmissions.

Implementation Phase- Implementation Phase- Plan, do, study, act.Plan, do, study, act.

• Team members further brainstormed the constraint areas. – Communication between ED and Medical unit– INR monitoring and warfarin therapy– Nurse initiated clinical guidelines– Discharge-time and trends in the Medical unit– Quality of admission data– Delays in ED-causes and effect– Form review by Medical Records.

• Consensus reached on plan, do, study act initiatives.

Implementation Phase-Implementation Phase-Diagnostic workDiagnostic work

ToolsDesk top audits, tally sheets, staff interviews bothstructured and unstructured, questionnaires, existinghospital data.

Who was involved?Health information manager, ED, medical unit, nursingstaff and clerical staff, ward nurses, executive, juniorand senior medical staff, director of pharmacy, directorof radiology, under graduate student. Patients and relatives.

Implementation Phase-Implementation Phase-Diagnostic workDiagnostic workWhat data/information was really useful/not useful?Anecdotal, face to face staff interviews, audits,previous studies, patient comments.

1. Face to Face Radiology delays as an issue debunked. New filmless system being implemented. Delays in therequest for and actioning pathology results highlighted-INR-therapeutic range and warfarin dose.2. INR Clinical Indicator Variance Analysis 2003This data supports anticoagulation management as one of our perceived causes of medical ward prolongedLOS affecting discharge, transfer & readmission.

3. Desktop audit indicated excellent compliance byNHW with discharge summaries but raised some questions about the quality of information accompanying patients on arrival to our hospital.

Identified some evidence of GP admitted patients having increased LOS for certain patient types.

4. Tally sheets!!-poor compliance, hostility, paperwork fatigue led to insufficient data.

Staff reactions- • Anger.• Disinterest.• Passive resistance. • Frustration.• Ability to see what

needs to be done but negative about means to achieve change.

• Powerlessness.• Blame culture.

Improvement and ProgressImprovement and Progress

1. Medical ward and ED identified as the most pressing communication issue. Positive channels of communication to be established and shared goals initiated

- Reduce duplication in history taking, trial innovations to ease the burden of the admission to ward process.

- Explore MAPU to improve patient flow.- Established a forum for both groups to have

dialogue and understand each other’s issues.

Improvement and ProgressImprovement and Progress

2. Communication with Medical staff group

to establish key responsibilities forinvestigating identified constraints

- Engage GPs-review admission process, LOS.- Exploration of nurse initiated activities to expedite

the discharge/transfer process i.e.pathology requests, referrals to allied health, medication.

- Identification of the use of evidence based care, clinical practice guidelines, beginning with anti-coagulation therapy.

1. Separate fact from opinion.

2. Distil the problem from the symptoms.3. Examine data quality carefully and adapt

diagnostic tools to be contextually appropriate- “you can’t weigh something with a tape measure”

4. Accept that change is painful but good leadership can transform negative energy into a positive outcome.

5. Harness the energy of the organisation champions.

1. Trial MAPU.

2. Develop education plan for Medical ward and ED nursing staff re history taking, referral, pathology and pharmaceuticals skills.

3. Develop an education plan for admission clerical staff and external referral agencies re accuracy of patient information.

4. Engage junior medical staff in a culture of teamwork and evidence based practice, clinical practice guidelines.

Questions

June DysonBendigo Health Care Group

BHCG Organisational BHCG Organisational Constraint areasConstraint areas

• Variation in patient management practices by doctors and nursing staff for Stroke patients. Impacts on quality of care and length of stay

• Limited availability of acute, rehab and aged care beds

BHCG Organisational BHCG Organisational Constraint areasConstraint areas

• Availability of registrars to assess potential admissions in the Emergency Department (ED)

• Repetitive documentation, assessment and data capture for patients

Priority Constraint Priority Constraint Variation in patient management for Variation in patient management for StrokeStroke

• Stroke is a discrete and important area across the continuum.

• There is some evidence that:– Stroke care and treatment could be improved in

the ED– Stroke care and treatment could be improved in

the acute phase– Stroke patients spend time additional time in acute

beds when they are ready for discharge– Follow-up for TIA and Stroke patients in the

community could be improved.

• Stroke patient journey times– A data collection tool was developed to better

understand the timing of the patient journey.– Developed by the Executive team in collaboration

with ED, acute and rehab staff.– Difficulty in reaching consensus on tool - the tool

was drafted at least six times. – Consumers were not involved at this point.– The data collection is in progress (it took six weeks

to reach agreement on the tool and manner of data collection)

Diagnostic work: Data collection toolDiagnostic work: Data collection tool

• Stroke residential care patients– A SPC analysis of stroke length of stay (2001-004) identified

a number of ‘special causes’– We reviewed the patient histories of ‘special causes’ to

determine the reasons for long lengths of stay– Particularly we looked at the time frames between acute

admission, Aged Care Assessment team assessment, placement on residential care waiting list

– This was compared to existing data looking at Stroke referral time to rehabilitation and residential care.

Diagnostic work: SPC of Diagnostic work: SPC of Stroke LOSStroke LOS

SPC chart of variation in Stroke length of stay: 2001-2004

Admission date

Length of stay Average LCL UCL2

The chart shows the length of stay of 627 stroke patients between June 2000 and June 2004. The upper and lower control (LCL) limits represent two standard deviations above and below the log (ln) length of stay (since the LOS data are skewed). Patients admitted with Stroke can expect acute lengths of stay between 0 and 44 days, with an average length of stay of 10 days. 10 'special causes' were identified: that is, patients whose length of stay exceeded the upper control limit.

Diagnostic work: Potential Diagnostic work: Potential causes of Stroke long LOScauses of Stroke long LOS

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Days post admission

NH wait to NH bed (ordeceased)

ACAS assess to NH wait

Rehab to 1st ACASassess.

Acute admit to 1stRehab assess.

Average time course for long stay Stroke patients (N=15)

The graph shows the average time course for Stroke patients with very long lengths of stay. The bars on the graph show how long (in days) the average patient can spend in acute care, until assessment and transfer to nursing home. The graph shows that approximately half of these patients LOS is taken up waiting for residential care.

Diagnostic work: Potential Diagnostic work: Potential causes of Stroke long LOScauses of Stroke long LOS

464646N =

Period

Waitlist to AdmitReferral to AdmitReferral to w aitlist

The boxplots above are based on data collected on 46 patient journeys between August 2003 and January 2004. The boxplots above show that 50% of patients placed on a waiting list for rehabilitation within 8 days of referral, and admitted to rehab within 12 days of referral. A number of patients are ‘outliers’ – with considerably longer than normal waiting times.

• The data was consistent with staff’s beliefs about the difficulty in finding residential care placements.

• A small subset of cases for Stroke LOS identified data collection problems

• There is a ‘weariness’ about the difficulties in finding residential care placement. It is ‘out of our hands’.

• The data did not provide clues to how to improve patient flow.

Diagnostic work: Long LOSDiagnostic work: Long LOS

• Two clinical teams have been established.– The first clinical team is looking at the problem of

variation and patient management. – A second clinical team is building on the work of an

existing working group to investigate options for patients waiting in acute care for residential placement.

– Establishment of an emergency department clinical team is contingent on the results of the data collection.

ProgressProgress

• Documentation clinical team established• Nursing Home working party-implementation

of Entry to Nursing Home process.• Elective surgery peer group working party

established– theatre utilisation– how patients are put on the waiting list – using patient hotel accommodation to encourage

day of stay admission

• Further data collection strategies in place

• It has been challenging garnering enthusiasm from clinical staff.

• Change is slower than we would have liked but is progressing.

• The executive team meetings have, for some time, been engaging in both executive team and clinical team activities and discussion.

• Communication has been an issue as not all of the team are fully conversant with the PFC process.

• Need to have senior members of the executive team active and on board early.

• Need to establish clinical teams as soon as the problem is identified

• Need to find a way to better engage clinicians– Overcome the ‘not another project’ feeling– Communicate the goals of the project uncritically– Deal with realistic and unrealistic expectations of

impact of the PFC on workload

• Reduce repetitive patient and clinician documentation (for Stroke cases)

• Improve consistency of care (Patient X receives the same care irrespective of treatment by Doctor A, B or C)

• Reduce delays for Rehabilitation and Residential care placement.

• Collect and analyse patient journey timings.

• Establish ED clinical team, if necessary• Complete review of documentation.

Trial this new documentation and reassess patient journey times

• Evaluate outcomes of nursing home clinical team and further development of new strategies.

Questions

Ms. Maggie Emmerton

Pharmacy Site ManagerDandenong HospitalSouthern Health

Discharge - Pharmacy

• Information / data needs• Script Accuracy• Communication• Discharge planning/priorities• Week end – resources, hours

• Diagnostic exercises:– Table top issue exploration x2– Discharge pharmacy flow– Pharmacy audits

• Participants: ED manager, ward pharmacists, clinician, Nurse managers, Chief pharmacist, project facilitator

• Reactions: gained new understanding of complexity of pharmacy issues and requirements

• Useful information: Internal pharmacy audits, ward experiences

Improvement PlanImprovement Plan• Data:

- Liaise with Admission clerks re data requirements- Liaise with Ward Clerks re data verification

• Script Accuracy:- RMO to verify script with 2nd person before

submission to pharmacy- Feedback through Pharmacy Intervention / Incident

Reporting Database

• Communication:– Designated ward staff member as central

communication point between ward staff and pharmacist

– Reduce interruptions through utilisation of LAN page

ProgressProgress• Progress:

-Liaison with Snr Health Information Mgr re Admission Clerk responsibilities. Incorporation into training schedule.

-Trialling of measures on designated ward-ward clerk monitoring patient data-designated central contact b/n ward & pharmacy-utilise LAN page in preference to phone to reduce

interruptions-encourage RMO’s to verify discharge script before

processing

Progress - OutcomesProgress - Outcomes

Ward 4 trials:--open communication b/n ward clerk and pharmacist re missing data-need to identify incorrect data-snapshot of actual data issues to be compiled for feedback to Admissions

-designated central contact effective. Some fine tuning of process required.-LAN page system well utilised

-Medical staff – little response to verbal communication. Request audit of specific issues with scripts.

The expected impact from the improvement measures undertaken is to reduce discharge delays related to barriers to the pharmacy process.

-Increase the accuracy of patient demographic data for SH.

-Increase accuracy of prescribing.

Next StepsNext Steps• Next Steps:

-evaluate current trials

-implement other actions to enhance script accuracy.-RMO induction / orientation package – repeat

session-unit meeting agenda – reinforce accuracy-pharmacy tutes – schedule meeting b/n ward

pharmacist and RMO, provide script writing assistance-re audit local ward scripts – provide feedback

Ms. Joanne Burns Director Patient Access and Demand StrategySouthern Health

1. Bed Bureau – operations and functions inconsistent across sites of SH.

• Resources• Communication• Trust• Protocols• KRA’s

2. Discharge Pharmacy• Information / data needs• Ward stock / requirements• Week ends• Communication• Script accuracy• Discharge planning / priorities

Bed Bureau• Inconsistent service• Communication ad hoc• Trust• Defined responsibilities• Bed allocation prioritisation• KRA’s

• Diagnostics:– x2 patient journeys– x4 table top sessions– Involving nursing, ward management, medical, heads of unit, ED,

Bed Bureau, orderlies, administrative and OT personnel

• Reactions:- overall positive vibe with recognition of difficulties involved, but general sentiment that most problems were caused by others. A need to take ownership of issues and work collaboratively to resolve.

• Useful data:-’ED time from bed request to bed allocation’-’ED time from bed request to transfer to ward’- Patient journey time through ED – although would be helpful

to map entire medical patient journey – identifying and understanding component parts to create better flow.

Improvement PlanImprovement Plan• Increase resources and service hours

• Establish communication procedures

• Establish bed allocation prioritisation principles

• Establish consistency of operation and function across sites

• Collect and collate activity data

• Develop Inpatient Access Manager role

• Report Bed Bureau activities to site exec

ProgressProgress• Access Working Group sub group – Bed Bureau-

established

• Resource costing profile

• Communication strategy / process documented & endorsed by site executive

• Policy requirements identified

• Development : elective capacity predictor tool

ProgressProgress

• Communication channels trialled and showed an improvement in time from bed request to bed allocation.

• Daily bed meetings and utilisation of Predictor tool provide an accurate count of daily acute capacity.

OutcomesOutcomes

• Regular meeting of Access working group sub group

• Daily Bed Management meeting – bed census, border information

• Changes to formal communication processes include LAN paging, Homer and email utilisation

• All participants found to have frustrations often with no channels for resolution

• Important to prevent information / problem overload. Tailor information to individuals that is pertinent and relevant to their sphere of interaction.

Looking forward we expect:

-better management of the elective and emergency demand balance

-accurate prediction and accommodation of elective surgical demand and a reduction in episodes of HIP

-reduced time for patient journey through the ED and admission to an in patient bed

-a decrease in time ‘Ready for discharge patients’ wait for a subacute bed

• Continue developing the work

• Improve discharge end of journey to enhance interface with subacute linking with RASP services

Questions

Dr Susan Sdrinis Manager – Medical OperationsPeninsula Health

Guiding Principles of Peninsula Health PFC

• Patient focussed• Improved patient outcomes• Right patient, place, resource, time and clinician• Prompt access • Optimal flow• Efficiency • Enhance professional networks and relationships

Priority Areas

• Optimise patient flow from the Emergency Department

• Eliminate delays for patients awaiting surgery

• Optimise bed utilisation across all sites

• Facilitate consistent systems and processes across Peninsula Health

• To improve patient flow between Emergency Department and Radiology Department

• To improve the service provided to Emergency Department patients associated with Radiology procedures

• Process mapping

• Brainstorming

• Tick charts

• Time measurements

Who was involved?– Patients– Frontline staff – Departmental Managers

Reactions?– Have done it before– Good, let’s get this right

Time Request is Faxed to PSA Contacted for Patient Transport

Time Faxed to PSA Contacted

Time PSA Contacted and PT Transported to Radiology

Time Transported to Radiology

Time PSA Contacted to PT Transport From Radiology to ED

Time PSA contacted for transport back to ED Time PSA Contacted to Time Transported to ED

Critical to Quality

Innovation Actions Achieved

Requests delivered timely

Using Fax Machine and speed dial

Speed dial formatted – Memory test on fax OK

Better communication if specialised resources required

Doctor goes to specialty modality technician during hours and speaks with MIT on duty afterhours

Leong to educate at registrars meeting and through Memo

ED electronic whiteboard in Radiology

Need to discuss further and bring in IT representative

Richard to organise meeting and invite Leong, Wendy, & Eric to progress

Timely transport of pt’s to radiology when contacted

To be discussed further. Start with implementing single point of contact

Wendy to implement single point of contact

Timely transport of pt’s back to ED when contacted

Radiology to contact PSA for all pt returns

Radiology agree to change practice. Bert to implement in Radiology. Wendy to implement in ED

Critical to Quality

Innovation Actions Achieved

Notification of patient in Radiology Waiting Room

ED will ensure staff direct pt’s to notify Radiology of their presence

This information to be placed on fax sheet. Wendy & Leong to implement.

Report process streamlined (A)

Radiology to prioritise all in hours ED radiological procedures as priority 1 for reporting

Bert to develop memo and confirm with Leong - Trial Period to be implemented – All portable procedures are to go straight back to ED consultant others to Radiologist as priority 1

Report process streamlined (B)

Place interim reports on Orion.

Richard to organise meeting and invite Susan, Shamala, & Bob Ribbons

ProgressProgress

• Describe progress so far?• What was the outcome?• What was trialled?• How many patients were involved?• What staff were involved?

Lessons learnedLessons learned

• Process mapping / data motivated and guided group

• Focussing on patient need rather than department / staff need

• Ownership of problem by both departments

• Having an independent facilitator

• Informal regular meetings encouraged brainstorming of solutions

• Involvement of frontline staff earlier

NHS Sustainability Model• Lowest scores were items 4 & 5

– 4 - Staff involvement and training to sustain the process– 5 – Staff attitudes towards sustaining the improved process

• Areas to focus on to increase the sustainability of the process were:– Involve staff through pressure testings– Team meetings– Include staff in Membership of the project group– Involve staff in the development and/or agreeance of tools– Involve staff in the decision making process– Provide regular feedback– Celebrate wins

• To support patients receive a customer focussed, time efficient, and accurate diagnostic process as a result of presenting to the emergency department for care of their injury or illness.

• 100% of pts are transported to Radiology within 12mins of contact

• 100% of pts are returned to ED within 10 mins of contact

• Radiology reporting streamlined to prioritise all in hours Emergency Department radiological procedures as priority 1 for reporting

• Continue to develop innovations to address all critical to quality items

• Involve more frontline staff in process

• Post implementation data analysis

Kate MacRae Director of Occupational TherapyPeninsula Health

Priority Areas

• Optimise patient flow from the Emergency Department

• Eliminate delays for patients awaiting surgery

• Optimise bed utilisation across all sites

• Facilitate consistent systems and processes across Peninsula Health

Summarise Priority Constraint Summarise Priority Constraint Area 3 – Bed optimisation – Transport Area 3 – Bed optimisation – Transport delaysdelays

• Poor systems of access to pool cars for clinical use

• System of ‘first in best dressed’ previously adopted across the network.

• The issue of increased incidence of manual handling of equipment by therapists was also raised as an OH&S issue.

• An analysis of number of delays in conducting home assessments, prior to discharge, was conducted over a 2 week period.

• The impact on increased LOS and subsequent delayed discharge was measured.

• All inpatient occupational therapists were involved.

• Staff viewed this activity positively.• The number of home assessments

conducted per ward was also measured.• The number and usage of each pool car

across the network was also plotted.

• The need for a car (station wagon) to be ‘quarantined’ at each site, which was prioritised for clinical use, was identified.

ProgressProgress

• A revised car booking system was trialled for 2 weeks, and then implemented as policy

• The additional car was purchased following executive discussion and approval.

• The increased through put and reduced LOS had impacted on the clinical need for access to pool cars.

• Quick wins are important!

• An analysis of one problem often identifies other issues, which will need to be addressed.

• Since the review of the car pool system there have been no documented occurrences of home assessments not being able to be conducted due to lack of transport.

• Manual handling of equipment has been rationalised.

• The project is now completed.

Questions

CARMEL BROWNE

BOX HILL HOSPITAL

SUMMARY OF CONSTRAINTSUMMARY OF CONSTRAINT

• Identifying issues of workload and capacity for the medical units to manage this number of patients.

• Balancing this with other pressure on bed access - psychiatric patients waiting for admission to adult or aged psychiatric services- elective surgical - medical imaging admissions.

• Utilising data we determined how many patients were allocated to each medical unit and where those patients were placed within the hospital.

• How many patients were waiting in ED to access a acute bed.

• How many patients were on the elective surgical list needing admission that day.

• How many patients were booked as elective imaging,of which some will require admission.

• How many psychiatric patients were in ED waiting admission to adult, adolescent or aged psychiatric services.

• Carmel Browne worked with key stakeholders to identify a more reasonable workload.

• An agreement was made to review medical rosters, patient numbers and to share patient allocation amongst registrars who may be quieter.

• A daily data summary sheet is emailed to key staff using the daily whole system data.

• A key facilitator in medical administration communicates with medical units to share the workload.

ProgressProgress

• This was trialed across all general medical units.

• A cross section view of all patients by ward - unit- or specialty revealed where constraints could be.

• The medical administration assistant then negotiated allocation of patients with all medical units.

ProgressProgress

•The improvement monitored the patient flow and resulted in a more manageable workload for medical units.•Patients benefits were reduced wait time in ED, and being seen more promptly by medical staff.

• This process is currently person dependant.

• The data analysis and creation of the daily sheet is time consuming.

ED had about x7 waiting for bedsx2 of these are psych patients who have been there coming up to 4 and 5 days respectively.

Hospital fullA1 x25 patients x7 wardsA2 x16 " x5 "B1 x10 " x3 "B2 x30 " x7 "Oncol x14 " x3 "Haem x13 " x2 "CCU x8Neuro x10 " x2 "Spec x12 "

Surgical x77 of 94 bedsThere is a lot of nursing sick leave in the operating theatre today. Usual agency had not been able to supply staff. If not all avenues have been exhausted and some afternoon cases will have to be cancelled.

DAILY REPORT SAMPLE

• Improved access to a bed and medical consultation for the patient.

• Improved collaboration amongst medical registrars.

• Development of an automated program will assist with the long term progress and sustainability of this trial

Questions

Team Presentations

Tony Snell and Prue Beams

5TH October 2004

Concurrent Session 1Concurrent Session 1Team PresentationsTeam Presentations

Bellarine Room 4– LaTrobe Regional Hospital– St Vincents Health– Northern Health– Angliss Hospital

Peter Wright - ED DirectorLatrobe Regional Hospital

1. Bed availability (ED Acute, Acute Sub-Acute) 2. Awaiting ACAS assessment 3. Delay in Allied Health Assessments 4. Reluctance to call Inpatient Referral 5. Medical rounds done too late in day6. Awaiting Inpatient Team assessment in ED7. Awaiting clinical investigations 8. HMO decision making delays9. Delay in CT results & ultrasound 10. No Radiology between 10pm - 8:30am

Priority Constraint Priority Constraint 1. Bed Allocation1. Bed Allocation

• Hourly patient tracking in ED has highlighted patients waiting 3 to 6 hours from time of bed allocation to actual time of admission.

• Goal to have all ED patients admitted to the hospital within one hour of the decision to admit.

Hourly Tracking AnalysisHourly Tracking Analysis

R = Radiology BA=Bed allocated waiting ward t/fer P = Pathology I = Inpatient Review W= Waiting to be seen C = Communication Delay BW = Waiting bed allocation E = ED Treating

3-12 hour waits in ED

0123456789

101112

R P W BW BA I C E

3hrs 4hrs 5hrs 6hrs 7hrs 8hrs 9hrs 10hrs 11hrs 12hrs+

• Hourly ED tracking undertaken to identify major flow constraints

• Refinement of data tracking to better reflect bed allocation issues, including ward, system, ED & clinical constraints

• ED AUM’s and ED Manager involved in data collection

• Hourly data tracking well received by staff, however busy times impact on data collection

• Relatives or carers were not involved

Diagnostic work continued ...Diagnostic work continued ...

• BAF bed allocated, but bed not empty (this includes verbal allocation for expected discharge)

• BAC bed allocated, but needs cleaning• BAS bed allocated, awaiting staff pick up, ie Ward Nurses or

Hospital Attendants• BAT bed allocated, treatment in ED before can be transferred,

ie: clinically unstable, IV medications etc• BAP bed allocated, paperwork holding up transfer, ie doctors

notes, admission notes, etc.

Refinement of hourly data tracking included breaking down codes for Bed Allocation constraints;

• Refined data collection will identify improvement areas.

• Possible improvement areas;– Ward meal breaks and stable patient transfer, no

ward staff available to do immediate admission– Patient paperwork in order prior to bed allocation– Staff availability for physical patient transfer – Bed Clean procedure performed on discharge, not

admission request

ProgressProgress

• We’re working on patient flow constraints in reverse to free beds for patient entry points such as ED. These initiatives include;

– Community Bed Register– Bed Manager Role– Social Worker Unification including GEM triage– Functional Mobility Program for GEM patients– Multi Disciplinary Admission / Discharge Summary– Bed Manager focus on Short Stay Unit utilisation– Alert system for 8 hour ED stays

Progress cont ….Progress cont ….

• Positive impacts to date; – 3% decrease in ED journey & average stay time.

– 23% increase in utilisation of Short Stay UnitUtilisation of Short Stay Unit (LRH)

1015202530354045505560657075808590

May 04 June 04 July 04 Aug 04

Progress cont ...Progress cont ...

• We expect to see more significant improvement as initiatives settle in.

• ED AUM’s, Management and all ED patients over 3 months were involved in the hourly data collection.

• What worked well;– Hourly tracking

• Simple and well accepted, if not liked• Highly visible• Highlighted key constraints

• What would you now do differently and why? – Start data collections earlier with better

tracking tools (initial tools inadequate)

Our expected impact will be;

• All patients admitted within an hour of bed allocation

• 12 hour stays in ED brought within target levels

• Utilisation of Short Stay Unit over 100%• Reduced Acute LOS

• Further work on Bed Waiting and Bed Allocation

• Implementation of the GEM Functional Mobility Program late September should impact on Acute LOS and impact on available beds for ED admissions.

• Refinement of hourly patient tracking will determine new action plans.

Questions

Contacts: Peter Wright ED Director pwright@lrh.com.au

Wen Bezzina PFC Co-ordinator wbezzina@lrh.com.au (03) 5173 8139

Department of Human Services Patient Flow Collaborative Angela Peluso - Clinical Lead Ian Jackson -...

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