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Jun
e 2
– 3
, 20
14
Dr. Phil Shin Chief of Medicine and
Medical Director, Critical Care &
Susan Woollard Program Director, Medicine, Critical Care and
Elder Care
Improving Patient Flow
North York General
• Community teaching hospital
• Affiliated with the University of Toronto
• Catchment area: 400,000 residents
Three Sites:
• General
• Branson
• Seniors’ Health Center
Beds:
• 413 acute care
• 200 long-term care
Volume:
• 110,000 Emergency Department visits annually
• 28,000 inpatient cases per year
• 5,800 births per year
%
Conservable
Days
90th ED LOS –
Admitted
Patients
% of Time
EAA 15 or
Fewer
25%
43%
89%
Our Improvement Story
2012 – 2015 Strategy
2nd Out of 74 Ontario Hospitals in ED Performance Funding Rank
Access to Care Executive Sponsor
Karyn Popovich & Dr. Donna McRitchie
Access to Care Committee
Chair: Karyn Popovich
Admin Janice Lepper
Access to Care Core Team
SI Leads: Maria Muia and Mary Lynne MacMaster
Project Manager: James Ibbott
Admin Jeanette Weetom & Audrey Oakley
A2C
Engagement
Groups
Change
Management
Consultants
Office of
Strategy
Management
Operations
Committee
Medical
Advisory
Committee
A2C Projects
Departmental /
Program Led
Improvements
Bed Transfer for Long Patient
Waits Expedite
Physician Service Expectations
Work with LHIN on Rehab / LTC
issues
Improve Ultra Sound TATs
Improve Cardio Resp. TATs
Do a Value Stream Analysis on UMS / BMS
Align Medicine Internists with Roles in UMS
Improve Inappropriate Admissions to
Hospitalist
CCAC Issues Log: RM&R, CM
Waiting, CCAC Policies
Site Visits to Southlake and
TEG. More benchmarking
Need IPAC Escalation Protocol
Portering Recommends
(George & UofT)
Work on Weekend Issues
NOW
Better Utilization of Stroke
Prevention / Clinic
Develop Cardia Care Pathway
(IPU) Improve Med-
Surg Clinic Capacity by
Appropriates Management
System for Wellsoft /
Teletrack Errors
Utilize NPs in ED
Managing Patient / Family
Expectations
Investigate why ALC is increasing
Improving Staffing: Problem
when going overcapacity
Escalation Protocol for
Surgery when cannot place
Protected Meeting Time
Standards
Patient Flow Navigators
Need a Cerner Flag for DI Consent
Standard Documentation / Planning for Long
Weekends
ALC Improvements
Escalation Protocol Phase
3
Isolation Room Capacity
Improvement
Conservable Days Working
Group
P&F Early Involvement in D/C Planning
Roles & Expectations in D/C Planning
Powerchart Enhancements D/C Planning
Sustainability in Access to
Care
Medical Imaging Service Delivery
Portering Service Delivery
P&FCC
Quality & Safety
Framework
Service Excellence
Model
Service Excellence
Connecting Care
Care Environments
Research & Innovation
LMS System
Education SI
Healthlinks
ED Renovations
Family Medicine Workflow
PowerScribe Upgrade to
PS360
cGTA and OnBase
HBAM & QBP
MH and Yellow Zone Process
Review
eCare
BDC Wait Time Improvement
Cardiac Clinic Outreach
Med-Surg Clinic Redesign
Senior Friendly Hospital
Branson CT Service
Consolidation
Access to Care
Governance Structure
2011/12 2012/13 2013/14 2014/15
Med-Surg Clinic
Short Stay
Beds
Escalation
Protocol
Daily Goal Rounds
Physician
Champions RM&R
Social Worker
Schedule
GIM Model
of Care
There’s No
Place Like
Home
Escalation
Protocol
(Phase 2)
Access to Care
Celebration &
Recognition
Teletracking
Upgrade
Discharge
Management
Planning Event
Leadership
Walkabouts for
Daily Goal
Rounds
Increase
Private
Rooms
Project Planned for
2014-15
ALC Improvements
Escalation Protocol
(Phase 3)
Sustainability for A2C
Patient & Family Early
Involvement in
Discharge Planning
Transportation Service
Improvements
MI Service
Improvements for ED
Access to Care
Project Timeline
• Trigger based on
patients waiting in ED,
ICU and elsewhere
• Unassigned are the
patients waiting in ED
that have not been
assigned to a bed
• ED and CTAS
information used to
show volume and
acuity
• Status comes out 5
times a day
Escalation Protocol
What are the Benefits
Escalation Protocol:
Transfer patient waiting to an
unbudgeted bed immediately
Patient transferred to inpatient unit
Other patients waiting benefit
from having access to care
on inpatient unit faster
Obtain clinical services sooner
Availability of resources in
Emergency / ICU
Better patient outcomes, safety and patient
experience
2011/12 2012/13 2013/14 2014/15
Med-Surg Clinic
Short Stay
Beds
Escalation
Protocol
Daily Goal Rounds
Physician
Champions RM&R
Social Worker
Schedule
GIM Model
of Care
There’s No
Place Like
Home
Escalation
Protocol
(Phase 2)
Access to Care
Celebration &
Recognition
Teletracking
Upgrade
Discharge
Management
Planning Event
Leadership
Walkabouts for
Daily Goal
Rounds
Increase
Private
Rooms
Project Planned for
2014-15
ALC Improvements
Escalation Protocol
(Phase 3)
Sustainability for A2C
Patient & Family Early
Involvement in
Discharge Planning
Transportation Service
Improvements
MI Service
Improvements for ED
Access to Care
Project Timeline
Daily Goal Round Agenda:
• Patient name/Diagnosis/MRP
• Expected Date of Discharge (EDD)
• Daily Goals - i.e., facilitate diagnostic tests, interventions, clinical assessments, etc.
• Outstanding Issues/Barriers – i.e. any outstanding items from Diagnostic Imaging, Lab results, referrals, consults, family meetings, social work, physiotherapy/occupational therapy, etc.
What’s Different? • Everyday • Before 10am • Frontline nurses
present patients
The Goal: To drive collaboration between members of our multidisciplinary team to facilitate a safe and effective discharge plan for patients, and their families and caregivers. Frequency: Every week day before 10:00am for 30-45 minutes
Daily Goal Rounds
The Goal: to collaborate with the multidisciplinary team to facilitate a safe and effective discharge plan. At bullet rounds the appropriate traffic light disposition will be determined.
Allotted Time: 30mins
Be precise
Utilize time well
Look at the big picture
Lean thinking!
Expedite discharges
Team approach
Agenda:
1) Patient name/Diagnosis/MRP
2) EDD (expected discharge date)
3) Daily Goals - i.e. facilitate diagnostic tests,
interventions, clinical assessments etc.
4) Outstanding issues/barriers – i.e. any
outstanding items from Diagnostic Imaging, Lab
results, referrals, consults, family meetings,
social work, PT/OT, etc.
Daily Goal Rounds
Daily Goal Rounds:
Impact to Staff
“Critical thinking of nurses has been enhanced, more proactive. Nurses now come with a discharge plan and are asking at Rounds “what the plan is””
“Helps to have Unit Coordinator to delegate and be more involve as a coach. It is now off the UC and more on Nurses”
“More confidence, better information from nursing,
nurses know their patients better i.e. lab results. Lots of great feedback”
“Nurses are more
accountable and physician seek out the primary nurse more than before.”
“Students enjoy the process and participate”
2011/12 2012/13 2013/14 2014/15
Med-Surg Clinic
Short Stay
Beds
Escalation
Protocol
Daily Goal Rounds
Physician
Champions RM&R
Social Worker
Schedule
GIM Model
of Care
There’s No
Place Like
Home
Escalation
Protocol
(Phase 2)
Access to Care
Celebration &
Recognition
Teletracking
Upgrade
Discharge
Management
Planning Event
Leadership
Walkabouts for
Daily Goal
Rounds
Increase
Private
Rooms
Project Planned for
2014-15
ALC Improvements
Escalation Protocol
(Phase 3)
Sustainability for A2C
Patient & Family Early
Involvement in
Discharge Planning
Transportation Service
Improvements
MI Service
Improvements for ED
Access to Care
Project Timeline
GIM/Physician Model of Care Result:
Medical School Cardiology
Respirology
Gastro-enterology
Internal Medicine
Oncology
Geriatrics
Infectious Diseases
Specialists in General Internal Medicine or General Internists Are expert diagnosticians: they are considered medical detectives Are leaders in medical education, particularly clinical examination
Specialize in the management of patients with multi-system or undifferentiated disease Sort out illnesses and balance their management
Endocrinology Rheumatology
Hematology Allergy and Immunology
What is a Specialist in
GENERAL INTERNAL MEDICINE
Critical Success Factors
Critical Care Process
(Intensivist - Led Model)
Rapid Referral Clinic
Medical Consult Service
ED Consultation
Inpatient Most Responsible
Physician
GIM Model of Care
Research Question
• Does the implementation of a general internal medicine
model of care in a community teaching hospital have a
measurable impact on the quality of patient care?
Physician Engagement Score 85% The provincial 75th
percentile was 66.1%
Staff Engagement Score 66.6% The provincial 75th percentile
was 66.1%
Critical Success Factors
Culture and Innovation
The Journey Continues
Thank You!
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