WQD2011 - Breakthrough Process Improvement - Tawam Hospital - The Surgical Admission Process

The Surgical Admission Process

A Cultural Shift Paradigm

Breakthrough Process Improvement Case

About Tawam Hospital

• 477-bed tertiary hospital in Al Ain

• Highly specialized and well trained doctors and nurses.

• In affiliation with Johns Hopkins Medicine from 2006

• JCI accredited since 2006 and reaccredited in 2009.

• Recognized as Baby Friendly Hospital.

• An educational hospital and training center for faculty of medicine and health sciences- UAE University

1.Project Selection

2.Current Situation Analysis

3. Solution Develop

ment

4.Implementation

PROJECT SELECTION & PURPOSE

T Data And Quality Tools Used To Select The Project

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Data Reason for use

Operational reports, KPI

indicators (as LOS, Delays in OR

start time, # of surgeries, # of

admissions ), patients feedback,

To take evidence based decisions considering a balanced view

of the process at hand.

Tools Reason for Use

Multidisciplinary team Pool of subject matter expertise to ensure comprehensive

understanding of the problem, broad generation of innovative

ideas and easy buy in during implementation

Brainstorming & Group discussion Proven effective tool to generate big number of ideas from all

stakeholders Prioritization matrix To select important projects based on objective and

comprehensive criteria to consider projects impact from all

aspectsProject Charter To clearly communicate, define goals, targets, scopes, and

expectations. To identify project responsibility and

accountability

SIPOC To identify the scope, inputs, outputs internal and external

customers, and main process steps.

Subject Matter Expert (SME) To consider the project form all aspects, with a professional

view

Involvement of potential stakeholders

in project selection

Surgery Quality Committee including:

• Division chiefs

• Nursing representatives

• Administration representatives

• Pharmacist

identified “Bed management” and OR booking” as two of the top five priority projects for the Surgery

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Why The Project Was Selected

• To select the priority projects a group consensus using a prioritization matrix consisting of 10 criteria was applied: – Patients needs & expectations – Outcome – Mission /Vision/Strategic Plan – Regulatory compliance – High Risk / Volume – Problem prone – Cost – Impact – Ease of implementation

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Why The Project Was Selected – 2

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Score of > 18 = Top Priority

Score of 15-18 = Moderate Priority

Score of 10-14= Low Priority

Score of < 10 = Not a Priority

ALIGNMENT WITH THE ORGANIZATION'S GOALS, PERFORMANCE MEASURES, AND/OR STRATEGIES

Affected Organizational Goals

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IDENTIFICATION OF POTENTIAL STAKEHOLDERS

Potential Internal & External Stakeholders

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Team analyzed:

•Patients flow •Areas affected by the project •+/- impact •Inputs /outputs/process steps

How

•Brain storming

•SMEs

•SIPOC

•Process Flow Chart

SIPOC

Types Of Potential Impact On Stakeholders & Potential

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1.Project Selection

2.Current Situation Analysis

3. Solution Develop

ment

4.Implementation

THE APPROACH/PROCESS THE TEAM

USED TO IDENTIFY THE POTENTIAL ROOT CAUSES/IMPROVEMENT OPPORTUNITY

Innovative Methods And Tools Used To Identify Possible Root Causes 1/2

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Process walk through

• Patients view

Cause & Effect Diagram

• Possible causes of the problem

Pareto

• Prioritize possible contributing factors

Structured Data Analysis

• Evidence based

Staff Shadowing

• In-depth understanding- provider view

Innovative methods and tools used to identify possible root causes2/2

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Describe The Team’s Innovative Analysis Of Data To Identify Possible Root

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Data analysis included an extensive assessment of:

• KPI results (including OR Cancellation Rate & number

of elective surgical admissions).

• Reasons of surgical cancellations on day of surgery.

• Reasons for “patients no show”(by calling the

patients).

• Available vs. needed” Surgical education materials”.

THE TEAM ANALYSIS OF INFORMATION TO IDENTIFY THE FINAL ROOT CAUSES

Tools Used To Identify The Final Root Cause(s)

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Team’s Analysis Of Data To Select The Final Root Cause(s)

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• The old process was inefficient

– No proper communication between various stakeholders (patient, or scheduling office, anesthesia clinic and financial clearance office).

• The OR elective cancellation rate (on day of surgery) was 20%.

– System errors accounted for a significant percentage of cancellations.

How The Team Validated Final Root Cause(s)

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Score

Strong Impact 9 Moderate 3 Low 1

Relationships

1.Project Selection

2.Current Situation Analysis

3. Solution Develop

ment

4.Implementation

METHODS USED TO IDENTIFY THE POSSIBLE SOLUTIONS/IMPROVEMENT ACTIONS.

Methods And Tools Used To Develop Possible Solutions /Improvement Actions

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• Run comprehensive literature review to identify other healthcare (HC) systems approach to similar problems.

• Used the PICO Model (Population Intervention Comparability

Outcome) to validate our comparison with HC systems similar to our environment.

• Held one to one discussions with the process owners. • Generated and captured possible solutions during brain storming sessions & 5 Whys Exercise

Team’s Analysis Of Data To Develop Possible Solutions

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• Improvement actions were based upon extensive review of:

– Base line KPIs and process related data

– Results of the studies done by the various team members about the reasons for the delay, cancellation rate and source by wards, etc.

– Possible impact on the results

– Easiness of implementation

– Impact on patients safety and satisfaction

– (as mentioned in 2A b & 3Ac).

Criteria The Team Decided To Use In Selecting The Final Solution(s)

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• Criteria for selection were chosen in a balanced approach considering:

– Financial

– Operational

– Customer

– Quality perspectives

Criteria The Team Decided To Use In Selecting Final Solution(s) 2/3

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HOW THE FINAL SOLUTIONS IMPROVEMENT ACTIONS WERE DETERMINED

Tools Used By The Team To Select The Final Solutions

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Tools Rational for use

Provided a holistic qualitative approach for identifying the possible solutions considering the 5

Ms and E and in relation to the Identified causes under the same categories. It also helped in

generating ideas for improvement.

During discussion on the possible root causes, all ideas generated were listed then they were

prioritized by the team using the Prioritization Matrix.

Prioritizati

on Matrix

This useful technique used to rank the solutions based on important criteria to identify the most

important solutions to work on first: (kindly refer to the scoring in 3Ac)

Fish Bone

Diagram

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Team’s Analysis Of Data To Select The Final Replicable Solution(s)/Improvement Actions 1/2

For example, Ortigo et al , found in a study including 6053 patients that the implementation of a Surgery Admission Unit for patients undergoing major elective surgery has proved to be an effective strategy for improving bed management, improving the proportion of patients admitted on same day as surgery and a shorter length of stay

Benchmarking with evidence based proven practices

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Team’s Analysis Of Data To Select The Final Replicable Solution(s)/Improvement Actions 2/2

FINAL SOLUTIONS VALIDATION

1.Project Selection

2.Current Situation Analysis

3. Solution Develop

ment

Implementation

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• Resistance from various stakeholders was both expected and encountered:

– Multiple meetings were held

– The SAU team identified physicians who presented a challenge. This was addressed to the Director of Peri-Operative Services.

– Protocol was strictly enforced such that surgeons who followed the protocol were able to get more cases on the schedule while those who were resistant lost operative time.

– Surgeons and staff were encouraged to counsel patients on the benefits of this process.

Types Of Resistance Identified And Addressed

The final solutions, validated through literature review and impact analysis included:

• Enriching the current function of the Day Case Unit by adding the function of a Surgical Admission Unit.

• Remodeling of the elective surgical admission process. All elective surgical admissions unless otherwise medically indicated will be admitted on the day of surgery.

• Developing a Surgical Admission Office

• Improving surgical educational materials

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Improvements Implemented

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• Centralize – Surgical Scheduler (medical background)

– Admissions/Bed Board Officer

– Insurance Specialist

– Patient Advocates

Improvements Implemented

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Surgery scheduled and communicated electronically to the office by surgeon

Patient seen in office, oriented, assigned patient advocate

Patient flow through system virtually shadowed by office

Patients called 1wk, 48, and 24hrs prior to surgery

Improvements Implemented

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Patients called to arrive 2 hours prior to surgery based on schedule

Goal set for patient arrival to being ready for transport to OR: 20 min

Ambulatory patients discharged efficiently based on nursing care pathways

Improvements Implemented

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Patient removed from schedule if not cleared and empty space communicated to surgeons

Surgical Schedule communicated electronically to entire organization at 48 and 24 hours

Charts available night before scheduled surgery and reviewed by nurse-Problems Identified

Beds allocated night before based on expected admissions

Improvements Implemented

RESULTS ACHIEVED

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Tangible Results

Other Results

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• Increased patients satisfaction

• Increased staff satisfaction

• Better hospital reputation and word of the mouth

• Increased efficiency

Creation And Installation Of A System For Sustaining Results

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Results of the following KPS were reviewed weekly by a core team :

• OR utilization

• OR start times

• Patient arrival times

• Patient transport times

• Reasons for cancellations

• Sharing of successes and recognition at Tawam and national levels

• At SEHA level won the Golden Medal

• Transparency

• Learning form challenges

• Next step: move the Pre-anesthesia clinic closer to the surgical admission office.

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Project Closure

Lessons Learnt

• Chronic problems are always associated with high resistance to change

• When incremental improvements are not effective, a process reengineering should be considered

• Team work is the fuel for success

Team Leader : Dr. Waleed Hassen, Chairman of Urology Team Members: • Alexander Jankuloski RN, Associate Director of Nursing

• Alec Napier, Operations Officer • Aysha Al Ameri, Administrative clerk, Surgical Admissions Office • Susie Delgado, Nurse Manager, Surgical Admissions Unit • Urszula Allen, Nurse Manager, Operating Room

• Mervat Mansour, Section Head, Quality Improvement &

Innovation ,DPI.

The Project Team

Any Questions?

Thank you