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  • 1. The Flinders Journey into a lean future. David Ben-Tovim, on behalf of the Redesigning Care team at the Flinders Medical Centre.
  • 2. • the purpose [of the changes] should be so that public services can adapt and adjust naturally, self-generating reform, rather than being continually prodded and pushed from the centre. (the Economist, May 2007)
  • 3. • The Flinders Medical Centre is a 500 bed teaching general hospital in the Southern Suburbs of Adelaide. • It is a good hospital whose energetic and committed staff have access to excellent resources, in a good health system.
  • 4. • E.g. in terms of life expectancy, Australia ranks 8th in the world, the UK 37th and the USA 45th (only a little below Bosnia Herzogovina!) • And by local standards, we were a low mortality hospital.
  • 5. But nevertheless, in 2003 we were in great difficulties • Congestion and high clinical risk in the Emergency Department, • Problems with meeting elective surgery guidelines, • Threats to some training programs, • Difficulties with recruitment and retention of key clinical staff.
  • 6. We were not health care change novices. • We had extensive experience of strategic plans and re-structuring. • We had implemented ‘payment by results’ some years ago. • We were really good at blaming each other. • We had tried most of the other things that hospitals elsewhere in Australia knew how to do.
  • 7. Redesigning Care • We all (clinicians and managers) agreed that we could not go on as we were. • We needed to do something different, even though we did not know what that was.
  • 8. Why Lean? • Because the challenges facing modern manufacturing are the same as those facing the health system. 3VQ Reconciling Volume, Velocity, DiVersity, and Quality By improving flow and reducing waste
  • 9. How Lean? • We can see our program as falling into three phases. Getting the knowledge. Stabilizing high volume value streams. 5S, Standard work, Problem solving
  • 10. Need to get some Lean glasses We went on a Lean manufacturing diploma course. We had a two day residential seminar. We read books, organise conferences and meet Lean sensie. We study in the school of hard knocks. Gradually, we started to see differently, & started to work differently.
  • 11. Seeing differently nvsier Div surgery Nursing Med Managerial Div Med
  • 12. Working differently: Redesigning Care Program phases P D A S 1 2 3 4 5 DiagnosticDiagnostic PhasePhase ProjectProject PhasePhase SustainSustain new waysnew ways of workingof working Share keyShare key learningslearnings InterventionIntervention PhasePhase P D A S P D A S P D A S P D A S Start of a patient journey
  • 13. High volume value streams Patient journeys can pass through: • Junction points or marshalling yards, • Main lines • Brach lines with quiet sidings.
  • 14. High volume value streams We started by mapping all our major services (the marshalling yards and the main lines). We began to see the hospital in terms of processing-based value streams.
  • 15. Phase 2. Stabilising high volume value streams Short Long Unplanned Planned
  • 16. ED recovery Complex queues due to 5 clinical priorities ▪ chaotic processing ▪ increasing delays ▪ increasing mortality •Stream patients into dischargeable and likely-to-be-admitted. •Use first-in, first-out for both streams Phase 2- stabilising high volume value streams
  • 17. Unplanned/Emergency Admissions ED B side A side ‘take system’ ▪ variability in demand over 4-5 day cycle ▪ central dispatcher over-rides clinical needs •Loss of ward differentiation •excessive motion and transportation of staff, patients and supplies
  • 18. Admitted patients streamed into •short stay (24-72 hrs) •long stay (>72 hrs) •No take •Pull to get right patients into right wards Acute assessment unit for initial review of complex medical cases Daily Load levelling between units at 8am Unplanned/Emergency Admissions After redesign
  • 19. General comments and ward priorities Demand Capacity ED RED Total patients in ED 60 AAU beds available 0 Unallocated FMC's 2 4D beds available 0 Predicted ED admits 6 Level 5 beds 8 ED Mental Health Level 6 beds 1 Total ED MH patients 8 CCU, CSS and ACPS beds 4 ED MH requiring 1:1 care 3 Available adult med & surgical beds 1 3 ED MH other detained 1 Bed Balance minus predicted & unallocated ED 1 1 ED MH voluntary 4 ICCU AMBER Current ICCU occupancy 27 Current status RED Minimal capacity in cardiology and GI value streams. Gen Med and Emerg short stay currently at capacity
  • 20. No stay Short stay (24-48 hrs) Planned admissions Longer stay ED med/surg Short stay AAU Sub-spec Gen Med Sub-spec Surgery Mental Health Mental H - short stay Clinic Cardiac short stay Surg short stay Surgery Long surgical waiting lists complex ▪ highly variable list structures ▪ Booking & OPD redesign ▪ program of list validation ▪ Checklist ▪ Elective Surgery Strategy - opportunity for extra planned work
  • 21. WE STARTED TO GET THE HANG OF IT Senior managers provide permissions for change Work groups develop innovative solutions Sharp end managers translate into everyday work Complex relationship between leadership and authority
  • 22. Third phase. • Work on new value streams; allied health, the frail elderly in hospital and in transition between hospitals and community, radiology, chest pain/cardiology.
  • 23. Third phase. • Standard work Restructuring sequences of ward rounds and junior doctor day, Managers in the gemba The nursing day, Safe care after hours. Better visual management-patient journey boards.
  • 24. Outcomes Since the first Redesigning Care intervention in 2003: • Restored capacity to undertake elective surgery • 10,000 bed days saved by reductions in length of stay. • Greatly improved staff morale and improved recruitment and retention medical and nursing staff.
  • 25. Outcomes Since the first Redesigning Care intervention in 2003: • We have gone from being the worst performing Emergency Department in the state, to the best of the major hospitals (despite a 50% increase in activity) • Unplanned readmissions declining. • Only hospital not subject to an ‘efficiency review’.
  • 26. Outcomes In the year before we began Redesigning Care, we made over 90 referrals to our medico-legal insurers. In the last 12 months, in our region we made 19, and our sister region made 149. Even adjusting for size differences, this is still a very large differerence
  • 27. Unplanned readmission rate and separations dec 2001 - present for level 5 and level 6 emergency overnight 5 6 7 8 9 10 11 12 13 2001m 122002m 22002m 42002m 62002m 8 2002m 10 2002m 122003m 22003m 42003m 62003m 8 2003m 10 2003m 122004m 22004m 42004m 62004m 8 2004m 10 2004m 122005m 22005m 42005m 62005m 8 2005m 10 2005m 122006m 22006m 42006m 62006m 8 2006m 10 2006m 122007m 2 800 900 1,000 1,100 1,200 1,300 1,400 1,500 1,600 mean unplanned readmission rate seps First RDC intervention Activity Unplanned Readmissions
  • 28. The Lean future There are really only two choices; • Build bigger boxes. • Or redesign how the work is done.
  • 29. The Lean future A Lean future will be safer, more efficient and more acceptable for patients and staff. It will provide more of the right care, to the right patient, at the right time, in the right place.
  • 30. The Lean future But more than that, it is not our place to say. Because all solutions are local and adapted to their specific population and healthcare environment.
  • 31. The Lean future The important thing is that we have started to work out how to become a learning and problem solving organisation. When we are all like that- watch out!