Andrew Stripp, Alfred Health - Timely Quality Care
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Andrew Stripp, Alfred Health - Timely Quality Care

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Andrew Stripp delivered the presentation at the 2014 Emergency Department Management Conference. ...

Andrew Stripp delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit: http://bit.ly/edmanagement14

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  • 1. Timely Quality Care Andrew Stripp July 2014 Melbourne
  • 2. Organisational Setting • Approx 7,500 individuals as 4,500 EFT • 700 specialist senior medical staff of whom 200 are ‘full time’ • Across three main hospital sites and a multitude of other community settings in central south-east Melbourne • Full range of services – Acute Mental Health and Community • Many national and State services e.g. – Paed Lung Transplant – Adult Heart and Lung Transplant – Trauma – Burns – Haemophilia • Local population of about 400,000 – State-wide services offer to 5.5m • We share our campuses with several academic organisations – Baker IDI, Burnett Institute and Monash University and others
  • 3. It’s a journey for everyone in the health service….. Overview of some of the key components based on Alfred Health’s experience & learning • Governance for improvement • Bed allocation & transfer processes • Inpatient unit support • In-patient response time • Importance of Sub Acute processes • Managing the elective program • Emergency department process redesign • Ward Governance • Problem Solvers
  • 4. Alfred Health Reflections (2012) 1. Active and very present Executive Management 2. Contextualise the change process 3. Understand the patient demand & capacity requirements of all medical & surgical units 4. Ensure the emphasis is on the quality of patient care not about meeting targets 5. Develop streams of care that support demand 6. Ensure the entire workforce have an up to date understanding of ‘flows’ 7. Ensure all levels of the organisation can effectively and rapidly problem solve 8. Empower medical leaders and nurse managers to run their ward 9. Provide clarity of responsibility for patient care 10.Don’t ignore after hours
  • 5. Contextualise the change process •One solution/process does not fit us all •Incremental steps or all at once •Good diagnostics but not over analysis – Sometimes ‘just do it’ •‘local leadership in a context of Executive involvement’ •Balance of ‘what’ with ‘how’
  • 6. Ensure there is capacity to effectively & rapidly problem solve – involving all levels of the organization • CEO, Consultants, Nurse Managers, Allied , Sub Acute etc… • Organizational structures • Weekly access meetings • Daily bed meetings • Lean thinking capability • Executive sponsorship for change The Alfred - Daily Bed Access Worksheet Date: 15/06/10 Time: 00:9:30 Current ED pts requiring a ward bed Current ED pts waiting > 8 hrs for bed Current ED pts requiring ICU/HDU bed MD elective pts requiring bed (incl. MD & ICU/HDU) Total Beds required @ 09.30hrs Potential beds available Predicted ED Admissions for today Bed Variance Predicted discharges yesterday Actual Discharges Yesterday Ward Discharges Yesterday ESSU Discharges Yesterday CGMC Transfers from wards Yesterday Current ED pts waiting > 8 hrs for Psych bed Potential beds available Psych Predicted Admissions for Today Psych Bed Variance Psych 7 4 0 23 32.5 77 30 14.5 51 41 17 24 2 0 0 0 0 Confirmed Potential Trsfer - out Trsfer - in Elective Emergency ICU 2EA(4D) 32 32 32 32 3 1 1 3 -1 2WS 40 32 40 39 4 3 2 6 -2 3CTC 48 40 44 4 44 2 5 2 5 -2 -1 4GMU 36 28 28 4 28 2 5 4 3 4AMU 20 20 20 8 23 3 7 4 1 5EA 32 30 31 31 10 1 2 7 -1 6EA 34 32 32 32 1 2 -1 6WS 34 28 28 28 1 2 2 1 0 7EA 34 28 28 28 3 3 1 -1 7WS 42 32 32 32 1 2 2 -3 F/House 15 15 15 15 2 1 1 2 3BSS 28 20 20 20 5 5 2 9 3 ESSU 12 12 12 13 8 4 1 12 ICU (eqv) 45 32 32 31.5 1 3 -1.5 Total 452 381 394 16 396.5 27 50 9 6 23 7 2 34.5 -4 -1 -1 3B DPU DOSA Daycases Vari 5 6 Psych Grd Floor 26 26 26 26 0 APPICS 4 4 2 2 0 1st Floor 28 28 28 28 0 PARC 10 10 10 10 0 Total 68 68 66 66 0 0 0 0 0 0 0 0 0 0 0 HITH Current pts New admits Potential admits 56 6 62 CGMC Variance AC1 33 33 0 Wait List No. of pts AC2 30 30 0 Aged Care 11 AC3 32 32 4 4 Rehab 5 ACG 15 15 1 1 Transitional RA 25 25 1 1 Hostel RB 26 26 1 1 Total 16 RC 25 25 1 1 Barringa 15 15 0 Total 201 201 8 0 8 SDMH Variance CGMC Surgical 0 SDMH Ortho 0 Other Medical 0 Total 0 0 0 0 Potential ED Transfers Ready p/work compl. 8 5 13 ND staffing variance Ward DischargesWard Total Bed capacity Budgeted Beds Current Beds open Psychiatry -Daily Bed Variance Current pt census (actual pt numbers) Bed VarianceAdmission beds Ward Admission Demand @ 0930 AM staffing variance (next day) PM staffing variance
  • 7. Daily meeting that understands the disposition of a ward in the context of the hospital and problem solves impediments to good patient care…  More accurate picture of the hospital  Enables earlier planning/intervention  More responsive system  Shared understanding  Identify daily constraints and provide support  Provides forum for discussion
  • 8. Weekly Patient Access (now TQC) Meeting • Executives, senior clinicians & managers from all 3 campuses • 50 % performance analysis, 50 % action • Analyse & review weekly access data • Identify options for improving performance • Initiate & monitor improvement strategies • Develop policies & procedures
  • 9. Some of our discussions • Do we believe in a four hour target ? • What does good care look like ? • I don’t understand why we are performing so poorly • How do we ensure what we do is safe • What is the standard response time for inter unit consultation and bed card changes • Do we need bed cards • Is it reasonable to expect an inpatient unit to respond within 2 hours of referral of admission ? • How can we recognize the achievements of our staff • What can we do to improve nights and weekends • What do we need to do to ensure we meet our obligations to the community, as a tertiary/quaternary hosp, as a teaching institution • What does good ward management look like ?
  • 10. Ensure the entire workforce have an up to date understanding of what's going on • Daily Nurse meetings • Daily dashboard • Intranet drill downs • Access meetings • Theatre meetings
  • 11. Junior medical Staff involvement - crucial • Weekly meeting with Advanced Trainees • Moving to open meeting with Adv Trainees and all other JMO’s • Improve the training experience • Identify issues • Some Project leadership
  • 12. ‘Management Initiative’ Clinical Imperative Failing on key Government indicators Capacity to operate when clinically indicated Complaints Patients receive intervention when planned Lost revenue opportunities Surgeons operate when they are scheduled Length of stay benchmarking Patients in hospital only as long as they need Theatre utilization Revenues are optimized for reinvestment in clinical initiatives Complex infrastructure for simple procedures Surgeons want a balance between elective and emergency surgery Enable innovation Innovate and best practice 12
  • 13. Patients will be reviewed by the inpatient team within 2 hours of being referred for admission. October 2013 Patients will be discharged from E&TC or admitted to the hospital as decided by the E&TC consultant staff. Patients will be admitted to a bed in the most appropriate clinical place, the first time. Patients will have their investigations, consultations and interventions completed as soon as possible, in order of request and in no longer than 24 hours. Patients will be actively managed to ensure they are only in hospital for as long as is clinically necessary. Patients that present to the E&TC will be assessed, have treatment and investigations initiated and a management plan in place within 60 minutes of arrival.
  • 14. Whole of Hospital Changes  Inpatient engagement & acceptance of ED’s authority  Roster re-profiling across the in-patient units  Bed model changes in all wards (admission beds, SAAU’s, MAAU's & Flex beds)  Treat in turn principle for all investigative & interventional areas  New after-hours models ensuring safer care in this vulnerable period
  • 15. Timely Quality Care - After hours 20th November 2012 Workflow Coordinator 17th July 2013 3rd October 2013 February 2013 New Roles Introduced •Clinical Lead •Clinical Ops Manager •Patient Flow Coordinator Clinical CARPS Launched H@NT Launched Changes so far
  • 16. Current areas of Interest • Elective Medical Admissions • Weekends & Evenings • Outpatients • Winter drivers and opportunities • JMO rotations • Perioperative Medicine
  • 17. Objectives • Progress the care of the individual patient. • Progression of care delivery models to achieve better patient outcomes. • A consistent framework across the organisation for interdisciplinary ward based leadership and service improvement. • Consistency in practice • What are the principles for good governance ? Progression of Care
  • 18. Excellence in Ward Governance
  • 19. How are we doing ?
  • 20. ED occupancy the past 4 weeks - 2012 Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total 0 31 28 34 35 32 37 33 33 1 30 29 34 36 30 36 32 32 2 31 30 31 31 26 34 29 30 3 32 30 29 31 23 34 31 30 4 32 29 28 27 21 33 30 28 5 28 26 28 25 20 31 30 27 6 29 26 27 25 22 32 28 27 7 28 25 27 23 22 31 25 26 8 26 24 29 21 22 31 27 26 9 26 25 28 19 23 33 31 26 10 28 30 30 21 25 36 31 28 11 29 36 33 24 30 36 31 31 12 32 42 37 28 34 40 31 35 13 34 45 37 30 37 39 27 35 14 38 45 41 33 38 37 29 37 15 36 47 39 32 41 36 32 37 16 35 48 39 33 41 38 34 38 17 30 45 37 32 41 36 32 36 18 31 43 34 32 38 35 35 36 19 27 44 37 30 38 36 34 35 20 26 44 35 34 39 32 34 35 21 29 41 34 36 37 35 32 35 22 30 38 35 34 35 34 34 34 23 30 36 33 34 39 33 33 34 Total 30 35 33 29 31 35 31 32 Av occupancy > 45 Av occupancy 39- 45 Av occupancy 39- 33 Av occupancy < 33
  • 21. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total 0 28 25 29 29 29 28 24 27 1 30 26 28 26 24 27 23 26 2 28 25 27 24 22 25 23 25 3 26 22 27 19 21 21 21 23 4 25 19 25 18 19 21 16 21 5 23 17 23 18 18 21 17 19 6 20 16 23 17 18 17 14 18 7 20 17 24 15 17 17 14 18 8 19 17 20 14 16 15 13 16 9 18 17 20 14 16 13 17 16 10 22 21 25 22 19 18 20 21 11 23 27 27 28 22 19 22 24 12 27 32 28 30 27 22 25 27 13 29 34 31 33 28 27 29 30 14 30 34 33 35 32 30 31 32 15 31 36 34 35 31 35 33 34 16 31 36 37 33 30 34 35 34 17 28 35 33 33 30 30 31 31 18 27 35 34 33 30 29 30 31 19 26 35 34 35 28 27 32 31 20 27 37 38 38 29 27 32 32 21 29 38 40 36 30 27 35 33 22 29 36 38 37 30 27 34 33 23 27 34 34 34 30 24 32 31 Total 26 28 30 27 25 24 25 26 The past 4 weeks - 2013
  • 22. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total 0 20 30 23 25 28 26 26 25 1 18 29 22 22 27 25 24 24 2 22 27 22 21 25 24 20 23 3 24 25 18 20 22 19 20 21 4 21 21 18 17 18 16 22 19 5 20 18 19 15 16 15 19 17 6 18 17 18 15 18 15 18 17 7 17 17 18 14 19 14 18 17 8 15 15 17 15 17 15 17 16 9 16 17 16 17 20 18 19 18 10 21 21 19 20 23 24 20 21 11 22 28 24 22 24 29 22 24 12 23 32 28 25 28 30 23 27 13 27 32 29 24 34 32 26 29 14 28 36 31 27 34 30 29 31 15 30 35 30 24 33 31 29 30 16 29 35 29 23 31 25 27 28 17 25 31 28 25 30 27 28 28 18 26 31 31 26 32 28 27 28 19 27 30 37 24 29 28 26 29 20 27 27 40 25 26 28 28 29 21 28 28 35 30 27 28 28 29 22 28 29 34 31 27 29 25 29 23 30 26 28 30 25 27 24 27 Total 23 26 25 22 25 24 23 24 The past 4 weeks - 2014
  • 23. Timely Quality Care Andrew Stripp July 2014 Melbourne