Improving the Patient
Journey
PAASPORT TO BETTER OUTCOMES
• Nicola Ryan, Senior Project Officer
• Dr. Gavin Teague, HOD An...
Key Drivers for Change at RPH
• Universal Drivers
• State and National Health Reform & Targets

• Clinical Services Plan
•...
Identify stakeholders

Sub- group: Pre Operative Assessment
Leader: Gavin Teague/Simon Wall/Penny
Toomey
Governance:
Repor...
Issues identified from previous
redesign projects
RPH Elective Surgery Patient Issues by Journey Group
Mapping from 2009 r...
RPH Pre-admission Assessment
Service (PAAS)
• Located adjacent to RPH
• Currently assesses all elective surgical patients ...
Clinic and Pre-operative
Assessment
• Inconsistent booking
practices; potential for loss
of documentation
• Complex patien...
Project Aims
• Patients having a seamless surgical
experience
• Enhanced satisfaction of patients/
families and staff
• Re...
Choosing a methodology
How to choose
methodologies when faced
with a choice?
• Suitability of methodology to
problem

• Av...
Using the DMAIC Process
• Process Mapping
• Voice of the staff
• Voice of the patient
• Voice of the organization
Challenges of Engagement
WE HAVE ALREADY DONE THIS!
NOT MORE FOUR HOUR RULE!

IT WON’T WORK
When
do I find
time to
do
this...
Challenges of Engagement
Defining the problem
We engaged over 100 stakeholders from across
the hospital through participation in:
5 Process Mapping...
Define - Process Map for
Preadmission
Themes Arising from Mapping
Measure - What is the Problem?
• PAAS appointments <2 weeks prior to DOS resulted in
increased cancellation rates on DOS
R...
Measure- Data Collected from Electronic
Booking System until Aug 2013
Pts on EBS

GEN SURG

ENT

OPHTHALMOLOGY

UROLOGY

V...
What is the Problem?
You told us that a lack of management of anti-coagulants cause day
of surgery cancellations…
PATIENT ...
Measure - What is the
Problem?
Note that while clinic appointments begin
from 8:00am, most Junior Doctors are
unable to at...
Measure - What is the Problem?
• VOP – patients complained about wait times (the average
patient waits at least 165 minute...
Measure- PAAS Activity 2012/13
What is the Problem?
Patient did not report (DNR) to Pre-admission appointment…
This means a
loss of clinicians
time due t...
Data Fair
Data Fair
• Outcomes:
– Voice of Registrar
– Social Work
– Pathology
– Breast Clinic
– Displays
• Anaesthesia
• ...
Analyse- Root Causes
1. Why do we have limited patient info prior to preadmission?
• No state-wide consent process for rel...
Analyse- Root Causes
3. Why is patient wait in pre-admission 165mins?
• Pre-admission often includes 3 different
appointme...
Solution Generation
• Early distribution of Patient
Health Questionnaire
• Triage Nurse
• Removal of surgical JMO and
repl...
Templates for standardised
letters to GP
Pre-admission PAASport
Developed by
Professor Krishna Boddu
• System of checklists
• Must be checked off at each
point of ...
Theatre Management System
• Electronic capture of the preanaesthetic assessment
• Improves communication
between anaesthet...
Telephone Screening
• Development of a screening tool
• Reduction in number of patients requiring a face to
face preadmiss...
The project timeline has been extended to accommodate
successful embedment of solutions
Excellence

“

We are what we repeatedly do

Excellence, therefore is not

”

an act but a habit
- Aristotle
Questions?
Contact us

Nicola.Ryan@health.wa.gov.au
Gavin.Teague@health.wa.gov.au
Krishna.Boddu@health.wa.gov.au
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Nicola Ryan, Royal Perth Hospital - Improving the Journey – PAASport to better outcomes

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Nicola Ryan, Senior Project Officer – Clinical Service Redesign, Royal Perth Hospital delivered this presentation at the Clinical Redesign & Process Mapping conference. This conference provides case studies of succesful redesign projects to assist delegates in identifying the root causes of issues impacting patient journeys and then develop and implement sustainable change processes to improve the way health care is delivered.

Find out more at www.healthcareconferences.com.au/clinicalredesign13

Published in: Health & Medicine, Education
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Nicola Ryan, Royal Perth Hospital - Improving the Journey – PAASport to better outcomes

  1. 1. Improving the Patient Journey PAASPORT TO BETTER OUTCOMES • Nicola Ryan, Senior Project Officer • Dr. Gavin Teague, HOD Anaesthesia, Project Lead • Professor Krishna Boddu, Service Director, Executive Sponsor
  2. 2. Key Drivers for Change at RPH • Universal Drivers • State and National Health Reform & Targets • Clinical Services Plan • National accreditation • Activity Based Funding/ Management
  3. 3. Identify stakeholders Sub- group: Pre Operative Assessment Leader: Gavin Teague/Simon Wall/Penny Toomey Governance: Reports to the Elective Patient Journey Task Force who in turn report to START KPI’s: · Cancellations · DNA’s · Number of visits pre op · Number of investigations requested? · Number of referrals to other specialties? Desirables: · Establish multidisciplinary clinic assessment for high risk pts · Pathways for referrals · Review rostering of anaesthetists – buddied to specialty teams - same anaesthetist in theatre reviews pt in clinic?
  4. 4. Issues identified from previous redesign projects RPH Elective Surgery Patient Issues by Journey Group Mapping from 2009 redesign project 60 Frequency of Issues 50 40 30 20 10 0 Request for Waitlist Pre – Admission Registration Journey Admission Journey Location of Issues Theatre Post – operation care & discharge
  5. 5. RPH Pre-admission Assessment Service (PAAS) • Located adjacent to RPH • Currently assesses all elective surgical patients for • Orthopaedics • Plastics • Urology • Vascular • General Surgery • Booked admissions • Limited capacity for walk ins • 2 anaesthetists; 1 clinical nurse; 2 registered nurses; 1 preadmission clerk • 30 patients a day on average • Runs a high risk assessment clinic (2 afternoons a week)
  6. 6. Clinic and Pre-operative Assessment • Inconsistent booking practices; potential for loss of documentation • Complex patients were not identified early in the process • Patients not “Ready for Care” at end of PAAS • No triage process • Short lead in time for patient assessment and optimisation • Poor medication advice
  7. 7. Project Aims • Patients having a seamless surgical experience • Enhanced satisfaction of patients/ families and staff • Reduction in cancelled cases and waiting times • Impart redesign and change management skills to hospital staff • Improve data collection practices • Continuous monitoring of KPIs
  8. 8. Choosing a methodology How to choose methodologies when faced with a choice? • Suitability of methodology to problem • Available resources • Need for data Courtesy of Hannah Moss and Sam Green DOH Western Australia
  9. 9. Using the DMAIC Process • Process Mapping • Voice of the staff • Voice of the patient • Voice of the organization
  10. 10. Challenges of Engagement WE HAVE ALREADY DONE THIS! NOT MORE FOUR HOUR RULE! IT WON’T WORK When do I find time to do this??? RESOURCES YOU CAN’T CHANGE THE CULTURE! NOTHING WILL CHANGE I THINK WE DO A GREAT JOB! I see you are doing the important work
  11. 11. Challenges of Engagement
  12. 12. Defining the problem We engaged over 100 stakeholders from across the hospital through participation in: 5 Process Mapping sessions Numerous 1:1 discussions 2 Root-Cause-Analysis sessions We logged 89 issues, 10 root causes and delay reasons We also asked our patients what they thought of the Pre-Admission process
  13. 13. Define - Process Map for Preadmission
  14. 14. Themes Arising from Mapping
  15. 15. Measure - What is the Problem? • PAAS appointments <2 weeks prior to DOS resulted in increased cancellation rates on DOS RPH: Time from seen in PAAS to Day of Surgery This line represents the 2 week mark Most patients are falling within the <2 weeks boundary
  16. 16. Measure- Data Collected from Electronic Booking System until Aug 2013 Pts on EBS GEN SURG ENT OPHTHALMOLOGY UROLOGY VASCULAR PTS ON LIST 187 130 469 606 41 NO OF PT CANCELLED 26 (14%) 20 (15%) 93 (20%) 113 (19%) 11 (27%) CANCELLATIONS 28 (15%) 30 (23%) 130 (27%) 150 (25%) 12 (29%) KNOWN REFERRAL 184 (98%) 0 (0%) 120 (26%) 59 (10%) 10 (21%) CONSENTS 178 (95%) 124 (95%) 461 (98%) 573 (95%) 24 (59%) CAT 3' s CONSENTED 61 (100%) 74 (92%) 346 (98%) 209 (97%) 4 (44%)
  17. 17. What is the Problem? You told us that a lack of management of anti-coagulants cause day of surgery cancellations… PATIENT UNFIT - - In ED PreOP High INR High potassium/ renal review Fluid overload Didn’t stop Warfarin Didn’t stop Clopidogrel UTI For LA needs – needs GA Ankle swollen In the month of September 2 patients did not stop taking their anti-coagulant medication and their surgery was cancelled on the day
  18. 18. Measure - What is the Problem? Note that while clinic appointments begin from 8:00am, most Junior Doctors are unable to attend the clinic until after 10:30am due to work on wards Pre-admission Patient Journey - Junior Doctor Consult Times 08:15 08:30 08:45 09:00 09:15 09:30 09:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 JMO 11:45 12:00 12:15 12:30 12:45 13:00 JMO JMO JMO JMO JMO JMO JMO JMO JMO JMO JMO JMO 13:15 13:30 13:45 14:00
  19. 19. Measure - What is the Problem? • VOP – patients complained about wait times (the average patient waits at least 165 minutes) • VOS – staff complained about wait times • VOO – inefficient use of resources RPH: Control Chart for time from arrival to departure pre-admission clinic
  20. 20. Measure- PAAS Activity 2012/13
  21. 21. What is the Problem? Patient did not report (DNR) to Pre-admission appointment… This means a loss of clinicians time due to waiting for patients who do not arrive. It is not clear at this stage why patients DNR There is great variation in DNRs across specialty
  22. 22. Data Fair Data Fair • Outcomes: – Voice of Registrar – Social Work – Pathology – Breast Clinic – Displays • Anaesthesia • Theatre • Pre-admission
  23. 23. Analyse- Root Causes 1. Why do we have limited patient info prior to preadmission? • No state-wide consent process for release of patient information • No minimum data set for referrals • Lack of standardised process for distribution of Health Questionnaire 2. Why do we only use 76% of our pre-admission capacity? • Low activity days • No centralised allocation for use of sessions • No formal process for filling cancellations • Some sessions left empty due to unpredictable
  24. 24. Analyse- Root Causes 3. Why is patient wait in pre-admission 165mins? • Pre-admission often includes 3 different appointments • Conflicting role demands: Junior Doctors • Lack of processes to accommodate variation in workload and staffing 4. Why can’t clinicians see if patients have attended pre-admission? • Pre-admission appointment only recorded in EBS for approx 50% patients • Use of recording systems (TOPAS) • Lack of formal data entry processes • Insufficient training in relevant programs
  25. 25. Solution Generation • Early distribution of Patient Health Questionnaire • Triage Nurse • Removal of surgical JMO and replacement with nurse case managers • Pharmacist • Physiotherapist • Walk in model of care – 50/50 • Patient PAASport • Standardized pre-op investigations by specialty • Inclusion of GP • Telephone screening
  26. 26. Templates for standardised letters to GP
  27. 27. Pre-admission PAASport Developed by Professor Krishna Boddu • System of checklists • Must be checked off at each point of the patient journey before the patient can move onto the next step. • Ensures efficiency and provides a system for accountability. • A coded medical record document remains in the patient notes
  28. 28. Theatre Management System • Electronic capture of the preanaesthetic assessment • Improves communication between anaesthetists • Improved legibility • Electronic capture of anaesthetic Hx. • Potential for communication across sites
  29. 29. Telephone Screening • Development of a screening tool • Reduction in number of patients requiring a face to face preadmission assessment • More efficient use of existing resources
  30. 30. The project timeline has been extended to accommodate successful embedment of solutions
  31. 31. Excellence “ We are what we repeatedly do Excellence, therefore is not ” an act but a habit - Aristotle
  32. 32. Questions?
  33. 33. Contact us Nicola.Ryan@health.wa.gov.au Gavin.Teague@health.wa.gov.au Krishna.Boddu@health.wa.gov.au
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