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  • 1. Patient Flow Collaborative Action Learning Session No 3 January 19th , 2005 Western Hospital Chair for the day – Jannie Selvidge Department of Human Services
  • 2. Welcome Today is an opportunity for further; • Sharing of ideas and discussion • Networking • Challenging yourselves and each other • Support to keep going
  • 3. Housekeeping • Phones and pagers • Delegate packs • Lunch will be served (12:00 – 12:45) • Rest rooms
  • 4. Agenda 9.45 – 10.15 Western Health Megan Bumpstead Scheduling elective patients 10.15 – 10.45 Southern Health Lesley Dwyer and Elective surgery planning Shannon Wight 10.45 – 11.00 Morning Tea 11.00 – 12.00 Discussion Time Lee Martin and - Access Toolkits Rochelle Condon - LOS Hot topic calls
  • 5. Agenda 12.00 – 12.45 Lunch 12.45 – 13.15 Maroondah Hospital Dominique Leyden Ward realignment 13.15 – 13.45 Emergency Department Lee Martin and Data analysis Prue Beams 13.45 – 14.15 Melbourne Health Marcus Kennedy Pilot site update 14.15 – 14.45 Melbourne Health David Smallwood Improving Communication
  • 6. Agenda 14.45 – 15.00 Afternoon Tea 15.00 – 16.00 Team Clusters PFC Leads - Learning Session 3 Agenda 16.00 Close
  • 7. Western Health Scheduling Elective Patients Meg Bumpstead Division of Surgery Western Health Department of Human Services
  • 8. Waiting List Scheduling Current Issues • Duplication of work • No knowledge transfer • Missed equipment/ prosthesis needs • Difficult to pull pts in waiting order • Difficult to fully utilise lists • Patients booked minimal consultation
  • 9. Waiting List Scheduling Interim Improvement Plan • Microsoft Outlook Diaries – Off site access to schedule for Surgeons – Access from NUM to theatre schedule – Still duplication
  • 10. Waiting List Scheduling
  • 11. Waiting List Scheduling Long term solutions • DHS secondment – Simon Jolly • Development of IT based scheduling tool
  • 12. Waiting List Scheduling
  • 13. Improvements • New Schedule will “talk” to PAS • Upper level schedule for Theatres • Individual Surgeon lists available off site • Ready reckoner for Equipment/ Prosthesis requirements
  • 14. Booking Processes Improvements to Date • Minimal Cancellation • No booking without unit consultation • Development new RFA – endoscopy • Development new RFA - theatre
  • 15. Questions
  • 16. Southern Health Elective surgery planning Lesley Dwyer And Shannon Wight Southern Health Department of Human Services
  • 17. QUEUING EQUITY PROJECT ESSENTIAL CRITERIA 1. To reduce the average waiting time for Category 2 Pt‟s on MMC, Clayton Waiting List. Actual 192 days KPI 173 days. 2. To treat the tail-ending patients – queuing equity. 3. In order to address a Waiting List Strategy – we need to start the ball rolling from “somewhere” PROCESS 1. Based on the volume of Theatre sessions and number of Category 2 Tail-ending patients. 2. Even distribution across Weekly Theatre Schedule. 3. Pre-Admission Clinic Collaboration 4. Clear communication with Surgical Registrars & support from Surgical Heads of Unit. 5. Awareness in Bed Bureau/Access Unit of Patient Urgency as to pt identification on Elective Admission List.
  • 18. QUEUING EQUITY PROJECT MEASURES 1. Access to Acute Bed 2. Cancellation Rate (HIP) 3. Visible reduction in average waiting time for Category 2 Patients. 4. Patient Satisfaction 5. Sustainable change to Monash Medical Centre. 05/06 Financial Year.
  • 19. Elective Theatre Access Management – List Construction • Problem “living within our means” Emergency WIES close to target BUT Elective WIES ahead of target in both waiting list electives and non- waiting list (other). MMC has the following profile: 70% Emergency 30% Elective 10% waiting list 20% other eg Gastroenterology
  • 20. Elective Theatre Access Management – List Construction • Proposal • Develop Strategies that reduce WIES but still deliver waiting list targets! • Ambitious target • Start date NOW! • List Construction Project • GO LIVE FEBRUARY • What are the elements of this project?
  • 21. Elective Theatre Access Management – List Construction • Key elements of Project • Resource appropriately – form a “can-do” group • Look for and incorporate “levers” eg ESAS non conformers, capacity at other sites. • Remain true to objective – don‟t cut across other initiatives rather use them to ensure outcomes are met eg Queuing Equity Project
  • 22. Elective Theatre Access Management – List Construction • Develop a rationale – quasi but important Formula: Emergency WIES + Cat 1 + Maternity = X Less Target =Y Available Cat 2’s, Cat 3’s, Non W/L Z • Z is calculated and distributed equitably across surgical units cognisant of demand pressures and waiting list targets
  • 23. Elective Theatre Access Management – List Construction • What might this look like? – Typical list • Cat 1 and/or Emergency • Long Wait Cat 2‟s – tails • Long Wait Cat 3 • How do we support clinicians? – Develop guidelines for booking – work with their special needs – Give information – Monitor progress and report back regularly
  • 24. Elective Theatre Access Management – List Construction • Why are we “picking on” surgical units when they are only a small part of the problem? • We are not - similar strategies will be developed for “other”
  • 25. Morning Tea –meet us back here at 11am
  • 26. Discussion Access Toolkits and LOS Innovations Lee Martin Manager, CIA Collaborative Director Department of Human Services
  • 27. Access Toolkit • System wide Toolkit • LOS Innovations – access toolkit
  • 28. Lunch –meet us back here at 12.45
  • 29. Maroondah Hospital Ward realignment Dominique Leyden Patient Flow Coordinator Department of Human Services
  • 30. Maroondah Hospital Dominique Leyden – Project Facilitator Innovations to Improve Patient Flow in the Area of Bed Management Department of Human Services
  • 31. Background – Why Bed Management? Rigorous diagnostics in phase 1 of patient flow collaborative identified our top three organisational constraints to be; 1. Theatre utilization - high HIP rate 2. Ward bed availability ( bed management) - Admission delays for elective surgery, - Admission delays from ED (Unable to meet 12 hour targets) 3. Acute/Sub Acute transition - Delayed access to NH and rehab beds
  • 32. Methodology • Repeat ward sample data collection Include all 5 acute ward areas • Conduct a brainstorming session • Map a medical unit ward round • Map the bed manager for a day
  • 33. Results: Ward Sample Data REASONS FOR DELAYS TO A PATIENT JOURNEY THROUGH WARDS Ward sample data collected August 9th to 22nd on all five acute wards at Maroondah Hospital Number of Number Reason for delay occurrences 1 Waiting for N/H or interim care bed 101 2 Waiting for Rehab bed 84 3 Waiting for medical review 75 4. Waiting for Allied Health review 32 5. Waiting for medical staff to write up 27 discharge summaries and medications 6. Waiting for ACAS 15 7. No clear plan of care 14
  • 34. Results – Brainstorming Session Set up to look at two key areas: • Delays caused by waiting for medical staff to review patients and do discharge paperwork • Delays associated with waiting for allied health review
  • 35. Results; Brainstorming Multi disciplinary team identified that; • Medicine functions independently of and separate to nursing and allied health, • Little consultation between disciplines
  • 36. Outcome An identified need within the organisation to change the current bed allocation process and move towards developing a ward based medical and allied health structure
  • 37. Current Bed Allocation Model 1 NORTH 1 SOUTH 2 SOUTH 2 NORTH 1 3 25 beds 30 beds 30 beds 25 beds EAST EAST Med 1 1 4 3 24 beds 9 30 beds o Endocrinology Med 2 1 4 4 2 8 o Oncology 1 1 4 1 o Haematology Med 3 1 2 1 2 4 o Cardiology 3 1 o Respiratory 1 2 Med 4 1 2 4 7 o Gastro o Infectious Diseases ACE Unit 1 9 1 Surg Unit 1 7 6 o Thoracic 1 Surg Unit 2 1 7 9 Orthopaedic Unit 17 6 Plastics 1 5 Urology 2 GEM 24 Estimated Medical Staff 24 22 23 16 2 14 involved in patient care (Excludes Consultants &
  • 38. Projected Benefits • Reduced LOS • Reduced 12 hour stays in ED • Improved median discharge time
  • 39. Proposed Model 1 SOUTH 1 NORTH 2 NORTH 2 SOUTH 1 EAST 23 3 EAST 30 24 32 30 BEDS 25 Beds Beds Beds Beds Beds Medical Unit 1 GEM Unit Medical Unit 4 Medical Unit 4 Surgical Unit Orthopaedic Unit 1 Endocrinology Gastro Medical Unit 2 Thoracic Surgery ACE Unit Medical Unit 3 Oncology Surgical Unit 2 Cardiology Haematology Plastics Respiratory Urology Estimated Medical Staff involved in patient care (Excludes Consultants & referrals) 5 2 6 7 9 5 Typical day – Current model of allocation – medical staff numbers (Excludes Consultants & referrals) 3 East 14 GEM 2 2 North 16 2 South 23 1 South 1 North 24 22
  • 40. Project Outline • Communication and consultation process Nov 4 – 25 2004 • Ward moves Dec 30 – 31st 2004
  • 41. Phase One 1 SOUTH 1 NORTH 2 NORTH 2 SOUTH 1 EAST 23 3 EAST 30 25 32 Beds 30 Beds BEDS 24 Beds Beds Beds Medical Unit 1 Orthopaedic Medical Unit 4 Medical Unit 4 Surgical Unit GEM Unit 1 Endocrinology Gastro Medical Unit 2 Thoracic Surgery ACE Unit Medical Unit 3 Oncology Surgical Unit 2 Cardiology Haematology Plastics Respiratory Urology Transit Lounge. Estimated Medical Staff involved in patient care (Excludes Consultants & referrals) 5 5 6 7 9 2 Typical day – Current model of allocation – medical staff numbers (Excludes Consultants & referrals) 3 East 14 1 North 24 2 North 16 2 South 23 1 South GEM - 2 22
  • 42. Phase Two 1 SOUTH 1 NORTH 2 NORTH 2 SOUTH 1 EAST 23 3 EAST 30 24 32 Beds 30 Beds BEDS 25 Beds Beds Beds Medical Unit 1 GEM Medical Unit 4 Medical Unit 4 Surgical Unit Orthopaedic 1 Endocrinology Gastro Medical Unit 2 Thoracic Surgery ACE Unit Medical Unit 3 Oncology Surgical Unit 2 Cardiology Haematology Plastics Respiratory Urology Transit Lounge. Estimated Medical Staff involved in patient care (Excludes Consultants & referrals) 5 2 6 7 9 5 Typical day – Current model of allocation – medical staff numbers (Excludes Consultants & referrals) 3 East 14 Gem - 2 2 North 16 2 South 23 1 South 1 North 24 22
  • 43. Successes • Hospital maintained capacity • 12 hour ED targets met • Emergency surgery continued • No patient/relatives complained!
  • 44. Questions?
  • 45. Emergency Department Data Analysis Lee Martin Director Patient Flow Collaborative & Prue Beams Data Consultant Department of Human Services
  • 46. Clinical Streams Triage Cat1 (Resuscitation) Patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 1228mins with a mean of 88mins.
  • 47. Clinical Streams - Triage Cat2 (Emergency) Patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 1122mins with a mean of 389mins.
  • 48. Clinical Streams - Triage Cat3 (Urgent) Patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 1061mins with a mean of 366mins.
  • 49. Clinical Streams - Triage Cat4 (Semi Urgent) Patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 930mins with a mean of 303mins.
  • 50. Clinical Streams - Triage Cat5 (Non Urgent) Patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 552mins with a mean of 164mins.
  • 51. Patient Journey Times in ED by Triage Cat - Summary table
  • 52. Patient Journey Times in ED by Triage Cat - Summary table
  • 53. ED Presentations by Diagnosis (Top 25) * Complete list available on request
  • 54. ED Presentations by Diagnosis (Top 25) - Only patients > Upper Limit (1,007mins) * Complete list available on request
  • 55. Time of Presentation to ED by Hour of Arrival
  • 56. ED Median/Mean Length of Stay - Admitted v Discharged streams
  • 57. ED Median Length of Stay - Admitted v Discharged streams
  • 58. ED Length of Stay Summary - Time bands
  • 59. Melbourne Health Pilot Site Update Marcus Kennedy Clinical Lead, Patient Flow Collaborative Department of Human Services
  • 60. Bed availability coordination group • Bed management has been organizationally restructured within the operational stream, and work is advanced in development of an electronic bed management and patient tracking system. • The organizational admission and access policy has been redrafted and is under executive review. This process clarifies and streamlines access routes and their management.
  • 61. Clinician communication coordination group • This group has actively engaged clinical staff at all levels. • Specific work has occurred in relation to: – time of day of discharge, – investigation services prioritization of access for discharge patients, – improved electronic referral and rostering systems, – weekly review and – audit of discharge practices.
  • 62. Operating Theatre coordination group • This group has developed – an online emergency booking system, and – improved systems of flow within the OR to reduce delays in start times. – A number of recovery room strategies to minimize exit block from recovery have been implemented. • Melbourne Health has recently made available an emergency operating theatre, and • Opened day procedural facilities that increase capacity.
  • 63. Subacute and rehab coordination group • This work group has performed major work to redefine the model of care in subacute services. • Major changes have occurred with implementation of – an improved bed management and access system, – improved relationships and patient flow systems between the acute and subacute campuses, and – improvements to patient length of stay.
  • 64. Radiology coordination group • Specific process improvements have occurred in this area with regard to weekend transport issue for patients requiring medical imaging. This has impacted length of stay for many patients. • Improved reporting systems have meant availability of reports in a more timely fashion. • Improvement opportunities for patient access, queue management and flow systems remain in this area.
  • 65. Emergency Flow Group • A web based patient status tracking system has been developed which is viewed on wards and other areas, to encourage pull strategies for patient movement out of ED. • This is linked to action cards and supported by the access policy (under revision). • ED processes of care have been reviewed, and innovative streaming systems are being implemented.
  • 66. Impact of Changes at Melbourne Health • Through December 2004 and January 2005, objective evidence of impacts is starting to be realised. • Length of stay in subacute areas has decreased significantly • Elective surgery access has been maintained, and activity increased in December • Cancellations of elective work due to bed unavailable have decreased
  • 67. 0 10 30 40 50 Ju l-0 Au 3 20 11 g- 0 Se 3 20 p- 0 9 Oc 3 t- 0 6 No 3 v- 0 De 3 c- 0 Ja 3 12 14 n- 0 4 Fe 4 b- 0 M 4 2 ar -0 7 Ap 4 r- decreased dramatically M 04 7 ay -0 5 Ju 4 n- 0 Ambulance Bypass 13 Ju 4 l-0 Ambulance bypass rates have Au 4 41 g- 0 Se 4 19 p- 0 Oc 4 40 t- 0 No 4 27 v- 0 6 De 4 c- 04 2
  • 68. Patient flow through emergency has improved dramatically % Emergency Patients Admitted < 12 hours 100% 95% 90% Upper Control Limit (+3SD) 85% 80% Mean 75% 70% 65% Lower Control Limit (-3SD) 60% 55% 50% 3 4 04 04 05 04 4 3 4 3 3 3 4 4 4 4 4 3 4 -0 -0 -0 l-0 l-0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 n- n- n- b- ov ov ar ec ec ug ep ug ep pr ay ct ct Ju Ju Ja Ju Ja Fe M O O A N N M D D A S A S
  • 69. ?Sustainability • The improvements in these measures (over several measurement periods) suggest that the gains may be sustainable. • The quantum of the change in particular in the “% admitted less than 12 hours” indicator is suggestive of major and fundamental system change. – In this measure, the performance has crossed the upper control limit in the statistical process control chart for the parameter.
  • 70. Melbourne Health Improving Clinical Communication Dr David Smallwood Department of Human Services
  • 71. Clinical Communication Working Party Background • The rigorous diagnostics phase identified constraints in patient flow due to: – Poor communication within and between units – Inconsistent admission and discharge processes – Ward round practices (senior and junior staff) – Problematic staff rosters (updated list) – Units being unavailable for referrals
  • 72. Clinical Communication Working Party Key Actions • Clinician communication survey • Discharge ward rounds
  • 73. Clinical Communication Working Party Clinical Communication Survey Audit of all Unit heads, Nurse Unit Managers and Senior Registrars with the aim: • Establish an awareness of PFC • Establish an understanding of existing processes. • Identify problematic areas. • Gain feedback from participants.
  • 74. Clinical Communication Working Party Clinical Communication Survey • Key Findings: - Irregular timing of ward rounds. - No communication process to notify timing of ward rounds. - Inconsistent after hour/weekend processes. - Varied methods of communication between senior and junior staff. - Minimal nurse & allied health attendance on ward rounds. - Varied patient decision making processes. - Lack of understanding/existence of admission policy.
  • 75. Clinical Communication Working Party Recommendations WARD ROUNDS • Published schedule • Additional consultant input on weekend ward rounds. • Multidisciplinary attendance. • Time efficiency eg. pre-ward round debriefs. • Criteria initiated discharge. – Less reliance on consultant review. – Nurse initiated.
  • 76. Clinical Communication Working Party Recommendations DISCHARGE PLANNING • Educate junior doctors about day prior discharge planning and re-enforce the benefits of this discharge process to senior doctors. • Prioritize patients who could potentially be discharged and assess them earlier so that discharge processes can begin as soon as possible e.g. clerical duties • Priority X-rays and bloods in am
  • 77. Clinical Communication Working Party Recommendations ROSTER AVAILABILITY • An up-to-date medical roster which is accessible to all staff at all times. WEB BASED Registrar availability for emergency contact. REFERRAL PROCESSES • Develop project dimensions and strengthen work towards the establishment of an „e-referral‟ system.
  • 78. Clinical Communication Working Party Discharge Ward Rounds • Discharge reviews: – 51% (53) reviewed Monday discharges out of 103 patients over two weeks. – Median discharge time of reviewed patient histories: 1500 hours – Median discharge times of all patients discharged on these two days: 1430 hours
  • 79. Clinical Communication Working Party Discharge Ward Rounds Discharge times 14 12 10 8 6 4 2 0 1 2 3 7 9 10 11 12 13 14 15 16 17 18 19 20
  • 80. Clinical Communication Working Party Discharge Ward Rounds • Weekly ward round • Varied wards, • Helpful „Magic Wand‟ approach • Participants include: – Senior Doctor (rotate between Gen Med, Surgery & ED) – Registrar – PFC coordinator – Bed Management – Occasional Executive representative
  • 81. Clinical Communication Working Party Discharge Ward Rounds Key reasons for delays: • Time of notification of patient transfer. • Time of/ waiting for ward round review. • Waiting on transport. • Inadequate documentation (e.g.discharge summary). • Waiting on results. • Delay in specialist unit review. • Transit lounge- use & availability • Boarders • Discharge time entry (electronic) • Poor communication eg family
  • 82. Clinical Communication Working Party Positive Impacts • Increased awareness. • Clarification of existing processes. • Increased Patient Flow Collaborative profile. • Encourages input from staff re improvements. • Communication between clinical staff. • More timely discharges • Nursing initiated action sheets
  • 83. Clinical Communication Working Party Positive Impacts 14 Median discharge time for October 1300 hours 12 Median discharge time for 15th Dec 1200 Avg discharges are 50 - 60 per day 10 8 6 4 2 0 08 09 10 11 12 13 14 15 16 17 18 19 20 21 25/10/2004 08/11/2004 07/12/2004 15/12/2004
  • 84. Discussion and challenges • Engagement of senior medical staff • Maintaining momentum/awareness •All clinicians • Creating new processes that do not rely in any one person
  • 85. Afternoon Tea –meet us back here at 3pm
  • 86. Team Clusters Lee Martin and PFC Leads Department of Human Services
  • 87. Clusters • LS3 Agenda and preparation • Involving your team – Who do you want to network with at LS3? – Who do people in your team need to meet at LS3? • Communication plans – How are you using your communication strategy? • Future events- newsletter • Evaluation forms
  • 88. Summary • Registrations for LS3 due 17th January • Keep marketing your achievements- present to your CEO where possible • Continue to engage and influence widely • Keep Going…..
  • 89. Have a safe trip home

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