Presentation details change project to improve patient flow and safety in Beaumont Hospital, Dublin, for patients whose discharge is delayed awaiting a residential nursing home bed

1. Delayed Discharges –A Patient Flow and Safety Imperative
Ann Marie O’Grady
Head of Clinical Services & Business Planning, Beaumont Hospital
Optimising the Patient Journey to Accelerate Patient Discharges
Improving Patient Safety & Hospital Patient Flow Conference
20thNovember 2014

2. Delayed Discharges –A Patient Flow and Safety Imperative
•What?
•Why?
•How?
•Now?

3. What?
Delayed discharges up by
15% in a year
Irish Medical Times

4. •Nationally highest level of new patients listed for long term care weekly (LTC) ....and increasing
Why?

5. 26500
27000
27500
28000
28500
29000
29500
30000
30500
2011
2012
Bed Days
Bed Days Utilisedfor Patients Awaiting Discharge to LTC

6. •Nationally highest level of patients listed for long term care weekly (LTC) ....and increasing
•Higher level of visibility demanded

7. Visibility

8. •Nationally highest level of patients listed for long term care weekly (LTC) ....and increasing
•Higher level of visibility demanded
•Accountability lying with one profession but authority and responsibility across the organisation
•Reputational risk
•Patient safety risk

9. How?
Project Objectives
1.Improved patient flow
2.Optimise utilisation of acute hospital beds
3.Improved patient safetyTo be achieved by:
•Standardising processes
•Optimising patient journey to discharge
•Creating shared ownership
•Increasing visibility to all stakeholders Supported by Lean Methodologies
Phase 1 –6 week experiment: Intensive review of all patients listed for LTC and current LTC process
Phase 2 –Redesign: Redesign and implement standardised process throughout the organisation
Phase 3 –Sustain: Embed changed process and continuously monitor and re- evaluate

10. Phase 1 –The Experiment

11. Before!

12. The “Experiment” Visual HospitalPfEP
LTC Process
•Building on the Lean processes either initiated or implemented by Beaumont Improving Care & Safety (BICS) Programme including “Visual Hospital” (Lean Enterprise Academy)
•Fairdeal/LTC steps documented & each patient’s journey was mapped on whiteboard in Patient Flow hub.
•MDT teams allocated to manage a group of patients. To identify the position of each patient in their journey, identify delays & actions required to move to the next step in the process.
•Key themes & learning

13. Phase 2

14. During Initial MDT & Family Meeting & discussion re listing processDay 0SW + NurseWard of CourtDay 20Family & MDT
Refer to COE Consultant
Day 0
Medical TeamReviewed by COE Consultant & Listed for LTCDay 1Med Elderly
Application for Fair Deal submitted
Day 10
Family/SW
Nursing home assessment and approval
Day 24
SW & Nurse
Application for Care Loan Submitted
Day 10
Family/SW
Prompt family re Fair Deal application
Day 8
Nurse/SW
CSAR Form submitted
Day 2
Medical SW + Nurse
Fair deal Application received by NHSO
Day 15 (max)
Nursing Home Support Office /Fair Deal Officer2ndFamily meetingDay 20SW & NurseFamily Nursing Home preferences identifiedDay 20SW & Nurse
Date of Determination
State Support approved
Day 22
NHSOFunding approvalDay 25NHSO
HSE determinations complete – charges apply
Day 26
Fair Deal Officer
Transport prescription
Day 27
Medical & NursingForm 4Day 10MedicineCare Rep AppliedDay 10Social Work & Family
LPF Decision
Day 20
LPFPower of AttorneyDay 20Family & MDT
Care Rep Court date
Day 23
Circuit Court
1
2
3
Options 1, 2 OR 3
ORORIf Care Loan Required
If Care Loan NOTRequiredOR
AND
If Care Rep required

15. Overview of LTC Process Redesign
23 Individual Steps
Phase1
•Internal Process: Decision to list to Fair deal application submission
Phase2
•Internal and External Process: FD Submission to Date of Determination
Phase 3
•Internal and External process: Date of Determination to Discharge to Nursing Home
•Process redesign
•Targets set for steps
•Control processes established

18. Phase 3: Sustain
•Small dedicated Integrated Delayed Discharge Teamput in place
–Skill mix –nursing and social work
–Coordinate the LTC pathway
–Responsibility for the final stage of patient journey to discharge and all communication with nursing homes
–Expertise in managing the very complex situations
•Visibility created –White Boards Patient Flow Office
–Integrated into daily ward/patient flow involvement
–Areas of breach highlighted and flagged for follow up

19. Simplified White Board

20. Phase 3: Sustain
•Small dedicated Integrated Delayed Discharge Teamput in place
–Skill mix –nursing and social work
–Coordinate the LTC pathway
–Responsibility for the final stage of patient journey to discharge and all communication with nursing homes
–Expertise in managing the very complex situations
•Visibility created –White Boards Patient Flow Office
–Integrated into daily ward/patient flow involvement
–Areas of breach highlighted and flagged for follow up
•Established SOPs for various points in the pathways e.g. first family meeting
•Educate and inform -again and again and again
–Staff
–Families
–Patients
•IT enabled –designed by project team and built in house, integrated with National HSE Business Intelligence Unit Delayed Discharge System

23. Monitor & Control

24. Phase 3: Sustain
•Small dedicated Integrated Delayed Discharge Teamput in place
–Skill mix –nursing and social work
–Coordinate the LTC pathway
–Responsibility for the final stage of patient journey to discharge and all communication with nursing homes
–Expertise in managing the very complex situations
•Visibility created –White Boards Patient Flow Office
–Integrated into daily ward/patient flow involvement
–Areas of breach highlighted and flagged for follow up
•Established SOPs for various points in the pathways e.g. first family meeting
•Educate and inform -again and again and again
–Staff
–Families
–Patients
•IT enabled –designed by project team and built in house, integrated with National HSE Business Intelligence Unit Delayed Discharge System
•Established dedicated communication pathway for nursing homes
•Built and maintained effective relationships with a wide range of stakeholders

25. External Engagement
•Nursing Homes
•HSE
•Special Delivery Unit
•Development of an Integrated Case Management Group to focus on those with longest length of stay
•Legal advisors
•Ward of Courts Office
•Nursing Home Support Office –local and national
•External private and voluntary providers
•HSE Social Care Division latterly
•....and more

26. Now?
•Highly expert coordinating team in place
•Standardised processes in place
•Monitoring in place to timelines
•Metrics allow internal performance to be monitored irrespective of external influencing factors
•Responsiveness
•Staff time focussed on adding value

27. Change?
•Change understanding
•Change attitude
•Change ownership
•Change processes
•Build empowerment

28. What’s the data telling us?

29. 2011
2012
2014 YTD
Transit Time Mean
124
112
92
Fair Deal Application Mean
30
21
17
CSAR Mean
14
12
7.5
0
20
40
60
80
100
120
140
Days
Key Performance Data Points

30. 24000
25000
26000
27000
28000
29000
30000
31000
2012
2013
2014 projected
Bed Days
2012
20132014 projected
Series1
30028
29144
26637
Bed Days Utilised for Patients Awaiting Discharge to LTC

31. 2012
20132014
Beaumont % of National
16.30%
16.20%
13.20%
0.00%
2.00% 4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
Percentage Beaumont % of National LTC Delayed Discharges

32. 0
10
20
30
40
5060
70
2012
2013
2014 Jan -Oct
Patients
No of Patients RIP while Awaiting Discharge to LTC

33. Fundamentally
•Visibility
•Standardised process
•Know what needs to be done...day in ...day out, consistently
•Know where responsibility and accountability lies
•Use technology to assist
•Each and every patient journey optimised

34. Intangibles
•Better understanding -less judgement
•Greater respect for roles
•Trust built
•Hidden expertise harnessed
•Expertise developed
•Reduced stress levels
•Sense of achievement
•Confidence
•Able to rapidly respond to discharge opportunities (competitive advantage!!!!)

35. Outcomes
1.Improved patient flow
•Optimised processes that hospital has control of
2.Optimise utilisation of acute hospital beds
•Optimal utilisation of residential and transitional beds/funding
3.Improved patient safetyAchieved by:
•Standardising processes
•Optimising patient journey to discharge
•Creating shared ownership internally and externally
•Increasing visibility to all stakeholders Through the passion, commitment, innovation and perseverance of staff

36. Original Project Team
Ann Marie O’Grady, Senior Management
Fiona Keogan, BICS Programme Manager
Annette Winston, Principal Social Worker
Rosaleen Cafferty, Patient Flow Manager
Una Donnelly, Senior Social WorkerCiara Ni Fhlathartaigh, Care of Elderly Programme Lead
Wider Team
Fair Deal Officer
Integrated Delayed Discharge Team
Social Work Department
Consultant Geriatricians
IT Department
Nursing
NCHDs
Consultants
Health & Social Care Professionals
Senior Management
Clerical
Management Information
Dream Team !!

37. Hospital wide ownership
of a
Hospital wide problem

38. “Striving for success without hard work is like trying to harvest where you haven't planted” David Bly