Making the Patient Journey Visible
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Richard Floyd (CDHB), HiNZ 2015 Conference, Christchurch
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Making the Patient Journey Visible
- 1. Saxon Connor, CDHB General Surgery Anthony Butler, PhD, CDHB Radiology, UOO Richard Floyd, Phd, CDHB BDU, UOO Sense Medical Making the Patient Journey Visible
- 3. As Quality of Care increases Delay Costs go down
- 4. 40%
- 5. “If we really value the patient's time, we will remove all the waste in the Health system.” David Meates, CDHB CEO
- 6. If you can not measure it, you can not improve it. Lord Kelvin, 1847
- 7. $1.4B Budget 700K - Lab Tests 35,000 – Surg Events 250,000 - Imaging 120,000 - FSAs 350,000 – FUs 90,000 - ED visits
- 8. Inpatients - 3M Radiology – 2.5M Laboratories – 7M Outpatients – 2.5M ED – 1M Approx – 20 to 40M ??
- 11. Assessed and Discharged SARA Admitted ED GP Complication Discharge Treatment Non operative Operative Investigation Gastro Radiology Bloods Curingtime Decision made Task requested Task performed Task reviewed Underinvestigation 00:00 hrs 00:00 hrs 00:00 hrs 00:00 hrs RxComplication 00:55 Turn Around Time (hh:mm) 00:10 Radiology 00:03 02:12 01:47 01:01 Theatre 05:30
- 12. Decision to discharge to time to discharge scatter plot 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 DelaybetweenDecisionandDischarge(hh:mm) Hour of Day whenDecisionto Discharge Time between Discharge Decision and Task Delivered
- 14. 87%
- 19. Cortex
- 25. Cortex Benefits • Saved an hour a day • Improved communications • Speeds up decision making • Reduced errors • Improved access information
- 26. Can I please have Cortex back? This is the number of lists I have made since Monday in order to try and keep track of my patients because I have to keep writing lists.
- 27. Delay
- 36. Where to
- 39. Communication Variables 10 Dimensions 53 Elements
- 40. “It's really clear that the most precious resource we all have is time.” Steve Jobs
- 41. Questions
Editor's Notes
- What I will talk about today is communication and a potential method for the delivery of services in hospitals which could change the way we communicate in those hospitals. This journey started 6 years ago when each member of my team at the CDHB PD course XcelR8 had to propose a change project for the team to deliver. I proposed a BI solution to identify all delays for patients at the Christchurch Hospital. I thought capturing all the events which impact upon patient journeys would be a snap. The idea was shot down as too blue sky, let alone deliverable.
- Now it is widely accepted that as quality of care increases, cost go down. And delay is the worst type of waste in a patient’s journey. Especially from a patient’s perspective.
- Here is an estimate of total delay in a vascular patients journey at Christchurch hospital; Only yesterday the chair of the Health IT Board cited a personal incidence of delay Being the naïve enthusiast I wanted to pursue my BI idea. So I approached Saxon with the idea. The hypothesis being there is significant non value added time in patient journeys. Understanding that delay would allow process improvement to streamline the patient journey.
- Thus, by making the patient journey visible we would have a mechanism for, as my CEO says, valuing the patients time. We have a measure for the time people take to get through ED, which the ministry publishes. If we have the EMR maturity model Why don’t we measure other flow events such as the time it takes to admit a patient; how long it takes to discharge a patient. Unfortunately we found we did not have the data on most of these transactions in a patients journey which impact on delay.
- As Lord Kelvin said … So the team resolved to create a method to achieve the required visibility so that we could measure and try to improve on delay
- When you look at the numbers around activity at Christchurch hospital they are what they are.
- But when we delve into the flow transactions associated with these events the number become interesting Pharms ?? Allied Health AP Oncology Surgery Anaesthesiology I was not be deterred by these numbers.
- In conjunction with Sense Medical we started by developing a simple app to capture decision making processes in a single General Surgery team at Christchurch Hospital.
- We wanted to know when a decision was made to order, for example, an x-ray, when the service was requested, when it was completed and when results were reviewed. Here is an example of one such chain of events Explain … The data revealed decisions and reviews spiked at 8 AM and 4 PM, ie. on the ward rounds.
- Thus therefore had rudimentary visibility of the patient journey in General Surgery For example on average it took 1:47 to review a radiology scan from the time the images were available. 104 patients 31 (30%) of patients went to theatre 12 (12%) seen and discharged in ED 15 (14%) had non general surgical diagnosis 1240 tasks time stamped Median LOS 25:00 hours (Range 2:00 to 268:00 hours)
- To illustrate what we could do with the data we found that patients who were discharged in the evening took significantly less time to get out of hospital. Explain … Great. So we had a method which could provide visibility of patient journeys. But clinicians did not need the burden of entering more data. So the method used to capture our flow data needed to change. Let’s look at the method most specialties at Christchurch Hospital use to manage their patients
- Members of clinicial teams, being responsible for a cohort of patients, will keep track of their patients each day by recording jobs and tasks on paper, ticking them off as they are completed. AS you will probably conclude this analogue information is siloed, invisible to the team, un-auditable, but it is mobile.
- But unfortunately 87% of doctors admit to losing it. So it is not ideal.
- I can see parallels with a similar transaction based activity …
- Thus I very rarely go to the bank, I can see my daughter is very busy spending my money, and I can easily get stuff done in the app.
- So why is it that I now have this Digital, Real time, Mobile and Auditable tool for my banking but we continue to use this
- One does ponder what the operational cost of this method is? The light bulb moment was when we realised by digitally managing clinical tasks, we could passively collect our flow data, and move away from traditional paper-based methods which impair communication, lead to errors and delay patient journeys. On reflection what we had was a very exciting challenge.
- Hence Sense Medical began developing the Cortex application. That was 2 years ago.
- You may have had an opportunity to see Cortex in action at the Canterbury Health System booth. The app has been embedded across the general surgical specialty at Christchurch Hospital. 50 clinicians, including SMOs, Charge Nurse Managers, Registrars and House Officers are using the app. Users now have mobile, synchronised and encrypted, access to patient lists, tasks, results, clinical notes, and the ability to order services.. All in patient context. We also passively collect flow data. It features a real time ADT feed. Different views of patients by location and team. You see here the chronology for this particular patient. Clinicians have full access to the results repository where they can sign off patient results. Interestingly the results repository has been hit on average 225 times a day since Cortex was implemented last year. The app also runs on Citrix Worx which adds data encryption, password authentication and micro VPN allowing it to run on wireless or mobile network
- Users can easily create tasks for patients from a task matrix, delegate those tasks to other team members, there is a notifications module and users can record notes against tasks.
- A ward round note has been developed which records diagnoses and plans. All available in real time so the change nurse of the ward does not need to chase house officers to get an update on their patients. 30,000 notes have been created through the app since we started.
- The app also has the ability to instigate the ordering of services for patients at the bed side. No more having to find the form, transcribe demographics, find the fax number, stand in front of the fax machine. All examples of delay.
- Which is all great functionality but what benefits are we seeing? 1 2 3 4 5 One of the simplest benefits house officers report is not having to find stickers to put on blood forms. They not longer need to print out patient lists or spend 30 minutes transcribing blood results onto paper before a post acute ward round. Which are all examples of delays. Just not patient centric. I also get these types of requests from House Officers who move on from General Surgery.
- My take away from this sort of feedback is there are subtle but significant differences the app is making to communication. So we have not just replaced paper we are now improving communication given we have taken a very structured approach to work flow and information. We have just started trialling the app in general Medicine which brings a different set of challenges given the different workflow.
- But has it made a difference in the delivery of care to patients. Have we been able to quantify delay? I delved into our results repository to see if the application has made any difference to delivery of services.
- The simple act of making results accessible on a mobile device has removed an information constraint which we believe is making a difference to the delivery of services to patients. But what of LOS, readmission rates, TAT in discharge. All in good time.
- Which brings us to the proposed communication protocol. Our scoping of the communication process for the delivery of services to patients has identified 15 steps. What you see is a summary.
- Describe … Cortex methods integrated with service event data from other systems will allow all 15 steps to be visible for most tasks and thus available for analysis. And there are work flow benefits from the protocol. Teams members could be passively notified of the time for a CT scan. But more importantly communication could be standardised, visible, and more importantly analysed. Are we there yet. As per my abstract I was hoping we would be for certain work flows. But prey tell we are not.
- Learnings We have the usual suspects …. Adherence Persistence Rapport
- It's about the clinician Removing information constraints Persistence Opportunities multiply as they are seized Rapport
- Within the month users should have real time notifications of result events and we will be able to quantify the impact visibility of the 15 steps has upon viewing and sign off of results and subsequent tasks. So the heavy lifting has been done in migrating from paper. And the potential benefits from the method and the protocol are fascinating. In the future house officers will not need to create paper based task lists for weekend HOs to complete. Tasks will just be delegated to that HO. And at some point the patients themselves will have visibility on the services they are being delivered. When is my CT scan scheduled for? What does this standard method mean for patient handovers? Could we move away from the 8AM and 4 PM rounds to virtual ward rounds? Then we may be able to fully assess delay.
- My wife challenged me on what the value proposition is. 800 doctors saving an hour a day at $100 an hour equates to $17M at Christchurch Hospital alone. And that does not include the thousands of nurses. Let alone quantifies the benefit of timely delivery of care
- Which raises the interesting question. How do clinicians communicate? I have delved but found very little which puts structure to this question.
- If anyone is interested in examining the 10 dimensions and the 53 elements I have identified I would love to catch up.
- In conclusion It is a about logic, data, standards, and the opportunities that come from the confluence of these factors. I agree with Steve … We need to develop methods which value patients’ and clinicians’ time. I believe the progress we have made in the ‘Making the patient journey visible’ project has got us a lot closer to achieving that aim.