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Hossam Elamir,TQMD, MBBCh
Quality & Accreditation Office, MKH
 Quality
 Definitions
 The Global Situation
 Causes
 The Local Problem
 EB Solutions
2
 Don’t kill me (no needless
deaths)
 Do help me & don’t hurt me
(no needless pain)
 Don’t make me feel helpless
 Don’t...
 This situation
continues for days
at the moment.
 According to one
of ED senior
physicians: “What
is the meaning of qua...
 EDOC: “institutional resources available are
insufficient to meet the basic service needs of
emergency patients.”
 Pati...
 Access block: A situation when“….. patients’ who
were admitted or planned for admission but
discharged from the emergenc...
 LM: “……a management practice based on the
philosophy of continuously improving processes by
either increasing customer v...
Vs
8
 One of the fittest athletes in the world
 His body fat is 3% less than supermodels
= 16
9
Womack & Jones (1996) Toussaint & Gerard (2010)
1. Specify value from the customer’s
perspective
1. Focus on patients (not...
3
11
12
“For every complex problem, there’s
a solution that is
simple, neat,and wrong”
H L Mencken
13
Donabedian,A. (1966)
Inputs
Structure
14
Current Beds Number
Beds number after
expansion
Access block
15
 Observation of all patients visited ED during 7
days (27 Nov. – 3 Dec. 2014)
 Design CapacityTotal time=
35 X 7 =245 be...
Patient Arrival Triage Doctor room
Observation
room
Lab/Rad
request
Lab/Rad done
Lab/Rad
result/report
ED doctor
Consultat...
Total visits to
ED in 7 days
6383
100%
Didn't go to
observation
4633
73%
Shouldn't go
to observation
316
18%
Stayed less
t...
0
50
100
150
200
250
300
350
LOS intervals
Missed variables
> 1:00
1:00 - < 2:00
2:00 - < 3:00
3:00 - < 4:00
4:00 - < 5:00...
90.42%
Aggregated LOS time of observation
room visits who deserve to be observed
(1434 patients)= 221.53 days
100%
Total c...
0 10 20 30 40 50 60 70 80 90 100
Total ED observation room
LOS
Major waste time
1078.98 hrs
1918.95 hrs
21
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
time-to-review-radiology-
report
time-to-review-lab-results
time-to-get-radiol...
 Inputs Solutions:
 Ambulance diversion
 1ry Healthcare centres to manage non-
urgent cases (e.g.: catheter change, blo...
 Minimal structural requirement to make it efficient
and accommodate the numbers
Control room
24
 Throughput (process) Solutions:
 Reply consultation promptly
 Use POC U/S
 Execute Radiology promptly
 Report Radiol...
 Output Solutions:
 Effective discharge service
 Bed crisis management protocols
 Bed manager
 Set time target to all...
 “Every system is
perfectly designed to
get the results it
gets.”
 "If we keep doing
what we have been
doing, we'll keep...
 Berwick, D. M. (2005), My right knee, Annals of Medicine
 ACEM. (2013) Policy on StandardTerminology. Melbourne, Austra...
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EDOC (2)

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EDOC (2)

  1. 1. Hossam Elamir,TQMD, MBBCh Quality & Accreditation Office, MKH
  2. 2.  Quality  Definitions  The Global Situation  Causes  The Local Problem  EB Solutions 2
  3. 3.  Don’t kill me (no needless deaths)  Do help me & don’t hurt me (no needless pain)  Don’t make me feel helpless  Don’t keep me waiting  Don’t waste resources - mine or anyone else’s Berwick, D. M. (2005) 3
  4. 4.  This situation continues for days at the moment.  According to one of ED senior physicians: “What is the meaning of quality!The patient died! We would save her live if she was transferred a little bit earlier to inpatient. 4
  5. 5.  EDOC: “institutional resources available are insufficient to meet the basic service needs of emergency patients.”  Patient Boarding: “a known practice in which patients are held or "boarded" in emergency departments waiting for inpatient beds in the hospital.” Blum et al. (2006) 5
  6. 6.  Access block: A situation when“….. patients’ who were admitted or planned for admission but discharged from the emergency department (ED) without reaching an inpatient bed, transferred to another hospital for admission, or died in the ED ….total ED time exceeded 8 hours.” ACEM. (2013)  Prolonged EDLOS: was defined as 4 hours in the UK, 4-6 hours in Canada and 8 hours inAustralia. Horwitz et al. (2010) 6
  7. 7.  LM: “……a management practice based on the philosophy of continuously improving processes by either increasing customer value or reducing non- value adding activities (Muda), process variation (Mura), and poor work conditions (Muri).” (p.365) Radnor et al. (2012) 7
  8. 8. Vs 8
  9. 9.  One of the fittest athletes in the world  His body fat is 3% less than supermodels = 16 9
  10. 10. Womack & Jones (1996) Toussaint & Gerard (2010) 1. Specify value from the customer’s perspective 1. Focus on patients (not the hospital or staff) and design care around them 2. Identify the value stream for each product/service provided 2. Identify value for the patient and get rid of everything else (waste) 3. Make the product/service flow uninterruptedly and standardise processes around best practice 4. Create pull systems between all steps where continuous flow is impossible 3. Minimise time to treatment and through its course 5. Manage towards perfection by systematically eliminating waste to achieve an ideal process 10
  11. 11. 3 11
  12. 12. 12
  13. 13. “For every complex problem, there’s a solution that is simple, neat,and wrong” H L Mencken 13
  14. 14. Donabedian,A. (1966) Inputs Structure 14
  15. 15. Current Beds Number Beds number after expansion Access block 15
  16. 16.  Observation of all patients visited ED during 7 days (27 Nov. – 3 Dec. 2014)  Design CapacityTotal time= 35 X 7 =245 bed days 245 X 24 hours = 5880 bed hours 16
  17. 17. Patient Arrival Triage Doctor room Observation room Lab/Rad request Lab/Rad done Lab/Rad result/report ED doctor Consultation request Unit doctor Admission/ discharge decision Patient transfer 17
  18. 18. Total visits to ED in 7 days 6383 100% Didn't go to observation 4633 73% Shouldn't go to observation 316 18% Stayed less than 6 hrs 1224 70% Stayed more than 6 hrs 210 12% Other 1750 27% Didn't go to observation 73% Stayed less than 6 hrs > 95% Stayed more than 6 hrs < 5% Other 27% Provide their needs in the primary healthcare centers 18
  19. 19. 0 50 100 150 200 250 300 350 LOS intervals Missed variables > 1:00 1:00 - < 2:00 2:00 - < 3:00 3:00 - < 4:00 4:00 - < 5:00 5:00 - < 6:00 > 6:00 7 232 340 247 168 94 210 136 19
  20. 20. 90.42% Aggregated LOS time of observation room visits who deserve to be observed (1434 patients)= 221.53 days 100% Total calculated ED time by design capacity= 245 days 32.63% Aggregated time of all patients with LOS > 6 hours (210 patients)= 79.95 days 20
  21. 21. 0 10 20 30 40 50 60 70 80 90 100 Total ED observation room LOS Major waste time 1078.98 hrs 1918.95 hrs 21
  22. 22. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% time-to-review-radiology- report time-to-review-lab-results time-to-get-radiology-report time-to-receive-lab-report time-to-execute-radiology time-to-reply-consultation time-to-transfer-pt-after- admission-decision 561.17 hrs 143.42hrs 143.52hrs 22
  23. 23.  Inputs Solutions:  Ambulance diversion  1ry Healthcare centres to manage non- urgent cases (e.g.: catheter change, blood collection)  Closed ED area with security  Proper triaging  Fast track 23
  24. 24.  Minimal structural requirement to make it efficient and accommodate the numbers Control room 24
  25. 25.  Throughput (process) Solutions:  Reply consultation promptly  Use POC U/S  Execute Radiology promptly  Report Radiology promptly 25
  26. 26.  Output Solutions:  Effective discharge service  Bed crisis management protocols  Bed manager  Set time target to all staff:  EDLOS < 6 hrs  wait times < 30% of total EDLOS  No patient boarded in ED > 45 mins  Initiation of crisis protocols should be zero 26
  27. 27.  “Every system is perfectly designed to get the results it gets.”  "If we keep doing what we have been doing, we'll keep getting what we've always gotten"—an expensive, high-tech, inefficient health-care system. P. Batalden D. Berwick 27
  28. 28.  Berwick, D. M. (2005), My right knee, Annals of Medicine  ACEM. (2013) Policy on StandardTerminology. Melbourne, Australia: The Australasian College for Emergency Medicine  Blum et al. (2006) Report From a Roundtable Discussion: Meeting the Challenge of Emergency Department Overcrowding/ Boarding. Washington, DC, USA: American College of Emergency Physicians  Horwitz et al. (2010) US Emergency Department Performance on WaitTime and Length ofVisit. Ann Emerg Med  Radnor et al. (2012) Lean in healthcare:The unfilled promise? Soc Sci Med  Guttmann et al. (2011) Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 28

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