1. Improving Patient Flow
John Ash
Director of Patient Flow
www.qualitysummit.ca
#QS14

2. Faculty/Presenter Disclosure
Faculty: [John Ash ]
Relationships with commercial interest:
• Not Applicable

3. Disclosure of Commercial Support
Potential for Conflict(s) of Interest:
• Allscripts Patient Flow will be discussed as a part of this presentation.
Allscripts Patient Flow was purchased by E-Health Saskatchewan, and is
being implemented by multiple regions across the province as directed by the
province.

4. Mitigating Potential Bias
• The approach discussed was established based on literature review and best
practice.
• The approach discussed has been adopted by the provincial Hoshin on ED waits
and Flow.

5. Regina Qu'Appelle Health Region

6.  Under the medium growth scenario the City of Regina would grow at a
rate of 2,500 people per year exceeding 226,500 in 2020 and 258,000 in
2035.
 In the last 14 years the overall population that RQHR serves has grown
2.7 per. However people 85 years old and older have doubled.
 2009 to 20013 Saskatchewan's
population grew more than
80,000
The Problem :
Population Growth +
242,827 245,784
246,877
243,767
246,889
252,366 253,809
266,386
230000
235000
240000
245000
250000
255000
260000
265000
270000
2003 2004 2005 2006 2007 2008 2009 2010
CoveredPopulation
Regina Qu'Appelle Health Region
Covered Population
2003-2010

7. The Problem :
Unhealthy Population +
High saturated fat & high sugar diets, smoking, recreational drug use, alcohol
use, lack of exercise are pre cursors for chronic disease
• 35% of 18y/o over population overweight (BMI 25% or greater)
• 21.5% of 18y/o over population obese (BMI > 30)
*70% of the burden of illness and injury is attributable to chronic disease.
1.2010 RQHR Health Status Report

8. The Problem :
Increasing Demand =
 RQHR ER visits have increased 15.1% and admissions from the ER have
increased 13.9% over past 5 years
 RQHR EMS transports to ER have risen 15% over the past 5 years
 Demand for urban LTC, Convalescence beds and Homecare spaces and
support has increased

9. = Poor Patient Flow
Summary 2012/13
Regina Qu'Appelle Health Region:
 Occupancy 120-130%
 Admitted ED patients awaiting IP bed
 Pasqua and Regina General combined norm: 20-25
 Peak 60+
 Use of overflow ER space 2012-2013: monthly occurrence
 Use of hallways for inpatient care: 9 designated spots
 ED Admission decision to placement in IP bed (Wave Time):
30+ hours

10. Effective patient flow is achieved by providing safe
quality care to the patient without delays
or waste.
Environmental scan highlighted leading
practices: IHI, Advisory Board International,
and other health jurisdictions including
Fraser Health, Australia, UK, Germany.
….Finding A Solution
Primary
Care
Acute Care
Community
Care

11. RQHR: First Steps
 Dedicating patient flow as area of focus: Resources/Structure
 Centralized bed management supported by clear business workflows, policies, and
integrated technology
 Allscripts Patient Flow Software implementation & business process redesign
 Real Time Demand Capacity Management (RTDC)
 Governance structure, standard work, and accountability framework for patient
flow: Everyone's responsibility
 Develop a Long-term strategy based on best practice
From – To

12. Primary
Care
Acute Care
Community
Care
Making a Long Term Plan to Long Term Problem
• Understanding and identifying opportunities through data &
value stream mapping
• Initial focus - in hospital - to improve ER overcrowding, achieve
surgical targets & reduce over-capacity
• Long term – full patient journey

13. The Solution
= A Strategic Approach to Patient Flow

14. Care Planning
 Patients are involved with care team and contribute to the development and delivery
of their care plan/timeline
 Care plans and discharge planning are considered standard work & patients are well
informed / prepared for discharge
 Short Term Initiatives:
 RQHR RPIW’s: Physician communication of Target Discharge Date (TDD) and Care Plan;
Multidisciplinary rounds
 Provincial RPIW: Repatriation
 Clinical Pathway development: RQHR and Province

15. Governance
 Standard work for leaders at all levels specific to patient flow – respond quickly &
effectively to patient flow issues
 Short Term Initiatives:
 Establish Department of Patient Flow
 Establish Patient Flow Senior Leadership Steering Committee (medical / administrative),
Operational Leadership Team (Service Line Dyads and KOTs)
 Defined Roles and Accountabilities for Senior Leaders and Managers
 Implement Real Time Demand Capacity (RTDC) roles & responsibilities for:
• AM/PM unit huddles
• Bed meetings
• Multidisciplinary rounds

16. Standard Work
 Standard work is imbedded in the organization & leaders hold themselves & teams
accountable
 Core business clearly understood by staff and quality standards for each service line
 Short Term Initiatives:
 Finalize standard work for:
• Multidisciplinary team meetings
• Unit huddles / bed meetings
• Bed management
 Revise policy / procedure for use of OCP beds
 Develop system level capacity response framework
to replace OCP

17. Load Leveling
 System demand is leveled where possible – surgical & clinic (i.e. Endo) targets are
achieved with increased throughput while limiting overall system disruption
 Operating room case complexity is factored into booking process
 Short Term Initiatives:
 Surgery Slate Leveling
 Assessment of Outpatient Clinic Admission Patterns
 LOS targets

18. Demand & Capacity Planning
 System Capacity Response Framework with adjustments made to address recurring
capacity demand mismatches
 Short Term Initiatives:
 Establish capacity response framework based on unit level escalation triggers
 Develop tools to predict demand a week in advance – for frontline unit managers / charge
nurses
 Create additional bed spaces through bed reallocation; short stay surgical and medical units;
convalescent beds

19. Escalation
 Negative capacity identified and mitigated ahead of time to limit impact.
 Unpredicted demand managed through interim plans at unit level.
 Short Term Initiatives:
 Implement RTDC standard work including:
• Unit level capacity plans to manage demand capacity mismatches in conjunction with physician &
physician leaders
• Review of unit level plans to identify system barriers
• System response to address system barriers
 Implement unit level demand capacity plans linked to
system capacity response framework

20. Quality and Safety
 Patient, staff safety and quality patient care at the core of every decision. Zero
defects. Zero unplanned readmissions.
 Patient, Staff and Physician engagement are supported by patient outcomes to drive
system change.
 Short Term Initiatives:
 Current Lean activity – Mistake Proofing & RPIWs
 Improve bed management processes to limit patient
movement through:
• Allscripts Patient Flow Software
• Bed management/allocation process review

21.  A best practice and literature review has highlighted a “systems approach” will
result in sustainable improvement to overall patient flow
 RQHR has integrated the findings of best practice into the development and
implementation of its patient flow strategic framework
 Annual work plan
 Integration with lean activity
Summary

24.  Reduced Admit No Bed #’s: Combined norm 10-16
 Periods of zero ANB
 Reduce System Wide Occupancy 92%-98% norm
 Improved Wave Time: 6-8 hours
 All 9 IP hallway beds permanently closed
 Infrequent use of ED overflow space
 ER Overcrowding: Seen as system issue
 Cooperative culture to managing occupancy
 Improved accountability and visibility
Outcomes

25.  Framework adopted by the provincial Hoshin : ED Waits and Flow.
Outcomes

26. Questions

27. Questions?
Contact Me:
John Ash
Regina Qu'Appelle Health Region,
Director of Patient Flow
john.ash@rqhealth.ca
www.qualitysummit.ca
#QS14