Toolkit for bed managers

IMPROVING PATIENT ACCESS
TO ACUTE CARE SERVICES
A practical toolkit for use in public hospitals
Developed by the Clinical Excellence Commission

Clinical Excellence Commission

Dear reader,
As you are no doubt aware, the flow of patients through an acute hospital
depends upon a complex set of relationships between many departments,
services and people. Achieving improvements in the way patients move
through such a complex system requires a coordinated approach to admission,
treatment and discharge of patients based on core principles of system
engineering. It requires hospitals to untangle the complexity of their existing
processes so they can understand where the key bottlenecks exist within their
clinical units. It also requires a fundamental commitment to providing safe,
effective, efficient and timely care where services are designed first and
foremost according to patient needs.
Successfully improving flow across an organisation requires an extraordinary
level of commitment to a complex and exhaustive change process. It also
requires acknowledgement that there may, at times, be a requirement to tackle
issues that have previously been “sacred cows” within your organisation. For
these problems to be solved, leaders in your organisation must be committed
to this change process in very practical ways. Appropriate time and resources
should be allocated to ensure the improvement process is successful. A realistic
assessment of the number of individuals and teams needing dedicated time
away from their usual clinical duties to commit to the change process should be
made, and steps taken to ensure that they have the capacity to do so.
This Toolkit is designed to be an aid to you and your organisation should
you choose to embark upon the journey to improve patient access to acute
services. The Toolkit is a compilation of strategies and ideas from multiple
sources including:
The NSW Institute for Clinical Excellence Patient Flow and
Safety Collaborative
NSW Health documents and projects
Access projects within New South Wales Public Hospitals
Weekend Discharge project
Effective Discharge Planning Framework
Emergency Department Access projects including the Rapid Emergency
Access Team (REAT) and Emergency Medical Unit (EMU) projects
Improving Patient Access to Acute Care Services

Operating Theatre project
Best practice sites identified during consultation with Area Health Services (AHS)
Other local, national and international experts, literature and projects
reporting success in improving patient flow.
Particular acknowledgement is made of the contribution of leaders of the
modernisation process within the UK National Health Service (Helen Bevan,
Kate Silvester, Richard Lendon, Ben Gowland, Karen Castille and many others)
to much of the thinking contained in the Toolkit. Similarly, the Australian
members of the Access Improvement Taskforce listed at the end of this

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document have all contributed greatly to ensuring that locally applicable
solutions are contained within this document.
The Toolkit is aimed at hospitals providing acute adult medical and surgical
care, although many of the principles may be applicable in obstetric, paediatric
and mental health services. The Toolkit does not specifically address flow issues
for these streams of patients.
The level of evidence for many of the interventions described in the Toolkit
is Level II, Level III or Level IV. The interventions described however, have
been shown to produce results at least at a local level. The Toolkit does not
claim to be a comprehensive list of effective strategies and interventions.
Rather it seeks to describe an approach that your organisation could adopt as
it starts to redesign its patient care processes, and to describe some practical
interventions that have been found to be useful in organisations elsewhere.
If an intervention isn’t included this does not mean that it is ineffective or
that its use is not recommended. Similarly, interventions that have worked
elsewhere may not be suitable, or may need to be adapted, for your institution.
Careful analysis of your local data needs to form the basis upon which you
determine which interventions are most appropriate to implement locally. This
preliminary analysis of local data is discussed in Section 2.2 - Review data to
understand hospital activity and performance.
We believe that the principles contained in this Toolkit can be applied to
small-scale (local clinical unit level) to large-scale (whole hospital) redesign
programs. The complexity and resource requirements may differ according
to the size of the project, but the fundamentals — of removing barriers to
efficient patient flow through providing care based on the needs and experience
of patients as they travel through the organisation — will remain the same
regardless of the project size. We hope that you will find this Toolkit useful as
you embark upon redesigning how patients interact with your health service.
Lastly, I would like to acknowledge the work of the team at the Clinical
Excellence Commission that have put this toolkit together. Louise Kershaw,
Director of the Patient Flow and Safety Collaborative, has assembled a vast
array of interventions that have been shown to improve patient access to
acute services and was a key driver in the writing of this toolkit. Together,
Louise, Lorraine McEvilly and Celia Mahoney have worked tirelessly to manage

the Patient Flow and Safety Collaborative and to produce the final toolkit. My
deepest thanks go to these extraordinary individuals.
Best wishes and good luck,

Dr. Rohan Hammett
Director
Healthcare Improvement Projects
NSW Clinical Excellence Commission
March 2005
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Contents
HOW TO USE THIS TOOLKIT 6
1. INTRODUCTION 7
2. PLANNING THE IMPROVEMENT WORK 11
2.1 Identify and define the problem 12
2.2 Review data to understand hospital activity and performance 12
2.3 Engage clinicians and convene the redesign team 14
2.3.1 Leadership 14
2.3.2 Team members 15
2.4 Diagnostic Work 16
2.4.1 Understanding the current systems and processes 16
2.4.2 Tools for understanding processes 17
2.5 Determine your aim 19
2.6 Designing and implementing changes 20
2.6.1 Identify interventions to implement 20
2.6.2 Practical ideas for effecting change 21
2.6.3 Implementation plan 22
2.7 Analyse the Results 23
2.7.1 Methods of measurement 23
2.8 Communicating the change 24
2.8.1 Key factors for successfully managing change 25
Case study - Western Sydney AHS -
Neck of Femur Patient Flow Group 26
Checklist prior to starting your improving access project 34
3. INTERVENTIONS 35
3.1 General strategies 36
3.1.1 Shared work plans, practices and schedules
within multi-disciplinary teams 36
3.1.2 Develop multi-disciplinary evidence based pathways 37
3.1.3 Relative performance table 37
3.1.4 Convene a redesign team 38
3.1.5 Improve communication systems 38
3.1.6 Referral to specialist services 39
3.1.7 Service level agreements 39

3.1.8 Managing capacity to respond to need for services 39
3.1.9 Minimise variation in capacity to provide care 40
3.1.10 Change to 7 day a week services 40
3.1.11 Buffer beds 40
3.1.12 Smoothing variation in elective activity 41
3.1.13 Develop advanced nursing roles 41
3.1.14 Up-skilling peripheral hospitals for complex patient needs 42
3.1.15 Align staff specialist/consultants work to maximise efficiency 42
3.1.16 Bed management system 43
3.1.17 Centralised bed authority/bed co-ordinator 43
3.1.18 Regular multi-disciplinary bed meetings 45
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3.1.19 Teleconference bed updates 45
3.1.20 Clinical prioritisation of patients 45
3.1.21 Reconfigure beds to reduce outliers 46
3.1.22 Over Census Policy 46
3.1.23 Guidelines and protocols for test ordering 47
3.1.24 Review permissions to order tests 48
3.1.25 Prioritise tests for Emergency Department
or patients waiting for discharge 48
3.1.26 Allocated time for emergency cases 48
3.1.27 Appropriate information on request form 49
3.1.28 Patients attending for tests 49
3.1.29 Stratified test ordering 50
3.2 Emergency patient flow 51
3.2.1 Pre-bypass hospital early warning system 51
3.2.2 Streaming techniques 53
3.2.3 Alternate admission processes 53
3.2.4 Develop alternate services to prevent ED presentation 54
3.2.5 Advanced nursing and allied health practitioner roles 54
3.2.6 Fast Track 54
3.2.7 See and Treat 55
3.2.8 Lean thinking 56
3.2.9 Clinical pathways around presenting problems not diagnoses 57
3.2.10 ED access to day surgical list bookings 57
3.2.11 Communications clerk 58
3.2.12 Emergency medicine unit 58
3.2.13 Flag and case manage frequent attendees 58
3.3 Improving Flow of Emergency Surgical Patients 59
3.3.1 Clinical guidelines or pathways 59
3.3.2 Team briefing and debriefing sessions 60
3.3.3 Emergency department physician admission rites 60
3.3.4 Review existing demand for emergency operating theatre time 61
3.3.5 Prioritisation protocol 61
3.3.6 Prioritisation team 61
3.3.7 Pre-operative placement of patients waiting for OT 61
3.4 Medical strategies 62
3.4.1 Medical assessment and planning unit 62

3.4.2 Day only admission ward for ED patients 62
3.4.3 Flag and case manage frequent medical admitted patients 62
3.4.4 Trial at home program 63
3.4.5 Improve appropriateness of admission 63
3.4.6 Safety risk assessment 63
3.5 Improving communication 64
3.5.1 Improving communication with GPs and community nursing 64
3.5.2 Generic transfer/discharge to hospital form for
all residential aged care facilities (nursing homes) 65
3.5.3 Link ‘discharge from ward time’ with ‘admission
from Emergency Department’ time 65
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3.5.4 Scheduled transfers 65
3.6 Improving discharge processes 66
3.6.1 Discharge risk assessment form 66
3.6.2 Admission and discharge plan 67
3.6.3 Criteria driven discharge 67
3.6.4 Nurse activated discharge 67
3.6.5 Monday morning audit 68
3.6.6 Weekend discharge pharmacy 68
3.6.7 Multi-disciplinary Discharge Meetings 69
3.6.8 Informing patients and carers about their discharge 70
3.6.9 Discharge checklist 70
3.6.10 Estimated day of discharge 71
3.6.11 Estimated length of stay table 71
3.6.12 Compare the estimated date of discharge
to the actual date of discharge 72
3.7 Aged care 73
3.7.1 Aged care assessment team (ACAT) 73
3.7.2 Transitional care beds 73
3.7.3 Community transitional care beds 73
3.7.4 ComPacks service model 74
3.7.5 Purchase transitional care beds 74
3.7.6 Direct emergency admission protocol 74
3.7.7 “Dependant care” stream of patients managed
by specialist nurse practitioner 74
3.7.8 Walking assistance program 75
3.8 Elective Patient Flow 75
3.8.1 Quarantined elective surgical beds 75
3.8.2 Criteria driven discharge 75
3.8.3 Surgical pathways and estimated day of discharge (EDD) 76
3.8.4 Increase day of surgery admission rates and
manage performance outliers better 76
3.8.5 Audit all theatre delays or cancellations 76
3.8.6 Surgical peri-operative liaison nurses 76
3.8.7 Medihotels 77

3.8.8 Flexible staffing 77
3.8.9 Align leave of multi-disciplinary surgical teams 77
3.8.10 Clinical teams operating pooled referrals 77
3.8.11 Clinical pathways 77
3.8.12 Improve completion of consent forms 78
3.8.13 Marking operating site 78
3.8.14 Improve compliance with fasting requirements 78
3.8.15 Predict surgical case length accurately 78
GLOSSARY OF TERMS 79
ACKNOWLEDGEMENTS 80
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How to use this Toolkit
The Improving Patient Access Toolkit is divided into the following sections:
Introduction to patient flow
Planning the improvement work
Diagnosing flow problems in your organisation
Key elements of an access improvement project
Interventions/change ideas
The Toolkit has been designed with the intention that you should adopt a
systematic approach to improving patient flow across your organisation. To do
this, you should start at the beginning of the Toolkit and work your way through
the different stages of designing and implementing a successful redesign
program. However, should you simply want change ideas and strategies to
implement, you should go directly to the interventions section where there are
detailed descriptions of many specific changes you can test.
Throughout the document you will find the following icons that will guide
you to useful resources.

Key to icons:

Tool available on CD Rom

Hospitals where interventions are in place

Resource available on the internet

Bookmark link within document

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1. Introduction
Introduction to the principles
of managing patient flow
During the course of a single treatment journey a patient will interact with
dozens of clinicians and clinical and non-clinical services that have the potential
to impact on their care. There are multiple steps and handovers that need to
occur smoothly for the patient to receive optimal care in as timely a manner as
possible. At key points in a hospital where many patients are interacting with a
single service (e.g. in the emergency, radiology, and pathology departments or
in the operating theatres) there is great potential for delays in the treatment of
one patient to result in flow-on of delays to other patients and to other services
throughout the hospital. Like a pebble causing ripples on a pond, relatively
small delays in the treatment of one or two individuals may have significant
ramifications for flow of patients across the whole organisation.
It is vital that hospitals have an understanding of the key groups of patients
they treat, and the type of care required to produce optimally efficient
management of flow of these patients. Interestingly, in most acute hospitals
patients fall into one of three categories:
Category 1 - short stay patients with an average
length of stay (ALOS) of less than 48 hours
Category 2 – multi-day patients with an ALOS of less than 10 days
Category 3 – patients with an ALOS greater than 10 days.
It is useful, in planning service delivery, to think of how services can be
arranged to optimise flow for these three groups of patients. As can be seen in
Figure 1, the majority of patients fit into category 2 (ALOS <10 days). For these
patients even a small reduction in length of stay will produce significant bed

capacity within an organisation. For example, if discharge planning processes
were improved, or delays in diagnostic tests eliminated, resulting in an
improvement in ALOS of 0.5 days, dozens of beds would be made available.
For patients in category 1 (ALOS <48 hours), strategies to provide
alternatives to acute hospital admission are likely to be most effective. For
example hospital-in-the-home services that can provide intravenous antibiotics
for cellulitis, or additional support services for elderly patients following a
fall, or provision of care for nursing home patients directly in their residential
facility, may all prevent admission for these patients.

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For category 3 patients (ALOS > 10 days) strategies focussed on
prevention of adverse events, improved liaison with community care
providers and case management may all help prevent the extreme lengths of
stay often seen in these patients.
In general, the types of services required to ensure optimal flow for each
category of patient will be similar almost regardless of the specific clinical
condition that has brought them into hospital. For example most category 1
patients require some simple diagnostic tests, short-term intravenous therapy
of some sort and some nursing care or monitoring for a short period of time.
If services are redesigned appropriately, much of this care could be provided
in facilities other than the acute hospital e.g. ambulatory care units, nursing
homes, general practice, or the patient’s home.
Similarly, the patients in category 2 will require diagnostic services, medical and
nursing management and planning to provide appropriate support post-discharge.
Much of this care can be planned before admission for elective patients, or very
early during their admission for emergency patients. The key constraint areas of
the hospital (e.g. radiology, pathology, operating theatres, intensive care) can
plan how many of these patients will require their services based on historical or
prospective data to minimise delays to their treatment. This will enable a matching
of capacity and demand that will improve the efficient flow of these patients and
prevent delays that increase length of stay and result in flow-on effects across the
whole organisation.

Figure 1

Length of stay | Medical Patients
250

200
Category 1 | prevent admission

150
Category 2 | take a day off clinically unnecessary

ALoS and it has a dramatic effect
100
Category 3 | these patients may have more
complex support needs
50

0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay (days) | Average LoS = 7.24 days
Source | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals

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The importance of managing variation
Many of the delays that plague patients attempting to access acute services
are not due to inadequate resources, but rather the result of the variation with
which these resources are utilised. For example, many hospitals have extensive
waiting lists for outpatient clinic appointments. When an analysis is undertaken
of the number of clinic appointment times available, it is often the case that the
current clinical capacity actually matches the demand for the service, except
that every time there is a public holiday or a conference, the outpatient clinic is
cancelled and as a result a waiting list is produced. If clinics were rescheduled
rather than cancelled this would not occur.
Similarly, the variation in the number of patients a hospital admits for
elective surgery may in itself be contributing to waiting lists, access block
and surgical cancellations. The graph shown in figure 2 below is taken from a
hospital that on average admitted 49.7 patients every day. In the top part of
the graph you can see that the number of patients admitted varied between
24 and 78 on any single day. To ensure it could provide enough beds for all
patients on 99.9% of days, this hospital required 78 beds to be kept open for
elective admissions. In the bottom part of the graph the same average number
of patients were admitted (49.7) but, by reducing the variation in the number
of patients admitted (38-70 cf 24-78), the number of beds required to ensure
availability for 99.9% of patients was reduced to 68.

Figure 2

Total Admissions | April-November
80
78 beds
70 required each
60 day to give
50
99.9% chance
of admission
40
Admissions
30
Average = 49.7
20 UPL = 78.1

Standardised Admissions | April-November
80

70 68 beds
60
required each
day to give
50
99.9% chance
40 of admission
Admissions
30
Average = 49.7
20 UPL = 67.9

Daily bed requirement reduced from 78 to 68
Source | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals 9

Thus if we manage the variation in the way we provide our services, we will
find greater capacity to deliver services in an efficient manner. Interestingly,
in most hospitals elective activity varies far greater than emergency activity
on a daily basis. Similarly, there is often far more variability in the number
of patients discharged than the number of patients admitted. Both of these
processes (number of elective patients admitted and number of patients
discharged) can be managed by the organisation itself. Understanding the
management of variation in service delivery is crucial to smoothing the flow of
patients through acute hospitals.
Gaining a greater understanding of the way in which patients move into,
through and out of the organisation and the bottlenecks that are hindering
efficient movement will assist in understanding which changes should be
made to gain improvement. To do this effectively an organisation will need to
examine its own data to identify patterns in activity that need to be redesigned.
The resources below contain more detailed descriptions of the information
contained in this introduction and can be referred to in order to gain a greater
understanding of the key principles of managing patient flow. The Toolkit may
then be utilised to redesign the way a patient travels through the system.

Improving patient flow

www.steyn.org.uk/

Queuing theory (NHS website)
Patient flows, waiting and managerial learning paper (NHS)
www.cognitus.co.uk/healthcare.html#1

NHS Flow Management Wizard
www.natpact.nhs.uk/demand_management/wizards/big_wizard/
index.php?page=/demand_management/wizards/big_wizard/Step_
4/Basic_Queuing_Theory.php

Foundations of demand and capacity (NHS presentation)

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2. Planning the
improvement work
Successful implementation of changes will depend on effective
project management throughout the period of the project.

Project steps
Identify and
define the
problem
review data to understand
activity and performance

engage clinicians and
convene the redesign team

complete baseline
diagnostic work

determine the aim

identify interventions to trial

design and implement
the changes

analyse the results

build in accountability to
help sustain changes

communicate
the changes
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2.1 Identify and define the problem
Before commencing work, it is useful to try to sum up the problem you wish
to improve in one sentence e.g. reduce or eliminate access block, improve
discharge processes for medical patients, or decrease delays in transferring
patients between hospitals. Identify the problem from the patients’ perspective
and use terms that describe their experience. This will help clarify the core
objective of the work you are about to undertake and prevent your project
from suffering from a diffuse, poorly directed lack of purpose.
The amount of work and degree of change required will vary depending on
the scope of the project. Significant improvements to patient access to acute
services may be produced by implementing change at local departmental level,
service, ward or across an entire hospital.

2.2 Review data to understand
hospital activity and performance
It is vital that characteristics of patient populations and their flow through
the system are understood. The following is a general list of data that will help
in understanding patient flow in the organisation and may be obtained from
the Patient Access System (PAS), Disease Index (DI), Emergency Department
Information System (EDIS) or the Health Information Exchange (HIE). Only
extract the data needed to help understand that part of the system of interest.
Use the data to highlight problems or to prove the changes implemented are
making a significant improvement.
1 Numbers of access block patients by day at 12 MD, 4 pm and 8 pm. This
will identify within-day variation in demand for services that will assist
with planning staffing needs throughout your organisation.
2 Number of beds used daily by ED status (admitted and discharged from
ED, admitted through ED, not admitted through ED) at peak times (12 MD

and 4 pm). This will assist in identifying the bed requirements for each
clinical department to deal with their emergency patient load. It should be
utilised in conjunction with an analysis of elective admissions by clinical
department to plan appropriate bed allocation.

12

3 Count the number of beds required to cover a given proportion of days
(e.g. 95% of days). This will help you to understand the size of the
improvement required to eliminate access block in your organisation.
4 Number of access block patients for each day of week. This will identify
the between-day variation in demand for services to assist with planning
schedules for clinical activity and staffing.
5 Percentage of overnight access block patients who reach a ward bed
before midday. This will help identify any problems related to turnover of
available beds.
6 Distribution of specialties for access block patients (% bed use by
Consultant Medical Officer specialty). This will help identify departments
in which redesign processes might be most useful, or in which there may
be a need for additional resources to improve flow.
7 Percentage bed base by Consultant Medical Officer specialty (Emergency
and non-emergency bed distributions). This will enable a current appraisal
of bed utilisation and management of bed allocation on a data-based
rather than historical basis.
8 Outliers by Consultant Medical Officer specialty and ward — bed days used.
This will identify the degree of disorganisation of current bed management
practices and provide a focus to case management models to improve
length of stay for these patients.
9 Emergency overnight medical discharge rate by day of week (% weekend
discharge). This will characterise variation in discharge practices across
days of the week. It should be done for a 12-month period. Note the peaks
in discharge prior to public holidays. Readmission rates after these public
holidays usually do not change despite the high discharge rates suggesting
that these patients really were ready for discharge. You can check these
readmission rates in your own organisation.
10 Elective overnight admission rate by day of week. This will show the
variation in elective services in your organisation. If this variability can be
minimised it will, of itself, create extra bed capacity in your organisation.

11 Analysis of length of stay against benchmark by Consultant Medical Officer.
This will help identify variation in clinical practices that may be contributing
to delays for patients. These can be addressed by the clinical unit manager.

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For access to or assistance with extracting the above data, contact the hospital
case mix manager (or person who collates data for reporting to the health
department). They will have access to the data and the skills and knowledge
to extract this data or will be able to suggest other sources of assistance.
Alternatively your executive sponsor will be useful in securing the services of
an appropriately skilled person to do this.

Access Blocked Patient Analysis 2002-2003 (NSH)

Hospital Flow Measurement Guide (IHI)
www.qualityhealthcare.org/IHI/Topics/Flow/PatientFlow/
EmergingContent/HospitalFlowMeasurementGuide.htm

2.3 Engage clinicians and
convene the redesign team

2.3.1 Leadership
Effective leadership is crucial to maintaining a focus on improving the
patient experience. The team should include:
someone with the skills, energy and enthusiasm to lead the project,
strong medical and nursing leadership at all organisational levels,
clinician managers who are effective champions for the project. They have
an important role in spreading improvements to other departments and may
be required to performance manage individual variance,
individual clinician leaders who participate and use their influence to
support change amongst their colleagues,

leaders with a clear vision of the project who can sell this vision to others.

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2.3.2 Team members
When bringing together a project group or a redesign team ensure
there is a mix of administration, medicine, nursing and allied health
representation relevant to the project’s aims. Enthusiasm and interest in
the project are essential qualities to look for in team members. They should
also have an operational role in the processes to be changed. Many sites
that have successfully improved patient flows have also actively involved
consumers in the work of their teams, in a manner appropriate to the
context of the organisation.
Team members also need to take the following roles:

2.3.2.1 Executive sponsor
Previous experience has demonstrated that effective sponsorship at an
executive level is crucial to successful implementation of organisational
change. Executive sponsors need to be at Area Health Service level or
executive level in a facility i.e. Director of Clinical Services or Hospital
Executive Director and be:
someone with enough influence in the organisation to oversee the change,
someone prepared to set aside time for the project.

2.3.2.2 Clinical leaders
Most projects require a nursing lead and a medical lead. They should be
someone who:
understands the processes of care,
is able to provide technical expertise in order to produce solutions that are
technically proper, ethically sound and effective,
can provide effective leadership,
is an opinion leader who can influence his/her peers to produce

improvement in existing systems of care delivery.

15

2.3.2.3 Project co-ordinator
Someone who:
understands not only the details of the system, but also the various effects
of making change(s) in the system,
has the necessary skills, including computer literacy, project management
and high-level organisational skills,
ideally has some experience in change management, process mapping and
Clinical Practice Improvement (CPI) techniques.

2.4 Diagnostic Work

2.4.1 Understanding the current
systems and processes
Identify what the main streams of activity are within the service where
you are seeking improvements e.g. elective day of surgery admission
stream, emergency medical admit and discharge from ED, elective medical
procedure admissions.
Identify what the key processes and issues are within those streams, using a
variety of means that collect patient and staff perspectives of the problem.
Use interviews, focus groups, patient journeys and process mapping.
Review:
current or recent projects, their aims and outcomes to date,
current policies and procedure manuals,
currently available data.
Measurement for Improvement, Improvement Leaders’
Guide (NHS)

www.modern.nhs.uk/improvementguides/
measurement/

16

2.4.2 Tools for understanding processes

2.4.2.1 Process mapping
The flow of patients through hospital, whether as emergency admission,
ED presentation, outpatient or for an elective procedure, involves multiple
processes, many of which may be repeated approximately the same way for
every patient. Even very complex procedures may be standardised, based on
sound scientific practice. This can help to reduce variation and inefficiency
caused by poor communication and redundant complexity. Process mapping is
a technique to identify inefficiencies; redundant steps in clinical workflow;
bottlenecks or blockage points where time or resources are wasted.
Improving Patient Flows - Guide to Process Mapping
(Institute for Clinical Excellence)
Improvement Leaders Guide to Process Mapping, Analysis and
Redesign 2002 (NHS)
Easy Guide to Clinical Practice Improvement 2002 (NSW Health)

2.4.2.2 Patient journey
Tracking a patient’s journey through the healthcare system is a simple way
to understand where problems lie and how the service looks through the eyes of
a patient. Any member of staff can do this by shadowing a patient through the
system and keeping a time log of activities. Alternatively, ask a patient or their
carer to write a diary of their experience. The patient journey may be used to
verify findings of the process mapping exercise and will allow identification of
any waits and delays in real time.

Patient Journey Tools (Institute for Clinical Excellence)

17

2.4.2.3 Understanding major bottlenecks
For those bottlenecks identified in the process mapping, you should audit
the reasons for patients waiting and measure the waiting times involved. For
example you could record the time from request for diagnostics to the time
results are reviewed by the referring team.

result review
decision request
available report

The time in between each of these steps can be useful to highlight what
works well, what is causing problems, and opportunities for improvement.
Other tools such as Fishbone (Ishekawa or Cause and Effect) Diagrams and
Pareto charts may be useful to determine what the underlying causes of the
problem are. Refer to the NSW Health Clinicians Toolkit.

Clinicians Toolkit (NSW Health)

2.4.2.4 Patient flow audits
Greater than 14 day audit — do a walk around of all patients with a length of
stay greater than 14 days. Ask if they are sick, are they waiting for something,
why have they not been able to go home?

Discharge Delay Data Collection Worksheet
(Western Sydney Health)

Monday audit — review all patients who are discharged on Monday. Ask the
following questions. Were they medically stable on Saturday or Sunday? Why
weren’t they discharged earlier? e.g. lack of services, waiting for a test,

waiting for review by medical officers.

Discharge Audit Tool (RNS Hospital)

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2.5 Determine your aim
Develop a statement about the aim of your project. An aim is used to keep
the team focused on what it is trying to achieve and provide a measure for the
project’s success.
Based on your diagnostic data, determine aims that include:
the percentage improvement you will work towards achieving,
the time within which you will achieve the aim.
Example: To have less than 10% of 75 year old patients experiencing four hour
access block within six months.
It is important to note a few key points about these aims:
1 Use the diagnostic work to find what is important to the different
stakeholder groups involved. Engage the team with something that matters
to each of them.
2 Once the issues the team wish to address are clear, set aims at hospital
and departmental level that act as levers to engage change at ward and
individual clinician level.
3 Make the aims SMART i.e. specific, measurable, achievable, results
orientated and time scheduled.
The aims should describe:
what is expected to happen,
the system to be improved,
the setting or sub-population of patients,
goals.

Develop Your Aims from your Diagnostics Presentation

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2.6 Designing and implementing changes

2.6.1 Identify interventions to implement
Once problems and issues have been identified and prioritised a decision
needs to be made regarding what changes you will implement to achieve the
aim. Go to Section 3 of the Toolkit which has a range of ideas, suggestions and
changes implemented in other organisations. Read through the interventions
listed in the appropriate section and download any references or tools. At
a redesign team meeting agree on a list of interventions you wish to trial
or implement, based on the results of your diagnostic work. It is important
to focus on interventions relevant to those significant problems identified
during your diagnostic analysis. Look for the common sense solutions before
introducing radical change. Many of these will emerge during process mapping
and redesign activity.
In some cases, a decision to implement a particular strategy may be made
straight away. This is appropriate where there is a high level of confidence
from the diagnostic work and evidence from other organisations where it is in
place, that it will effect an improvement. However other interventions will
need to be trialled, adapted to local context and evaluated for effectiveness
before a decision to implement is made. Clinical Practice Improvement (CPI)
methodology is a useful tool for trialing interventions.

Easy Guide to Clinical Practice Improvement Methodology
(NSW Health)
PDSA Worksheet (Institute for Clinical Excellence)

20

2.6.2 Practical ideas for effecting change
Create a culture where change is encouraged and people are willing to try
something new.
Use cases that actually happened in your hospital to demonstrate process
and system problems affecting patient outcomes to foster organisational and
individual will to change.
Publicise the findings of the diagnostic work to highlight problem areas and
engage clinical staff and management.
Use success stories to create an expectation that change can occur.
Establish a process in your hospital or department to keep up to date with
the current best practice.
Use incentives, e.g. wards with high morning discharge rates given priority
for receiving extra staff.
Acknowledge and celebrate success when it is achieved.
This should help to create a culture where things change/improve constantly so
that a state of change/improvement becomes the stable state.

Improvement Leaders Guide -
Managing the Human Dimension of Change (NHS)
www.modern.nhs.uk/improvementguides/human

Organisational Change, a Review for Healthcare Managers,
Professionals and Researchers (NHS)
www.sdo.lshtm.ac.uk/pdf/changemanagement_review.pdf

Making Informed Decisions on Change (NHS)
www.sdo.lshtm.ac.uk/pdf/changemanagement_booklet.pdf

Quality collaboratives: Lessons from research
(The Nordic School of Public Health)

Improvement Leaders Guide - Spread and Sustainability, 2002
(NHS)

21

2.6.3 Implementation plan
Once you have a list of interventions you plan to trial, create an
implementation plan including a breakdown of the interventions into lists of
tasks you need to complete in order to implement the intervention. Brainstorm
potential barriers and plan to proactively manage these. Many of the barriers
to change that will be encountered relate to poor communication. Give all
appropriate people the opportunity to be involved. The implementation plan
should be specific with individuals accountable for completion of work by a
specific date. The following example is an excerpt from an implementation
plan that describes a few of the actions that may be required to implement
nurse initiated X-rays.

Figure 3
Example | Implementation plan
Planned step Action Identified Strategies Individual
required barriers to overcome responsible
barriers and by when
Introduce Write a Radiology Joint working Training
nurse protocol apprehension group to programme
initiated detailing re service develop the in draft by Dr
X-ray indications getting protocol and Sarah Jones
for nurse overwhelmed guidelines for 04/04/04
initiated when RN can
X-ray initiate
Develop Nurses Training by Joint working
a form not having radiology and group chaired
specifically confidence emergency by and
for this to make the departments supported by
purpose decision due for nurses Peter Brown.
to lack of to ensure First meeting
information they feel 06/05/04
skilled and
supported

in decision
making.
Work with Doctors Involve the
radiology concern over ED doctors in
department the quality of the protocol
to develop the service development
agreed
guidelines
Set up
monitoring
systems
22

2.7 Analyse the results
The team should determine how to measure the progress of their work and
develop a strategy to achieve this. Avoid the temptation to spend so much time
collecting or pursuing “perfect” data that the improvement work doesn’t get
started. Measurement plays the following important roles.
Key measures are required to assess progress on your aim.
Specific measures can be used to learn more about the problems that exist
within the system.
Balancing measures are needed to assess whether the system as a whole is
being improved.
Data from the system (including from patients and staff) can be used to
focus improvement and refine changes.

2.7.1 Methods of measurement
Different methods may be used to gain measures, both qualitative and
quantitative, to provide the information described above.
Clinical measures of patients’ health
Documentation of behaviour
Questionnaires
Interviews
Assessments
Summary of databases
Chart audits
Observations

23

Once process mapping is complete it usually highlights areas requiring further
information gathering or audit. This will help the team to fully understand the
nature and size of the problem to be addressed and prioritise the area to work on.

Measurement Strategy Worksheet

Measurement Presentation - Helen Ganley (NSH)

Weekend Discharge Audit Report (RNS Hospital)

SPC for Beginners - Powerpoint Presentation (NHS)
www.modern.nhs.uk/InnovationandKnowledge
Group/7338/SPC_for_beginners_web.ppt

Patient Perceived Needs Survey (NICS)

2.8 Communicating the change
For these projects to work smoothly there needs to be good communication
with individuals, departments, patients, providers, management and clinicians.
As interventions are implemented, display information about the changes
that have been made and the results achieved in a clear graphical format. Show
performance against targets.
Every individual in the healthcare team including nurses, doctors, allied
health professionals, administrators, managers, secretaries, cleaners, food
services and porters, play a significant part in the patient’s journey. They will
all offer a different and valuable perspective. Remember, if people know what

is going on and are actively involved, they will have greater ownership of the
problem and the solutions.
Identify data and measures that have “shock” value and use them to gain
acknowledgement of the problem and engagement of staff in the need for
change. Identify all those who have some role to play in the care processes that
you aim to change and be open and share information with them.

24

2.8.1 Key factors for successfully managing change
Evidence suggests that the following factors all significantly improve the
chances of a project making an effective and sustainable impact.
An organisational will and commitment to change the system to, first and
foremost, meet the needs of the patients.
Visible commitment from executive and senior management.
Local ownership of solutions to the problems encountered by local clinical
and management teams.
Resources committed to the redesign process, including personnel
experienced in change management to facilitate this locally.
A core multi-disciplinary team who drive change, facilitated and supported
by a project coordinator.
Medical, nursing and allied health engagement, leadership, and participation
in the team.
Investigation and data analysis of existing issues and problems utilising
tools such as extensive process mapping and redesign of inefficient
processes of care.
Rapid implementation of strategies that have been shown to be effective in
improving flow in similar hospitals.


25

Case study - Western Sydney AHS -
Neck of Femur Patient Flow Group:
Contact Details: Maria Lingam maria_lingham@wsahs.nsw.gov.au
Rosio Cordova rosio_cordova@wsahs.nsw.gov.au

Team Members
Cathie Whitehurst Executive Representative

Celine Hill Team Leader, Trauma Program Manager

Rosio Cordova Facilitator, Quality Manager

Maria Lingam Clinical Nurse Consultant (Orthopaedics)

Narelle Allen Clinical Nurse Educator (Orthopaedics)

Gail Hook NUM, D4A (Orthopaedics ward)

Robert Dowsett Director ED Westmead

Gayle McInerney Director ED Auburn

Geoff Shead Surgery Stream representative

Randolph Gray Orthopaedic Registrar

Elizabeth Stafidas Surgical Support Services representative

Peter Landau Staff Specialist, Geriatric Medicine

Sue Voss Anaesthetics Consultant

Linda Gutierrez Trauma Data Manager

Dr John Fox Director, Orthopaedics Unit, Westmead Hospital

Dr Roger Brighton Director, Orthopaedics Unit, Blacktown Hospital

The Aim
According to evidence-based best practice, patients with fracture of the
neck of femur (NOF) should have early surgery (within 24 to 36 hours) once a
medical assessment has been made.
The aim of the project was to increase by 25% the current rate of patients
with NOF fractures (those patients who were identified clinically fit and not
requiring extensive diagnostic tests) having an operation within 24 hours by
January 2004.
26

Background
Analysis of data previous to project commencement (Jan 02 to Jun 03)
identified that only 42% of patients with neck of femur fracture were
reaching theatre within 24 hours.
Furthermore, an audit on patients who didn’t go to theatre within 24 hours
demonstrated 30% didn’t do so because they were unfit and/or required extensive
diagnostic tests such as bone scan and Magnetic Resonance Imaging (MRI).
Based on the analysis, it was evident that we were able to improve
access to theatre for those patients who were delayed for other reasons
than identified above.

Project Development
A multi-disciplinary team was formed with representatives of key
stakeholders including cross campus representation to facilitate transfer of
knowledge and expertise. A number of tools were used to determine the nature
and extent of the problem and to identify how change could be achieved within
the resources available.
A brainstorming exercise took place in order to identify the current patient
journey (Figure 7 - page 32). This identified the following issues:
Patients with NOF fracture were in most cases referred for geriatric review
before seeing the Orthopaedic registrar: especially in cases where there is
pain but X-ray is normal and patient is able to walk.
Geriatric review only occurs during working hours. Patients presenting after
hours have to wait until next day.
Orthopaedic review only occurs until 9pm, if a call is made after that
time then the patient will wait in ED until the next day to be seen by the
Orthopaedic registrar.
The Anaesthetist can request further medical review, delaying operating
time (which can take an extra day).

Patients from district hospitals usually wait longer due to the lack of bed
and/or incomplete documentation.
Customer expectations were collected anecdotally. Expectations from the
following customers and service partners were noted:
Patients wanted to receive prompt and adequate treatment and staff
expressed their will to provide patients with efficient services.

27

A cause effect analysis (Figure 4) assisted the team in identifying the priority
areas requiring attention. The team decided to focus on issues surrounding
accessibility and assessment. The issues surrounding patients’ fitness and co-
morbidities was something the team was unable to influence. There was a
similar issue with insufficient operating theatre times, as this required the
provision of major financial resources.

Figure 4
Assessment Accessibility

No specialised Booking times
nursing review in ED
Disorganised booking times

Geriatrician review vs
Orthopaedic review Orthopaedic review vs
Anaesthetist review
Incomplete patient
documentation No beds available
upon transfer

NOF patients
waiting more
Patient requires Theatre availablity than 24 hours
MRI or Bonescan for operation
Family refuses operation Lack of OT time
Patient is
medically unfit NOF not considered for
emergency theatre
Patient
Operating
theatre

Action
The following interventions were implemented in order to simplify the
current patient flow process (Figure 5). Timeframes, responsibilities and
performance measures were assigned to various members of the team. Key
strategies focused on redesigning the current process.

28

Figure 5
Issues Intervention implemented
Patients referred Once ED Registrar reviews tests and admission is
for geriatric review identified, then the ED Registrar calls the Orthopaedic
before seeing the Registrar as well as informing the Geriatric Registrar.
Orthopaedic Registrar.

Geriatric review In absence of the Geriatric Registrar, the Medical Registrar
only occurs during can review the patient after hours or weekends.
working hours.

Orthopaedic review only ED Registrar is able to organise transfer of patients to
occurs until 9pm, if a the Orthopaedics Ward upon confirmation of fracture.
call is made after that
time then the patient
will wait in ED until the
next day to be seen.

The Anaesthetist can Anaesthetist review occurs at the beginning of the diagnostic
request further medical process rather than at the end, upon admission to the ward.
review, delaying
operating time.

Patients from district Checklist is used upon transfer of NOF patients from district
hospitals wait longer for hospitals to ensure documentation is complete. This reduces
operation due to the lack delays to theatre due to incomplete documentation.
of bed and/or incomplete District hospital patients are returned to the hospital
documentation. of origin after operation for post-operation treatment.
This reduces long waits in ED due to the lack of bed, as
this has been quarantined in the hospital of origin.

Disorganised Orthopaedic Registrar will book theatre when diagnosis is
booking times. confirmed either before 9pm or between 7am-7.30am as this
would help in organising lists and prioritising theatre patients.

No specialised nursing The Clinical Nurse Consultant (Orthopaedics) is called upon
review in ED. patient’s ED admission to start the care management process
rather than waiting until the patient is admitted to the ward,
i.e. this assists early identification of what the patient requires
in terms of protection of skin integrity, rehabilitation etc.
Education sessions were conducted at various shifts in ED to
raise awareness among staff.
Data collection. The current data collection form was modified to allow capture
of information on reasons why the patient is delayed in going to
theatre within 24 hours.
29

Results
Data was collected pre and post project implementation. A comparison
of the data showed that an average of 70% of patients with neck of femur
fracture reached theatre within 24 hours during the seven months of project
implementation compared to 42% before the project (refer to Figure 6).
Overall, the rate of NOF fracture patients going to theatre within 24 hours
increased by 28%.
A further positive outcome of the project was that it crossed departmental
boundaries in order to achieve what is best for the patient.

Figure 6
Pre-project mean 42% NOF Project

100% UCL = 100%

Mean = 70.1%
Rate

50%

LCL = 24.4%

0

Jan 02 - Jun 03 Jul 03 - Jan 04

30

Holding the gains
There are a number of strategies in place to sustain improvements post
project such as:
Continued data collection process for the NOF information to review ongoing
performance indicators and provide performance report to management.
Monthly monitoring of performance and presentation of findings to
management meetings of Orthopaedics, Anaesthetics, Geriatrics as well as
ward staff.
Orientation of Orthopaedic and Geriatric Registrars on the NOF Program and
management guidelines.
Continue active communication between the fractured neck of femur team
and the Orthopaedic Registrars to deal with any new reasons for delays.
Establish communication between the ASET team CNC and the Orthopaedics
CNC to identify NOF patients early in Emergency.
Continue early medical review/Geriatric Registrar.
Organise fractured neck of femur case conferences twice weekly to monitor
appropriateness of the current patient journey.


31

Figure 7

NOF Fracture Patient Flow (pre-project)

Patient
presents Time recorded & triage
to ED-Triage category provided

Patient is
admitted MRN is produced

JRMO Time is recorded prospectively In ED X-ray order is put
medical Tests include X-ray & blood in X-ray box & pick up
assessment pathology tests by X-ray staff

Test results Geriatrician
reviewed in informed or Med.
ED by Senior reg called after
ED Doctor hours

Special Medical
Geriatric Is geriatric Yes Fracture of
Yes review Yes tests for hip management
Admission admission hip?
required? needed? required? pain ordered

No No Time Ortho
registrar is called
Patient sent Seen by to be recorded by
Yes
home the Ortho Geriatric registrar
registrar
Seen by Time to be recorded
the Ortho by Ortho registrar
registrar and
Patient No Time of diagnosis
Op theatre booked at time follows as
requires per 1 & mode to be
Some # missed. admission to of diagnosis before 9pm or
recorded
Patients may Ortho ward? booked at 7am next day
be recalled
Yes

Is bed Yes Is fracture Yes Fit for Yes OT Yes Rejected by Yes Ward
available? confirmed? OT? available? anaesthetist? (medical
assessment)

Booking time
Patient may recorded in
be admitted Op theatre,
to Ortho No No No No No operating time
ward during including start
the night if Wait in ED Ward Ward Ward Patient has & finish times
X-ray shows (special (medical (OT rebook operation
fracture tests) management) daily)

32

Figure 8

NOF Fracture Patient Flow (post-project)
Patient presents Time recorded & triage category provided
to ED-Triage MRN is produced

Nurse suspects
NOF fracture

ED Nurse orders
an X-ray

ED Nurse calls CNC to review patient’s needs
on Ortho CNC skin integrity, rehabilitation etc

ED Registrar review
patient & order blood
tests & ECG

Confirmation of
NOF fracture

Patient admitted
ED Registrar to to D4A
call the NOF team Obvious Yes
(Ortho Registrar and fracture?
Geriatric Registrar)
Book theatre at
the same time

Is patient fit Yes Patient goes
to theatre? to theatre

No
Anaesthetists No
agree with
NOF team?
Yes
Further investigation,
other teams review
are requested Improving Patient Access to Acute Care Services

33

Checklist
prior to starting your
improving access project

Organisational commitment secured

Principles of change understood

Diagnostic work

Scope of project defined

Engagement of stakeholders

Convene project team

Project aim agreed with team

Defined project plan

Potential interventions identified

Measurement strategy in place

PDSA cycles planned

34

3. Interventions
An intervention is a change, idea or strategy that is designed to improve
outcomes for patients, staff and the organisation. These interventions are
tried and tested ideas and may produce dramatic improvements in patient
flow in an organisation where they have not previously existed. However, these
“fixes” may not produce long-term sustained improvement unless a structured,
organisation-wide redesign process occurs. It is likely that long-term gains will
only be sustained by adapting an organisational approach to matching service
capacity and demand and smoothing variation in activity as outlined in the
general interventions below.
The interventions are divided into three sections:
General strategies
Emergency patient flow
Elective patient flow

The layout for each intervention is as follows:
Intervention title - a short description of the intervention and key elements of
implementation.

Tools to assist with implementing the intervention are contained
in the attached CD. A tool is anything that is of practical use in
implementing the change. This may be a checklist, Powerpoint
presentation or file.

A hospital or organisation where the intervention is in place
- not a comprehensive list as these interventions are often in
place in many sites.

Resources – These are links to websites or reference
documents that contains more detail on the intervention or
any reported results.

Bookmark link within document.

35

3.1 General strategies
These interventions have a whole of organisation or hospital scope, may
be applied to many different types of patients or are applicable in many
different settings.

Tools - Patient Flow
www.ihi.org/IHI/Topics/Flow/PatientFlow/Tools/

A common cause of miscommunication and delay is a lack of clarity among
all members of the multi-disciplinary team about what should be done
(therapy) and when (urgency). It can cause delays in the patient receiving the
most appropriate care or treatment and non-compliance with evidence based
best practice.

3.1.1 Shared work plans, practices and schedules within
multi-disciplinary teams
Coordinate ward rounds, team meetings and case conferences and publicise
regular meeting times to maximise opportunities for communication regarding
patient management. Leadership from senior clinical staff is pivotal to the
viability of scheduled multi-disciplinary meetings as it requires all team
members to attend and be punctual. Consider rescheduling meetings if the
team is on call, to minimise interruptions. Allocate responsibility to one person
to communicate changed times or cancellations.

Royal Prince Alfred Hospital

Where possible have consistency in work practices. For example use the
same forms across areas that share staff or use similar layout of equipment in
treatment rooms. Shared referral criteria, documentation and clinical protocols
will make the patient journey safer and reduce the margin for error.

Royal North Shore, Prince of Wales,
Hornsby and Albury Hospitals

Multi-Disciplinary Assessment Form (RNS Hospital)

Draft National Medication Chart (Safety and Quality Council)
www.safetyandquality.org/index.cfm?page=Action&anc=Health%20R
eform%20%2D%20Safety%20and%20Quality%20Action%20Areas
36

3.1.2 Develop multi-disciplinary evidence based pathways
To provide consistent, streamlined patient care, develop evidence based
pathways for high volume ED presentations and/or admissions. Or to save time,
borrow someone else’s and convene a multi-disciplinary team to modify them
to meet local needs.
www.mja.com.au/public/issues/180_06_150304/suppl_contents_
150304.html
www.cochrane.org/index0.htm
www.nicsl.com.au/projects_projects_detail.
aspx?view=6&subpage=28
www.nicsl.com.au/knowledge_literature.aspx

TASC Chest Pain and Stroke Pathways (Nepean Hospital)

Nepean, Gosford, Royal North Shore and Dubbo Hospitals

3.1.3 Relative performance table
Provide feedback to individual clinicians and wards on their performance
on key indicators e.g. unplanned readmission rates. Where performance or
improvement is inconsistent between departments or clinicians, consider
making this information publicly available. This does not have to involve large
amounts of data and can use measures relevant to the department and changes
being implemented (e.g. number of operations delayed due to incomplete
consent forms by surgeon, weekend discharge rate by ward and/or physician).

Wyong, Dubbo and Royal North Shore Hospitals

Western Australian Audit of Surgical Mortality Annual
Report 2003 pp 38-41

www.waasm.uwa.edu.au/

37

3.1.4 Convene a redesign team
Whenever change is being considered in a process or system, convene a
team who will take ownership and drive the change and communicate it to
others. Ensure participation from all groups that have active involvement in
the system. At the process mapping workshop identify participants who appear
to take ownership of the issues and the problems that are identified. Include
someone from each of the key stakeholder groups including representation
from “upstream” and “downstream” of the processes of concern. The redesign
team will prioritise the problems (waits, bottlenecks etc.) identified during the
operations review and process mapping sessions. Measure, where necessary, to
detect at which steps in the process delays occur. This data is used to inform
the team in their redesign of the process.

Redesign Team Success - Who to involve to ensure success -
Powerpoint Presentation (Institute for Clinical Excellence)

St George, Liverpool, Albury and Dubbo Hospitals

The Clinicians Toolkit, Easy Guide to Clinical Practice
Improvement (NSW Health)

Link to engage clinicians and convene the redesign team

3.1.5 Improve communication systems
Review suitability of existing information technology (IT) systems, paging
systems, number and placement of telephones or computers. Try innovative
solutions such as:
Communication clerks.
Personal Digital Assistant’s solutions such as electronic reminders, electronic

guideline documents etc.
Other IT solutions such as point of care ordering systems.
Staff exchange between wards, departments or hospitals.
Scheduled multi-disciplinary case meetings.
Team briefing or debriefing sessions.
Link to Improve Discharge Processes
Link to Surgical Strategies
Link to Emergency Department Strategies
38

3.1.6 Referral to specialist services
Develop alternate methods for referral to specialist services e.g. fax or
email. Establish a common departmental email address that is accessible to all
members of the specialist team so that on call rosters do not need to be known
by those who are referring patients.
Privacy note: Our advice from NSW Health is that it is acceptable to send
patient information necessary for a referral using AHS email servers but that
confidential information should not be sent through commercial email providers.

3.1.7 Service level agreements
Develop and implement internal and external service agreements. Internal
service level agreements may for example be established between ED and
wards around agreed time to transfer, or with radiology regarding time to
report available. External agreements may be used to facilitate patient
transfer between tertiary referral/base and peripheral hospitals. Include
peripheral hospitals in a process mapping session looking at patient flow
between the hospitals. Develop an area clinical services and bed management
plan that includes transfer and clinical criteria protocols that have been
agreed with peripheral hospitals. Broker management (including bed
manager) and medical staff agreement for base hospitals to take patients
not able to be managed by peripherals and peripherals to take patients not
requiring base hospital level support. Include inter-hospital transfers in the
bed management prioritisation protocols.

Wollongong, Albury, St George and Calvary Hospitals

Link to Management of Hospital Beds

3.1.8 Managing capacity to respond to need for services
Capacity refers to the ability of an organisation to provide a specific volume
of service and is determined by the resources it has and the efficiency with
which the resources are used. Demand for health care is fairly consistent and
predictable. Introducing variation and unpredictability into capacity to provide
care (e.g. not providing seven day a week diagnostic or allied health services)
causes waits and delays.

39

3.1.9 Minimise variation in capacity to provide care
Use staggered accrued days off (ADO) instead of hospital wide ADO’s.
Reschedule vital clinics so that they are not cancelled when there is a public
holiday.

3.1.10 Change to seven day a week services
Change to seven day a week services and reward those that provide this.
Look at services such as radiology, imaging and allied health to ensure there is
weekend access, especially for those patients waiting for discharge who cannot
leave until they have been seen by one of these services. Ensure all inpatients
receive a medical review seven days per week — if they are sick enough to
require a bed in hospital, they are sick enough to have daily review of their
management plan.

3.1.11 Buffer beds
Buffer beds are used to supply capacity at those times when historical data
predicts there will be an increased need for beds. Commonly they will be
opened on Monday, Tuesday and Wednesdays, or evenings. These are the times
when demand for elective surgical beds is greatest and access block is likely to
be at its highest level.

St Vincent’s Health, Victoria

40

3.1.12 Smoothing variation in elective activity
Where there are waiting lists, or difficulty in managing operating theatre
availability, smooth the system wide flow of elective surgery admissions. Data
on demand for operating rooms can be used to work with surgeons to adjust
the scheduling of surgical patients. Do a small test first, limiting or capping
elective surgical admissions within a defined unit with one specialty:
1 Identify the average daily number of elective surgical admissions.
2 Limit the admissions for the day to the average daily number of elective
surgical admissions (may take less but not more than the average).
3 Analyse the results of the test and use this information to work with
surgeons to adjust scheduling of surgical patients.
Case for Improvement, Institute for Healthcare Improvement
www.qualityhealthcare.org/QHC/Topics/Flow/

NHS Improvement Leaders Guide to Matching Capacity and Demand
www.modern.nhs.uk/improvementguides/capacity

3.1.13 Develop advanced nursing roles
Further develop specialist roles for nursing or allied health staff. Review the
skill mix in your team, where gaps exist, consider who may be able to fill them
and the education and training required. Where appropriate, consider models
where nurses have ultimate responsibility for patient management. Develop the
role of enrolled nurses to be accredited to take on more responsibilities.

Redesign Tip
During the redesign process identify those bottlenecks that
occur as a result of patients waiting for one member of the
multi-disciplinary team. Review the tasks performed by that
team member. Ask:

1. Can any of these tasks be performed
by another team member?
2. Will that team member require additional
training or education in order to perform
the tasks safely and effectively?
3. What additional communication processes need to be
established to ensure coordination of care?

41

3.1.14 Up-skilling peripheral hospitals for complex
patient needs
Where the peripheral hospital doesn’t have the skills to look after particular
patients (e.g. a PICC line or PEG tube) organise a training session by a nurse
from the base or tertiary hospital. This person may also act as a contact point
for problems and issues encountered by the peripheral hospital in management
of related technical or procedural problems. This encourages sharing of
skills and enables nurses to maintain their standards of clinical practice.
Alternatively, skills may be developed in the community or be made available
by the hospital as part of an outreach service thereby preventing unnecessary
transport to hospital.

Dubbo Hospital

3.1.15 Align staff specialist/consultants work to
maximise efficiency
Organise across hospital coverage of specialty teams (e.g. don’t have a
surgical team on the emergency roster on days when they have an elective
surgical list). Broker agreement between medical specialists to pool patients and
deliver 365 day a year medical review by the team. This may require medical
specialists to agree on a routine therapeutic plan (pathway) and a facility for
providing hand over for those patients deviating from the agreed plan.

42

Management of hospital beds
The management and coordination of placement of patients
in appropriate inpatient beds is a complex and challenging
logistical exercise. However, it is critical to achieving best
outcomes for patients and a harmonious low-stress working
environment for staff.

3.1.16 Bed management system
Use a centralised bed management system with seven-day bed management/
patient flow personnel responsible for all admissions and transfers.

3.1.17 Centralised bed authority/bed coordinator
Assign a person to act as the centralised bed authority for each shift in
smaller hospitals (fewer than 200 beds). Ensure they have access to up to
date bed information. Assign a location or group of individuals to act as the
centralised bed authority in larger hospitals (more than 200 beds). The team
should be informed of all admissions and discharges and can help find the most
effective way to bring patients into beds for both elective and emergency
procedures/treatment. Key responsibilities of the centralised bed management
team include convening multi-disciplinary bed meetings, diagnosing issues
around bed management and coordinating development and implementation of
strategies to realign bed stock and bed management processes.
Bed Management Information Sheet (St George Hospital).
Example of two strategies that facilitate the discharge of
patients at St George.
Projected activity report template (St George Hospital).

43

The patient flow or bed management team
Each hospital should have a core patient flow management
team with operational responsibility for bed management,
including the following people:
Bed manager/patient flow manager who has the support
of the executive for decision-making and communicates with
units about placements and anticipated bed needs. This person
should have networking skills and credibility with senior clinical
staff. The role will also serve as a conduit for all direct patient
admissions and have a watching brief on other avenues of
admission outlined in alternate admission processes.

Nepean Hospital

Executive sponsor – A senior manager (e.g. Director of
Clinical Services, Director of Nursing or hospital Executive
Director) who ensures high-level support and action where
needed to drive change.
Medical leader to provide input into bed management
meetings and coordinate weekend discharge ward rounds.
They should have the seniority and influence to follow-up with
specialist clinicians if a patient seems to be inappropriately
occupying an inpatient bed. They should convene/attend
meetings of senior staff to ensure that extra ward rounds or
reviews take place if required.

RNS Hospital

Weighting the Wait
Powerpoint Presentation (RNS Hospital)

44

3.1.18 Regular multi-disciplinary bed meetings
Convene a morning multi-disciplinary meeting to discuss the bed situation
for the day. Identify the pressures in the system, plan for admissions and
discharges to occur at an appropriate time and brainstorm ideas to prevent
access block. This meeting should also improve communication, as each
department will be aware of the facility wide difficulties. Also called “bed
parliament” or “bed huddle”.

3.1.19 Teleconference bed updates
Set up regular teleconference meeting times during the day to update bed
status and help co-ordinate flow throughout the hospital.

3.1.20 Clinical prioritisation of patients
Wards have ownership of their specialty beds and decision-making
responsibility for accepting patients for admission to the ward with strict rules
for prioritisation and acceptance of patients for admission as agreed with the
central bed management authority. Use of a uniform prioritisation system
promotes equity of access and provides a logical basis for prioritising need. Use
the following decision making hierarchy for admitting patients:
1 Retrieve outliers
2 Accept own specialty patients from ED
3 Accept own specialty transfers from lower service level hospital
4 Bring in elective patients
5 Accept other specialty patients from ED

Redesign tip
Use this intervention to decrease outliers. Adapt the protocol
above or develop your own guidelines for prioritising patient need.

St Vincent’s Health, Victoria

45

Case study
St Vincent’s Health made significant improvements in their
access block, length of stay and elective surgery cancellation
rates by implementation of ward bed ownership and patient
admission prioritisation rules. They also introduced:
a structured process for admitting patients,
planned weekend bed closures and extended opening,
multi-disciplinary team discharge meetings,
services such as a “medihotel” and “awaiting placement
ward” to prevent patients from being admitted and
occupying a bed earlier than necessary when coming in for
elective surgery.

3.1.21 Reconfigure beds to reduce outliers
The evidence is that outlying patients (those that are accommodated on
a ward not catering to the patient’s requirements for specialist nursing care)
have poorer outcomes and longer length of stay. Understand each specialties’
bed capacity in relation to the demands placed on them. The number of beds
in each specialty in a hospital is usually historically determined rather than
related to the volume required by patient activity. Reduction of the number
and incidence of outliers becomes more difficult as occupancy rates increase.
Reduce bed occupancy by introducing strictly controlled buffer beds.

Link to Buffer Beds 3.1.11

3.1.22 Over census policy

An over census policy is based on the premise that it is better to have one
extra patient on a ward than 15 extra patients in an ED. The bed manager visits
all units to identify available beds and staff assigned to them. An assessment of
ward staff capacity to safely take additional admissions is made. Each patient
waiting admission in the ED is assigned to an inpatient hallway bed and no unit
will be assigned more than two over census patients. Establish strict criteria
for selecting and prioritising these patients (e.g. must have stable vital signs).
If considering this intervention, negotiation with your organisation’s nursing
establishment is essential prior to implementation.

46

Case study
The over census policy was introduced in Stony Brook
Hospital, Kentucky. The ED was having continuing problems
becoming blocked due to too many patients waiting for
admission to an inpatient bed. This adversely affected their
ability to provide safe, prompt emergency care. The wards
gave problems with discharging patients as the reason they
could not take ED patients. They introduced a “full capacity
protocol”. When a predefined number of patients are waiting
for admission in ED, patients are placed in hallways of the
wards they will be admitted to. Strict criteria for placement
in a hallway bed was established and adhered to. This shifted
the responsibility of the patient from ED, who has little
influence over the discharge process, to the ward orchestrating
the discharge. The system led to a reduction in delays and
blockages in the discharge process, better resource utilisation,
better access to emergency care and prompter access to
appropriate inpatient care.

Full Capacity Protocol
(Stony Brook University Hospital, Kentucky USA)
www.viccellio.com/overcrowding.htm

Adopt a Boarder, Urgent Matters E-Newsletter
(George Washington University Medical Centre, School of
Public Health and Health Services, Washington DC, USA)
www.urgentmatters.org/enewsletter/vol1_issue4/P_adopt_
boarder.asp

3.1.23 Guidelines and protocols for test ordering
Develop clear guidelines for ordering specific diagnostic tests. There may be

either a list of tests for a medical condition (e.g. Pulmonary Embolus clinical
protocol) or a list of indications for a specific test (e.g. indications for head CT).
Deep Vein Thrombosis Clinical Protocol,
Monash Medical Centre, Victoria
Pulmonary Embolism Clinical Protocol,

47

3.1.24 Review permissions to order tests
Develop protocols for ordering specific tests. Nurse initiated X-ray in the ED
can help fast track patients and ensure test results are available when the patient
has their initial medical assessment. In the case of a patient entering ED with
pneumonia, a nurse initiated chest X-ray at triage can decrease time to antibiotics.

Pathology Traffic Light Protocol (Lyell McEwin Hospital, SA)
Radiology Traffic Light Protocol (Northern Sydney Health)

Hornsby, Coffs Harbour, Canberra and RNS Hospitals

Rational Investigation Ordering Collaborative Project
www.nsahs.nsw.gov.au/teachresearch/cpiu/rio_project.shtml

3.1.25 Prioritise tests for emergency department or
patients waiting for discharge
Introduce a simple system such as coloured stickers or different coloured
pathology form for emergency department or discharge pathology.

Sydney, Wollongong, Albury and Dubbo Hospitals

Post-op Hip/Knee Stamp (Wollongong Hospital)

3.1.26 Allocated time for emergency cases
For specialty procedures that have waiting lists such as CT and ultrasound,
review historical data and determine predictable level of emergency demand
and allocate “emergency slots” in the appointment schedule.

Liverpool, Dubbo, Sydney and Sydney Eye Hospitals

48

Case study – Pathology
Sydney Hospital identified waits for pathology results as
a major source of delay in their emergency department. A
process mapping session identified multiple issues and some
easy quick wins. Their key interventions were:
increased number of tests done on site rather than being
sent to another campus,
changes to hours of service,
changes to pathology collectors schedule to better
coordinate demand with service availability,
changes to local courier service,
increased communication between laboratory and ED staff.
They achieved a sustained reduction in time to pathology
results from a mean time of 116 minutes to 65 minutes.

3.1.27 Appropriate information on request form
Educate JMOs and other staff on correct completion of request forms including
location of the patient and clinical notes. Have correct phone numbers for
clinician’s point of contact for radiology rooms on display in ED and wards.

Liverpool and Albury Hospitals

3.1.28 Patients attending for tests
Where the patient has to attend a particular department for a test, ensure
there are sufficient portering/transport services to minimise delays and
waits. Redesign processes for calling for and transporting patients. Review

communications for these services and try using two-way radios or a computer
system for tracking patient’s movements around the hospital departments.

Albury, Dubbo, Wollongong and John Hunter Hospitals

49

3.1.29 Stratified test ordering
The literature suggests that 20-30% of all pathology tests ordered are
inappropriate. To increase appropriateness and cut down on unnecessary test
use, introduce a stratified ordering system in which certain tests need to be
approved by a registrar or senior clinician. Results in organisations using this
approach demonstrated reduction in inappropriate tests.
Radiology Traffic Light Order System (NSH) Radiology Request
Form for Stratified Ordering (Dubbo Hospital)
Pathology Traffic Light Protocol (Lyell McEwin Hospital, SA)

Case study
During the Patient Flow and Safety Collaborative, Albury
Hospital aimed to improve the flow of patients in the ED. At
a process mapping session, radiology diagnostic imaging was
identified as a major bottleneck. Audit of length of time taken
to complete various phases of the patient journey confirmed
delays were occurring at multiple steps. They implemented a
raft of interventions including:
Designated triage number for x-ray,
Second pager implemented internally for trauma calls,
Wardsperson called by triage nurse or clerk,
ED initiated call in of second radiographer for prolonged
delays or significant backlog,
Back up wardsperson if ED wardsperson is busy,
PAC system implemented,
Multi-disciplinary team meetings between ED, Radiology
Department and Wardspersons Department.

50

3.2 Emergency patient flow

3.2.1 Pre-bypass hospital early warning system
The hospital early warning system is a coordinated hospital-wide response
that occurs when a hospital is at high risk of going on ambulance bypass. For
this system to work a substantive process of engaging all clinical departments
in committing to enact the agreed protocols needs to occur.

The Austin and Repatriation Hospital, Victoria


51

Case study – hospital early warning system
(HEWS)
The Austin Hospital was concerned that their ability to
respond and recover from stresses placed on the organisation,
exhibited by increased levels of access block, could
compromise emergency patient care. They recognised that
ambulance bypass is a significant hospital event and not just an
ED problem. They also thought, when the probability of bypass
in the next hour was high, that an organised, systematic,
hospital-wide response could assist in avoiding bypass and
improving emergency patient care. The HEWS system was the
hospital-wide response at Austin. It had ED director support and
authorisation and was coordinated by the bed manager or after
hours site manager with teleconferences occurring regularly
three times a day and at times when pre-bypass is declared.
The Austin designated pre-bypass as an internal emergency
– “Yellow Code 3- Pre-bypass” commonly called Respond Yellow.
Prior to a Respond Yellow being called there are a series of
actions that the ED has to perform.
When a Respond Yellow is called this triggers a further series
of actions by a range of people across the organisation.
A further refinement of the system was introduced whereby
each Respond Yellow is classified as a:
Bed Access Response – where there is a lack of beds available
to ED patients
Clinical Activity Response – where there are many ill patients
needing clinical assessment at a single point of time in the ED
Response by hospital staff is different depending on the type
of alert.
A trial comparing hospitals using a HEWS system with those

who weren’t showed a greater reduction in bypass in the HEWS
group despite them seeing more patients and taking more
ambulance patients. The HEWS group also showed an 88 minute
reduction (11.4%) in ED length of stay for admitted patients.

HEWS Tool - HEWS ED Actions prior to declaring Pre-bypass
HEWS Tool Pre-bypass Protocols
HEWS Tool - Response by medical staff

52

Results - HEWS implementation - The Austin

3.2.2 Streaming techniques
Streaming techniques recognise alternate methods of grouping and managing
ED patient queues than through a universal triage system. Streaming occurs in a
variety of forms and is based on recognition of the benefits of dividing patients
into alternate streams and journeys to better manage bottlenecks and waits.

3.2.3 Alternate admission processes
Develop and formalise other avenues for emergency patient admission to a
hospital bed other than through ED. These alternate avenues may be managed
by a bed/patient flow manager with agreed criteria for entry to ensure
appropriateness. Other patient journeys include direct:

admission to ward by specialist team or GP,
referral to hospital in the home,
referral to hospital ambulatory care,
admission from specialty clinic to ward.

53

3.2.4 Develop alternate services to prevent
ED presentation
Develop and formalise other journeys for emergency patients other than
presentation to ED. These services may include:
chronic disease case manager and/or hospital in the home,
referral to community care,
community facilitated care packages - ComPacks,
accessible specialist outpatient clinic appointments for “urgent patients”,
direct referral to hospital ambulatory care,
GP after hours clinics.

3.2.5 Advanced nursing and allied health practitioner roles
Use nurses with advanced clinical skills e.g. clinical initiative nurses, who
work from protocols and guidelines to fast track the assessment and treatment
of ED patients. Use physiotherapists to oversee and deliver management of
minor fractures.

The ED Work Practice Review Project 2001
(Wollongong Hospital)

3.2.6 Fast Track
Fast Track refers to type of streaming where an alternative patient pathway
(or part of a pathway) can be dealt with rapidly, in the primary care section
(e.g. “walking wounded”) as part of the ED service.
Fast Track Interventions in the ED
(NICS - Literature Review)
www.nicsl.com.au/knowledge_literature.aspx

54

3.2.7 See and Treat
See and Treat is a type of fast tracking where a senior clinician or clinical
team triages patients and provides immediate care and disposition where
possible. It may be most useful to implement in an ED with a high volume of
low acuity patients with straightforward presenting problems. It is a model
for seeing, triaging and offering on-the-spot treatment to patients with minor
ailments or injuries so that they are in the Emergency Department for as short
a length of time as possible.

See and Treat, NHS

Calvary Hospital - ACT

Fast Track Interventions in the ED
(NICS - Literature Review)
www.nicsl.com.au/knowledge_literature_detail.
aspx?view=15

Figure 9

Calvary Hospital - Reduction in the number
of patient queries on waiting time in ED as
a result of implementing see and treat
250

200
Number of queries

150

100

50

0
Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12 Wk13
Week

55

Figure 10

Calvary Hospital - Reduction in the number of “did not
waits” in ED as a result of implementing see and treat
60

50

40
Total number

30

20

10

0
B1 B2 Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12
Week

3.2.8 Lean thinking
Identify common processes from the main streams of patients within the ED.
At each step of the process identify and eradicate steps that are wasted time
and effort from the optimal patient outcome perspective.

The Key Lean Thinking Principles (Lean Australia)
www.leanaust.com/about.htm

56

Redesign tip
Use lean thinking principles when you are redesigning your
processes. Lean thinking identifies activities that add value to
what you are trying to achieve in your organisation. It identifies
those activities that don’t add value and creates flow by
radically reorganising processes and creating a pull through the
system. Identify any sources of waste and redesign individual
process steps to eradicate:
overproduction (services available but not used),
waiting,
transporting (provide services in the
location they are needed),
inappropriate or unnecessary processing
(only do things once),
unnecessary inventory (equipment or
supplies not used or turned over),
unnecessary movement (futile activity which
adds no value to the patient experience).

3.2.9 Clinical pathways around presenting problems not
diagnoses
Develop clinical pathways or guidelines for management of high volume
presentations particularly where there is evidence of poor patient outcomes or
evidence-based treatment is not being delivered.

Dubbo, Nepean, John Hunter and Blacktown Hospitals

TASC Chest Pain and Stroke Pathways (Nepean Hospital)

Fractured NOF Guidelines (Hornsby Hospital)
Paediatric Presentation Protocols (Blacktown Hospital)

3.2.10 ED access to day surgical list bookings
Set up a process enabling ED doctors to book patients in for day surgery the
following day. This allows patients to be sent home rather than taking an ED or
inpatient bed.

Royal North Shore Hospital
57

Redesign tip
Ensure that a process is in place for patients to be properly
informed about fasting, OT time, and the need to provide
transport home.
Set up a process for the ED to communicate essential
information to the day surgical ward and the OT so these
departments are prepared to receive the patient when they
present.

3.2.11 Communications clerk
Process map communication channels within the emergency department.
Redesign processes and institute a new position in ED that is responsible
for answering phone calls, coordinating patient movement between other
departments such as radiology and the wards. Use the process redesign to
inform their role and job description.

Wollongong and John Hunter Hospitals

3.2.12 Emergency medicine unit
Patients who require a short period of admission for observation and
treatment (e.g. < 24 hours) are admitted to a short stay bed in an EMU. To be
effective, the unit should be operated as an extension of ED services, adjacent
to and staffed by the ED. Strict protocols around patient selection and length of
stay need to be enacted to ensure throughput is maintained.

St George and Hornsby Hospitals

EMU Net News Reference Article (ARCHI)

3.2.13 Flag and case manage frequent attendees
This is a preventative model of care, targeting high users of the public
hospital system, which aims to provide more coordinated care between
hospital and primary care. Frequent ED attendees that could have been more
appropriately case managed in primary care are identified. A nurse case

58

manager is based in ED and works with primary and community care service
providers to coordinate the patients’ care.

The Austin and Repatriation Medical Centre and the Alfred
Hospital, Victoria

The Hospital Admission Risk Program (HARP), (Royal District
Nursing Service, Victoria)
www.rdns.com.au/Innovation/HARP.htm
www.health.vic.gov.au/hdms/harp/index.htm

HARP - Reducing the Avoidable Use of Hospitals (ARCHI)
www.archi.net.au/content/index.phtml?itemId=tag./document/
index.phtml/id/3056

3.3 Improving flow of
emergency surgical patients
Link to elective patient flow strategies (page 75)

3.3.1 Clinical guidelines or pathways
Clinical guidelines or pathways — for high volume emergency cases such as
fractured hip — ensure correct emergency theatre prioritisation and protocols
for test ordering, management of anti-coagulation therapy and anaesthetic/
medical/aged care consultation.

Liverpool, St George, Tamworth, Albury, Westmead, Hornsby
and Port Macquarie Hospitals

Fractured NOF Guidelines (Hornsby Hospital)

Step Guide to Improving Operating Theatre Performance, 2002
(NHS)

59

3.3.2 Team briefing and debriefing sessions
After complex cases convene a quick meeting of multi-disciplinary team
members to review aspects of pre-operative and intraoperative care. Focus on
processes and communication. Don’t make it a name and blame exercise but
use it as an opportunity to discuss changes to improve care next time.

3.3.3 Emergency department physician admission rites
Emergency department physicians may be given admission rites for specific
presentations or diagnoses. Identify those emergency surgical presentations
where diagnoses are relatively straightforward and need for admission is
predictable. For these patient groups broker agreement amongst specialty
teams to allow ED physician admission rights and early transfer of patient to an
appropriate ward. This may be written into guidelines or pathways.

Albury Hospital

Emergency Patient Admissions Policy (Albury Hospital)

Prioritisation and provision of
emergency theatre time
Ensuring there is adequate theatre availability is essential
for providing good clinical outcomes and preventing surgical
patients taking up valuable beds while waiting for their
operation to be performed.

60

3.3.4 Review existing demand for
emergency operating theatre time
Review theatre usage hours by type of surgery and time of demand.
Using this information, ensure adequate emergency operating theatre time
is provided during and out of hours. Use an afternoon trauma list to avoid
repeated cancellation of lower priority cases not deemed to be urgent enough
to operate on between 10pm and 8am.

Liverpool, Tweed and Port Macquarie Hospitals

3.3.5 Prioritisation protocol
Have a prioritisation protocol that provides transparency to emergency
operating theatre scheduling and monitor cases not achieving benchmark “to
operating theatre” times.

Emergency Theatre Allocation Guidelines (WAHS)
Emergency Surgery Guidelines (Liverpool Hospital)

3.3.6 Prioritisation team
The admitting surgical team performs an initial assessment of urgency for
each patient requiring emergency surgery. A designated senior anaesthetist and
peri-operative nurse have the right to challenge the assessment of urgency. The
team of anaesthetist, nurse and surgeon then negotiate priorities (based on a
protocol) and agree final schedule of emergency cases.

Liverpool Hospital

3.3.7 Pre-operative placement of patients waiting for OT

Patients who are waiting for emergency surgery to be nursed on a specialty
ward rather than being left to wait in the emergency department.

Albury and Liverpool Hospitals


61

3.4 Medical strategies

3.4.1 Medical Assessment and Planning Unit
The MAPU is a physician led unit which has 365 day a year general physician
cover to review new medical admissions. It has a strict management protocol
that includes a maximum LOS of two days, monitored beds, increased allied
health staff levels, full time resident medical officer cover and twice-daily
specialist medical review.

Royal Brisbane Hospital

Responses to Access Block in Australia - Queensland (MJA)
www.mja.com.au/public/issues/178_03_030203/cam10542_ash_
fm.html

3.4.2 Day only admission ward for ED patients
This ward functions as a temporary location for the admitted patients in ED.
Selected patients are accommodated there while waiting for a ward bed. It can
be part of the discharge lounge or EMU. The beds operate for eight to 12 hours
per day during busy periods (as determined during diagnostic work). It may be
used to transfer a predictable number of patients from the ED every morning.

John Hunter and Blacktown Hospitals

3.4.3 Flag and case manage frequent
medical admitted patients
Provide case management across the acute and chronic setting for patients

who are admitted frequently. Provide specialist nursing consultants who work
within a multi-disciplinary team to manage these patients across the acute
community interface.
Heart Failure Program (St George Hospital)
Heart Failure Program Direct Admission from GP (Royal North
Shore Hospital)

62

Some chronic care or aged care patients may be referred directly from their
GP into a specialist hospital or community team. Set up the process and criteria
for appropriate direct admission. Educate GPs and provide them with contact
details to enact this.

3.4.4 Trial at home program
This program provides the opportunity for a patient to go home for an
overnight stay before they have been discharged. Similar to a “gate pass”, it
allows patients to test their level of confidence in being cared for at home.
Notes are kept on the ward and it is guaranteed a bed will be found if needed,
the next day (or week). The patient does not have to present in the ED to be
readmitted. This reduces the number of patients who readmit within 48 hours
of discharge and diverts work from the ED.

Tamworth Hospital

3.4.5 Improve appropriateness of admission
Develop a set of criteria for admission for high volume patient groups.
Audit for inappropriate admissions and performance manage, or call admitting
consultant, to justify their decision to admit to an appropriate audit committee.

3.4.6 Safety risk assessment
Safety risk assessments are intended to reduce the likelihood of a patient
being involved in an adverse event, thus reducing the length of stay. If a risk
assessment shows that a patient is at high risk of falling, a falls prevention
strategy or protocol should be put in place for that patient. A risk assessment
allows careful planning of appropriate interventions for an at risk patient. This
information should be collected when the patient enters the system and updated
when there is a change in their condition. Keep the information visible to prevent

the patient repeatedly telling different people the same information.

Royal North Shore, Broken Hill and Prince of Wales Hospitals

Adverse Patient Outcome Program - Powerpoint Presentation
(John Flynn and Tweed Hospitals)

63

3.5 Improving communication

3.5.1 Improving communication with GPs
and community nursing
Improving communication with primary care and community care providers
will increase patient safety, smooth the transition home and decrease
unplanned readmissions. The following strategies have proven to be effective in
improving the flow of information out of the acute care setting:
Clear delineation of staff roles and responsibility for communication with
GPs and community services.
A legible accurate discharge summary that includes reasons for changes in
ongoing treatment such as medication dosage. Audit the number of patients
who are discharged without a discharge summary.
Educate hospital doctors on the importance of timely discharge
summaries through induction and regular feedback, especially in the
discharge planning meetings.
Electronic discharge summaries.
DOCFAX consent form reviewed and implemented to allow for faxing (rather
than mailing) discharge summaries. (Hospitals, like most big organisations have
a delay in their mailing system caused by additional steps in the process).
Clerical support provided to standardise the settings on fax machines with
quick dial GP numbers.
Process for obtaining GP contact details from patient at the time of admission.
GP contact details on central database and updated regularly from
division of GP’s.
Informed consent for collection, use and disclosure of health information
obtained and signed in the pre admission clinic and emergency department.

The Tweed Hospital, RPA and SESAHS Hospitals

Discharge Prescription Form
(Sydney Hospital and Sydney Eye Hospitals)

NSW Electronic Discharge Referral System Project
www.ciap.health.nsw.gov.au/project/gp/edrs.html/#areaprog/

64

3.5.2 Generic transfer/discharge to hospital form for all
residential aged care facilities (nursing homes)
Convene a meeting of DONs from surrounding nursing homes and negotiate
agreement on common processes and documentation for transfer and discharge
of nursing home patients. This will help facilitate admission in ED, continuity of
care and discharge planning from time of admission.

Hornsby Hospital

3.5.3 Link “discharge from ward time” with “admission
from emergency department” time
Review all ED patients who will require admission to an inpatient ward and
estimate the time they will be ready for transfer. The ward the patient will be
transferred to then manages their discharges to occur in time to have the bed
available at the ED “ready for transfer time”. An appointment time for transfer
may be made between the ED and the ward.
Discharge Appointment Time Intervention (RNS Hospital)
Proposed Protocol for Piloting of Discharge Appointment Time
(NSH)

3.5.4 Scheduled transfers
A variation on the linked discharge and admission intervention. Schedule
all internal patient transfers and discharges. This allows synchronisation of
transfers and staff workload.
Scheduling Transfers and Discharge
www.ihi.org/IHI/Topics/Flow/PatientFlow/Changes/
ScheduletheDischarge.htm

65

3.6 Improving discharge processes
Reviewing and improving discharge processes on a ward and hospital-wide
basis is crucial to achieving efficient patient flow. Effort spent improving other
areas may be wasted if discharge processes are disorganised.

Effective Discharge Planning Framework and
Implementation Strategy (NSW Health)

3.6.1 Discharge risk assessment form
A risk assessment is a useful tool for preventing problems in the discharge of
a patient to the community. An effective discharge risk assessment is one that
is carried out prior to, or on admission to hospital and is broad enough to cover
most common issues. The risk assessment should highlight:
problems that may prevent patients being discharged as soon as they are
medically stable.
any services or treatment a patient may need to prepare for discharge.
any services or treatment a patient may need after discharge.
Examples of discharge risk include polypharmacy, pressure sore, special
dietary needs or poor mobility. A risk assessment as a stand-alone document
is fairly meaningless but needs to be a trigger for activation of a series of
processes and protocols.
Implementing Discharge Risk Screening Tool (NSW Health)
Discharge Risk Assessment Screening Tool (RPA Hospital)
Discharge Risk Screen Example (NSW Health)

66

3.6.2 Admission and discharge plan
Anticipate and plan for discharge from the time of admission. Include
discharge risk screening and actions as a result of risk screening, in the nursing
care plan.

Albury, Dubbo, Wollongong, Queanbeyan and Broken Hill
Hospitals

Discharge Plan (Dubbo Hospital)
Guidelines for Discharge Planning (Wagga Wagga Hospital)
Ward Discharge Checklist, (RNS Hospital)

Some hospitals have one document that incorporates both the discharge risk
assessment and the safety risk assessment. This may take longer to implement
as it requires input and sign-off from all professions and disciplines.

Multi-Disciplinary Assessment Form (RNS Hospital)
Care Plan Audit Tool (RPA Hospital)

3.6.3 Criteria driven discharge
Develop consensus with medical staff on a process and criteria for discharge.
Use either a discharge checklist, or document in the patient’s progress notes, a
list of conditions to be met and treatment to be completed prior to discharge.

Discharge Checklist example (NSW Health)

3.6.4 Nurse activated discharge
Discharge patients when they are medically stable and ready, not the next day
after a consultant ward round or after they have a non-urgent test. Implementing
nurse activated discharge under medical direction ensures that no patients are

unnecessarily delayed due to lack of medical cover. This is a similar concept
to protocol driven discharge in that once the predetermined treatment and
management criteria have been met, the patient can leave hospital.

Broken Hill Hospital

Nurse Initiated Discharge Policy (Dubbo Hospital)

67

3.6.5 Monday morning audit
Review all the patients who are stable and ready for discharge. Look at how
many patients are stable enough to have been discharged earlier i.e. on the
Saturday or Sunday and reasons for delay.

Nepean and Port Macquarie Hospitals

Discharge Audit Tool (RNS Hospital)

Link to Diagnostic Work

3.6.6 Weekend discharge pharmacy
One of the identified causes of delays to discharging patients is the lack of
weekend pharmacy services. Have a store of commonly prescribed medications
accessible to medical staff or a senior nurse manager who has received training
to dispense these items safely. Send the patients home with 24 or 48 hours
supply of medications. Alternatively, broker agreement with a community
pharmacy to supply the medications at neutral cost to the hospitals.

Tamworth and Albury Hospitals

Add the scheduled date and time of discharge to medication prescription to
enable prioritisation of completion of discharge scripts by hospital pharmacy.

Wollongong Hospital

Keep a drug trolley on a ward stocked with generic medications to provide a

supply for weekend discharges.

Hornsby Hospital

68

Case study
Tamworth Hospital identified a number of issues that
prevented smooth and timely discharge of their patients. They
implemented a number of interventions including:
a potential weekend discharge list used by after hours nurse
managers to identify patients who may be discharged,
a review of efficiency of VMO rounds and instigation of a
ward round trolley for use by JMOs so they have easy access
to items required to finalise discharge documentation at the
time of the round,
data collection and feedback to medical VMO’s on variation
in LOS,
redesign booking in process for day only medical admissions,
external benchmarking,
education for clinicians on relevance and use of estimated
discharge date (EDD).
They were able to achieve 100% of patients on their “potential
discharges” list actually discharged on that day. They also
increased their weekend discharge rate from 15% to 17%.

3.6.7 Multi-disciplinary discharge meetings
Members of the multi-disciplinary team meet to discuss patients with
complex discharge needs. Where possible and appropriate have community
nursing representation at these meetings.

Royal Prince Alfred and Queanbeyan Hospitals

Guidelines for Multi-disciplinary Team Meetings (RPA Hospital)

69

3.6.8 Informing patients and carers
about their discharge
Provide information to raise awareness of discharge and its timing to
staff, patients and carers to ensure realistic expectations of the discharge
process. There are some elements of the process that patients or their
families can and should take responsibility for themselves such as organising
transport home. Communication of the estimated day of discharge to
patients and their families allows them to take a more active and effective
role in planning for their discharge.
Patient Information Brochure Example (NSW Health)
Patient Discharge Brochure (Liverpool Hospital)
Leaving Hospital Patient Brochure (Tweed Hospital)
Discharge Planning Brochure (Tweed Hospital)
Nursing Home Final - Questionnaire (Centre for Allied Health
Evidence, University of SA and Department Public Health,
Adelaide University)

www.unisa.edu.au/cahe

3.6.9 Discharge checklist
A discharge checklist is another way to plan the patients’ discharge
effectively. Use a simple checklist or make note of all tasks to be completed
and patients’ needs to be met prior to them leaving the hospital.


Discharge Checklist Example (NSW Health)

70

3.6.10 Estimated day of discharge
Note the estimated day of discharge (EDD) on admission or when the treating
team first reviews the patient. Communicate EDD with team, including the
patient and their family. The EDD should be utilised by the multi-disciplinary
team for planning discharge. When implementing an EDD intervention,
extensive promotion and education is required regarding its rationale and use.
Audit reasons why the patient was not discharged on their estimated discharge
date and analyse reasons for delay if patient is medically stable. The EDD may
be established using either of two methods or a combination of both:
Medical staff to document EDD in the medical record or on a ward
communications board.
Negotiate agreement with medical staff on estimated length of stay for high
volume presentations. Nursing staff may then use this to document EDD.

Coffs Harbour, Prince of Wales, Royal Prince Alfred, Dubbo,
Hornsby, Nepean and Queanbeyan Hospitals

Estimated Discharge Date Tool (Dubbo Hospital)
Implementing Estimated Date for Discharge Tool (NSW Health)
EDD Staff Information Brochure (Hornsby Hospital)
Estimated Discharge Date Poster (Prince of Wales Hospital)
EDD Stamp (Wyong Hospital)

3.6.11 Estimated length of stay table
To assist with implementation of the EDD, develop an Average Length of Stay
(ALOS) table for your ward using data from the HIE. Base the table on diagnosis
and procedure data not coded DRGs. Use data from the previous six months for
that ward. Update the table every 6-12 months as changes to treatment and
management regimes may alter ALOS significantly.
average length of stay table laminated and placed at work station

average length of stay table updated six monthly to accommodate changes
in clinical practice

71

3.6.12 Compare the estimated date of discharge to the
actual date of discharge
Where the actual date of discharge occurs after the estimated date of
discharge identify causes not related to the medical condition of the patient.
This should provide an opportunity to identify emerging trends of barriers to
discharge and also identify areas successfully meeting EDDs and the methods
used to achieve this.

Tamworth Hospital

Estimated Discharge Date and Actual Discharge Date Variance
Monitoring Tool (Tweed Hospital)
Estimated Day Discharge versus Actual Day Discharge Variance
Monitoring Tool (NSW Health)

Case study
Wyong Hospital identified significant variance in medical
length of stay between individual clinicians and a low weekend
discharge rate. After process mapping they implemented a
range of interventions in their 30 bed acute medical ward
including personal discharge information tags for nurses;
documentation of EDD including an EDD stamp and visual
prompting on ward whiteboards; introduction of a fourth
medical team and trial of a discharge coordinator.
They achieved a reduction in ALOS of 11.3%; an increase
in weekend discharge rates from 10% to 22% and improved
discharge risk assessment and documentation of EDD. The
discharge coordinator was integral to the success of the
improved risk assessment.

72

3.7 Aged care

3.7.1 Aged care assessment team (ACAT)
An ACAT team provides specialist assessment and recommendations for the
care of frail and elderly patients. Referral criteria and contact details for the
ACAT team should be clearly visible in the ED. Set up processes so that patients
are referred to the service as early as triage. Encourage early multi-disciplinary
care with the aged care service and the ED working together to ensure a
smooth journey for an older person entering hospital. An early ACAT assessment
may speed the process of aged care or community care placement.

Prince of Wales, Royal Prince Alfred Hospital, St George,
Westmead and Hornsby Hospitals

3.7.2 Transitional care beds
Transitional care beds are beds made available for patients recuperating
from their acute illness, waiting for community services or for nursing home
placement to become available. These patients may be accommodated in
beds with appropriate staffing, with a strong rehabilitation focus and with an
increased level of allied health services. Transfer of convalescing patients to
transitional care beds prevents blocking of acute ward beds with patients who
do not require a high level of acute specialty medical or nursing input.

3.7.3 Community transitional care beds
Patients have their transitional care provided for them at home. GPs, nursing
and allied health professionals care for patients in the home while they wait for
appropriate placement or are rehabilitated and maintained within the community.

ComPacks Guidelines and Information (NSW Health)

73

3.7.4 ComPacks service model
The ComPacks service model is based on community case management and
service brokerage. It targets inpatients requiring two or more community care
services and aims to return them home safely with the support they require.
Hospital staff identify patients eligible for a ComPack and then initiate the
involvement of a contracted community care case manager (community options
programs managers) who have responsibility for:
working with hospital staff to jointly manage each eligible patient’s discharge,
brokering for the care and support services for a period of up to six weeks
and linking them into long term sustainable services where required.

3.7.5 Purchase transitional care beds
A hospital may purchase transitional care beds from a community nursing
home for aged care patients. This funds nursing homes to provide extra staffing
capacity required.


3.7.6 Direct emergency admission protocol
Fast track transfer of older people to an appropriate ward rather than
keeping them in the emergency department.

Albury Hospital


Link to Alternate Admission Processes

3.7.7 “Dependant care” stream of patients managed by
specialist nurse practitioner
This intervention is aimed at patients who have a number of complex co-
morbidities requiring a high level of support for their personal needs. The
patient’s overall management is coordinated by a nurse practitioner.

74

3.7.8 Walking assistance program
Prevent deconditioning of at risk older patients caused by inactivity resulting
from their hospitalisation. Use an enrolled nurse assistant from outpatients
department or nursing pool to walk patients twice a day seven days a week.
This has demonstrated improvements in patient mobility and satisfaction.

Functional Conditioning Program
(RNS Hospital and Bayside Health)

3.8 Elective patient flow
Improved knowledge and management of elective surgical throughput offers
one of the greatest opportunities to modify and smooth hospital workload. This
is primarily because the specialty bed type, estimated length of stay and ICU
use of each patient can be accurately predicted and so may be planned for.

3.8.1 Quarantined elective surgical beds
Allocate a defined number of beds and staff for quarantined elective surgical
beds. These beds will not be available to medical patients being admitted
through the ED. The number of beds to be quarantined will require careful
analysis of actual surgical activity requirements and acute admissions via ED.
The strategy should decrease the volume of elective surgical patients cancelled
but should be accompanied by service agreements to ensure efficient utilisation
of these beds 365 days of the year.

3.8.2 Criteria driven discharge
Develop consensus with medical staff on process and criteria. Incorporate
into a clinical pathway, use a discharge checklist or list of criteria written in
progress notes, for patients to complete prior to discharge.

Discharge Checklist Example (NSW Health)

Link to Improving Discharge Processes

75

3.8.3 Surgical pathways and estimated day of discharge
(EDD)
Work out the average length of stay for standard elective surgical procedures
and use this to give all patients an estimated discharge day. Link discharge
planning processes to the EDD.

3.8.4 Increase day of surgery admission rates and
manage performance outliers better
Bring patients in for preparation earlier by using outpatient pre-operative
assessment clinics. Any necessary tests, pre-anaesthetic assessment, an
explanation of their procedure and consent, may be completed at an
outpatient appointment.

3.8.5 Audit all theatre delays or cancellations
Implement a system to identify all OT cancellations or delays in operation
start time. Use process mapping or other diagnostic techniques to identify
reasons for delay or cancellation. Redesign processes to improve pre-operative
preparation and eliminate other causes for delay.

Liverpool and Westmead Hospital

OT Postponement Report Form (Liverpool Hospital)

3.8.6 Surgical peri-operative liaison nurses
Employ specialist nurses to manage elective surgical streams and case-
manage specific cases. These nurses may assist in managing interfaces between

ED, day surgery, wards, operating theatre and ICU.


76

3.8.7 Medihotels
Use commercial motel/hotel, existing unit accommodation (nurses’ home)
or purpose built facility to accommodate low acuity patients that can attend to
their own personal care but need inpatient/ambulatory care and are unable to
travel from home daily. Determine entry criteria and staff appropriately.

St Vincent’s Health, Victoria and Monash Medical Centre,
Victoria

3.8.8 Flexible staffing
Match elective surgical bed availability and staffing to demand for beds. Use
anticipated admission data to map demand on a day to day basis.

3.8.9 Align leave of multi-disciplinary surgical teams
Map surgeon, anaesthetist and nursing leave and where possible align
leave within teams. This helps prevent theatre closures, downtime and
under-utilising staff.

3.8.10 Clinical teams operating pooled referrals
A cooperative arrangement where the medical clinician group manage
patients as a team rather than as individual clinicians. Clinicians’ annual leave,
conference leave etc, is coordinated within the group. This allows waiting lists
to be managed with significantly increased capacity. On average patients wait
shorter lengths of time to have a procedure and less theatre time is wasted.

Royal Prince Alfred Hospital Cardiac Surgery Team

3.8.11 Clinical pathways

Clinical pathways for short stay elective cases including pathology and
radiological investigations required.

23 hour Clinical Guideline Template (RNS Hospital)
Elective Surgical Program Presentation (Auburn Hospital)

Royal North Shore and Auburn Hospitals

77

3.8.12 Improve completion of consent forms
Process map completing of consent for main streams of surgical patients.
Identify problems and solutions. If redesigning processes does not deliver
satisfactory improvement try displaying number of operations against number
of consent forms completed on patient arrival at OT by surgeon.

Dubbo Hospital

3.8.13 Marking operating site
Mark operating site and complete consent form concurrently. Follow ACSQHC
guidelines for surgical site marking to reduce advent events.

www.safetyandquality.org

3.8.14 Improve compliance with fasting requirements
Use clear signs at the patient bedside and in the notes indicating if the
patient is nil by mouth or needs to stop taking a routine medication etc.

3.8.15 Predict surgical case length accurately
Scheduling surgical cases and adhering to the scheduled operating list is
complicated by the fact that the demand for surgery is often unpredictable and
the length of the surgery for similar cases varies. To better manage the surgical
schedule, use control charts to plot data over time and study variation in case
length. The control chart provides estimates of the variation that should be taken
into account in scheduling. A control chart will identify the normal variation in
the system, as well as variation due to unusual or unpredictable cases.

Unusual variation may be related to routine cases that develop
unpredictable complications, unexpected shortages of staff, last-minute
changes in a surgeon’s schedule, and unavailable equipment. These special
causes of delay are not predictable, but can be eliminated or minimised by
building contingencies into the system to reduce their impact.
Study variation in different types of surgical cases, variation among
surgeons, and other sources of variation.
Schedule complex or unpredictable cases at the end of the day or in a
separate room to minimise their impact on the start of other cases.
78

Case study
During a process mapping session, Dubbo Base Hospital identified several problems
that caused delays in the transition of patients through the operating theatre.
These included patients arriving on the day of surgery without consent forms signed;
shortage of OT trolleys; no-one available at the OT desk to accept handover of
patients; difficulties scheduling out of hours surgery and lack of coordination between
day surgery unit and the OT. They implemented a combination of interventions
including:
redesign of scheduling process with clear accountability for OT manager,
appointment of OT patient reception coordinator,
appointment of OT CNS position to coordinate theatre schedule,
redesign of processes that coordinate the day surgery and radiology interface,
graph and display the number of patients by surgeon with consent forms not complete.
Better coordination within different hospital units has resulted from these changes.
Maximum time from call for patient to OT door went from 65 minutes to eight
minutes. Maximum patient waiting time for check in to theatres went from 40 minutes
to five minutes.

Glossary of terms
Aim - an objective or desired outcome.

Barriers - problems encountered that impede or prevent implementation of
interventions or affecting any type of change.

Clinician - any medical, nursing or allied health staff member who is involved
in the clinical care of the patient.

Criteria - a set of conditions to be met.

Interventions - a change made to a process or activity that affects the way
clinical or administrative work is done.

Outliers (Ward outliers) - patients who are being nursed on a specialty ward that
is not aligned to the condition for which they are primarily receiving treatment.

Project Management - the planning and organisation of a specific undertaking
or course of action which has a defined objective.

Protocol - a set of rules or procedures to follow in a specified situation.

Weekend Discharge - the number of patients discharged on Saturday and Sunday
as a proportion of the total number of patients discharged in a seven day week.
79

Acknowledgements
The Clinical Excellence Commission wishes to acknowledge the contribution of
the following people in development of the toolkit:
Louise Kershaw - Director, Patient Flow and Safety Collaborative and
Director, Project and Data Management
Lorraine McEvilly - Project Coordinator, Patient Flow and Safety Collaborative
and Director, Chronic Care Collaborative
Celia Mahoney - Administration Officer
Participating hospitals and team members of the
ICE Patient Flow and Safety Collaborative.
Ellin Trickey - Project Officer
Rohan Hammett - Director, Health Care Improvement Projects
The numerous members of the health workforce who were consulted in the
development of this toolkit.

Members of the Patient Flow and
Safety Collaborative Planning Group
Mary Chiarella (Co-chair) Pat Cregan (Co-chair)
Sally McCarthy Jenny Becker
Jeff Rowland Lorraine Lovitt
John de Campo Kym Scanlon
Judy Lumby Rob Day
Louise Kershaw Tony O’Connell
Roy Donnelly Linda Sorrell
Ian O’Rourke Rohan Hammett
Anna Thornton Lorraine McEvilly
Linda Justin

Members of the Access Improvement Working Party
Cameron Bennett Louise Kershaw

Greg Rochford David Ben-Tovim
Marcus Kennedy Anna Thornton
George Braitberg Sally McCarthy
Paul Tridgell Adam Chan
Brian McCaughan Don Campbell
Bernadette McDonald Barbara Daly
Tony O’Connell Rohan Hammett
Ian O’Rourke Philip Hoyle
Drew Richardson Greg Knoblanche
Maureen Robinson
80

The Clinical Excellence Commission also wishes to acknowledge
the following organisations and individuals for allowing their
documents to be used as resources in this toolkit:

Albury Base Hospital
Auburn Hospital
Austin and Repatriation Medical Centre, Victoria
Australian Resource Centre for Healthcare Innovations (ARCHI)
Blacktown and Mount Druitt Health
Central Coast Area Health Service
Dubbo Base Hospital
Associate Professor Karen Grimmer, Centre for Allied Health Evidence,
University of South Australia
Liverpool Hospital
Mr John Moss, Department of Public Health, Adelaide University
National Health Service Modernisation Agency, UK
National Institute of Clinical Studies (NICS)
Northern Sydney Health
NSW Health
John Ovretveit, Professor of Health Policy and Management,
the Nordic School of Public Health
Sue Quayle, ARCHI
South East Sydney Area Health Service
Dr Peter Stuart, Lyell McEwin Hospital, South Australia
Tweed Hospital
Western Australian Audit of Surgical Mortalities
Western Sydney Health
Wollongong Hospital

Contacts
For further information please go to www.cec.health.nsw.gov.au

Clinical Excellence Commission

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