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Toolkit for bed managers


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Toolkit for bed managers

  1. 1. IMPROVING PATIENT ACCESS TO ACUTE CARE SERVICES A practical toolkit for use in public hospitals Developed by the Clinical Excellence Commission Clinical Excellence Commission
  2. 2. 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 1
  3. 3. 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 Improving Patient Access to Acute Care Services 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 2
  4. 4. 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 Improving Patient Access to Acute Care Services 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 3
  5. 5. 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 Improving Patient Access to Acute Care Services 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 4
  6. 6. 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 Improving Patient Access to Acute Care Services 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 5
  7. 7. 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 Improving Patient Access to Acute Care Services Bookmark link within document 6
  8. 8. 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 Improving Patient Access to Acute Care Services 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. 7
  9. 9. 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 Improving Patient Access to Acute Care Services 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 8
  10. 10. 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 Improving Patient Access to Acute Care Services 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
  11. 11. 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 Queuing theory (NHS website) Patient flows, waiting and managerial learning paper (NHS) NHS Flow Management Wizard index.php?page=/demand_management/wizards/big_wizard/Step_ 4/Basic_Queuing_Theory.php Improving Patient Access to Acute Care Services Foundations of demand and capacity (NHS presentation) 10
  12. 12. 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 Improving Patient Access to Acute Care Services analyse the results build in accountability to help sustain changes communicate the changes 11
  13. 13. 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 Improving Patient Access to Acute Care Services 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
  14. 14. 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. Improving Patient Access to Acute Care Services 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. 13
  15. 15. 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) 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, Improving Patient Access to Acute Care Services leaders with a clear vision of the project who can sell this vision to others. 14
  16. 16. 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: 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. 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 Improving Patient Access to Acute Care Services improvement in existing systems of care delivery. 15
  17. 17. 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) Improving Patient Access to Acute Care Services measurement/ 16
  18. 18. 2.4.2 Tools for understanding processes 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) 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) Improving Patient Access to Acute Care Services 17
  19. 19. 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) 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, Improving Patient Access to Acute Care Services waiting for review by medical officers. Discharge Audit Tool (RNS Hospital) 18
  20. 20. 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 (Institute for Clinical Excellence) Improving Patient Access to Acute Care Services 19
  21. 21. 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) Improving Patient Access to Acute Care Services 20
  22. 22. 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) Organisational Change, a Review for Healthcare Managers, Professionals and Researchers (NHS) Making Informed Decisions on Change (NHS) Quality collaboratives: Lessons from research (The Nordic School of Public Health) Improving Patient Access to Acute Care Services Improvement Leaders Guide - Spread and Sustainability, 2002 (NHS) 21
  23. 23. 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 Improving Patient Access to Acute Care Services 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
  24. 24. 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 Improving Patient Access to Acute Care Services 23
  25. 25. 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 (Institute for Clinical Excellence) Measurement Presentation - Helen Ganley (NSH) Weekend Discharge Audit Report (RNS Hospital) SPC for Beginners - Powerpoint Presentation (NHS) 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 Improving Patient Access to Acute Care Services 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
  26. 26. 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. Improving Patient Access to Acute Care Services 25
  27. 27. Case study - Western Sydney AHS - Neck of Femur Patient Flow Group: Contact Details: Maria Lingam Rosio Cordova 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 Improving Patient Access to Acute Care Services 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
  28. 28. 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). Improving Patient Access to Acute Care Services 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
  29. 29. 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. Improving Patient Access to Acute Care Services 28
  30. 30. 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. Improving Patient Access to Acute Care Services 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
  31. 31. 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 Improving Patient Access to Acute Care Services 30
  32. 32. 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. Improving Patient Access to Acute Care Services 31
  33. 33. 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) Improving Patient Access to Acute Care Services 32
  34. 34. 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
  35. 35. 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 Improving Patient Access to Acute Care Services 34
  36. 36. 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. Improving Patient Access to Acute Care Services Bookmark link within document. 35