1. society
2. welfare
3. healthcare
4. hospital

Patient Flow
Collaborative
Angela Peluso - Clinical Lead
Ian Jackson - Presenter
Eastern Health – Maroondah Hospital
Department of Human Services
Summarise Organisational
Constraint areas
• Bed Management
- Admission delays for elective surgery
- Admission delays from ED
• Acute/Sub Acute
- Delayed access to Rehab & NH beds
• Theatre Utilization
- High HIP rate
Summarise Priority Constraint
Area 2
• Acute to Sub Acute
-Delayed access to NH Beds
-Delayed access to Rehab beds
Diagnostic work
• Ward sample data repeated
-Confirmed previously identified constraints
• Brainstorming session
-Included all stakeholders – NUM’s, Allied
Health, Medical Rep (Geriatrician), Reps from
off-site rehab facilities
-Confirmed process issues and recommended
these be mapped
• Process Mapping session
-Identified key constraints in transition
process
Diagnostic work cont.
• Staff reactions
-Committed to “doing something” to improve
things
- Enthusiastic about possibilities
- Acknowledgement that even small changes
could have big effects
- “Lets do it!”
Improvement Plan
• Establish clinical area team
- Identify clinical area team leader
- Include key stakeholders
-Medical representative – Geriatrician
- Rep from PJC
- NUM’s from GEM, ortho & medical
wards
- Allied health – social worker & physio
- Aged care nurse consultant
Improvement Plan Cont.
• Investigate the following six key areas
identified as contributing to delays
1.
2.
3.
4.
5.
6.
Referral process to allied health
Organising OT home visits
ACAS referral process
Refusal of rehab bed by patient/family
Delays in discharge summary documentation
Out of hours communication with central booking
office
Progress
Implementing the following changes
1. Faxing allied health referrals
2. NUM generated ACAS referrals
3. Improved communication channels with
centralized bookings office
Lessons learnt
• Need for all key stake holders to be
involved
-delivers better more sustainable outcomes
• Select “right person” for “right job”
-need to be motivated & outcome focused
• “Rome wasn’t built in a day”
-be patient
Desired Impact
• Reduce LOS
• Reduce 12 hour waits in Ed
• Better more effective communication
channels between sites
• Improved patient care
Next Steps
• Review and update relevant policies &
procedures
• Review admission/discharge criteria for
hospital GEM ward
Questions
Patient Flow
Collaborative
Janine Rogers,
CHIP Manager
Calvary Health Care ACT
Department of Human Services
Summarise Organisational
Constraint areas
• Allied Health (AH) referral processinappropriate & not timely
• Radiology-timeliness & accessibility
• Nursing Paperwork-duplicative & excessive
• VMO Rounds-disjointed & not well managed
from
• ACAT Services-limited appointments &
difficulties with rebooking
Summarise Priority Constraint
Area 1
• AH Issues
– Inappropriateness of referral
– Timeliness of referral
– Referral process
Diagnostic work
• Brainstorming
– Ad hoc referral arrangements
– Timing issues
– Communication issues
• Consumer
– Not seen in ED
• Determine what is process now
• Tick and flick exercise in ED and Medical for
–
–
–
–
Response times
Relevance of referral
Who is making referral
Process effectiveness.
Improvement Plan
• AH referral indicators
– Determine indicators
– Pilot in two areas, then
– Specific to each service area
• Refine process
– Determine time intervals from referral to
assessment and then set optimum goal
– Structured flow for referral
• Facilitate communication between parties
– Streamline process
– Ease of access to contact # and names
Progress
• AH referral audit underway
• Referral process set into flow diagram
• Specific AH Indicators for pilot accepted
– AH and nursing input
• Evaluation audit on pilot to be
completed
Lessons learnt
• Managing detractors and concerned
staff
• Getting everyone in the right place at
the right time
• Reliance on senior 3rd party to share
project information
• Don’t do this during accreditation
Desired Impact
• Timeliness
– Patients requiring AH intervention to be seen
within …?…. (optimal time frame)
• Appropriateness
– All AH referrals to have a clear rationale for
assessment
• Knowledge
– Increase knowledge across hospital on referral
indicators
• Communication
– % of referrals that follow correct communication
process
Next Steps
• Radiology mapping
• Revise nursing assessment
– Standardise across hospital
– Standardise risk assessments
– Include expectation management
• Increase efficiency of VMO rounds
• ACAT service
Questions
Team Presentations
Melanie Hendrata and Kim Moyes
5TH October 2004
Department of Human Services
Concurrent Session 1
Team Presentations
Bellarine Room 3
– Northeast Health - Wangaratta
– Bendigo Healthcare Group
– Southern Health – Dandenong Hospital
– Peninsula Health
– Box Hill Hospital
Patient Flow
Collaborative
Christine Giles
Northeast Health Wangaratta
Department of Human Services
Rigorous Diagnostics
• Poor communication pathways both
verbal and written- Inadequate or
incorrect documentation of patients’
social & medical history.
• Inconsistencies with quality of
admission data from GP’s and
referring agencies.
Rigorous Diagnostics
• Patients being asked the same questions
repeatedly by different personnel.
• Organisation duplication of paperwork.
• Discharge dependant on timing of medical
rounds, availability of bed elsewhere, family.
• Delays in radiology.
Organisational Constraint Areas
1. Communication and Information
Transfer.
2. Emergency Department-time taken
between decision to admit and
admission to ward.
3. Medical ward LOS-activities affecting
discharge, transfer & readmissions.
Implementation PhasePlan, do, study, act.
• Team members further brainstormed the
constraint areas.
–
–
–
–
–
–
–
Communication between ED and Medical unit
INR monitoring and warfarin therapy
Nurse initiated clinical guidelines
Discharge-time and trends in the Medical unit
Quality of admission data
Delays in ED-causes and effect
Form review by Medical Records.
• Consensus reached on plan, do, study act
initiatives.
Implementation PhaseDiagnostic work
Tools
Desk top audits, tally sheets, staff interviews both
structured and unstructured, questionnaires, existing
hospital data.
Who was involved?
Health information manager, ED, medical unit, nursing
staff and clerical staff, ward nurses, executive, junior
and senior medical staff, director of pharmacy, director
of radiology, under graduate student. Patients and
relatives.
Implementation PhaseDiagnostic work
What data/information was really useful/not useful?
Anecdotal, face to face staff interviews, audits,
previous studies, patient comments.
1. Face to Face Radiology delays as an issue debunked.
New filmless system being implemented. Delays in the
request for and actioning pathology results highlightedINR-therapeutic range and warfarin dose.
2. INR Clinical Indicator Variance Analysis 2003
This data supports anticoagulation management as one
of our perceived causes of medical ward prolonged
LOS affecting discharge, transfer & readmission.
Implementation PhaseDiagnostic work
3. Desktop audit indicated excellent compliance by
NHW with discharge summaries but raised some
questions about the quality of information
accompanying patients on arrival to our hospital.
Identified some evidence of GP admitted patients
having increased LOS for certain patient types.
4. Tally sheets!!-poor compliance, hostility,
paperwork fatigue led to insufficient data.
Implementation PhaseDiagnostic work
Staff reactions• Anger.
• Disinterest.
• Passive resistance.
• Frustration.
• Ability to see what
needs to be done but
negative about means
to achieve change.
• Powerlessness.
• Blame culture.
Improvement and Progress
1. Medical ward and ED identified as the most
pressing communication issue. Positive
channels of communication to be established
and shared goals initiated
Reduce duplication in history taking, trial
innovations to ease the burden of the admission to
ward process.
Explore MAPU to improve patient flow.
Established a forum for both groups to have
dialogue and understand each other’s issues.
Improvement and Progress
2. Communication with Medical staff group
to establish key responsibilities for
investigating identified constraints
- Engage GPs-review admission process, LOS.
- Exploration of nurse initiated activities to expedite
the discharge/transfer process i.e.pathology
requests, referrals to allied health, medication.
- Identification of the use of evidence based care,
clinical practice guidelines, beginning with anticoagulation therapy.
Lessons learnt
1.
Separate fact from opinion.
2.
Distil the problem from the symptoms.
3.
Examine data quality carefully and adapt
diagnostic tools to be contextually appropriate“you can’t weigh something with a tape measure”
Accept that change is painful but good leadership
can transform negative energy into a positive
outcome.
4.
5.
Harness the energy of the organisation champions.
Next Steps
1.
Trial MAPU.
2.
Develop education plan for Medical ward and ED
nursing staff re history taking, referral, pathology
and pharmaceuticals skills.
3.
Develop an education plan for admission clerical
staff and external referral agencies re accuracy of
patient information.
4.
Engage junior medical staff in a culture of
teamwork and evidence based practice, clinical
practice guidelines.
Questions
Patient Flow
Collaborative
June Dyson
Bendigo Health Care Group
Department of Human Services
BHCG Organisational
Constraint areas
• Variation in patient management
practices by doctors and nursing staff
for Stroke patients. Impacts on quality
of care and length of stay
• Limited availability of acute, rehab and
aged care beds
BHCG Organisational
Constraint areas
• Availability of registrars to assess
potential admissions in the Emergency
Department (ED)
• Repetitive documentation, assessment
and data capture for patients
Priority Constraint
Variation in patient management for
Stroke
• Stroke is a discrete and important area
across the continuum.
• There is some evidence that:
– Stroke care and treatment could be improved in
the ED
– Stroke care and treatment could be improved in
the acute phase
– Stroke patients spend time additional time in acute
beds when they are ready for discharge
– Follow-up for TIA and Stroke patients in the
community could be improved.
Diagnostic work
• Stroke patient journey times
– A data collection tool was developed to better
understand the timing of the patient journey.
– Developed by the Executive team in collaboration
with ED, acute and rehab staff.
– Difficulty in reaching consensus on tool - the tool
was drafted at least six times.
– Consumers were not involved at this point.
– The data collection is in progress (it took six weeks
to reach agreement on the tool and manner of
data collection)
Diagnostic work: Data collection tool
Diagnostic work
• Stroke residential care patients
– A SPC analysis of stroke length of stay (2001-004) identified
a number of ‘special causes’
– We reviewed the patient histories of ‘special causes’ to
determine the reasons for long lengths of stay
– Particularly we looked at the time frames between acute
admission, Aged Care Assessment team assessment,
placement on residential care waiting list
– This was compared to existing data looking at Stroke referral
time to rehabilitation and residential care.
Diagnostic work: SPC of
Stroke LOS
SPC chart of variation in Stroke length of stay: 2001-2004
Length of stay
Average
LCL
UCL2
100
Length of stay (Days)
90
80
70
60
50
40
30
20
10
22
/0
6/
20
22
00
/0
8/
20
22
00
/1
0/
20
22
00
/1
2/
20
22
00
/0
2/
2
0
22
/0 01
4/
20
22
01
/0
6/
20
22
01
/0
8/
20
22
01
/1
0/
20
22
01
/1
2/
20
22
01
/0
2/
2
0
22
/0 02
4/
20
22
02
/0
6/
20
22
02
/0
8/
20
22
02
/1
0/
20
22
02
/1
2/
20
22
02
/0
2/
22 200
3
/0
4/
20
22
03
/0
6/
20
22
03
/0
8/
20
22
03
/1
0/
20
22
03
/1
2/
20
22
03
/0
2/
20
22
04
/0
4/
20
22
04
/0
6/
20
04
0
Admission date
The chart shows the length of stay of 627 stroke patients between June 2000 and June 2004. The upper and lower control (LCL) limits
represent two standard deviations above and below the log (ln) length of stay (since the LOS data are skewed). Patients admitted with
Stroke can expect acute lengths of stay between 0 and 44 days, with an average length of stay of 10 days. 10 'special causes' were
identified: that is, patients whose length of stay exceeded the upper control limit.
Diagnostic work: Potential
causes of Stroke long LOS
Average time course for long stay Stroke patients (N=15)
Acute admit to 1st
Rehab assess.
Rehab to 1st ACAS
assess.
ACAS assess to NH wait
NH wait to NH bed (or
deceased)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Days post admission
The graph shows the average time course for Stroke patients with very long lengths of stay. The bars on
the graph show how long (in days) the average patient can spend in acute care, until assessment and
transfer to nursing home. The graph shows that approximately half of these patients LOS is taken up
waiting for residential care.
Diagnostic work: Potential
causes of Stroke long LOS
60
19
50
19
40
6
30
29
13
29
13
6
20
6
28
38
24
Days
10
0
N=
46
46
46
Referral to w aitlist
Referral to Admit
Waitlist to Admit
Period
The boxplots above are based on data collected on 46 patient journeys between August
2003 and January 2004. The boxplots above show that 50% of patients placed on a
waiting list for rehabilitation within 8 days of referral, and admitted to rehab within 12
days of referral. A number of patients are ‘outliers’ – with considerably longer than
normal waiting times.
Diagnostic work: Long LOS
• The data was consistent with staff’s beliefs
about the difficulty in finding residential care
placements.
• A small subset of cases for Stroke LOS
identified data collection problems
• There is a ‘weariness’ about the difficulties in
finding residential care placement. It is ‘out
of our hands’.
• The data did not provide clues to how to
improve patient flow.
Improvement Plan
• Two clinical teams have been
established.
– The first clinical team is looking at the problem of
variation and patient management.
– A second clinical team is building on the work of
an existing working group to investigate options
for patients waiting in acute care for residential
placement.
– Establishment of an emergency department clinical
team is contingent on the results of the data
collection.
Progress
• Documentation clinical team established
• Nursing Home working party-implementation
of Entry to Nursing Home process.
• Elective surgery peer group working party
established
– theatre utilisation
– how patients are put on the waiting list
– using patient hotel accommodation to encourage
day of stay admission
• Further data collection strategies in place
Lessons learnt
• It has been challenging garnering
enthusiasm from clinical staff.
• Change is slower than we would have
liked but is progressing.
Lessons learnt
• The executive team meetings have, for
some time, been engaging in both
executive team and clinical team
activities and discussion.
• Communication has been an issue as
not all of the team are fully conversant
with the PFC process.
Lessons learnt
• Need to have senior members of the
executive team active and on board early.
• Need to establish clinical teams as soon as
the problem is identified
• Need to find a way to better engage clinicians
– Overcome the ‘not another project’ feeling
– Communicate the goals of the project uncritically
– Deal with realistic and unrealistic expectations of
impact of the PFC on workload
Desired Impact
• Reduce repetitive patient and clinician
documentation (for Stroke cases)
• Improve consistency of care (Patient X
receives the same care irrespective of
treatment by Doctor A, B or C)
• Reduce delays for Rehabilitation and
Residential care placement.
Next Steps
• Collect and analyse patient journey
timings.
• Establish ED clinical team, if necessary
• Complete review of documentation.
Trial this new documentation and
reassess patient journey times
• Evaluate outcomes of nursing home
clinical team and further development
of new strategies.
Questions
Patient Flow
Collaborative
Ms. Maggie Emmerton
Pharmacy Site Manager
Dandenong Hospital
Southern Health
Department of Human Services
Summarise Priority Constraint
Area 1
Discharge - Pharmacy
•
•
•
•
•
Information / data needs
Script Accuracy
Communication
Discharge planning/priorities
Week end – resources, hours
Diagnostic work
• Diagnostic exercises:
– Table top issue exploration x2
– Discharge pharmacy flow
– Pharmacy audits
• Participants: ED manager, ward pharmacists, clinician,
Nurse managers, Chief pharmacist, project facilitator
• Reactions: gained new understanding of complexity of
pharmacy issues and requirements
• Useful information: Internal pharmacy audits, ward
experiences
Improvement Plan
• Data:
- Liaise with Admission clerks re data requirements
- Liaise with Ward Clerks re data verification
• Script Accuracy:
- RMO to verify script with 2nd person before
submission to pharmacy
- Feedback through Pharmacy Intervention / Incident
Reporting Database
• Communication:
– Designated ward staff member as central
communication point between ward staff and
pharmacist
– Reduce interruptions through utilisation of LAN page
Progress
• Progress:
-Liaison
with Snr Health Information Mgr re Admission Clerk
responsibilities.
Incorporation into training schedule.
-Trialling of measures on designated ward
-ward clerk monitoring patient data
-designated central contact b/n ward & pharmacy
-utilise LAN page in preference to phone to reduce
interruptions
-encourage RMO’s to verify discharge script before
processing
Progress - Outcomes
Ward 4 trials:-open communication b/n ward clerk and pharmacist re missing
data
-need to identify incorrect data
-snapshot of actual data issues to be compiled for feedback to
Admissions
-designated central contact effective. Some fine tuning of process
required.
-LAN page system well utilised
-Medical staff – little response to verbal communication.
Request audit of specific issues with scripts.
Desired Impact
The expected impact from the improvement
measures undertaken is to reduce discharge
delays related to barriers to the pharmacy
process.
-Increase the accuracy of patient
demographic data for SH.
-Increase accuracy of prescribing.
Next Steps
• Next Steps:
-evaluate current trials
-implement other actions to enhance script accuracy.
-RMO induction / orientation package – repeat session
-unit meeting agenda – reinforce accuracy
-pharmacy tutes – schedule meeting b/n ward
pharmacist and RMO, provide script writing assistance
-re audit local ward scripts – provide feedback
Patient Flow
Collaborative
Ms. Joanne Burns
Director Patient Access and
Demand Strategy
Southern Health
Department of Human Services
Summarise Organisational
Constraint areas
1. Bed Bureau – operations and functions
inconsistent across sites of SH.
•
•
•
•
•
Resources
Communication
Trust
Protocols
KRA’s
Summarise Organisational
Constraint areas
2. Discharge Pharmacy
•
•
•
•
•
•
Information / data needs
Ward stock / requirements
Week ends
Communication
Script accuracy
Discharge planning / priorities
Summarise Priority Constraint
Area 1
Bed Bureau
• Inconsistent service
• Communication ad hoc
• Trust
• Defined responsibilities
• Bed allocation prioritisation
• KRA’s
Diagnostic work
• Diagnostics:
– x2 patient journeys
– x4 table top sessions
– Involving nursing, ward management, medical, heads of unit, ED,
Bed Bureau, orderlies, administrative and OT personnel
• Reactions:
- overall positive vibe with recognition of difficulties involved, but
general sentiment that most problems were caused by others. A need
to take ownership of issues and work collaboratively to resolve.
• Useful data:
-’ED time from bed request to bed allocation’
-’ED time from bed request to transfer to ward’
- Patient journey time through ED – although would be helpful
to map entire medical patient journey – identifying and
understanding component parts to create better flow.
Improvement Plan
• Increase resources and service hours
• Establish communication procedures
• Establish bed allocation prioritisation principles
• Establish consistency of operation and function across
sites
• Collect and collate activity data
• Develop Inpatient Access Manager role
• Report Bed Bureau activities to site exec
Progress
• Access Working Group sub group – Bed Bureauestablished
• Resource costing profile
• Communication strategy / process documented &
endorsed by site executive
• Policy requirements identified
• Development : elective capacity predictor tool
Progress
• Communication channels trialled and showed
an improvement in time from bed request to
bed allocation.
• Daily bed meetings and utilisation of Predictor
tool provide an accurate count of daily acute
capacity.
Outcomes
• Regular meeting of Access working group sub group
• Daily Bed Management meeting – bed census, border
information
• Changes to formal communication processes include
LAN paging, Homer and email utilisation
Lessons learnt
• All participants found to have
frustrations often with no channels for
resolution
• Important to prevent information /
problem overload. Tailor information to
individuals that is pertinent and
relevant to their sphere of interaction.
Desired Impact
Looking forward we expect:
-better management of the elective and emergency
demand balance
-accurate prediction and accommodation of elective
surgical demand and a reduction in episodes of HIP
-reduced time for patient journey through the ED and
admission to an in patient bed
-a decrease in time ‘Ready for discharge patients’ wait
for a subacute bed
Next Steps
• Continue developing the work
• Improve discharge end of journey to
enhance interface with subacute linking
with RASP services
Questions
Patient Flow
Collaborative
Dr Susan Sdrinis
Manager – Medical Operations
Peninsula Health
Department of Human Services
Summarise Organisational
Constraint areas
Guiding Principles of Peninsula Health PFC
•
•
•
•
•
•
•
Patient focussed
Improved patient outcomes
Right patient, place, resource, time and clinician
Prompt access
Optimal flow
Efficiency
Enhance professional networks and relationships
Summarise Organisational
Constraint areas
Priority Areas
• Optimise patient flow from the Emergency
Department
• Eliminate delays for patients awaiting surgery
• Optimise bed utilisation across all sites
• Facilitate consistent systems and processes across
Peninsula Health
Summarise Priority Constraint
Area 1
• To improve patient flow between Emergency
Department and Radiology Department
• To improve the service provided to Emergency
Department patients associated with Radiology
procedures
Diagnostic work
• Process mapping
• Brainstorming
• Tick charts
• Time measurements
Diagnostic work
Who was involved?
– Patients
– Frontline staff
– Departmental Managers
Reactions?
– Have done it before
– Good, let’s get this right
Diagnostic work
Time Request is Faxed to PSA Contacted for Patient Transport
250
Minutes
200
150
100
50
0
55 905 950 030 140 210 235 247 340 421 535 610 636 726 824 001 109
8
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
2
2
Time Faxed to PSA Contacted
21
21
19
18
17
17
17
16
16
16
15
15
14
14
13
13
13
13
13
12
11
11
10
10
09
09
08
23
21
00
33
50
33
11
26
25
02
50
00
26
10
50
25
15
02
00
23
55
43
40
11
58
13
15
Minutes
Diagnostic work
Time PSA Contacted and PT Transported to Radiology
50
45
40
35
30
25
20
15
10
5
0
Time Transported to Radiology
Diagnostic work
Time PSA Contacted to PT Transport From Radiology to ED
16
14
10
8
6
4
2
Time PSA contacted for transport back to ED
Time PSA Contacted to Time Transported to ED
22
27
21
25
19
05
16
43
16
08
15
47
15
19
15
03
14
26
14
20
13
35
12
45
12
10
11
26
10
43
10
15
09
33
0
08
30
Minutes
12
Improvement Plan
Critical to
Quality
Innovation
Actions
Requests delivered
timely
Using Fax Machine and
speed dial
Speed dial formatted –
Memory test on fax OK
Better communication
if specialised
resources required
Doctor goes to specialty
modality technician during
hours and speaks with MIT
on duty afterhours
Leong to educate at
registrars meeting and
through Memo
ED electronic
whiteboard in
Radiology
Need to discuss further
and bring in IT
representative
Richard to organise
meeting and invite Leong,
Wendy, & Eric to progress
Timely transport of
pt’s to radiology when
contacted
To be discussed further.
Start with implementing
single point of contact
Wendy to implement single
point of contact
Timely transport of
pt’s back to ED when
contacted
Radiology to contact PSA
for all pt returns
Radiology agree to change
practice. Bert to
implement in Radiology.
Wendy to implement in ED
Achieved
Yes
Improvement Plan
Critical to
Quality
Innovation
Actions
Notification of patient
in Radiology Waiting
Room
ED will ensure staff direct
pt’s to notify Radiology
of their presence
This information to be
placed on fax sheet.
Wendy & Leong to
implement.
Report process
streamlined (A)
Radiology to prioritise all
in hours ED radiological
procedures as priority 1
for reporting
Bert to develop memo
and confirm with Leong
- Trial Period to be
implemented – All
portable procedures are
to go straight back to ED
consultant others to
Radiologist as priority 1
Report process
streamlined (B)
Place interim reports on
Orion.
Richard to organise
meeting and invite
Susan, Shamala, & Bob
Ribbons
Achieved
Progress
• Describe progress so far?
• What was the outcome?
• What was trialled?
• How many patients were involved?
• What staff were involved?
Lessons learned
• Process mapping / data motivated and guided group
• Focussing on patient need rather than department /
staff need
• Ownership of problem by both departments
Lessons learned
• Having an independent facilitator
• Informal regular meetings encouraged brainstorming
of solutions
• Involvement of frontline staff earlier
Lessons learned
NHS Sustainability Model
• Lowest scores were items 4 & 5
– 4 - Staff involvement and training to sustain the process
– 5 – Staff attitudes towards sustaining the improved process
• Areas to focus on to increase the sustainability of the
process were:
–
–
–
–
–
–
–
Involve staff through pressure testings
Team meetings
Include staff in Membership of the project group
Involve staff in the development and/or agreeance of tools
Involve staff in the decision making process
Provide regular feedback
Celebrate wins
Desired Impact
• To support patients receive a customer focussed,
time efficient, and accurate diagnostic process as a
result of presenting to the emergency department for
care of their injury or illness.
Desired Impact
• 100% of pts are transported to Radiology within
12mins of contact
• 100% of pts are returned to ED within 10 mins of
contact
• Radiology reporting streamlined to prioritise all in
hours Emergency Department radiological procedures
as priority 1 for reporting
Next Steps
• Continue to develop innovations to address all critical
to quality items
• Involve more frontline staff in process
• Post implementation data analysis
Patient Flow
Collaborative
Kate MacRae
Director of Occupational Therapy
Peninsula Health
Department of Human Services
Summarise Organisational
Constraint areas
Priority Areas
• Optimise patient flow from the Emergency
Department
• Eliminate delays for patients awaiting surgery
• Optimise bed utilisation across all sites
• Facilitate consistent systems and processes across
Peninsula Health
Summarise Priority Constraint
Area 3 – Bed optimisation – Transport
delays
• Poor systems of access to pool cars for
clinical use
• System of ‘first in best dressed’
previously adopted across the network.
• The issue of increased incidence of
manual handling of equipment by
therapists was also raised as an OH&S
issue.
Diagnostic work
• An analysis of number of delays in conducting
home assessments, prior to discharge, was
conducted over a 2 week period.
• The impact on increased LOS and subsequent
delayed discharge was measured.
• All inpatient occupational therapists were
involved.
Diagnostic work
• Staff viewed this activity positively.
• The number of home assessments
conducted per ward was also measured.
• The number and usage of each pool car
across the network was also plotted.
Improvement Plan
• The need for a car (station wagon) to
be ‘quarantined’ at each site, which was
prioritised for clinical use, was
identified.
Progress
• A revised car booking system was
trialled for 2 weeks, and then
implemented as policy
• The additional car was purchased
following executive discussion and
approval.
• The increased through put and reduced
LOS had impacted on the clinical need
for access to pool cars.
Lessons learnt
• Quick wins are important!
• An analysis of one problem often identifies
other issues, which will need to be addressed.
Desired Impact
• Since the review of the car pool system
there have been no documented
occurrences of home assessments not
being able to be conducted due to lack
of transport.
• Manual handling of equipment has been
rationalised.
Next Steps
• The project is now completed.
Questions
Patient Flow
Collaborative
CARMEL BROWNE
BOX HILL HOSPITAL
Department of Human Services
SUMMARY OF CONSTRAINT
• Identifying issues of workload and
capacity for the medical units to
manage this number of patients.
• Balancing this with other pressure on
bed access - psychiatric patients waiting
for admission to adult or aged
psychiatric services- elective surgical medical imaging admissions.
Diagnostic work
• Utilising data we determined how many patients were
allocated to each medical unit and where those
patients were placed within the hospital.
• How many patients were waiting in ED to access a
acute bed.
• How many patients were on the elective surgical list
needing admission that day.
• How many patients were booked as elective
imaging,of which some will require admission.
• How many psychiatric patients were in ED waiting
admission to adult, adolescent or aged psychiatric
services.
Improvement Plan
• Carmel Browne worked with key stakeholders to
identify a more reasonable workload.
• An agreement was made to review medical rosters,
patient numbers and to share patient allocation
amongst registrars who may be quieter.
• A daily data summary sheet is emailed to key staff
using the daily whole system data.
• A key facilitator in medical administration
communicates with medical units to share the
workload.
Progress
• This was trialed across all general
medical units.
• A cross section view of all patients by
ward - unit- or specialty revealed where
constraints could be.
• The medical administration assistant
then negotiated allocation of patients
with all medical units.
Progress
•The improvement monitored the
patient flow and resulted in a more
manageable workload for medical
units.
•Patients benefits were reduced wait
time in ED, and being seen more
promptly by medical staff.
Lessons learnt
• This process is currently person
dependant.
• The data analysis and creation of the
daily sheet is time consuming.
DAILY REPORT SAMPLE
ED had about x7 waiting for beds
x2 of these are psych patients who have been there coming up to 4 and 5 days
respectively.
Hospital full
A1
x25 patients
A2
x16
"
B1
x10
"
B2
x30
"
Oncol x14
"
Haem x13
"
CCU
x8
Neuro x10
"
Spec x12
"
x7 wards
x5 "
x3 "
x7 "
x3 "
x2 "
x2 "
Surgical x77 of 94 beds
There is a lot of nursing sick leave in the operating theatre today.
Usual agency had not been able to supply staff.
If not all avenues have been exhausted and some afternoon cases will have to
be cancelled.
Desired Impact
• Improved access to a bed and medical
consultation for the patient.
• Improved collaboration amongst
medical registrars.
Next Steps
• Development of an automated program
will assist with the long term progress
and sustainability of this trial
Questions
Team Presentations
Tony Snell and Prue Beams
5TH October 2004
Department of Human Services
Concurrent Session 1
Team Presentations
Bellarine Room 4
– LaTrobe Regional Hospital
– St Vincents Health
– Northern Health
– Angliss Hospital
Patient Flow
Collaborative
Peter Wright - ED Director
Latrobe Regional Hospital
Department of Human Services
Summarise Organisational
Constraint areas
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Bed availability (ED Acute, Acute Sub-Acute)
Awaiting ACAS assessment
Delay in Allied Health Assessments
Reluctance to call Inpatient Referral
Medical rounds done too late in day
Awaiting Inpatient Team assessment in ED
Awaiting clinical investigations
HMO decision making delays
Delay in CT results & ultrasound
No Radiology between 10pm - 8:30am
Priority Constraint
1. Bed Allocation
• Hourly patient tracking in ED has highlighted
patients waiting 3 to 6 hours from time of bed
allocation to actual time of admission.
• Goal to have all ED patients admitted to the
hospital within one hour of the decision to
admit.
Hourly Tracking Analysis
3-12 hour waits in ED
12
11
10
9
8
7
6
5
4
3
2
1
0
R
3hrs
4hrs
P
5hrs
W
6hrs
BW
7hrs
BA
8hrs
9hrs
I
10hrs
C
11hrs
E
12hrs+
R = Radiology
BA=Bed allocated waiting ward t/fer
P = Pathology
I = Inpatient Review
W= Waiting to be seen
C = Communication Delay
BW = Waiting bed allocation
E = ED Treating
Diagnostic work
• Hourly ED tracking undertaken to identify major
flow constraints
• Refinement of data tracking to better reflect bed
allocation issues, including ward, system, ED &
clinical constraints
• ED AUM’s and ED Manager involved in data
collection
• Hourly data tracking well received by staff,
however busy times impact on data collection
• Relatives or carers were not involved
Diagnostic work continued ...
Refinement of hourly data tracking included breaking
down codes for Bed Allocation constraints;
• BAF bed allocated, but bed not empty (this includes verbal
allocation for expected discharge)
• BAC bed allocated, but needs cleaning
• BAS bed allocated, awaiting staff pick up, ie Ward Nurses or
Hospital Attendants
• BAT bed allocated, treatment in ED before can be transferred,
ie: clinically unstable, IV medications etc
• BAP bed allocated, paperwork holding up transfer, ie doctors
notes, admission notes, etc.
Improvement Plan
• Refined data collection will identify
improvement areas.
• Possible improvement areas;
– Ward meal breaks and stable patient transfer, no
ward staff available to do immediate admission
– Patient paperwork in order prior to bed allocation
– Staff availability for physical patient transfer
– Bed Clean procedure performed on discharge, not
admission request
Progress
• We’re working on patient flow constraints in
reverse to free beds for patient entry points
such as ED. These initiatives include;
–
–
–
–
–
–
–
Community Bed Register
Bed Manager Role
Social Worker Unification including GEM triage
Functional Mobility Program for GEM patients
Multi Disciplinary Admission / Discharge Summary
Bed Manager focus on Short Stay Unit utilisation
Alert system for 8 hour ED stays
Progress cont ….
• Positive impacts to date;
– 3% decrease in ED journey & average stay time.
– 23% increase in utilisation of Short Stay Unit
Occupancy %
Utilisation of Short Stay Unit (LRH)
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
May 04
June 04
July 04
Aug 04
Progress cont ...
• We expect to see more significant
improvement as initiatives settle in.
• ED AUM’s, Management and all ED patients
over 3 months were involved in the hourly
data collection.
Lessons learnt
• What worked well;
– Hourly tracking
• Simple and well accepted, if not liked
• Highly visible
• Highlighted key constraints
• What would you now do differently and
why?
– Start data collections earlier with better
tracking tools (initial tools inadequate)
Desired Impact
Our expected impact will be;
• All patients admitted within an hour of
bed allocation
• 12 hour stays in ED brought within
target levels
• Utilisation of Short Stay Unit over 100%
• Reduced Acute LOS
Next Steps
• Further work on Bed Waiting and Bed
Allocation
• Implementation of the GEM Functional
Mobility Program late September should
impact on Acute LOS and impact on
available beds for ED admissions.
• Refinement of hourly patient tracking
will determine new action plans.
Questions
Contacts:
Peter Wright
ED Director
[email protected]
Wen Bezzina
PFC Co-ordinator
[email protected]
(03) 5173 8139