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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 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
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 isnt 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
Contents
HOW TO USE THIS TOOLKIT 1. INTRODUCTION 2. PLANNING THE IMPROVEMENT WORK Identify and define the problem Review data to understand hospital activity and performance Engage clinicians and convene the redesign team Leadership Team members Diagnostic Work Understanding the current systems and processes Tools for understanding processes Determine your aim Designing and implementing changes Identify interventions to implement Practical ideas for effecting change Implementation plan Analyse the Results Methods of measurement Communicating the change Key factors for successfully managing change Case study - Western Sydney AHS Neck of Femur Patient Flow Group Checklist prior to starting your improving access project 3. INTERVENTIONS 3.1 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5 3.1.6 3.1.7 3.1.8 3.1.9 3.1.10 3.1.11 3.1.12 3.1.13 3.1.14 3.1.15 3.1.16 3.1.17 3.1.18 General strategies Shared work plans, practices and schedules within multi-disciplinary teams Develop multi-disciplinary evidence based pathways Relative performance table Convene a redesign team Improve communication systems Referral to specialist services Service level agreements Managing capacity to respond to need for services Minimise variation in capacity to provide care Change to 7 day a week services Buffer beds Smoothing variation in elective activity Develop advanced nursing roles Up-skilling peripheral hospitals for complex patient needs Align staff specialist/consultants work to maximise efficiency Bed management system Centralised bed authority/bed co-ordinator Regular multi-disciplinary bed meetings 2.1 2.2 2.3 2.3.1 2.3.2 2.4 2.4.1 2.4.2 2.5 2.6 2.6.1 2.6.2 2.6.3 2.7 2.7.1 2.8 2.8.1 6 7 11 12 12 14 14 15 16 16 17 19 20 20 21 22 23 23 24 25 26 34 35 36 36 37 37 38 38 39 39 39 40 40 40 41 41 42 42 43 43 45
3.1.19 3.1.20 3.1.21 3.1.22 3.1.23 3.1.24 3.1.25 3.1.26 3.1.27 3.1.28 3.1.29 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 3.2.7 3.2.8 3.2.9 3.2.10 3.2.11 3.2.12 3.2.13 3.3 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5 3.3.6 3.3.7 3.4 3.4.1 3.4.2 3.4.3 3.4.4 3.4.5 3.4.6 3.5 3.5.1 3.5.2 3.5.3
Teleconference bed updates Clinical prioritisation of patients Reconfigure beds to reduce outliers Over Census Policy Guidelines and protocols for test ordering Review permissions to order tests Prioritise tests for Emergency Department or patients waiting for discharge Allocated time for emergency cases Appropriate information on request form Patients attending for tests Stratified test ordering Emergency patient flow Pre-bypass hospital early warning system Streaming techniques Alternate admission processes Develop alternate services to prevent ED presentation Advanced nursing and allied health practitioner roles Fast Track See and Treat Lean thinking Clinical pathways around presenting problems not diagnoses ED access to day surgical list bookings Communications clerk Emergency medicine unit Flag and case manage frequent attendees Improving Flow of Emergency Surgical Patients Clinical guidelines or pathways Team briefing and debriefing sessions Emergency department physician admission rites Review existing demand for emergency operating theatre time Prioritisation protocol Prioritisation team Pre-operative placement of patients waiting for OT Medical strategies Medical assessment and planning unit Day only admission ward for ED patients Flag and case manage frequent medical admitted patients Trial at home program Improve appropriateness of admission Safety risk assessment Improving communication Improving communication with GPs and community nursing Generic transfer/discharge to hospital form for all residential aged care facilities (nursing homes) Link discharge from ward time with admission from Emergency Department time
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3.5.4 3.6 3.6.1 3.6.2 3.6.3 3.6.4 3.6.5 3.6.6 3.6.7 3.6.8 3.6.9 3.6.10 3.6.11 3.6.12 3.7 3.7.1 3.7.2 3.7.3 3.7.4 3.7.5 3.7.6 3.7.7 3.7.8 3.8 3.8.1 3.8.2 3.8.3 3.8.4 3.8.5 3.8.6 3.8.7 3.8.8 3.8.9 3.8.10 3.8.11 3.8.12 3.8.13 3.8.14
Scheduled transfers Improving discharge processes Discharge risk assessment form Admission and discharge plan Criteria driven discharge Nurse activated discharge Monday morning audit Weekend discharge pharmacy Multi-disciplinary Discharge Meetings Informing patients and carers about their discharge Discharge checklist Estimated day of discharge Estimated length of stay table Compare the estimated date of discharge to the actual date of discharge Aged care Aged care assessment team (ACAT) Transitional care beds Community transitional care beds ComPacks service model Purchase transitional care beds Direct emergency admission protocol Dependant care stream of patients managed by specialist nurse practitioner Walking assistance program Elective Patient Flow Quarantined elective surgical beds Criteria driven discharge Surgical pathways and estimated day of discharge (EDD) Increase day of surgery admission rates and manage performance outliers better Audit all theatre delays or cancellations Surgical peri-operative liaison nurses Medihotels Flexible staffing Align leave of multi-disciplinary surgical teams Clinical teams operating pooled referrals Clinical pathways Improve completion of consent forms Marking operating site Improve compliance with fasting requirements
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Key to icons:
Tool available on CD Rom
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.
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 patients 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
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Category 2 | take a day off clinically unnecessary ALoS and it has a dramatic effect
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Figure 2
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
Improving Patient Access to Acute Care Services
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Project steps
Identify and define the problem review data to understand activity and performance
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Improving Patient Access to Acute Care Services
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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. 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. 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. 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. 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. 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. 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. 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. 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.
leaders with a clear vision of the project who can sell this vision to others.
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is an opinion leader who can influence his/her peers to produce improvement in existing systems of care delivery.
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www.modern.nhs.uk/improvementguides/ measurement/
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decision
request
result available
review 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)
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Figure 3
Nurses not having confidence to make the decision due to lack of information
Joint working group chaired by and supported by Peter Brown. First meeting 06/05/04
Work with radiology department to develop agreed guidelines Set up monitoring systems
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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)
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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 Celine Hill Rosio Cordova Maria Lingam Narelle Allen Gail Hook Robert Dowsett Gayle McInerney Geoff Shead Randolph Gray Elizabeth Stafidas Peter Landau Sue Voss Linda Gutierrez Dr John Fox Dr Roger Brighton
Improving Patient Access to Acute Care Services
Executive Representative Team Leader, Trauma Program Manager Facilitator, Quality Manager Clinical Nurse Consultant (Orthopaedics) Clinical Nurse Educator (Orthopaedics) NUM, D4A (Orthopaedics ward) Director ED Westmead Director ED Auburn Surgery Stream representative Orthopaedic Registrar Surgical Support Services representative Staff Specialist, Geriatric Medicine Anaesthetics Consultant Trauma Data Manager Director, Orthopaedics Unit, Westmead Hospital 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.
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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 didnt go to theatre within 24 hours demonstrated 30% didnt 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.
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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 comorbidities 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
No specialised nursing review in ED
Accessibility
Booking times Disorganised booking times Geriatrician review vs Orthopaedic review Orthopaedic review vs Anaesthetist review
No beds available
Patient requires MRI or Bonescan Patient is medically unfit Family refuses operation 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.
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Figure 5 Issues
Patients referred for geriatric review before seeing the Orthopaedic Registrar. Geriatric review only occurs during working hours. 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. The Anaesthetist can request further medical review, delaying operating time. Patients from district hospitals wait longer for operation due to the lack of bed and/or incomplete documentation.
Intervention implemented
Once ED Registrar reviews tests and admission is identified, then the ED Registrar calls the Orthopaedic Registrar as well as informing the Geriatric Registrar.
In absence of the Geriatric Registrar, the Medical Registrar can review the patient after hours or weekends.
ED Registrar is able to organise transfer of patients to the Orthopaedics Ward upon confirmation of fracture.
Anaesthetist review occurs at the beginning of the diagnostic process rather than at the end, upon admission to the ward.
Checklist is used upon transfer of NOF patients from district hospitals to ensure documentation is complete. This reduces delays to theatre due to incomplete documentation. District hospital patients are returned to the hospital 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. Orthopaedic Registrar will book theatre when diagnosis is confirmed either before 9pm or between 7am-7.30am as this would help in organising lists and prioritising theatre patients. The Clinical Nurse Consultant (Orthopaedics) is called upon patients 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. 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.
Improving Patient Access to Acute Care Services
Data collection.
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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%
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LCL = 24.4%
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Jul 03 - Jan 04
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Figure 7
Patient is admitted
MRN is produced
Time is recorded prospectively Tests include X-ray & blood pathology tests Geriatrician informed or Med. reg called after hours Geriatric Yes review needed? No Seen by the Ortho registrar Is geriatric admission required? Yes
Yes
Fracture of hip?
Medical management
Time Ortho registrar is called to be recorded by Geriatric registrar Time to be recorded by Ortho registrar Time of diagnosis & mode to be recorded
No Op theatre booked at time of diagnosis before 9pm or booked at 7am next day
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Ward (medical assessment) Booking time recorded in Op theatre, operating time including start & finish times
Patient may be admitted to Ortho ward during the night if X-ray shows fracture
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Figure 8
ED Registrar review patient & order blood tests & ECG Confirmation of NOF fracture Patient admitted to D4A Obvious fracture? Yes Book theatre at the same time
ED Registrar to call the NOF team (Ortho Registrar and Geriatric Registrar)
Yes
No
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Checklist
prior to starting your improving access project
Organisational commitment secured
Diagnostic work
Engagement of stakeholders
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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
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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
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The Clinicians Toolkit, Easy Guide to Clinical Practice Improvement (NSW Health)
Personal Digital Assistants 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
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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?
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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
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Redesign tip
Improving Patient Access to Acute Care Services
Use this intervention to decrease outliers. Adapt the protocol above or develop your own guidelines for prioritising patient need. St Vincents Health, Victoria
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Case study
St Vincents 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.
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 organisations nursing establishment is essential prior to implementation.
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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
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, Monash Medical Centre, Victoria
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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
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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.
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A trial comparing hospitals using a HEWS system with those who werent 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
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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
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Figure 10
Calvary Hospital - Reduction in the number of did not waits in ED as a result of implementing see and treat
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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 dont 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).
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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.
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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
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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
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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)
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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.
Adverse Patient Outcome Program - Powerpoint Presentation (John Flynn and Tweed Hospitals)
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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/
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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)
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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
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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 VMOs 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%.
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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
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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.
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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.
Employ specialist nurses to manage elective surgical streams and casemanage specific cases. These nurses may assist in managing interfaces between ED, day surgery, wards, operating theatre and ICU. Royal Prince Alfred Hospital
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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 Vincents Health, Victoria and Monash Medical Centre, Victoria
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www.safetyandquality.org
Unusual variation may be related to routine cases that develop unpredictable complications, unexpected shortages of staff, last-minute changes in a surgeons 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.
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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.
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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.
Louise Kershaw David Ben-Tovim Anna Thornton Sally McCarthy Adam Chan Don Campbell Barbara Daly Rohan Hammett Philip Hoyle Greg Knoblanche
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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 Monash Medical Centre, Victoria 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 Royal Prince Alfred Hospital 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