Patient access

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Patient access improvement toolkit
Patient access improvement toolkit
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Introduction
This tool provides a brief summary of information
from the attached toolkits and guides provided
for the Patient Flow Collaborative teams. The
summary concepts are designed to provide
operational managers with a focused checklist of
effective access strategies. Concepts are broken
down into three categories Escalation These
concepts can be used during access block and when
escalation policies have been put into action
(see No. 7) Short term Can be implemented
fairly quickly, 0-12 weeks Long term Can be
implemented 12 weeks plus. Use the navigation
bar on the left hand side to click through the
seven strategies.
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Key system strategies

• Remove bottlenecks identify bottlenecks in
  patients process and remove
• Remove process steps and queues that add no value
  to patient care
• Reduce queues reduce queues where identified by
  matching capacity and resource to demand
• Reduce variation reduce variation in planned
  presentations, treatment and patient processes
  including waiting times
• Reduce handovers reduce the number of handovers
  of care
• Standardise practices to promote safety and
  quality by using care bundles, protocols etc.
• Optimise patient flow through the care journey

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Menu Clinical innovation areas
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1. Emergency care

• Fast track low acuity patients
• Provide Out Patient Department appointments and
  ready access to diagnostics for the next morning
  to promote discharge from Emergency Departments
• 1-2 hourly rounds (computer) by the person in
  charge of the coordination of Emergency
  Department
• Provide diagnostic appointments and outpatient
  appointments for Emergency Department patients
  each morning 
• Use Hospital in the Home (HiTH) as a bridge to
  plan semi-urgent care (e.g. TURP)
• Enable Emergency Departments to directly admit to
  Acute or Sub-acute beds  
• Inpatient unit admission whilst in Emergency
  Department if ready for inpatient care
• Manage delays through tracking systems
• Implement the 5 key themes for effective
  emergency care
• Clarify and promote the role of ED floor
  consultants in management of patient flow.

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2. Inpatient care

• Short term
• Implement twice daily medical/nursing care team
  review of flow delays for every inpatient
• Prioritise patients waiting for diagnostic tests
• Use a Care Bundle for length of stay management,
  including
• Care plan discussed with patient
• Discharge medication
• Follow up arrangements e.g. OPD etc.
• Day/time of discharge communicated to
  patient/carer
• Discharge letter to General Practitioner
  completed and sent
• Transport plan completed with patient and
  transport provider
• (see Care bundle graph tool)
• Embed Length of Stay management planning
• Inform patient of estimated length of stay (LOS)
• Agree transport at earliest opportunity
• Prepare discharge medications at least one day
  before discharge
• Effectively monitor and manage delays in LOS
• Promote review each day
• Early discharge to HITH and medi-hotel
• Prioritise semi-emergency access to Operating
  Room (e.g. NOF/TURP)

 
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2. Inpatient care
 

• Long term
• Implement 8 am medical meetings (white board
  rounds)
• Implement 9 am ward meetings
• Implement ward based length of stay management
  and capacity and demand planning (see toolkits)
• Implement delay tracking systems
• Implement unit based capacity and demand
  management systems
• Streamline inpatient access to diagnostic tests
  and to operating room.

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3. Operating theatres

• Short term
• Prioritise emergency, semi-emergency and elective
  cases
• Ensure links between bed management, theatre,
  relevant investigation and ICU are made (if
  relevant)
• Ensure there are ward based medical staff on
  operating days to facilitate early review and
  discharge of patients
• Ensure preadmission maximised including
  medication, tests and other relevant advice
• Eliminate schedule conflicts for medical staff in
  OR. (A receiving team registrar cannot be
  performing an elective surgery list etc).
• Long term
• Monitor and track
• - Start and finish times
• - Cancellations by hospital
• - Cancellations by patient
• - Patient transport to and from theatre
• Promote day surgery as the norm.

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4. Outpatients

• Short term
• Eliminate all unnecessary follow up appointments
  by investing time in discharge process
  referrals to General Practitioners
  (proformas/chronic disease Mx plans)
• Validate Out Patients Department lists every 13
  weeks
• Provide single point of contact for making and
  cancelling cancelling appointments
• - Monitor FTA
• - Consider courtesy calls 1-2 days prior
  appointments for high FTA type clinics
• Provide emergency slots in the morning to promote
  effective Emergency Department and inpatient
  length of stay
• Promote nurse managed discharge from clinics.
• Long term
• Review capacity and demand
• Provide waiting times data
• Promote protocol referral processes
• Promote telephone follow up and telephone Out
  Patient Department
  appointments when no medical examination is
  required.

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5. Surgical flow including pre-op and waiting
list management

• Short term
• Promote early comprehensive pre-operative
  assessment
• Confirm operation date by phone day before
  admission for every patient
• Schedule admissions whilst accommodating
  emergency demand predictions
• Validate/audit and manage the waiting list queue
  every 13 weeks by phone.
• Long term
• Manage elective demand per 3 month targets
• Schedule demand and annual leave holidays,
  conferences per speciality over 12 month period
• Manage leave plans for medical/nursing staff
• Streamline elective processes to minimise steps
• Provide a skilled, trained elective team, which
  includes administration, nursing and medical
  duties
• Elective additions to waiting lists only after
  review of availability and capacity of services
  (i.e. service available, patient ready for care).

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6. Managing flow

• Essential management of patient flow across the
  organisation demands effective processes and
  clear live data. Processes should be in place to
  provide short term and long term management of
  capacity and demand. Data should be live and
  predicted for future trends
• Structures of patient flow management should
  include frontline staff reporting to a senior
  manager who has a clear view of organisation
  demand and access to resources to resolve issues
  ( Chief Executive Officer delegation)
• A live I.T. bed management delay tracker and
  capacity and demand data should be available
  across the organisation to promote patient flow
• One of the most important pieces of information
  is capacity of the whole hospital and demand
  waiting to enter services. The traditional role
  of site (after hours) manager/bed managers needs
  to include
• Management of all patient flow demand for
  inpatient services
• Integration of emergency and elective demands and
  targets
• Length of stay management including admission,
  length of stay and discharge processes.

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7. Escalation plans
Identify the single point of accountability e.g.
General Manager to stop other duties and focus on
the issues at hand. During escalation, due to
bed block and bypass, simple effective innovation
can assist management of patient flow.
Short-term actions can include

• Review all inpatients by the patients clinical
  team
• Executive grand round of all patients. This team
  should include Executive General Manager, Senior
  Clinical Lead and Senior Nurse Lead
• Tracking of all in patient delays should be
  enforced on all wards
• Predicting Emergency Department admissions over
  the next 24 48 hours to plan bed requirements
• Increase Emergency Department staff for
  expediting treatment of low acquity patients
• Arrange one hourly Bed Manager and Lead Executive
  meetings
• Agree and review tasks every 2 hours until
  situation reversed.

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Acknowledgements
Jenny Bartlett Chief Clinical Advisor, Office of
the Chief Clinical Advisor Lee Martin Manager,
Clinical Innovation Patient Flow Collaborative
Marcus Kennedy Clinical Lead, Patient Flow
Collaborative Patient Flow Collaborative
Team Rochelle Condon, Improvement Lead Ruth
Smith, Improvement Lead Fiona Dickson,
Improvement Lead John Walker, Communications and
Logistics Lead Prue Beams, Data Consultant
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Contacts
Support to implement these system wide
initiatives is available via the Patient Flow
Collaborative team who can be contact
via Clinical Innovation Agency Email cia_at_dhs.vi
c.gov.au Phone [phone] Patient Flow
Collaborative Team Lee Martin 9616 7859
Manager, Clinical Innovation Patient Flow
Collaborative Director Rochelle Condon 9616
9026 Improvement Lead Ruth Smith 9616
9025 Improvement Lead Fiona Dickson 9616
9030 Improvement Lead Prue Beams 9616
7742 Data Consultant John Walker 9616
9037 Communications and Logistics Lead