Patient Flow Collaborative

1
Patient Flow Collaborative
Angela Peluso - Clinical Lead Ian Jackson -
PresenterEastern Health Maroondah Hospital
2
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

3
Summarise Priority Constraint Area 2

• Acute to Sub Acute
• -Delayed access to NH Beds
• -Delayed access to Rehab beds

4
Diagnostic work

• Ward sample data repeated
• -Confirmed previously identified constraints
• Brainstorming session
• -Included all stakeholders NUMs, 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

5
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!

6
Improvement Plan

• Establish clinical area team
• - Identify clinical area team leader
• - Include key stakeholders
• -Medical representative Geriatrician
• - Rep from PJC
• - NUMs from GEM, ortho medical wards
• - Allied health social worker physio
• - Aged care nurse consultant

7
Improvement Plan Cont.

• Investigate the following six key areas
  identified as contributing to delays
• 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

8
Progress

• Implementing the following changes
• Faxing allied health referrals
• NUM generated ACAS referrals
• Improved communication channels with centralized
  bookings office

9
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 wasnt built in a day
• -be patient

10
Desired Impact

• Reduce LOS
• Reduce 12 hour waits in Ed
• Better more effective communication channels
  between sites
• Improved patient care

11
Next Steps

• Review and update relevant policies procedures
• Review admission/discharge criteria for hospital
  GEM ward

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• Questions

?
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Patient Flow Collaborative
Janine Rogers, CHIP Manager Calvary Health
Care ACT
14
Summarise Organisational Constraint areas

• Allied Health (AH) referral process-
  inappropriate not timely
• Radiology-timeliness accessibility
• Nursing Paperwork-duplicative excessive
• VMO Rounds-disjointed not well managed from
• ACAT Services-limited appointments difficulties
  with rebooking

15
Summarise Priority Constraint Area 1

• AH Issues
• Inappropriateness of referral
• Timeliness of referral
• Referral process

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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.

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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

18
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

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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
• Dont do this during accreditation

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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

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Next Steps

• Radiology mapping
• Revise nursing assessment
• Standardise across hospital
• Standardise risk assessments
• Include expectation management
• Increase efficiency of VMO rounds
• ACAT service

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• Questions

?
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Team Presentations
Melanie Hendrata and Kim Moyes 5TH October 2004
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Concurrent Session 1Team Presentations

• Bellarine Room 3
• Northeast Health - Wangaratta
• Bendigo Healthcare Group
• Southern Health Dandenong Hospital
• Peninsula Health
• Box Hill Hospital

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Patient Flow Collaborative
Christine Giles Northeast Health Wangaratta
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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 GPs and referring agencies.

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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.

28
Organisational Constraint Areas

• Communication and Information Transfer.
• Emergency Department-time taken between decision
  to admit and admission to ward.
• Medical ward LOS-activities affecting discharge,
  transfer readmissions.

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Implementation Phase- Plan, 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.

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Implementation Phase-Diagnostic 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.

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Implementation Phase-Diagnostic 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
  highlighted-
• INR-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.

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Implementation Phase-Diagnostic 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.

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Implementation Phase-Diagnostic 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.

34
Improvement and Progress

• 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 others issues.

35
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
  anti-coagulation therapy.

36
Lessons learnt

• Separate fact from opinion.
• Distil the problem from the symptoms.
• Examine data quality carefully and adapt
  diagnostic tools to be contextually appropriate-
  you cant weigh something with a tape measure
• Accept that change is painful but good leadership
  can transform negative energy into a positive
  outcome.
• Harness the energy of the organisation champions.

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Next Steps

• Trial MAPU.
• Develop education plan for Medical ward and ED
  nursing staff re history taking, referral,
  pathology and pharmaceuticals skills.
• 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.

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• Questions

?
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Patient Flow Collaborative
June DysonBendigo Health Care Group
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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

42
BHCG Organisational Constraint areas

• Availability of registrars to assess potential
  admissions in the Emergency Department (ED)
• Repetitive documentation, assessment and data
  capture for patients

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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.

44
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)

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Diagnostic work Data collection tool
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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.

47
Diagnostic work SPC of Stroke LOS
48
Diagnostic work Potential causes of Stroke long
LOS
49
Diagnostic work Potential causes of Stroke long
LOS
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Diagnostic work Long LOS

• The data was consistent with staffs 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.

51
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.

52
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

53
Lessons learnt

• It has been challenging garnering enthusiasm from
  clinical staff.
• Change is slower than we would have liked but is
  progressing.

54
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.

55
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

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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.

57
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.

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• Questions

?
59
Patient Flow Collaborative
Ms. Maggie EmmertonPharmacy Site
ManagerDandenong HospitalSouthern Health
60
Summarise Priority Constraint Area 1

• Discharge - Pharmacy
• Information / data needs
• Script Accuracy
• Communication
• Discharge planning/priorities
• Week end resources, hours

61
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

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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

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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 RMOs to verify discharge script
  before
• processing

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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.

65
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.

66
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

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Patient Flow Collaborative
Ms. Joanne Burns Director Patient Access and
Demand StrategySouthern Health
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Summarise Organisational Constraint areas

• Bed Bureau operations and functions
  inconsistent across sites of SH.
• Resources
• Communication
• Trust
• Protocols
• KRAs

69
Summarise Organisational Constraint areas

• Discharge Pharmacy
• Information / data needs
• Ward stock / requirements
• Week ends
• Communication
• Script accuracy
• Discharge planning / priorities

70
Summarise Priority Constraint Area 1

• Bed Bureau
• Inconsistent service
• Communication ad hoc
• Trust
• Defined responsibilities
• Bed allocation prioritisation
• KRAs

71
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.

72
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

73
Progress

• Access Working Group sub group Bed Bureau-
  established
• Resource costing profile
• Communication strategy / process documented
  endorsed by site executive
• Policy requirements identified
• Development elective capacity predictor tool

74
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.

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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

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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.

77
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

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Next Steps

• Continue developing the work
• Improve discharge end of journey to enhance
  interface with subacute linking with RASP services

79

• Questions

?
80
Patient Flow Collaborative
Dr Susan Sdrinis Manager Medical
OperationsPeninsula Health
81
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

82
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

83
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

84
Diagnostic work

• Process mapping
• Brainstorming
• Tick charts
• Time measurements

85
Diagnostic work

• Who was involved?
• Patients
• Frontline staff
• Departmental Managers
• Reactions?
• Have done it before
• Good, lets get this right

86
Diagnostic work
87
Diagnostic work
88
Diagnostic work
89
Improvement Plan
90
Improvement Plan
91
Progress

• Describe progress so far?
• What was the outcome?
• What was trialled?
• How many patients were involved?
• What staff were involved?

92
Lessons learned

• Process mapping / data motivated and guided group
  
• Focussing on patient need rather than department
  / staff need
• Ownership of problem by both departments

93
Lessons learned

• Having an independent facilitator
• Informal regular meetings encouraged
  brainstorming of solutions
• Involvement of frontline staff earlier

94
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

95
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.

96
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

97
Next Steps

• Continue to develop innovations to address all
  critical to quality items
• Involve more frontline staff in process
• Post implementation data analysis

98
Patient Flow Collaborative
Kate MacRae Director of Occupational
TherapyPeninsula Health
99
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

100
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 OHS issue.

101
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.

102
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.

103
Improvement Plan

• The need for a car (station wagon) to be
  quarantined at each site, which was prioritised
  for clinical use, was identified.

104
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.

105
Lessons learnt

• Quick wins are important!
• An analysis of one problem often identifies
  other issues, which will need to be addressed.

106
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.

107
Next Steps

• The project is now completed.

108

• Questions

?
109
Patient Flow Collaborative
CARMEL BROWNE BOX HILL HOSPITAL
110
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.

111
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.

112
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.

113
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.

114
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.

115
Lessons learnt

• This process is currently person dependant.
• The data analysis and creation of the daily sheet
  is time consuming.

116
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 x7 wards A2 x16 " x5 " B1 x10 " x3
" B2 x30 " x7 " Oncol x14 " x3
" Haem x13 " x2 " CCU x8 Neuro x10 " x2
" Spec x12 " 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.
117
Desired Impact

• Improved access to a bed and medical consultation
  for the patient.
• Improved collaboration amongst medical
  registrars.

118
Next Steps

• Development of an automated program will assist
  with the long term progress and sustainability of
  this trial

119

• Questions

?
120
Team Presentations
Tony Snell and Prue Beams 5TH October 2004
121
Concurrent Session 1Team Presentations

• Bellarine Room 4
• LaTrobe Regional Hospital
• St Vincents Health
• Northern Health
• Angliss Hospital

122
Patient Flow Collaborative
Peter Wright - ED DirectorLatrobe Regional
Hospital
123
Summarise Organisational Constraint areas

• 1. Bed availability (ED Acute, Acute
  Sub-Acute)
• 2. Awaiting ACAS assessment
• 3. Delay in Allied Health Assessments
• 4. Reluctance to call Inpatient Referral
• 5. Medical rounds done too late in day
• 6. Awaiting Inpatient Team assessment in ED
• 7. Awaiting clinical investigations
• 8. HMO decision making delays
• 9. Delay in CT results ultrasound
• 10. No Radiology between 10pm - 830am

124
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.

125
Hourly Tracking Analysis
R Radiology BABed 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
126
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 AUMs 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

127
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.

128
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

129
Progress

• Were 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

130
Progress cont .

• Positive impacts to date
• 3 decrease in ED journey average stay time.
• 23 increase in utilisation of Short Stay Unit

131
Progress cont ...

• We expect to see more significant improvement as
  initiatives settle in.
• ED AUMs, Management and all ED patients over 3
  months were involved in the hourly data
  collection.

132
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)

133
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

134
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.

135

• Questions
• Contacts
• Peter Wright
• ED Director
• pwright_at_lrh.com.au
• Wen Bezzina
• PFC Co-ordinator
• wbezzina_at_lrh.com.au
• [phone]

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