By Allan Ajami (ED NUM /Change Manager)

The St George Experience

Top tips

Lessons learned

NSW Gov't has spent billions over the last 5 years and set to spend billions in the coming years on Health infrastructure. Currently there are 50 projects in progress worth $4.7 billion Several facilities recently redeveloped- RNS, Liverpool, Port Macquarie, Wagga, Orange…. Several others in planning or delivery phase : Sutherland, Gosford, Wyong, Wollongong, Blacktown, Westmead, St George Once in a 10-20 year opportunity

2011 pre announcement of funding for a new ED

Serve a population base of

over 200,000

Large CALD community 33% Aged population (25 %

>70y)

Paediatrics:25 % of presentations

Admit rate of 35%

St George Emergency Department: MADMEN

Airport Botany Bay

Bondi Beach

St George Emergency Department: MADMEN

o Level One Trauma centre

o 2011: 62,500 presentations

o Within top four busiest EDs in NSW

o ED treatment space = 40

o Current bed base 650 beds o 6% increase in Presentations,

St George Emergency Department: 2011

Discharged home:

65% within 4hrs

DTA: 43% within 4hrs

Variation: 1 and 12 hrs

Average time to ED doctor: 74 mins Variation: 1min – 5hrs

Pathology: Average: 1 hour Variation: 20 mins-3hrs

Admitted LOS in ED (EAP): 64% within 8 hrs Variation: 1hr – 36 hrs

Register Assessment Diagnostics

Disposition Decision

Transfer to Ward Discharge Triage

Radiology: 55% within 1 hr Variation: 26mins – 6 hrs

Admitted LOS in ED (NEAT): 17% within 4 hrs Variation: 1hr – 36 hrs

National Emergency Access Target-(NEAT)

90% of ED presentations need to be out of the ED with in 4 hrs.

Staged over 4 years. 69% 2012 76% 2013 83% 2014 90% 2015

mm…..4 Hours

Hmmm…..4 Hours

St George Emergency Department: Future State Vision St George Emergency Department: Ideal Pt journey

Immediately

Lab 30-60 min

Point of care Testing

Within 3 hours

Within Benchmark,

ideally within 30 mins

Radiology 80% within 1 hour

100% within 2 hours

Within 4 hours

Register

Assessment Diagnostics

Disposition Decision

Transfer to Ward/ Ward

Care

Discharge Hospital

Triage

2011 funding for new ED

Allowed us to look at long term solutions

Not only around process and people but also around technology and layout

Improve design and capacity of the unit- WHS,IC, storage,training facilities,privacy,computers

Implement new MoC- SAS/ETZ/FT Improve utilisation of EDSSU Improve Radiology TAT

Enhance Triage MoC Expand Acute model and remove

Subacute model Enhance coordination-Emergency

Journey Coordinator Enhance communication Enhance workforce

2012 2013 2014 2015

Phase 1 Phase 2 Phase 3

Move into new ED October 2014) ED Redevelopment

4 Hr Rule ED Flow Co-

ordinator Triage Cat 2

2011

NEAT Target: 69% 76% 83% 90%

Point of Care testing

JMO eMR entry

Pre-Lead

Reduce work place variations in senior staff practice Intern

Assignment

Admit Phone Individual phones Reduce

overheads

Streamline ED Forms STOP

Reducing the frequency and volume of interruptions

Decrease non-specialists tasks being done

eMR efficiency

JMO Assignment

Dual Med Reg cover

Dual Surg Reg cover

ED Pt Flow Coordinator

ED Clinical Notes documentation

ED workforce review PA, ED techs

Surgical Assessment Unit MAU after hours admission

criteria

Dual ED SS cover 7 days ED SS cover P3

Team Structure P2 Team Structure P3

Day Shift Roles Evening Shift Roles

Phase 4.....

LEAD

Solutions Prioritised and timed Solutions timeline: The ED Vision

Team effort- Working parties established to refine solutions for each individual area.

They each developed implementation plans consisting of

solutions

Implementation time line – quick wins

Risks and issues - mitigation strategies

Communication plans

Trials, review , evaluate

Change Management plan/register Identify all changes and their impact Utilise AIM Engage Stakeholders (internal/external) Manage resistance

Scenario testing

Equipment

Training orientation ED staff and key stakeholders

Open days staff - community

Go live day

Redevelopment is really an Opportunity to reflect on what we do and look for ways to do it better!

“By failing to prepare, you are preparing to fail". Benjamin Franklin

Designing and Building a new ED is really only 25% of the solution.

In order to improve patient care and performance you need to design a efficient system and develop a highly skilled and cohesive team

The design then really takes care of it self!

ECI ACEM MoH Site visits Literature review International models Staff Suggestions Pt Voice

5% +5%+ 5% - 10% increase in presentations =5% improvement overall

• Use Redesign methodology to

• Identify issues across the patient journey

• Design solutions

• Implement the best solutions

• Ensure we analyse problems before developing solutions by utilising data analysis, project & change management

• Proven to deliver long-term sustainable changes

Project Initiation &

Start-up

Diagnostics

Solution Design

Implementation Planning Implementation

Checkpoints Implementation

Planning

Evaluation Sustainability Knowledge

Sharing

Diagnostics

Process: process flow, policies, procedures & protocols

People: Involvement, roles & responsibilities, reporting lines & capability

Technology: changes to systems & reports or introduction of new technology

Facilities: Physical layout of the building

Collaboration is key- don’t forget external stakeholders

Get passionate- engage people on an emotional level. Lead them from fear/ anxiety to anticipation and excitement.

AHFG are guidelines! If you have good rationale stick to your guns!

ICT - look at new innovative technologies that will assist practice into the future, paperlite, task management and ensure you future proof for new ways of practice

Future proof as much as possible – flexibility in design for new models/growth

Better integration of Support services, eg Radiology/Pathology

allan.ajami@sesiahs.health.nsw.gov.au

Questions?