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James Lind, Acting Director of Access and Patient Flow Unit, Gold Coast Hospital delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow conference 2013 in Melbourne. For more information on the annual event, please visit the conference website: http://bit.ly/1f3Pp03
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1
6th Annual Hospital bed management and patient flow conference
25 Feb 2013
2
The team
3
What is the Gold Coast health Service district?
Demographics
Gold Coast
Southport
Gold Coast
Robina
Carrara
Hospital
4
You pay for this……. But not for this!
Why would we go back?
5
Are we Patient-centric?
3P philosophy is it right?
•Patients
•Providers
•Payers
Are we patient centric
6
Distances between: Southport-Robina 20kms- 25kms 25-27 mins Southport- Pindara 6.4kms- 8.9kms 12-15 mins Robina- Pindara 13kms- 17.7kms 18-22 mins
Physiotherapy
Post-Surgery
Robina
Self- Referral
CNC Clinic
Robina
Preadmission
Outpatients
Robina
Genetic Counselling
Robina
-counselling Brisbane
Operating
Theatre
Robina
Hookwire ONLY
Southport Radiology
Riverwalk Way Robina
Physiotherapy / OT
For OP appointment
GCH Southport
Lymphosintigraphy +HW
Pindara Private Hospital
Benowa
KS Guided Core FNA
Medical Imaging
GCH Southport
Lymphosintigraphy + HW
South Coast Radiology
Chemotherapy (most)
Hormonal Treatment
GCH Oncology Southport
FNA In clinic
GCH Southport
Frozen Section -
GCH Southport
Our organisation is provider centric
7
Is there a common ground through KPIs
8
90 in 4
The bodies of work
9
Stage 0:
Plan
Weeks 1-6 Weeks 7- 10 Weeks 11-20
Stage 1:
Diagnostics
Stage 2:
Solution
design
Stage 3:
Implementation
Weeks -4 to 0
Commencing: 11th April
Methodology
Week 15 Week 16 Week 17
w/c 9 May w/c 16 May w/c 23 May
• Sponsors and leads
checking readiness
factors to progress
strategic enablers and
phase 1
• Communications
planning (including
launch)
• KPI reporting
mechanism design
• Strategic enablers &
phase 1 solutions
commence
implementation
• Communication events
• Formalise monitoring &
reporting
• Continued
implementation and
support
• PJP Project Board
meeting
3 May
Implementation
Report signed
off
10
Strategic enablers
subacute &
community care
Inpatient
care
Emergency
care
• Planning does not happen
effectively at a strategic level
• Responsibilities for bed
management are assigned
across many different roles.
This causes confusion and
impedes effective patient
flow management
• The geriatric population are a
disproportional number of ED attendances
and admissions
• The elderly are accessed blocked from
designated inpatient units
• Cat 2 waiting times exceed
QH targets of 10 min
• Cat 3 waiting times exceed
the QH target 30 min
• The current model of care for out-of-hours and weekends does
not allow for ongoing quality patient management nor efficient
discharges
• Access block is compounded by a poor rate of discharges over
weekends
• Patients do not receive allied health care over the weekends
• Pharmacy is unable to meet the demand for clinical pharmacy services,
causing medication related discharge delays and an increased risk of
medication errors
• Limited pharmacy services „after hours‟ increases the risk of medication error
• Most consultant ward rounds are not
scheduled and often occur at an
extremely fast pace
• Poor documentation from treating
teams leads to delays in patient care
activities being carried out
• Poor communication within the
multidisciplinary team
• Lack of coordinated patient care
• The transit unit is underutilised at
Southport and is not configured to be
used as a discharge unit
• Patients are not transferred to the
Southport transit unit due to delays in
prescription writing
• Robina does not have a transit unit
• Patients are staying in hospital
too long because referrals to
subacute care isn‟t starting early
enough in the patients‟ journey
• Referrals to subacute are not
comprehensive enough
• Transport delay is a major
factor in timely patient
transport both within the
organisation and home
• Patients perceive their treatment is
uncoordinated, not integrated and
not communicated effectively
• Inconsistent referral methods
across specialities and teams
causing confusion
• Delays occur in actioning
referrals and assessments
• Patient / Carer Experience surveys
indicated that there is a lack of co-ordination
and integration of care (including discharge)
• Discharge planning is fragmented and starts
too late in the patient journey
• There is lack of coordinated care and
discharge planning between staff that can
lead to delays in patients discharge
• Consistently high bed occupancy
adds complexity to management of
patient flow
• The District‟s patient flow procedure is
complex and not applied consistently
or effectively
• Medical and surgical elective
admissions are not always aligned to
capacity
• PAU is perceived to have fragmented
processes with increased patient delays for
review
• PAU lacks support from senior medical staff
• Patients and staff experience delays of up to
one week, waiting for diagnostic tests
• Patients often arrive in the medical imaging
department with patient preparation
requirements incomplete causing delays in
patient throughput.
• There is a lack of
clarity in the
accountability and
ownership of patient
and process of
referrals
• Medical officer
referrals are not
consistently responded
to in a timely manner
or by appropriate
seniority leading to
compromises in patient
safety
The diagnostic exercise identified a range of issues across the patient journey
Diagnostic Phase - Overview
Draft for discussion only – Not for distribution – Gold Coast Health Service District 10
Draft for discussion only
11
A range of stakeholders have been engaged to identify and develop solutions to
address the key issues identified in the diagnostic report
27
solution design
workshops
conducted
15
working parties
established
Leading best
practice research
69
patient interviews
conducted
More than 200 staff and external
stakeholders have contributed to the
solution design phase
Workshops
Approach to solution design
11
12
12
Implementation Report – How did we get here?
12
This report is a documented practical guide for implementation of the identified
solutions aligned to the District goal for access block.
Post-acute care
Treatment
/care
Communication & HR
Information management & reporting
Patient flow & bed management
TransitionReferral
Inpatient care
Discharge
coordination
Care
delivery
Assess &
admit
Emergency care
DecisionTreatAssessTriagePre- present
& present
• A high proportion of QAS presentations consist of category 1 and 2
patients
• A high proportion of elderly patients present as category 2 and 3.
Generally, these patients are more likely to need an inpatient bed
• Services are fragmented and difficult
for both care providers and consumers
to navigate
• Inaccurate or inappropriate referrals
are often made due to a lack of
awareness regarding what services are
available and how they should be
accessed
• Delays between referral and transfer to
sub-acute services result increased
length of stay
• There is limited or no coordination
between service providers
• Patients and staff also experience delays
waiting for diagnostic tests and receiving test
results
• There are opportunities to improve the
utilisation of theatres across campuses
• Pre-admission clinic is perceived to have
fragmented processes with increased patient
delays for review and lacks support from senior
medical staff
• The number of
presentations at
ED is increasing,
with an
increasing
proportion of
elderly patients
presenting at ED
• Typically elderly
patients are
complex and
have multiple co-
morbidities, they
are more likely to
present to
hospital more
than once
• Several issues can routinely
impact patient care during the
assessment and admission
process, and when patients are
transferred to the ward
• Medical and surgical
elective admissions are
not always scheduled to
align to available bed
capacity
• Challenges experienced
by staff who coordinate
patient flow are
exacerbated because
relevant information is
not available to support
timely decision making
• Responsibilities for bed
management are
assigned across many
different roles. This
causes a mismatch and
impedes effective patient
flow management
• High levels of ward block impede the ability of the
District to transfer patients from the ED to an
inpatient bed and some wards are more frequently
access blocked
• Elderly patients wait longer for an inpatient bed
and also end up having a longer length of stay
• Significant delays occur waiting for inpatient teams
to review patients in the emergency department.
This exacerbates access block
• Unclear communications between patients and staff
result in patients not feeling valued or empowered
• Patients perceive that their treatment is
uncoordinated and not communicated effectively to
them
• Poor data integrity
impedes patient care
throughout the
patient journey
• Discharge planning in the District is fragmented
and starts too late in the patient journey
• Challenges related to the coordination of care
within teams impedes the discharge process
• Access block is compounded by a poor rate of
discharges on the weekends
• Failure to prepare and send patient discharge
summaries is impeding continuity of care within
the community
• Wait times for transport services provided by
QAS contribute to discharge delays from the
transit lounge
• There is a perception that the transit lounge
could be utilised to facilitate a greater proportion
of discharges from the Southport campus
This approach involved District staff prioritising a over 250 solution ideas based on
ease and impact
Solution themes
Patient flow and bed management
Care coordination and communication
Diagnostics
Pharmacy
ED cat 2 & 3
Geriatric model of care
subacute referrals
Transit lounge
Transport
Pre-admission
Out of hours rostering
Greater level of impact
21 3
Gre
ate
r e
ase
of im
ple
me
nta
tio
n
21
3
Approach to solution design
11
Implementation Report
The purpose of this document is to:
• Detail the District‟s solutions to
patient flow issues
• Provide appropriate plans to guide
the implementation
• Provide a framework for managing
the implementation
• Outline benefit management
approach
• Identify key readiness criteria
•
April 2011
Stage 3: Implementation Report
Solutions Report
Diagnostic Report
Stage 0:
Plan
Weeks 1-6 Weeks 7- 10 Weeks 11-20
Stage 1:
Diagnostics
Stage 2:
Solution
design
Stage 3:
Implementation
Weeks -4 to 0
Diagnostic
Report
Solution Design
Report
Project Plan Implementation
Report
13
Overview of the Implementation Report – for each solution
13
Solution statement
Implement standardised and streamlined discharge process including clear roles and responsibilities to improve patient
experience, quality and timeliness of discharge
Proposed benefits and outcomes:
Reduced confusion and duplication between staff
Reduce discharge delays
Improved patient and carer experience
Earlier discharge of inpatients
Improved staff satisfaction including primary care
Leading practice:
• Best practice is a comprehensive discharge plan
developed within 48 hours of admission
• Identification of patient trajectories early and
matches patients to next step (Barwon Health)
• Re-engineering discharge incorporates Virtual
Louise for discharge education and dedicated
discharge planning work station (protected space)
• Clinical care pathways facilitate discharge by
achieving enhanced and quicker patient recovery
(Health Advisory Board, 2010)
KPIs
• Discharge by time of day
• Patient experience indicators
• Utilisation of discharge tools
• Number of patients with discharge summaries within 24 hours of discharge
• Feedback from General Practitioners
Solution design:
Implement standardised and streamlined discharge process that reflects leading
practice (should include informing patient and family of likely discharged date as
early as possible)
Implement early assessment and identification of discharge needs.
Implement consistent patient education on discharge (patient hand-outs)
Evaluate the effectiveness of tools used to facilitate discharge and recommend
changes to simplify
Review roles and responsibilities for alignment of discharge processes including
ownership of the patient (family and carers)
Measure and report adherence to streamline process and monitor effectiveness
of tools and teams
Key issues/insights:
• Patient / Carer Experience surveys indicated that
there is a lack of co-ordination and integration of
care (including discharge)
• Discharge planning is fragmented and starts too
late in the patient journey
• There is lack of coordinated care and discharge
planning between staff that can lead to delays in
patients discharge
• Poor communication between and within
disciplines.
• Team members work in silos and do not share
information with other disciplines
• Perceived inconsistency in providing information /
education to patients
Sponsor: Morven Gemmill
Solution l: Implement standardised and streamlined discharge process and toolsSolution l: Implement standardised and streamlined discharge process and tools
1
Tasks Owner Dependency 1 2 3 4 5 6 7 8 9 10 11 12 Ongoing
Planning and preparation
Leadership Sponsor
Change Management leadership Lead
Determine sponsors and advocates Lead
Agree responsibilities Sponsor
Change Readiness Sponsor
Sponsor the change Sponsor
Monitor change management & stakeholders Lead
Report progress to executive sponsor Lead
Formalise working party Sponsor
Identify and agree working party Sponsor
Obtain commitment from working party members Lead
>>>>>>>…
Resource requirement plan
Review current staffing levels and services provided Lead
Develop draft staged plan for additional resoucres to meet demand for clinical
pharmacy services
Lead
Seek feedback from stakeholders regarding resource plan Lead
Resource plan endorsed Sponsor/board Board approval
Funding approved Executive Executive approval
Recruitment and deployment
Positions advertised Lead
Interviews completed Lead
Order of merit for HP3 and HP4 pharmacists finalised Lead
Appoint from order of merit Lead Executive approval
Pharmacists commence Lead
Orientate to department Lead
Deploy pharmacists as agreed in implementation plan Lead
Resources
Identify requirements in line with endorsed implementation plan Lead
Purchase required dect phones, wireless computers, lockers Lead Executive approval
Communications plan
Identify audience groups impacted by change Lead Executive approval
Determine communication needs Lead
Develop communication messages Lead
Deliver communications Lead
Gather feedback Lead
Measurement and reporting
Agree benefits Lead/MAC
Determine KPIs to support benefits Lead/MAC
Define measurement approach Lead
Develop measurement tools Lead
Measure and report progress Lead
Inpatient unit based clinical pharmacy services - implementaton Timeline: Week
1Draft for discussion only – Not for distribution – Gold Coast Health Service District
Risks:
• Failure to gain support for clinical pharmacy services will further contribute to
Pharmacy staff burnout resulting in excessive sick leave and turnover
• Lack of space at Southport
Key Solution: [summary headline of the solution topic]
Implementation team
Team role Team member Day per week Total weeks
Sponsor Jane Hancock 0
Project lead Trudy McGovern 1 8
Team member Liz Coombes 0
Team member Linda Stockwell 0
Team member Balaji Hiremagalur 0
Team member Paula Duffy – to confirm 0
Implementation team
Team role Team member Day per week Total weeks
Sponsor Jane Hancock 0
Project lead Trudy McGovern 1 8
Team member Liz Coombes 0
Team member Linda Stockwell 0
Team member Balaji Hiremagalur 0
Team member Paula Duffy – to confirm 0
Parallel projects:
PJP projects:
• Co-ordination of care and communication
• Transit Unit
• Transport
External
• Medication Services Queensland – review of
statewide medication discharge procedure (postive
impact)
• eHealth
Other resource requirements:
• Clinical pharmacy service – approx 16 FTE HP3/4/5 pharmacists to GCUH
transition to cover existing beds
• Computers, phones, lockers
KPI‟s
• Organisational KPI‟s
• Readmission rates
• Length of Stay
• Solution KPI‟s
• Medication error rate
• Time to complete medication discharge
• Quality of medication list in EDS
• Pharmacist ratios
• Patient KPI‟s
• Patient experience
Quick Wins (operational milestones thought to deliver
specific benefits within eight weeks of operation).
• Simplifying the medication discharge procedure to
reduce time and improve quality of the discharge
Dependencies:
• Medical and nursing staff to follow revised medication discharge procedures
• Adequate capacity to orientate, train and supervise pharmacists
Updated solution statements
reflecting latest thinking developed
by working parties and Sponsors
Detailed work break down
structure for the
implementation including:
• Duration of tasks (in weeks)
• Owners of tasks
• Dependencies
• Milestones
Outline business case for
the implementation
including:
• People involved in
implementing and
estimated time
commitments
• Other, non staff resources
required (eg. IT)
• Discussion of risks and
dependencies for the
implementation
• Quick wins and benefits
• Related projects
14
Before any project can be mobilised, a number of key steps must be completed.
Mobilisation check list
14
Checklist for Executive Sponsor Mobilisation of Solution Implementation
Project Lead identified and availability confirmed
Working party members identified and availability confirmed
Additional resources identified and confirmed
Change Readiness assessment for mobilisation:
oEnvironment
oStakeholders
oCommunication
oResources
oSchedule
oGovernance
o Risk
Funding and resource requirements defined (if applicable)
Funding and resource secured (if applicable)
Competing interests identified
Risks identified and mitigation strategies in place
15
Solutions in action
16
Implementation road map
16
The recommended phasing of implementation starts with the strategic enablers and
quick wins, as planning and preparation starts for the next phase.
0-3 months 3-6 months 6-9 months 9-12 months 12-18 months
Prepare & Plan Implement
Prepare & Plan Implement
Evaluate, Monitor & Manage
Strategic Enablers
Evaluate, Monitor & Manage 2 - Team based care coordination and communication
1 - Patient Flow Strategy and Infrastructure
Implement
Evaluate, Monitor & Manage
3 - Bed management standard business rules
4 - Improve Category 2 and 3 emergency patient journey
5 - Early identification of Subacute patients
6 - Demand management for transportation services
7 – In-patient Unit Rounds & Communication
8 - Medical officer referrals business rules
9 - Allied health referral coordination
10 - Standard discharge process and tools
11 - Medical imaging systems realignment
12 - surgical pre-admission clinic service redesign
14 - Transit unit review and model of care development
13 – In-patient unit based clinical pharmacist
15 - Weekend activity and service alignment
Phase 1 Solutions
Phase 2 Solutions
Phase 3 Solutions
17
17
Project Board
Project Team
Working
Party 1
Working
Party 2
Working
Party 3
Responsibilities include:
• Review and endorse
implementation plans
• Sponsor the implementation
of initiatives and supporting
solution teams
•Support solution teams and
review solution status reports
• Consider and approve
resourcing requests
• Design and implement risk
Mitigation strategies.
Responsibilities include:
• Provide program leadership and support to the assigned sponsors and project leads (responsible
owners)
• Organise and facilitate establishment of working parties
• Report overall program progress to project board and executive sponsor
• Monitor compliance with readiness assessments, timeframes and implementation plans
• Provide program management and utilise deep knowledge of hospital processes and peoples to lead
delivery of implementation activities
•Escalate overall program issues, risks and dis-benefits to the executive sponsor
Accountable Executive (Sponsor) •.
Responsible Officer (Project Lead)
Working Party Members
Managing Implementation
Consumer
on board
18
So did it work for consumers?
We hit our NEAT, NEST and budget
targets……or did we miss the point!
19
So what do consumers want or Complain about!!!
Consumers
• Communication
- To he listen to and respected
- To be kept in the picture
• They expect to wait!!!
Complaints
• Poor communication
• Poor treatment
• Poor access
Hospitals
• NEAT
• NEST
• Budget
• MORI
• SAC events
• Standardized mortality
20
How do we measure it? Patients consented in hospital
Followed up in phone interview
Open standardised questions
Theme then classified
• 3 methodologies choosen
- Feedback after visit
- Real time interview
- PET
Measurements
21
Patient Experience Trackers
Ask the same questions to staff and
patients to identify gaps
eg do you know your estimated day
of discharge
22
So what have we done ? “In ED from
10am until
8.30pm-that is a
long day”
“Signage is awful”
“I was left in a soiled bed
and PJs for some time”
“The nurse to nurse
“handover” of information
about me was wrong”
Implemented
NEAT
Decluttered
and Rewritten
signs
Intentional
hourly ward
rounds
Patient
included in
hand over
So what else
23
What are the main lessons learnt
•What patients want may be different to what is perceived
•Current KPI cannot capture the consumers needs
•There is significant overlap in some KPIs
•Fixing entire systems benefits both consumers and staff
25
Can we Beat Disney at their own game
Can we beat Disney at their own game?
26
26
Thank you