TO ACUTE CARE SERVICES

A practical toolkit for use in public hospitalsDeveloped by the Clinical Excellence Commission

Clinical Excellence Commission

IMPROVING PATIENT ACCESS

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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

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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 isn’t 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 HammettDirectorHealthcare Improvement ProjectsNSW Clinical Excellence CommissionMarch 2005

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HOW TO USE THIS TOOLKIT 6

1. INTRODUCTION 7

2. PLANNING THE IMPROVEMENT WORK 11

2.1 Identify and define the problem 122.2 Review data to understand hospital activity and performance 122.3 Engage clinicians and convene the redesign team 142.3.1 Leadership 142.3.2 Team members 152.4 Diagnostic Work 162.4.1 Understanding the current systems and processes 162.4.2 Tools for understanding processes 172.5 Determine your aim 192.6 Designing and implementing changes 202.6.1 Identify interventions to implement 202.6.2 Practical ideas for effecting change 212.6.3 Implementation plan 222.7 Analyse the Results 232.7.1 Methods of measurement 232.8 Communicating the change 242.8.1 Key factors for successfully managing change 25 Case study - Western Sydney AHS -

Neck of Femur Patient Flow Group 26 Checklist prior to starting your improving access project 34

3. INTERVENTIONS 35

3.1 General strategies 363.1.1 Shared work plans, practices and schedules

within multi-disciplinary teams 363.1.2 Develop multi-disciplinary evidence based pathways 373.1.3 Relative performance table 373.1.4 Convene a redesign team 383.1.5 Improve communication systems 383.1.6 Referral to specialist services 393.1.7 Service level agreements 393.1.8 Managing capacity to respond to need for services 393.1.9 Minimise variation in capacity to provide care 403.1.10 Change to 7 day a week services 403.1.11 Buffer beds 403.1.12 Smoothing variation in elective activity 413.1.13 Develop advanced nursing roles 413.1.14 Up-skilling peripheral hospitals for complex patient needs 423.1.15 Align staff specialist/consultants work to maximise efficiency 423.1.16 Bed management system 433.1.17 Centralised bed authority/bed co-ordinator 433.1.18 Regular multi-disciplinary bed meetings 45

Contents

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3.1.19 Teleconference bed updates 453.1.20 Clinical prioritisation of patients 453.1.21 Reconfigure beds to reduce outliers 463.1.22 Over Census Policy 463.1.23 Guidelines and protocols for test ordering 473.1.24 Review permissions to order tests 483.1.25 Prioritise tests for Emergency Department

or patients waiting for discharge 483.1.26 Allocated time for emergency cases 483.1.27 Appropriate information on request form 493.1.28 Patients attending for tests 493.1.29 Stratified test ordering 503.2 Emergency patient flow 513.2.1 Pre-bypass hospital early warning system 513.2.2 Streaming techniques 533.2.3 Alternate admission processes 533.2.4 Develop alternate services to prevent ED presentation 543.2.5 Advanced nursing and allied health practitioner roles 543.2.6 Fast Track 543.2.7 See and Treat 553.2.8 Lean thinking 563.2.9 Clinical pathways around presenting problems not diagnoses 573.2.10 ED access to day surgical list bookings 573.2.11 Communications clerk 583.2.12 Emergency medicine unit 583.2.13 Flag and case manage frequent attendees 583.3 Improving Flow of Emergency Surgical Patients 593.3.1 Clinical guidelines or pathways 593.3.2 Team briefing and debriefing sessions 603.3.3 Emergency department physician admission rites 603.3.4 Review existing demand for emergency operating theatre time 613.3.5 Prioritisation protocol 613.3.6 Prioritisation team 613.3.7 Pre-operative placement of patients waiting for OT 613.4 Medical strategies 623.4.1 Medical assessment and planning unit 623.4.2 Day only admission ward for ED patients 623.4.3 Flag and case manage frequent medical admitted patients 623.4.4 Trial at home program 633.4.5 Improve appropriateness of admission 633.4.6 Safety risk assessment 633.5 Improving communication 643.5.1 Improving communication with GPs and community nursing 643.5.2 Generic transfer/discharge to hospital form for

all residential aged care facilities (nursing homes) 653.5.3 Link ‘discharge from ward time’ with ‘admission

from Emergency Department’ time 65

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3.5.4 Scheduled transfers 653.6 Improving discharge processes 663.6.1 Discharge risk assessment form 663.6.2 Admission and discharge plan 673.6.3 Criteria driven discharge 673.6.4 Nurse activated discharge 673.6.5 Monday morning audit 683.6.6 Weekend discharge pharmacy 683.6.7 Multi-disciplinary Discharge Meetings 693.6.8 Informing patients and carers about their discharge 703.6.9 Discharge checklist 703.6.10 Estimated day of discharge 713.6.11 Estimated length of stay table 713.6.12 Compare the estimated date of discharge

to the actual date of discharge 723.7 Aged care 733.7.1 Aged care assessment team (ACAT) 733.7.2 Transitional care beds 733.7.3 Community transitional care beds 733.7.4 ComPacks service model 743.7.5 Purchase transitional care beds 743.7.6 Direct emergency admission protocol 743.7.7 “Dependant care” stream of patients managed

by specialist nurse practitioner 743.7.8 Walking assistance program 753.8 Elective Patient Flow 753.8.1 Quarantined elective surgical beds 753.8.2 Criteria driven discharge 753.8.3 Surgical pathways and estimated day of discharge (EDD) 763.8.4 Increase day of surgery admission rates and

manage performance outliers better 763.8.5 Audit all theatre delays or cancellations 763.8.6 Surgical peri-operative liaison nurses 763.8.7 Medihotels 773.8.8 Flexible staffing 773.8.9 Align leave of multi-disciplinary surgical teams 773.8.10 Clinical teams operating pooled referrals 773.8.11 Clinical pathways 773.8.12 Improve completion of consent forms 783.8.13 Marking operating site 783.8.14 Improve compliance with fasting requirements 783.8.15 Predict surgical case length accurately 78

GLOSSARY OF TERMS 79

ACKNOWLEDGEMENTS 80

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How to use this ToolkitThe Improving Patient Access Toolkit is divided into the following sections:

� Introduction to patient flow

� Planning the improvement work

� Diagnosing flow problems in your organisation

� Key elements of an access improvement project

� Interventions/change ideas

The Toolkit has been designed with the intention that you should adopt a systematic approach to improving patient flow across your organisation. To do this, you should start at the beginning of the Toolkit and work your way through the different stages of designing and implementing a successful redesign program. However, should you simply want change ideas and strategies to implement, you should go directly to the interventions section where there are detailed descriptions of many specific changes you can test.

Throughout the document you will find the following icons that will guide you to useful resources.

Key to icons:

Tool available on CD Rom

Hospitals where interventions are in place

Resource available on the internet

Bookmark link within document

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1. IntroductionIntroduction 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.

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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 patient’s 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

Category 1 | prevent admission

Category 3 | these patients may have more complex support needs

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Length of stay | Medical Patients

Length of stay (days) | Average LoS = 7.24 daysSource | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals

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The importance of managing variationMany of the delays that plague patients attempting to access acute services

are not due to inadequate resources, but rather the result of the variation with which these resources are utilised. For example, many hospitals have extensive waiting lists for outpatient clinic appointments. When an analysis is undertaken of the number of clinic appointment times available, it is often the case that the current clinical capacity actually matches the demand for the service, except that every time there is a public holiday or a conference, the outpatient clinic is cancelled and as a result a waiting list is produced. If clinics were rescheduled rather than cancelled this would not occur.

Similarly, the variation in the number of patients a hospital admits for elective surgery may in itself be contributing to waiting lists, access block and surgical cancellations. The graph shown in figure 2 below is taken from a hospital that on average admitted 49.7 patients every day. In the top part of the graph you can see that the number of patients admitted varied between 24 and 78 on any single day. To ensure it could provide enough beds for all patients on 99.9% of days, this hospital required 78 beds to be kept open for elective admissions. In the bottom part of the graph the same average number of patients were admitted (49.7) but, by reducing the variation in the number of patients admitted (38-70 cf 24-78), the number of beds required to ensure availability for 99.9% of patients was reduced to 68.

Figure 2

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Total Admissions | April-November

Standardised Admissions | April-November

78 beds required each day to give 99.9% chance of admission

68 beds required each day to give 99.9% chance of admission

Daily bed requirement reduced from 78 to 68

AdmissionsAverage = 49.7UPL = 67.9

AdmissionsAverage = 49.7UPL = 78.1

Source | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals

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

Foundations of demand and capacity (NHS presentation)

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2. Planning the improvement workSuccessful implementation of changes will depend on effective project management throughout the period of the project.

Project steps

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review data to understand activity and performance

Identify and define the problem

engage clinicians and convene the redesign team

complete baseline diagnostic work

determine the aim

identify interventions to trial

design and implement the changes

analyse the results

communicate the changes

build in accountability to help sustain changes

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2.1 Identify and define the problemBefore commencing work, it is useful to try to sum up the problem you wish

to improve in one sentence e.g. reduce or eliminate access block, improve discharge processes for medical patients, or decrease delays in transferring patients between hospitals. Identify the problem from the patients’ perspective and use terms that describe their experience. This will help clarify the core objective of the work you are about to undertake and prevent your project from suffering from a diffuse, poorly directed lack of purpose.

The amount of work and degree of change required will vary depending on the scope of the project. Significant improvements to patient access to acute services may be produced by implementing change at local departmental level, service, ward or across an entire hospital.

2.2 Review data to understand hospital activity and performance

It is vital that characteristics of patient populations and their flow through the system are understood. The following is a general list of data that will help in understanding patient flow in the organisation and may be obtained from the Patient Access System (PAS), Disease Index (DI), Emergency Department Information System (EDIS) or the Health Information Exchange (HIE). Only extract the data needed to help understand that part of the system of interest. Use the data to highlight problems or to prove the changes implemented are making a significant improvement.

1 Numbers of access block patients by day at 12 MD, 4 pm and 8 pm. This will identify within-day variation in demand for services that will assist with planning staffing needs throughout your organisation.

2 Number of beds used daily by ED status (admitted and discharged from ED, admitted through ED, not admitted through ED) at peak times (12 MD and 4 pm). This will assist in identifying the bed requirements for each clinical department to deal with their emergency patient load. It should be utilised in conjunction with an analysis of elective admissions by clinical department to plan appropriate bed allocation.

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3 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.

4 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.

5 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.

6 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.

7 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.

8 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.

9 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.

10 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.

11 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.

Access Blocked Patient Analysis 2002-2003 (NSH)

Hospital Flow Measurement Guide (IHI)

www.qualityhealthcare.org/IHI/Topics/Flow/PatientFlow/EmergingContent/HospitalFlowMeasurementGuide.htm

2.3 Engage clinicians and convene the redesign team

2.3.1 LeadershipEffective leadership is crucial to maintaining a focus on improving the

patient experience. The team should include:

� someone with the skills, energy and enthusiasm to lead the project,

� strong medical and nursing leadership at all organisational levels,

� clinician managers who are effective champions for the project. They have an important role in spreading improvements to other departments and may be required to performance manage individual variance,

� individual clinician leaders who participate and use their influence to support change amongst their colleagues,

� leaders with a clear vision of the project who can sell this vision to others.

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2.3.2 Team membersWhen bringing together a project group or a redesign team ensure

there is a mix of administration, medicine, nursing and allied health representation relevant to the project’s aims. Enthusiasm and interest in the project are essential qualities to look for in team members. They should also have an operational role in the processes to be changed. Many sites that have successfully improved patient flows have also actively involved consumers in the work of their teams, in a manner appropriate to the context of the organisation.

Team members also need to take the following roles:

2.3.2.1 Executive sponsorPrevious experience has demonstrated that effective sponsorship at an

executive level is crucial to successful implementation of organisational change. Executive sponsors need to be at Area Health Service level or executive level in a facility i.e. Director of Clinical Services or Hospital Executive Director and be:

� someone with enough influence in the organisation to oversee the change,

� someone prepared to set aside time for the project.

2.3.2.2 Clinical leadersMost projects require a nursing lead and a medical lead. They should be

someone who:

� understands the processes of care,

� is able to provide technical expertise in order to produce solutions that are technically proper, ethically sound and effective,

� can provide effective leadership,

� is an opinion leader who can influence his/her peers to produce improvement in existing systems of care delivery.

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2.3.2.3 Project co-ordinatorSomeone who:

� understands not only the details of the system, but also the various effects of making change(s) in the system,

� has the necessary skills, including computer literacy, project management and high-level organisational skills,

� ideally has some experience in change management, process mapping and Clinical Practice Improvement (CPI) techniques.

2.4 Diagnostic Work

2.4.1 Understanding the current systems and processes� Identify what the main streams of activity are within the service where

you are seeking improvements e.g. elective day of surgery admission stream, emergency medical admit and discharge from ED, elective medical procedure admissions.

� Identify what the key processes and issues are within those streams, using a variety of means that collect patient and staff perspectives of the problem. Use interviews, focus groups, patient journeys and process mapping.

� Review:

� current or recent projects, their aims and outcomes to date,

� current policies and procedure manuals,

� currently available data.

Measurement for Improvement, Improvement Leaders’ Guide (NHS)

www.modern.nhs.uk/improvementguides/measurement/

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2.4.2 Tools for understanding processes

2.4.2.1 Process mappingThe flow of patients through hospital, whether as emergency admission,

ED presentation, outpatient or for an elective procedure, involves multiple processes, many of which may be repeated approximately the same way for every patient. Even very complex procedures may be standardised, based on sound scientific practice. This can help to reduce variation and inefficiency caused by poor communication and redundant complexity. Process mapping is a technique to identify inefficiencies; redundant steps in clinical workflow; bottlenecks or blockage points where time or resources are wasted.

Improving Patient Flows - Guide to Process Mapping (Institute for Clinical Excellence)

Improvement Leaders Guide to Process Mapping, Analysis and Redesign 2002 (NHS)

Easy Guide to Clinical Practice Improvement 2002 (NSW Health)

2.4.2.2 Patient journeyTracking a patient’s journey through the healthcare system is a simple way

to understand where problems lie and how the service looks through the eyes of a patient. Any member of staff can do this by shadowing a patient through the system and keeping a time log of activities. Alternatively, ask a patient or their carer to write a diary of their experience. The patient journey may be used to verify findings of the process mapping exercise and will allow identification of any waits and delays in real time.

Patient Journey Tools (Institute for Clinical Excellence)

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2.4.2.3 Understanding major bottlenecksFor those bottlenecks identified in the process mapping, you should audit

the reasons for patients waiting and measure the waiting times involved. For example you could record the time from request for diagnostics to the time results are reviewed by the referring team.

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)

2.4.2.4 Patient flow auditsGreater than 14 day audit — do a walk around of all patients with a length of stay greater than 14 days. Ask if they are sick, are they waiting for something, why have they not been able to go home?

Discharge Delay Data Collection Worksheet (Western Sydney Health)

Monday audit — review all patients who are discharged on Monday. Ask the following questions. Were they medically stable on Saturday or Sunday? Why weren’t they discharged earlier? e.g. lack of services, waiting for a test, waiting for review by medical officers.

Discharge Audit Tool (RNS Hospital)

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2.5 Determine your aimDevelop a statement about the aim of your project. An aim is used to keep

the team focused on what it is trying to achieve and provide a measure for the project’s success.

Based on your diagnostic data, determine aims that include:

� the percentage improvement you will work towards achieving,

� the time within which you will achieve the aim.

Example: To have less than 10% of 75 year old patients experiencing four hour access block within six months.

It is important to note a few key points about these aims:

1 Use the diagnostic work to find what is important to the different stakeholder groups involved. Engage the team with something that matters to each of them.

2 Once the issues the team wish to address are clear, set aims at hospital and departmental level that act as levers to engage change at ward and individual clinician level.

3 Make the aims SMART i.e. specific, measurable, achievable, results orientated and time scheduled.

The aims should describe:

� what is expected to happen,

� the system to be improved,

� the setting or sub-population of patients,

� goals.

Develop Your Aims from your Diagnostics Presentation (Institute for Clinical Excellence)

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2.6 Designing and implementing changes

2.6.1 Identify interventions to implementOnce problems and issues have been identified and prioritised a decision

needs to be made regarding what changes you will implement to achieve the aim. Go to Section 3 of the Toolkit which has a range of ideas, suggestions and changes implemented in other organisations. Read through the interventions listed in the appropriate section and download any references or tools. At a redesign team meeting agree on a list of interventions you wish to trial or implement, based on the results of your diagnostic work. It is important to focus on interventions relevant to those significant problems identified during your diagnostic analysis. Look for the common sense solutions before introducing radical change. Many of these will emerge during process mapping and redesign activity.

In some cases, a decision to implement a particular strategy may be made straight away. This is appropriate where there is a high level of confidence from the diagnostic work and evidence from other organisations where it is in place, that it will effect an improvement. However other interventions will need to be trialled, adapted to local context and evaluated for effectiveness before a decision to implement is made. Clinical Practice Improvement (CPI) methodology is a useful tool for trialing interventions.

Easy Guide to Clinical Practice Improvement Methodology (NSW Health)

PDSA Worksheet (Institute for Clinical Excellence)

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2.6.2 Practical ideas for effecting changeCreate a culture where change is encouraged and people are willing to try

something new.

� Use cases that actually happened in your hospital to demonstrate process and system problems affecting patient outcomes to foster organisational and individual will to change.

� Publicise the findings of the diagnostic work to highlight problem areas and engage clinical staff and management.

� Use success stories to create an expectation that change can occur.

� Establish a process in your hospital or department to keep up to date with the current best practice.

� Use incentives, e.g. wards with high morning discharge rates given priority for receiving extra staff.

� Acknowledge and celebrate success when it is achieved.

This should help to create a culture where things change/improve constantly so that a state of change/improvement becomes the stable state.

Improvement Leaders Guide - Managing the Human Dimension of Change (NHS)

www.modern.nhs.uk/improvementguides/human

Organisational Change, a Review for Healthcare Managers, Professionals and Researchers (NHS)

www.sdo.lshtm.ac.uk/pdf/changemanagement_review.pdf

Making Informed Decisions on Change (NHS)

www.sdo.lshtm.ac.uk/pdf/changemanagement_booklet.pdf

Quality collaboratives: Lessons from research (The Nordic School of Public Health)

Improvement Leaders Guide - Spread and Sustainability, 2002 (NHS)

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2.6.3 Implementation planOnce you have a list of interventions you plan to trial, create an

implementation plan including a breakdown of the interventions into lists of tasks you need to complete in order to implement the intervention. Brainstorm potential barriers and plan to proactively manage these. Many of the barriers to change that will be encountered relate to poor communication. Give all appropriate people the opportunity to be involved. The implementation plan should be specific with individuals accountable for completion of work by a specific date. The following example is an excerpt from an implementation plan that describes a few of the actions that may be required to implement nurse initiated X-rays.

Figure 3

Example | Implementation planPlanned step Action

requiredIdentified barriers

Strategies to overcome barriers

Individual responsible and by when

Introduce nurse initiated X-ray

Write a protocol detailing indications for nurse initiated X-ray

Radiology apprehension re service getting overwhelmed

Joint working group to develop the protocol and guidelines for when RN can initiate

Training programme in draft by Dr Sarah Jones 04/04/04

Develop a form specifically for this purpose

Nurses not having confidence to make the decision due to lack of information

Training by radiology and emergency departments for nurses to ensure they feel skilled and supported in decision making.

Joint working group chaired by and supported by Peter Brown. First meeting 06/05/04

Work with radiology department to develop agreed guidelines

Doctors concern over the quality of the service

Involve the ED doctors in the protocol development

Set up monitoring systems

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2.7 Analyse the resultsThe team should determine how to measure the progress of their work and

develop a strategy to achieve this. Avoid the temptation to spend so much time collecting or pursuing “perfect” data that the improvement work doesn’t get started. Measurement plays the following important roles.

� Key measures are required to assess progress on your aim.

� Specific measures can be used to learn more about the problems that exist within the system.

� Balancing measures are needed to assess whether the system as a whole is being improved.

� Data from the system (including from patients and staff) can be used to focus improvement and refine changes.

2.7.1 Methods of measurementDifferent methods may be used to gain measures, both qualitative and

quantitative, to provide the information described above.

� Clinical measures of patients’ health

� Documentation of behaviour

� Questionnaires

� Interviews

� Assessments

� Summary of databases

� Chart audits

� Observations

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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)

Measurement Presentation - Helen Ganley (NSH)

Weekend Discharge Audit Report (RNS Hospital)

SPC for Beginners - Powerpoint Presentation (NHS)

www.modern.nhs.uk/InnovationandKnowledgeGroup/7338/SPC_for_beginners_web.ppt

Patient Perceived Needs Survey (NICS)

2.8 Communicating the changeFor these projects to work smoothly there needs to be good communication

with individuals, departments, patients, providers, management and clinicians.

As interventions are implemented, display information about the changes that have been made and the results achieved in a clear graphical format. Show performance against targets.

Every individual in the healthcare team including nurses, doctors, allied health professionals, administrators, managers, secretaries, cleaners, food services and porters, play a significant part in the patient’s journey. They will all offer a different and valuable perspective. Remember, if people know what is going on and are actively involved, they will have greater ownership of the problem and the solutions.

Identify data and measures that have “shock” value and use them to gain acknowledgement of the problem and engagement of staff in the need for change. Identify all those who have some role to play in the care processes that you aim to change and be open and share information with them.

2.8.1 Key factors for successfully managing changeEvidence suggests that the following factors all significantly improve the

chances of a project making an effective and sustainable impact.

� An organisational will and commitment to change the system to, first and foremost, meet the needs of the patients.

� Visible commitment from executive and senior management.

� Local ownership of solutions to the problems encountered by local clinical and management teams.

� Resources committed to the redesign process, including personnel experienced in change management to facilitate this locally.

� A core multi-disciplinary team who drive change, facilitated and supported by a project coordinator.

� Medical, nursing and allied health engagement, leadership, and participation in the team.

� Investigation and data analysis of existing issues and problems utilising tools such as extensive process mapping and redesign of inefficient processes of care.

� Rapid implementation of strategies that have been shown to be effective in improving flow in similar hospitals.

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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 Executive Representative

Celine Hill Team Leader, Trauma Program Manager

Rosio Cordova Facilitator, Quality Manager

Maria Lingam Clinical Nurse Consultant (Orthopaedics)

Narelle Allen Clinical Nurse Educator (Orthopaedics)

Gail Hook NUM, D4A (Orthopaedics ward)

Robert Dowsett Director ED Westmead

Gayle McInerney Director ED Auburn

Geoff Shead Surgery Stream representative

Randolph Gray Orthopaedic Registrar

Elizabeth Stafidas Surgical Support Services representative

Peter Landau Staff Specialist, Geriatric Medicine

Sue Voss Anaesthetics Consultant

Linda Gutierrez Trauma Data Manager

Dr John Fox Director, Orthopaedics Unit, Westmead Hospital

Dr Roger Brighton Director, Orthopaedics Unit, Blacktown Hospital

The AimAccording 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 didn’t go to theatre within 24 hours demonstrated 30% didn’t 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 DevelopmentA 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 co-morbidities 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

PatientOperating theatre

Assessment Accessibility

NOF patients waiting more than 24 hours for operation

Incomplete patient documentation

upon transfer

No specialised nursing review in ED

Booking times

Geriatrician review vs Orthopaedic review

No beds available

Disorganised booking times

Orthopaedic review vs Anaesthetist review

Patient requires MRI or Bonescan

Patient is medically unfit NOF not considered for

emergency theatre

Theatre availablity

Lack of OT timeFamily refuses operation

ActionThe 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 5Issues Intervention implementedPatients referred for geriatric review before seeing the Orthopaedic Registrar.

Once ED Registrar reviews tests and admission is identified, then the ED Registrar calls the Orthopaedic Registrar as well as informing the Geriatric Registrar.

Geriatric review only occurs during working hours.

In absence of the Geriatric Registrar, the Medical Registrar can review the patient after hours or weekends.

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.

ED Registrar is able to organise transfer of patients to the Orthopaedics Ward upon confirmation of fracture.

The Anaesthetist can request further medical review, delaying operating time.

Anaesthetist review occurs at the beginning of the diagnostic process rather than at the end, upon admission to the ward.

Patients from district hospitals wait longer for operation due to the lack of bed and/or incomplete documentation.

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.

Disorganised booking times.

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.

No specialised nursing review in ED.

The Clinical Nurse Consultant (Orthopaedics) is called upon patient’s 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.

Data collection. 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.

ResultsData 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

100%

50%

0

Rate

NOF Project

UCL = 100%

Mean = 70.1%

LCL = 24.4%

Pre-project mean 42%

Jan 02 - Jun 03 Jul 03 - Jan 04

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Holding the gainsThere are a number of strategies in place to sustain improvements post

project such as:

� Continued data collection process for the NOF information to review ongoing performance indicators and provide performance report to management.

� Monthly monitoring of performance and presentation of findings to management meetings of Orthopaedics, Anaesthetics, Geriatrics as well as ward staff.

� Orientation of Orthopaedic and Geriatric Registrars on the NOF Program and management guidelines.

� Continue active communication between the fractured neck of femur team and the Orthopaedic Registrars to deal with any new reasons for delays.

� Establish communication between the ASET team CNC and the Orthopaedics CNC to identify NOF patients early in Emergency.

� Continue early medical review/Geriatric Registrar.

� Organise fractured neck of femur case conferences twice weekly to monitor appropriateness of the current patient journey.

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Figure 7

NOF Fracture Patient Flow (pre-project)

Yes

Patient presents to ED-Triage

Admission required?

Yes

No

Time recorded & triage category provided

Patient is admitted MRN is produced

JRMO medical assessment

Time is recorded prospectivelyTests include X-ray & blood pathology tests

In ED X-ray order is put in X-ray box & pick up by X-ray staff

Test results reviewed in ED by Senior ED Doctor

Patient sent home

Geriatric review needed?

Is geriatric admission required?

Geriatrician informed or Med. reg called after hours

Some # missed. Patients may be recalled

Patient may be admitted

to Ortho ward during the night if X-ray shows

fracture

Yes Yes Special tests for hip pain ordered

Fracture of hip?

Medical management

Seen by the Ortho registrar

Patient requires admission to Ortho ward?

No

No

Yes

Op theatre booked at time of diagnosis before 9pm or booked at 7am next day

Is bed available?

No

Wait in ED

Is fracture confirmed?

Yes Fit for OT?

Yes OT available?

Yes Rejected by anaesthetist?

Yes Ward (medical assessment)

No

Ward (special tests)

No

Ward (medical management)

No

Ward (OT rebook daily)

No

Patient has operation

Yes

Seen by the Ortho registrar and follows as per 1

Time to be recorded by Ortho registrar

Time of diagnosis & mode to be recorded

Time Ortho registrar is called to be recorded by Geriatric registrar

Booking time recorded in Op theatre, operating time including start & finish times

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Figure 8

NOF Fracture Patient Flow (post-project)

ED Nurse calls on Ortho CNC

ED Nurse orders an X-ray

Confirmation of NOF fracture

Nurse suspects NOF fracture

Patient presents to ED-Triage

ED Registrar review patient & order blood tests & ECG

ED Registrar to call the NOF team (Ortho Registrar and Geriatric Registrar)

Patient admitted to D4A

Book theatre at the same time

Obvious fracture?

Is patient fit to theatre?

Anaesthetists agree with NOF team?

Further investigation, other teams review are requested

Patient goes to theatre

Yes

Yes

No

No

Yes

Time recorded & triage category providedMRN is produced

CNC to review patient’s needsskin integrity, rehabilitation etc

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Checklistprior to starting your improving access project

� Organisational commitment secured

� Principles of change understood

� Diagnostic work

� Scope of project defined

� Engagement of stakeholders

� Convene project team

� Project aim agreed with team

� Defined project plan

� Potential interventions identified

� Measurement strategy in place

� PDSA cycles planned

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3. InterventionsAn 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

The layout for each intervention is as follows:

Intervention title - a short description of the intervention and key elements of implementation.

Tools to assist with implementing the intervention are contained in the attached CD. A tool is anything that is of practical use in implementing the change. This may be a checklist, Powerpoint presentation or file.

A hospital or organisation where the intervention is in place - not a comprehensive list as these interventions are often in place in many sites.

Resources – These are links to websites or reference documents that contains more detail on the intervention or any reported results.

Bookmark link within document.

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3.1 General strategiesThese interventions have a whole of organisation or hospital scope, may

be applied to many different types of patients or are applicable in many different settings.

Tools - Patient Flow

www.ihi.org/IHI/Topics/Flow/PatientFlow/Tools/

A common cause of miscommunication and delay is a lack of clarity among all members of the multi-disciplinary team about what should be done (therapy) and when (urgency). It can cause delays in the patient receiving the most appropriate care or treatment and non-compliance with evidence based best practice.

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%20Reform%20%2D%20Safety%20and%20Quality%20Action%20Areas

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3.1.2 Develop multi-disciplinary evidence based pathwaysTo provide consistent, streamlined patient care, develop evidence based

pathways for high volume ED presentations and/or admissions. Or to save time, borrow someone else’s and convene a multi-disciplinary team to modify them to meet local needs.

www.mja.com.au/public/issues/180_06_150304/suppl_contents_150304.html

www.cochrane.org/index0.htm

www.nicsl.com.au/projects_projects_detail.aspx?view=6&subpage=28

www.nicsl.com.au/knowledge_literature.aspx

TASC Chest Pain and Stroke Pathways (Nepean Hospital)

Nepean, Gosford, Royal North Shore and Dubbo Hospitals

3.1.3 Relative performance tableProvide feedback to individual clinicians and wards on their performance

on key indicators e.g. unplanned readmission rates. Where performance or improvement is inconsistent between departments or clinicians, consider making this information publicly available. This does not have to involve large amounts of data and can use measures relevant to the department and changes being implemented (e.g. number of operations delayed due to incomplete consent forms by surgeon, weekend discharge rate by ward and/or physician).

Wyong, Dubbo and Royal North Shore Hospitals

Western Australian Audit of Surgical Mortality Annual Report 2003 pp 38-41

www.waasm.uwa.edu.au/

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3.1.4 Convene a redesign teamWhenever change is being considered in a process or system, convene a

team who will take ownership and drive the change and communicate it to others. Ensure participation from all groups that have active involvement in the system. At the process mapping workshop identify participants who appear to take ownership of the issues and the problems that are identified. Include someone from each of the key stakeholder groups including representation from “upstream” and “downstream” of the processes of concern. The redesign team will prioritise the problems (waits, bottlenecks etc.) identified during the operations review and process mapping sessions. Measure, where necessary, to detect at which steps in the process delays occur. This data is used to inform the team in their redesign of the process.

Redesign Team Success - Who to involve to ensure success - Powerpoint Presentation (Institute for Clinical Excellence)

St George, Liverpool, Albury and Dubbo Hospitals

The Clinicians Toolkit, Easy Guide to Clinical Practice Improvement (NSW Health)

Link to engage clinicians and convene the redesign team

3.1.5 Improve communication systemsReview suitability of existing information technology (IT) systems, paging

systems, number and placement of telephones or computers. Try innovative solutions such as:

� Communication clerks.

� Personal Digital Assistant’s 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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3.1.6 Referral to specialist servicesDevelop alternate methods for referral to specialist services e.g. fax or

email. Establish a common departmental email address that is accessible to all members of the specialist team so that on call rosters do not need to be known by those who are referring patients.

Privacy note: Our advice from NSW Health is that it is acceptable to send patient information necessary for a referral using AHS email servers but that confidential information should not be sent through commercial email providers.

3.1.7 Service level agreementsDevelop and implement internal and external service agreements. Internal

service level agreements may for example be established between ED and wards around agreed time to transfer, or with radiology regarding time to report available. External agreements may be used to facilitate patient transfer between tertiary referral/base and peripheral hospitals. Include peripheral hospitals in a process mapping session looking at patient flow between the hospitals. Develop an area clinical services and bed management plan that includes transfer and clinical criteria protocols that have been agreed with peripheral hospitals. Broker management (including bed manager) and medical staff agreement for base hospitals to take patients not able to be managed by peripherals and peripherals to take patients not requiring base hospital level support. Include inter-hospital transfers in the bed management prioritisation protocols.

Wollongong, Albury, St George and Calvary Hospitals

Link to Management of Hospital Beds

3.1.8 Managing capacity to respond to need for servicesCapacity refers to the ability of an organisation to provide a specific volume

of service and is determined by the resources it has and the efficiency with which the resources are used. Demand for health care is fairly consistent and predictable. Introducing variation and unpredictability into capacity to provide care (e.g. not providing seven day a week diagnostic or allied health services) causes waits and delays.

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3.1.9 Minimise variation in capacity to provide careUse staggered accrued days off (ADO) instead of hospital wide ADO’s.

Reschedule vital clinics so that they are not cancelled when there is a public holiday.

3.1.10 Change to seven day a week servicesChange to seven day a week services and reward those that provide this.

Look at services such as radiology, imaging and allied health to ensure there is weekend access, especially for those patients waiting for discharge who cannot leave until they have been seen by one of these services. Ensure all inpatients receive a medical review seven days per week — if they are sick enough to require a bed in hospital, they are sick enough to have daily review of their management plan.

3.1.11 Buffer bedsBuffer beds are used to supply capacity at those times when historical data

predicts there will be an increased need for beds. Commonly they will be opened on Monday, Tuesday and Wednesdays, or evenings. These are the times when demand for elective surgical beds is greatest and access block is likely to be at its highest level.

St Vincent’s Health, Victoria

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3.1.12 Smoothing variation in elective activityWhere there are waiting lists, or difficulty in managing operating theatre

availability, smooth the system wide flow of elective surgery admissions. Data on demand for operating rooms can be used to work with surgeons to adjust the scheduling of surgical patients. Do a small test first, limiting or capping elective surgical admissions within a defined unit with one specialty:

1 Identify the average daily number of elective surgical admissions.

2 Limit the admissions for the day to the average daily number of elective surgical admissions (may take less but not more than the average).

3 Analyse the results of the test and use this information to work with surgeons to adjust scheduling of surgical patients.

Case for Improvement, Institute for Healthcare Improvement

www.qualityhealthcare.org/QHC/Topics/Flow/

NHS Improvement Leaders Guide to Matching Capacity and Demand

www.modern.nhs.uk/improvementguides/capacity

3.1.13 Develop advanced nursing rolesFurther develop specialist roles for nursing or allied health staff. Review the

skill mix in your team, where gaps exist, consider who may be able to fill them and the education and training required. Where appropriate, consider models where nurses have ultimate responsibility for patient management. Develop the role of enrolled nurses to be accredited to take on more responsibilities.

Redesign TipDuring 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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3.1.14 Up-skilling peripheral hospitals for complex patient needs

Where the peripheral hospital doesn’t have the skills to look after particular patients (e.g. a PICC line or PEG tube) organise a training session by a nurse from the base or tertiary hospital. This person may also act as a contact point for problems and issues encountered by the peripheral hospital in management of related technical or procedural problems. This encourages sharing of skills and enables nurses to maintain their standards of clinical practice. Alternatively, skills may be developed in the community or be made available by the hospital as part of an outreach service thereby preventing unnecessary transport to hospital.

Dubbo Hospital

3.1.15 Align staff specialist/consultants work to maximise efficiency

Organise across hospital coverage of specialty teams (e.g. don’t have a surgical team on the emergency roster on days when they have an elective surgical list). Broker agreement between medical specialists to pool patients and deliver 365 day a year medical review by the team. This may require medical specialists to agree on a routine therapeutic plan (pathway) and a facility for providing hand over for those patients deviating from the agreed plan.

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Management of hospital bedsThe management and coordination of placement of patients

in appropriate inpatient beds is a complex and challenging logistical exercise. However, it is critical to achieving best outcomes for patients and a harmonious low-stress working environment for staff.

3.1.16 Bed management systemUse a centralised bed management system with seven-day bed management/

patient flow personnel responsible for all admissions and transfers.

3.1.17 Centralised bed authority/bed coordinatorAssign a person to act as the centralised bed authority for each shift in

smaller hospitals (fewer than 200 beds). Ensure they have access to up to date bed information. Assign a location or group of individuals to act as the centralised bed authority in larger hospitals (more than 200 beds). The team should be informed of all admissions and discharges and can help find the most effective way to bring patients into beds for both elective and emergency procedures/treatment. Key responsibilities of the centralised bed management team include convening multi-disciplinary bed meetings, diagnosing issues around bed management and coordinating development and implementation of strategies to realign bed stock and bed management processes.

Bed Management Information Sheet (St George Hospital). Example of two strategies that facilitate the discharge of patients at St George.

Projected activity report template (St George Hospital).

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The patient flow or bed management teamEach hospital should have a core patient flow management

team with operational responsibility for bed management, including the following people:

Bed manager/patient flow manager who has the support of the executive for decision-making and communicates with units about placements and anticipated bed needs. This person should have networking skills and credibility with senior clinical staff. The role will also serve as a conduit for all direct patient admissions and have a watching brief on other avenues of admission outlined in alternate admission processes.

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

Weighting the WaitPowerpoint Presentation (RNS Hospital)

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3.1.18 Regular multi-disciplinary bed meetingsConvene a morning multi-disciplinary meeting to discuss the bed situation

for the day. Identify the pressures in the system, plan for admissions and discharges to occur at an appropriate time and brainstorm ideas to prevent access block. This meeting should also improve communication, as each department will be aware of the facility wide difficulties. Also called “bed parliament” or “bed huddle”.

3.1.19 Teleconference bed updates Set up regular teleconference meeting times during the day to update bed

status and help co-ordinate flow throughout the hospital.

3.1.20 Clinical prioritisation of patientsWards have ownership of their specialty beds and decision-making

responsibility for accepting patients for admission to the ward with strict rules for prioritisation and acceptance of patients for admission as agreed with the central bed management authority. Use of a uniform prioritisation system promotes equity of access and provides a logical basis for prioritising need. Use the following decision making hierarchy for admitting patients:

1 Retrieve outliers

2 Accept own specialty patients from ED

3 Accept own specialty transfers from lower service level hospital

4 Bring in elective patients

5 Accept other specialty patients from ED

Redesign tipUse this intervention to decrease outliers. Adapt the protocol

above or develop your own guidelines for prioritising patient need.

St Vincent’s Health, Victoria

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Case studySt Vincent’s 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.

3.1.21 Reconfigure beds to reduce outliersThe evidence is that outlying patients (those that are accommodated on

a ward not catering to the patient’s requirements for specialist nursing care) have poorer outcomes and longer length of stay. Understand each specialties’ bed capacity in relation to the demands placed on them. The number of beds in each specialty in a hospital is usually historically determined rather than related to the volume required by patient activity. Reduction of the number and incidence of outliers becomes more difficult as occupancy rates increase. Reduce bed occupancy by introducing strictly controlled buffer beds.

Link to Buffer Beds 3.1.11

3.1.22 Over census policyAn 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 organisation’s nursing establishment is essential prior to implementation.

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Case studyThe 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

3.1.23 Guidelines and protocols for test orderingDevelop 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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3.1.24 Review permissions to order testsDevelop protocols for ordering specific tests. Nurse initiated X-ray in the ED

can help fast track patients and ensure test results are available when the patient has their initial medical assessment. In the case of a patient entering ED with pneumonia, a nurse initiated chest X-ray at triage can decrease time to antibiotics.

Pathology Traffic Light Protocol (Lyell McEwin Hospital, SA)

Radiology Traffic Light Protocol (Northern Sydney Health)

Hornsby, Coffs Harbour, Canberra and RNS Hospitals

Rational Investigation Ordering Collaborative Project

www.nsahs.nsw.gov.au/teachresearch/cpiu/rio_project.shtml

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

Post-op Hip/Knee Stamp (Wollongong Hospital)

3.1.26 Allocated time for emergency casesFor specialty procedures that have waiting lists such as CT and ultrasound,

review historical data and determine predictable level of emergency demand and allocate “emergency slots” in the appointment schedule.

Liverpool, Dubbo, Sydney and Sydney Eye Hospitals

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Case study – PathologySydney Hospital identified waits for pathology results as

a major source of delay in their emergency department. A process mapping session identified multiple issues and some easy quick wins. Their key interventions were:

� increased number of tests done on site rather than being sent to another campus,

� changes to hours of service,

� changes to pathology collectors schedule to better coordinate demand with service availability,

� changes to local courier service,

� increased communication between laboratory and ED staff.

They achieved a sustained reduction in time to pathology results from a mean time of 116 minutes to 65 minutes.

3.1.27 Appropriate information on request formEducate JMOs and other staff on correct completion of request forms including

location of the patient and clinical notes. Have correct phone numbers for clinician’s point of contact for radiology rooms on display in ED and wards.

Liverpool and Albury Hospitals

3.1.28 Patients attending for testsWhere the patient has to attend a particular department for a test, ensure

there are sufficient portering/transport services to minimise delays and waits. Redesign processes for calling for and transporting patients. Review communications for these services and try using two-way radios or a computer system for tracking patient’s movements around the hospital departments.

Albury, Dubbo, Wollongong and John Hunter Hospitals

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3.1.29 Stratified test orderingThe literature suggests that 20-30% of all pathology tests ordered are

inappropriate. To increase appropriateness and cut down on unnecessary test use, introduce a stratified ordering system in which certain tests need to be approved by a registrar or senior clinician. Results in organisations using this approach demonstrated reduction in inappropriate tests.

Radiology Traffic Light Order System (NSH) Radiology Request

Form for Stratified Ordering (Dubbo Hospital)

Pathology Traffic Light Protocol (Lyell McEwin Hospital, SA)

Case studyDuring 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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3.2 Emergency patient flow

3.2.1 Pre-bypass hospital early warning systemThe hospital early warning system is a coordinated hospital-wide response

that occurs when a hospital is at high risk of going on ambulance bypass. For this system to work a substantive process of engaging all clinical departments in committing to enact the agreed protocols needs to occur.

The Austin and Repatriation Hospital, Victoria

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Case study – hospital early warning system (HEWS)

The Austin Hospital was concerned that their ability to respond and recover from stresses placed on the organisation, exhibited by increased levels of access block, could compromise emergency patient care. They recognised that ambulance bypass is a significant hospital event and not just an ED problem. They also thought, when the probability of bypass in the next hour was high, that an organised, systematic, hospital-wide response could assist in avoiding bypass and improving emergency patient care. The HEWS system was the hospital-wide response at Austin. It had ED director support and authorisation and was coordinated by the bed manager or after hours site manager with teleconferences occurring regularly three times a day and at times when pre-bypass is declared. The Austin designated pre-bypass as an internal emergency – “Yellow Code 3- Pre-bypass” commonly called Respond Yellow.

Prior to a Respond Yellow being called there are a series of actions that the ED has to perform.

When a Respond Yellow is called this triggers a further series of actions by a range of people across the organisation.

A further refinement of the system was introduced whereby each Respond Yellow is classified as a:

� Bed Access Response – where there is a lack of beds available to ED patients

� Clinical Activity Response – where there are many ill patients needing clinical assessment at a single point of time in the ED

Response by hospital staff is different depending on the type of alert.

A trial comparing hospitals using a HEWS system with those who weren’t 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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Results - HEWS implementation - The Austin

3.2.2 Streaming techniquesStreaming techniques recognise alternate methods of grouping and managing

ED patient queues than through a universal triage system. Streaming occurs in a variety of forms and is based on recognition of the benefits of dividing patients into alternate streams and journeys to better manage bottlenecks and waits.

3.2.3 Alternate admission processesDevelop and formalise other avenues for emergency patient admission to a

hospital bed other than through ED. These alternate avenues may be managed by a bed/patient flow manager with agreed criteria for entry to ensure appropriateness. Other patient journeys include direct:

� admission to ward by specialist team or GP,

� referral to hospital in the home,

� referral to hospital ambulatory care,

� admission from specialty clinic to ward.

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3.2.4 Develop alternate services to prevent ED presentation

Develop and formalise other journeys for emergency patients other than presentation to ED. These services may include:

� chronic disease case manager and/or hospital in the home,

� referral to community care,

� community facilitated care packages - ComPacks,

� accessible specialist outpatient clinic appointments for “urgent patients”,

� direct referral to hospital ambulatory care,

� GP after hours clinics.

3.2.5 Advanced nursing and allied health practitioner rolesUse nurses with advanced clinical skills e.g. clinical initiative nurses, who

work from protocols and guidelines to fast track the assessment and treatment of ED patients. Use physiotherapists to oversee and deliver management of minor fractures.

The ED Work Practice Review Project 2001 (Wollongong Hospital)

3.2.6 Fast TrackFast Track refers to type of streaming where an alternative patient pathway

(or part of a pathway) can be dealt with rapidly, in the primary care section (e.g. “walking wounded”) as part of the ED service.

Fast Track Interventions in the ED (NICS - Literature Review)

www.nicsl.com.au/knowledge_literature.aspx

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3.2.7 See and TreatSee and Treat is a type of fast tracking where a senior clinician or clinical

team triages patients and provides immediate care and disposition where possible. It may be most useful to implement in an ED with a high volume of low acuity patients with straightforward presenting problems. It is a model for seeing, triaging and offering on-the-spot treatment to patients with minor ailments or injuries so that they are in the Emergency Department for as short a length of time as possible.

See and Treat, NHS

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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3.2.8 Lean thinkingIdentify common processes from the main streams of patients within the ED.

At each step of the process identify and eradicate steps that are wasted time and effort from the optimal patient outcome perspective.

The Key Lean Thinking Principles (Lean Australia)

www.leanaust.com/about.htm

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Redesign tipUse 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 don’t 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).

3.2.9 Clinical pathways around presenting problems not diagnoses

Develop clinical pathways or guidelines for management of high volume presentations particularly where there is evidence of poor patient outcomes or evidence-based treatment is not being delivered.

Dubbo, Nepean, John Hunter and Blacktown Hospitals

TASC Chest Pain and Stroke Pathways (Nepean Hospital)Fractured NOF Guidelines (Hornsby Hospital)Paediatric Presentation Protocols (Blacktown Hospital)

3.2.10 ED access to day surgical list bookingsSet up a process enabling ED doctors to book patients in for day surgery the

following day. This allows patients to be sent home rather than taking an ED or inpatient bed.

Royal North Shore Hospital

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Redesign tipEnsure 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.

3.2.11 Communications clerkProcess map communication channels within the emergency department.

Redesign processes and institute a new position in ED that is responsible for answering phone calls, coordinating patient movement between other departments such as radiology and the wards. Use the process redesign to inform their role and job description.

Wollongong and John Hunter Hospitals

3.2.12 Emergency medicine unitPatients who require a short period of admission for observation and

treatment (e.g. < 24 hours) are admitted to a short stay bed in an EMU. To be effective, the unit should be operated as an extension of ED services, adjacent to and staffed by the ED. Strict protocols around patient selection and length of stay need to be enacted to ensure throughput is maintained.

St George and Hornsby Hospitals

EMU Net News Reference Article (ARCHI)

3.2.13 Flag and case manage frequent attendeesThis is a preventative model of care, targeting high users of the public

hospital system, which aims to provide more coordinated care between hospital and primary care. Frequent ED attendees that could have been more appropriately case managed in primary care are identified. A nurse case

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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.htmwww.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

3.3 Improving flow of emergency surgical patients

Link to elective patient flow strategies (page 75)

3.3.1 Clinical guidelines or pathwaysClinical guidelines or pathways — for high volume emergency cases such as

fractured hip — ensure correct emergency theatre prioritisation and protocols for test ordering, management of anti-coagulation therapy and anaesthetic/medical/aged care consultation.

Liverpool, St George, Tamworth, Albury, Westmead, Hornsby and Port Macquarie Hospitals

Fractured NOF Guidelines (Hornsby Hospital)

Step Guide to Improving Operating Theatre Performance, 2002 (NHS)

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3.3.2 Team briefing and debriefing sessionsAfter complex cases convene a quick meeting of multi-disciplinary team

members to review aspects of pre-operative and intraoperative care. Focus on processes and communication. Don’t make it a name and blame exercise but use it as an opportunity to discuss changes to improve care next time.

3.3.3 Emergency department physician admission ritesEmergency department physicians may be given admission rites for specific

presentations or diagnoses. Identify those emergency surgical presentations where diagnoses are relatively straightforward and need for admission is predictable. For these patient groups broker agreement amongst specialty teams to allow ED physician admission rights and early transfer of patient to an appropriate ward. This may be written into guidelines or pathways.

Albury Hospital

Emergency Patient Admissions Policy (Albury Hospital)

Prioritisation and provision of emergency theatre time

Ensuring there is adequate theatre availability is essential for providing good clinical outcomes and preventing surgical patients taking up valuable beds while waiting for their operation to be performed.

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3.3.4 Review existing demand for emergency operating theatre time

Review theatre usage hours by type of surgery and time of demand. Using this information, ensure adequate emergency operating theatre time is provided during and out of hours. Use an afternoon trauma list to avoid repeated cancellation of lower priority cases not deemed to be urgent enough to operate on between 10pm and 8am.

Liverpool, Tweed and Port Macquarie Hospitals

3.3.5 Prioritisation protocolHave a prioritisation protocol that provides transparency to emergency

operating theatre scheduling and monitor cases not achieving benchmark “to operating theatre” times.

Emergency Theatre Allocation Guidelines (WAHS)

Emergency Surgery Guidelines (Liverpool Hospital)

3.3.6 Prioritisation teamThe admitting surgical team performs an initial assessment of urgency for

each patient requiring emergency surgery. A designated senior anaesthetist and peri-operative nurse have the right to challenge the assessment of urgency. The team of anaesthetist, nurse and surgeon then negotiate priorities (based on a protocol) and agree final schedule of emergency cases.

Liverpool Hospital

3.3.7 Pre-operative placement of patients waiting for OTPatients 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

Emergency Patient Admissions Policy (Albury Hospital)

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3.4 Medical strategies

3.4.1 Medical Assessment and Planning UnitThe MAPU is a physician led unit which has 365 day a year general physician

cover to review new medical admissions. It has a strict management protocol that includes a maximum LOS of two days, monitored beds, increased allied health staff levels, full time resident medical officer cover and twice-daily specialist medical review.

Royal Brisbane Hospital

Responses to Access Block in Australia - Queensland (MJA)

www.mja.com.au/public/issues/178_03_030203/cam10542_ash_fm.html

3.4.2 Day only admission ward for ED patientsThis ward functions as a temporary location for the admitted patients in ED.

Selected patients are accommodated there while waiting for a ward bed. It can be part of the discharge lounge or EMU. The beds operate for eight to 12 hours per day during busy periods (as determined during diagnostic work). It may be used to transfer a predictable number of patients from the ED every morning.

John Hunter and Blacktown Hospitals

3.4.3 Flag and case manage frequent medical admitted patients

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.

3.4.4 Trial at home programThis program provides the opportunity for a patient to go home for an

overnight stay before they have been discharged. Similar to a “gate pass”, it allows patients to test their level of confidence in being cared for at home. Notes are kept on the ward and it is guaranteed a bed will be found if needed, the next day (or week). The patient does not have to present in the ED to be readmitted. This reduces the number of patients who readmit within 48 hours of discharge and diverts work from the ED.

Tamworth Hospital

3.4.5 Improve appropriateness of admissionDevelop a set of criteria for admission for high volume patient groups.

Audit for inappropriate admissions and performance manage, or call admitting consultant, to justify their decision to admit to an appropriate audit committee.

3.4.6 Safety risk assessmentSafety risk assessments are intended to reduce the likelihood of a patient

being involved in an adverse event, thus reducing the length of stay. If a risk assessment shows that a patient is at high risk of falling, a falls prevention strategy or protocol should be put in place for that patient. A risk assessment allows careful planning of appropriate interventions for an at risk patient. This information should be collected when the patient enters the system and updated when there is a change in their condition. Keep the information visible to prevent the patient repeatedly telling different people the same information.

Royal North Shore, Broken Hill and Prince of Wales Hospitals

Adverse Patient Outcome Program - Powerpoint Presentation (John Flynn and Tweed Hospitals)

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3.5 Improving communication

3.5.1 Improving communication with GPs and community nursing

Improving communication with primary care and community care providers will increase patient safety, smooth the transition home and decrease unplanned readmissions. The following strategies have proven to be effective in improving the flow of information out of the acute care setting:

� Clear delineation of staff roles and responsibility for communication with GPs and community services.

� A legible accurate discharge summary that includes reasons for changes in ongoing treatment such as medication dosage. Audit the number of patients who are discharged without a discharge summary.

� Educate hospital doctors on the importance of timely discharge summaries through induction and regular feedback, especially in the discharge planning meetings.

� Electronic discharge summaries.

� DOCFAX consent form reviewed and implemented to allow for faxing (rather than mailing) discharge summaries. (Hospitals, like most big organisations have a delay in their mailing system caused by additional steps in the process).

� Clerical support provided to standardise the settings on fax machines with quick dial GP numbers.

� Process for obtaining GP contact details from patient at the time of admission.

� GP contact details on central database and updated regularly from division of GP’s.

� Informed consent for collection, use and disclosure of health information obtained and signed in the pre admission clinic and emergency department.

The Tweed Hospital, RPA and SESAHS Hospitals

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)

3.5.4 Scheduled transfersA variation on the linked discharge and admission intervention. Schedule

all internal patient transfers and discharges. This allows synchronisation of transfers and staff workload.

Scheduling Transfers and Discharge

www.ihi.org/IHI/Topics/Flow/PatientFlow/Changes/ScheduletheDischarge.htm

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3.6 Improving discharge processesReviewing and improving discharge processes on a ward and hospital-wide

basis is crucial to achieving efficient patient flow. Effort spent improving other areas may be wasted if discharge processes are disorganised.

Effective Discharge Planning Framework and Implementation Strategy (NSW Health)

3.6.1 Discharge risk assessment formA risk assessment is a useful tool for preventing problems in the discharge of

a patient to the community. An effective discharge risk assessment is one that is carried out prior to, or on admission to hospital and is broad enough to cover most common issues. The risk assessment should highlight:

� problems that may prevent patients being discharged as soon as they are medically stable.

� any services or treatment a patient may need to prepare for discharge.

� any services or treatment a patient may need after discharge.

Examples of discharge risk include polypharmacy, pressure sore, special dietary needs or poor mobility. A risk assessment as a stand-alone document is fairly meaningless but needs to be a trigger for activation of a series of processes and protocols.

Implementing Discharge Risk Screening Tool (NSW Health)

Discharge Risk Assessment Screening Tool (RPA Hospital)

Discharge Risk Screen Example (NSW Health)

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3.6.2 Admission and discharge planAnticipate and plan for discharge from the time of admission. Include

discharge risk screening and actions as a result of risk screening, in the nursing care plan.

Albury, Dubbo, Wollongong, Queanbeyan and Broken Hill Hospitals

Discharge Plan (Dubbo Hospital)

Guidelines for Discharge Planning (Wagga Wagga Hospital)

Ward Discharge Checklist, (RNS Hospital)

Some hospitals have one document that incorporates both the discharge risk assessment and the safety risk assessment. This may take longer to implement as it requires input and sign-off from all professions and disciplines.

Multi-Disciplinary Assessment Form (RNS Hospital)

Care Plan Audit Tool (RPA Hospital)

3.6.3 Criteria driven dischargeDevelop consensus with medical staff on a process and criteria for discharge.

Use either a discharge checklist, or document in the patient’s progress notes, a list of conditions to be met and treatment to be completed prior to discharge.

Discharge Checklist example (NSW Health)

3.6.4 Nurse activated dischargeDischarge patients when they are medically stable and ready, not the next day

after a consultant ward round or after they have a non-urgent test. Implementing nurse activated discharge under medical direction ensures that no patients are unnecessarily delayed due to lack of medical cover. This is a similar concept to protocol driven discharge in that once the predetermined treatment and management criteria have been met, the patient can leave hospital.

Broken Hill Hospital

Nurse Initiated Discharge Policy (Dubbo Hospital)

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3.6.5 Monday morning auditReview all the patients who are stable and ready for discharge. Look at how

many patients are stable enough to have been discharged earlier i.e. on the Saturday or Sunday and reasons for delay.

Nepean and Port Macquarie Hospitals

Discharge Audit Tool (RNS Hospital)

Link to Diagnostic Work

3.6.6 Weekend discharge pharmacyOne of the identified causes of delays to discharging patients is the lack of

weekend pharmacy services. Have a store of commonly prescribed medications accessible to medical staff or a senior nurse manager who has received training to dispense these items safely. Send the patients home with 24 or 48 hours supply of medications. Alternatively, broker agreement with a community pharmacy to supply the medications at neutral cost to the hospitals.

Tamworth and Albury Hospitals

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 studyTamworth 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 VMO’s 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%.

3.6.7 Multi-disciplinary discharge meetingsMembers of the multi-disciplinary team meet to discuss patients with

complex discharge needs. Where possible and appropriate have community nursing representation at these meetings.

Royal Prince Alfred and Queanbeyan Hospitals

Guidelines for Multi-disciplinary Team Meetings (RPA Hospital)

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3.6.8 Informing patients and carers about their discharge

Provide information to raise awareness of discharge and its timing to staff, patients and carers to ensure realistic expectations of the discharge process. There are some elements of the process that patients or their families can and should take responsibility for themselves such as organising transport home. Communication of the estimated day of discharge to patients and their families allows them to take a more active and effective role in planning for their discharge.

Patient Information Brochure Example (NSW Health)

Patient Discharge Brochure (Liverpool Hospital)

Leaving Hospital Patient Brochure (Tweed Hospital)

Discharge Planning Brochure (Tweed Hospital)

Nursing Home Final - Questionnaire (Centre for Allied Health Evidence, University of SA and Department Public Health, Adelaide University)

www.unisa.edu.au/cahe

3.6.9 Discharge checklistA discharge checklist is another way to plan the patients’ discharge

effectively. Use a simple checklist or make note of all tasks to be completed and patients’ needs to be met prior to them leaving the hospital.

Royal North Shore Hospital

Discharge Checklist Example (NSW Health)

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3.6.10 Estimated day of dischargeNote the estimated day of discharge (EDD) on admission or when the treating

team first reviews the patient. Communicate EDD with team, including the patient and their family. The EDD should be utilised by the multi-disciplinary team for planning discharge. When implementing an EDD intervention, extensive promotion and education is required regarding its rationale and use. Audit reasons why the patient was not discharged on their estimated discharge date and analyse reasons for delay if patient is medically stable. The EDD may be established using either of two methods or a combination of both:

� Medical staff to document EDD in the medical record or on a ward communications board.

� Negotiate agreement with medical staff on estimated length of stay for high volume presentations. Nursing staff may then use this to document EDD.

Coffs Harbour, Prince of Wales, Royal Prince Alfred, Dubbo, Hornsby, Nepean and Queanbeyan Hospitals

Estimated Discharge Date Tool (Dubbo Hospital)

Implementing Estimated Date for Discharge Tool (NSW Health)

EDD Staff Information Brochure (Hornsby Hospital)

Estimated Discharge Date Poster (Prince of Wales Hospital)

EDD Stamp (Wyong Hospital)

3.6.11 Estimated length of stay tableTo assist with implementation of the EDD, develop an Average Length of Stay

(ALOS) table for your ward using data from the HIE. Base the table on diagnosis and procedure data not coded DRGs. Use data from the previous six months for that ward. Update the table every 6-12 months as changes to treatment and management regimes may alter ALOS significantly.

� 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 studyWyong 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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3.7 Aged care

3.7.1 Aged care assessment team (ACAT)An ACAT team provides specialist assessment and recommendations for the

care of frail and elderly patients. Referral criteria and contact details for the ACAT team should be clearly visible in the ED. Set up processes so that patients are referred to the service as early as triage. Encourage early multi-disciplinary care with the aged care service and the ED working together to ensure a smooth journey for an older person entering hospital. An early ACAT assessment may speed the process of aged care or community care placement.

Prince of Wales, Royal Prince Alfred Hospital, St George, Westmead and Hornsby Hospitals

3.7.2 Transitional care bedsTransitional care beds are beds made available for patients recuperating

from their acute illness, waiting for community services or for nursing home placement to become available. These patients may be accommodated in beds with appropriate staffing, with a strong rehabilitation focus and with an increased level of allied health services. Transfer of convalescing patients to transitional care beds prevents blocking of acute ward beds with patients who do not require a high level of acute specialty medical or nursing input.

3.7.3 Community transitional care bedsPatients have their transitional care provided for them at home. GPs, nursing

and allied health professionals care for patients in the home while they wait for appropriate placement or are rehabilitated and maintained within the community.

ComPacks Guidelines and Information (NSW Health)

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3.7.4 ComPacks service modelThe ComPacks service model is based on community case management and

service brokerage. It targets inpatients requiring two or more community care services and aims to return them home safely with the support they require. Hospital staff identify patients eligible for a ComPack and then initiate the involvement of a contracted community care case manager (community options programs managers) who have responsibility for:

� working with hospital staff to jointly manage each eligible patient’s discharge,

� brokering for the care and support services for a period of up to six weeks and linking them into long term sustainable services where required.

3.7.5 Purchase transitional care bedsA hospital may purchase transitional care beds from a community nursing

home for aged care patients. This funds nursing homes to provide extra staffing capacity required.

Royal North Shore Hospital

3.7.6 Direct emergency admission protocolFast track transfer of older people to an appropriate ward rather than

keeping them in the emergency department.

Albury Hospital

Emergency Patient Admissions Policy (Albury Hospital)

Link to Alternate Admission Processes

3.7.7 “Dependant care” stream of patients managed by specialist nurse practitioner

This intervention is aimed at patients who have a number of complex co-morbidities requiring a high level of support for their personal needs. The patient’s overall management is coordinated by a nurse practitioner.

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3.7.8 Walking assistance programPrevent deconditioning of at risk older patients caused by inactivity resulting

from their hospitalisation. Use an enrolled nurse assistant from outpatients department or nursing pool to walk patients twice a day seven days a week. This has demonstrated improvements in patient mobility and satisfaction.

Functional Conditioning Program (RNS Hospital and Bayside Health)

3.8 Elective patient flowImproved knowledge and management of elective surgical throughput offers

one of the greatest opportunities to modify and smooth hospital workload. This is primarily because the specialty bed type, estimated length of stay and ICU use of each patient can be accurately predicted and so may be planned for.

3.8.1 Quarantined elective surgical bedsAllocate a defined number of beds and staff for quarantined elective surgical

beds. These beds will not be available to medical patients being admitted through the ED. The number of beds to be quarantined will require careful analysis of actual surgical activity requirements and acute admissions via ED. The strategy should decrease the volume of elective surgical patients cancelled but should be accompanied by service agreements to ensure efficient utilisation of these beds 365 days of the year.

3.8.2 Criteria driven dischargeDevelop consensus with medical staff on process and criteria. Incorporate

into a clinical pathway, use a discharge checklist or list of criteria written in progress notes, for patients to complete prior to discharge.

Discharge Checklist Example (NSW Health)

Link to Improving Discharge Processes

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3.8.3 Surgical pathways and estimated day of discharge (EDD)

Work out the average length of stay for standard elective surgical procedures and use this to give all patients an estimated discharge day. Link discharge planning processes to the EDD.

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.

3.8.5 Audit all theatre delays or cancellationsImplement a system to identify all OT cancellations or delays in operation

start time. Use process mapping or other diagnostic techniques to identify reasons for delay or cancellation. Redesign processes to improve pre-operative preparation and eliminate other causes for delay.

Liverpool and Westmead Hospital

OT Postponement Report Form (Liverpool Hospital)

3.8.6 Surgical peri-operative liaison nursesEmploy specialist nurses to manage elective surgical streams and case-

manage 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 MedihotelsUse 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 Vincent’s Health, Victoria and Monash Medical Centre, Victoria

3.8.8 Flexible staffingMatch elective surgical bed availability and staffing to demand for beds. Use

anticipated admission data to map demand on a day to day basis.

3.8.9 Align leave of multi-disciplinary surgical teamsMap surgeon, anaesthetist and nursing leave and where possible align

leave within teams. This helps prevent theatre closures, downtime and under-utilising staff.

3.8.10 Clinical teams operating pooled referralsA cooperative arrangement where the medical clinician group manage

patients as a team rather than as individual clinicians. Clinicians’ annual leave, conference leave etc, is coordinated within the group. This allows waiting lists to be managed with significantly increased capacity. On average patients wait shorter lengths of time to have a procedure and less theatre time is wasted.

Royal Prince Alfred Hospital Cardiac Surgery Team

3.8.11 Clinical pathwaysClinical pathways for short stay elective cases including pathology and

radiological investigations required.

23 hour Clinical Guideline Template (RNS Hospital)

Elective Surgical Program Presentation (Auburn Hospital)

Royal North Shore and Auburn Hospitals

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3.8.12 Improve completion of consent formsProcess map completing of consent for main streams of surgical patients.

Identify problems and solutions. If redesigning processes does not deliver satisfactory improvement try displaying number of operations against number of consent forms completed on patient arrival at OT by surgeon.

Dubbo Hospital

3.8.13 Marking operating siteMark operating site and complete consent form concurrently. Follow ACSQHC

guidelines for surgical site marking to reduce advent events.

www.safetyandquality.org

3.8.14 Improve compliance with fasting requirementsUse clear signs at the patient bedside and in the notes indicating if the

patient is nil by mouth or needs to stop taking a routine medication etc.

3.8.15 Predict surgical case length accuratelyScheduling surgical cases and adhering to the scheduled operating list is

complicated by the fact that the demand for surgery is often unpredictable and the length of the surgery for similar cases varies. To better manage the surgical schedule, use control charts to plot data over time and study variation in case length. The control chart provides estimates of the variation that should be taken into account in scheduling. A control chart will identify the normal variation in the system, as well as variation due to unusual or unpredictable cases.

Unusual variation may be related to routine cases that develop unpredictable complications, unexpected shortages of staff, last-minute changes in a surgeon’s 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 studyDuring 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 termsAim - 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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AcknowledgementsThe 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.

Members of the Patient Flow and Safety Collaborative Planning GroupMary Chiarella (Co-chair) Pat Cregan (Co-chair)Sally McCarthy Jenny BeckerJeff Rowland Lorraine LovittJohn de Campo Kym Scanlon Judy Lumby Rob DayLouise Kershaw Tony O’Connell Roy Donnelly Linda SorrellIan O’Rourke Rohan HammettAnna Thornton Lorraine McEvillyLinda Justin

Members of the Access Improvement Working PartyCameron Bennett Louise KershawGreg Rochford David Ben-TovimMarcus Kennedy Anna ThorntonGeorge Braitberg Sally McCarthyPaul Tridgell Adam Chan Brian McCaughan Don CampbellBernadette McDonald Barbara Daly Tony O’Connell Rohan Hammett Ian O’Rourke Philip HoyleDrew Richardson Greg KnoblancheMaureen Robinson

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

Clinical Excellence Commission