Delayed Discharges – A Patient Flow and Safety Imperative

Ann Marie O’GradyHead of Clinical Services & Business Planning,

Beaumont Hospital

Optimising the Patient Journey to Accelerate Patient Discharges

Improving Patient Safety & Hospital Patient Flow Conference

20th November 2014

Delayed Discharges – A Patient Flow and Safety Imperative

• What?

• Why?

• How?

• Now?

What?

Delayed discharges up by

15% in a year

Irish Medical Times

• Nationally highest level of new patients listed for long term care weekly (LTC) ....and increasing

Why?

26500

27000

27500

28000

28500

29000

29500

30000

30500

2011

2012

Be

d D

ays

Bed Days Utilised for Patients Awaiting Discharge to LTC

• Nationally highest level of patients listed for long term care weekly (LTC) ....and increasing

• Higher level of visibility demanded

Visibility

• Nationally highest level of patients listed for long term care weekly (LTC) ....and increasing

• Higher level of visibility demanded• Accountability lying with one profession but authority

and responsibility across the organisation • Reputational risk • Patient safety risk

How?

Project Objectives1. Improved patient flow

2. Optimise utilisation of acute hospital beds3. Improved patient safety

To be achieved by: • Standardising processes

• Optimising patient journey to discharge• Creating shared ownership

• Increasing visibility to all stakeholders

Supported by Lean Methodologies

Phase 1 – 6 week experiment: Intensive review of all patients listed for LTC and current LTC

process

Phase 2 – Redesign: Redesign and implement standardised

process throughout the organisation

Phase 3 – Sustain: Embed changed process and

continuously monitor and re-evaluate

Phase 1 – The Experiment

Before!

The “Experiment”

Visual

Hospital

PfEP

LTC Process

• Building on the Lean processes either initiated or implemented by Beaumont Improving Care & Safety (BICS) Programme including “Visual Hospital” (Lean Enterprise Academy)

• Fairdeal/LTC steps documented & each patient’s journey was mapped on whiteboard in Patient Flow hub.

• MDT teams allocated to manage a group of patients. To identify the position of each patient in their journey, identify delays & actions required to move to the next step in the process.

•Key themes & learning

Phase 2

During Initial MDT & Family

Meeting & discussion re listing process

Day 0

SW + Nurse

Ward of CourtDay 20

Family & MDT

Refer to COE Consultant

Day 0

Medical Team

Reviewed by COE Consultant & Listed for LTC

Day 1

Med ElderlyApplication for

Fair Deal submitted

Day 10

Family/SW

Nursing home assessment

and approvalDay 24

SW & Nurse

Application for Care

Loan Submitted

Day 10Family/SW

Prompt family re Fair

Deal application

Day 8

Nurse/SW

CSAR Form submittedDay 2

Medical SW + Nurse

Fair deal Application received by

NHSODay 15 (max)

Nursing Home

Support Office /Fair

Deal Officer

2nd Family meetingDay 20

SW & Nurse

Family Nursing Home

preferences identified

Day 20

SW & Nurse

Date of Determination

State Support approved

Day 22

NHSO Funding approvalDay 25NHSO

HSE determinations

complete –charges apply

Day 26

Fair Deal Officer

Transport prescription

Day 27

Medical & Nursing

Form 4Day 10

Medicine

Care Rep AppliedDay 10

Social Work & Family

LPF DecisionDay 20

LPF

Power of AttorneyDay 20

Family & MDT

Care Rep Court date

Day 23Circuit Court

1

2

3

Options 1, 2 OR 3

OR

OR

If Care Loan

Required

If Care Loan NOTRequired

OR

AND

If Care Rep required

Overview of LTC Process Redesign

23 Individual Steps

Phase 1

• Internal Process: Decision to list to Fair deal application submission

Phase 2

• Internal and External Process: FD Submission to Date of Determination

Phase 3

• Internal and External process: Date of Determination to Discharge to Nursing Home

•Process redesign

•Targets set for steps

•Control processes established

Phase 3: Sustain

• Small dedicated Integrated Delayed Discharge Teamput in place – Skill mix – nursing and social work – Coordinate the LTC pathway – Responsibility for the final stage of patient journey to

discharge and all communication with nursing homes– Expertise in managing the very complex situations

• Visibility created – White Boards Patient Flow Office – Integrated into daily ward/patient flow involvement – Areas of breach highlighted and flagged for follow up

Simplified White Board

Phase 3: Sustain

• Small dedicated Integrated Delayed Discharge Team put in place – Skill mix – nursing and social work – Coordinate the LTC pathway – Responsibility for the final stage of patient journey to discharge and all

communication with nursing homes– Expertise in managing the very complex situations

• Visibility created – White Boards Patient Flow Office – Integrated into daily ward/patient flow involvement – Areas of breach highlighted and flagged for follow up

• Established SOPs for various points in the pathways e.g. first family meeting

• Educate and inform - again and again and again – Staff – Families– Patients

• IT enabled – designed by project team and built in house, integrated with National HSE Business Intelligence Unit Delayed Discharge System

Monitor & Control

Phase 3: Sustain

• Small dedicated Integrated Delayed Discharge Team put in place – Skill mix – nursing and social work – Coordinate the LTC pathway – Responsibility for the final stage of patient journey to discharge and all communication

with nursing homes– Expertise in managing the very complex situations

• Visibility created – White Boards Patient Flow Office – Integrated into daily ward/patient flow involvement – Areas of breach highlighted and flagged for follow up

• Established SOPs for various points in the pathways e.g. first family meeting• Educate and inform - again and again and again

– Staff – Families– Patients

• IT enabled – designed by project team and built in house, integrated with National HSE Business Intelligence Unit Delayed Discharge System

• Established dedicated communication pathway for nursing homes• Built and maintained effective relationships with a wide range of stakeholders

External Engagement

• Nursing Homes

• HSE

• Special Delivery Unit

• Development of an Integrated Case Management Group to focus on those with longest length of stay

• Legal advisors

• Ward of Courts Office

• Nursing Home Support Office – local and national

• External private and voluntary providers

• HSE Social Care Division latterly

• ....and more

Now?

• Highly expert coordinating team in place

• Standardised processes in place

• Monitoring in place to timelines

• Metrics allow internal performance to be monitored irrespective of external influencing factors

• Responsiveness

• Staff time focussed on adding value

Change?

• Change understanding

• Change attitude

• Change ownership

• Change processes

• Build empowerment

What’s the data telling us?

2011 2012 2014 YTD

Transit Time Mean 124 112 92

Fair Deal Application Mean

30 21 17

CSAR Mean 14 12 7.5

0

20

40

60

80

100

120

140

Day

sKey Performance Data Points

24000

25000

26000

27000

28000

29000

30000

31000

2012

2013

2014 projected

Be

d D

ays

2012 2013 2014 projected

Series1 30028 29144 26637

Bed Days Utilised for Patients Awaiting Discharge to LTC

2012 2013 2014

Beaumont % of National

16.30% 16.20% 13.20%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

Pe

rce

nta

geBeaumont % of National LTC Delayed

Discharges

0

10

20

30

40

50

60

70

2012 2013 2014 Jan - Oct

Pat

ien

tsNo of Patients RIP while Awaiting

Discharge to LTC

Fundamentally

• Visibility

• Standardised process

• Know what needs to be done...day in ...day out, consistently

• Know where responsibility and accountability lies

• Use technology to assist

• Each and every patient journey optimised

Intangibles

• Better understanding - less judgement

• Greater respect for roles

• Trust built

• Hidden expertise harnessed

• Expertise developed

• Reduced stress levels

• Sense of achievement

• Confidence

• Able to rapidly respond to discharge opportunities (competitive advantage!!!!)

Outcomes1. Improved patient flow

• Optimised processes that hospital has control of 2. Optimise utilisation of acute hospital beds

• Optimal utilisation of residential and transitional beds/funding3. Improved patient safety

Achieved by: • Standardising processes• Optimising patient journey to discharge• Creating shared ownership internally and externally• Increasing visibility to all stakeholders

Through the passion, commitment, innovation and perseverance of staff

Original Project Team

Ann Marie O’Grady, Senior Management Fiona Keogan, BICS Programme ManagerAnnette Winston, Principal Social Worker Rosaleen Cafferty, Patient Flow Manager

Una Donnelly, Senior Social WorkerCiara Ni Fhlathartaigh, Care of Elderly Programme Lead

Wider Team

Fair Deal Officer

Integrated Delayed Discharge Team

Social Work Department

Consultant Geriatricians

IT Department

Nursing

NCHDs

Consultants

Health & Social Care Professionals

Senior Management

Clerical

Management Information

Dream Team !!

Hospital wide

ownership

of a

Hospital wide

problem

“Striving for success without hard work is like trying to harvest where you haven't planted” David Bly