department of human services five innovations to improve length of stay management and whole system...

Department of Human Services

Five innovations to improve length of stay management and whole system patient flow


IntroductionThis guide is for Health Services aiming to improve their inpatient processes and care delivery.

The five innovations are based around developing a shared understanding of capacity and demand, empowering all staff to manage patient’s length of stay, using simple improvement tools and care bundle techniques and promoting leadership through executive involvement and organisational escalation plans.

Use this guide as the starting point to develop an improvement plan. Click on the tabs to progress through the five improvements.

Additional resources to support the innovations are available in the Patient Flow Change Package.

For further information on the Patient Flow Collaborative, please visit www.health.vic.gov.au/patientflow


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Variation patterns - large variation in admission patterns

Range between the process limits is 19-95Average is 57

Understanding data

ThreeTally charts and actionplans

FourInpatientcarebundles

FiveEscalation plans

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Range between the process limits is 5-107Average is 56

Understanding data

Variation patterns - large variation in discharge patterns






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Discharges vary more than Admissions

Understanding data Variation patterns – mismatch between discharge (capacity) and admission (demand) patterns.



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Note: Average LoS = 7.24 days

Understanding data

Medical Patients

0

50

100

150

200

250

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay (days)

Nu

mb

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of

pa

tie

nts

Take ½ day off clinically unnecessary LoS and it has a dramatic impact

? prevent admission? prevent admission

These patients may have more complex support needs

These patients may have more complex support needs

Reducing length of stay


Provide care in another environment linking to community, e.g. HARP

Take half day off clinically unnecessary LOS and it has dramatic impact through reduction in waits,

delays, unnecessary queues, better decision making and communication.


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Understanding data

Variation in admissions and discharges - Specialist Medical Ward


Match admission demand to capacity created through

timely discharge


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Understanding data

Variation in Admissions and Discharges - Specialist Surgical Ward (2003-04)



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Admission via ED Day range Mean

Cardiology 3 5 4

Medicine 8 10 9

Surgery 7 10 8

Neuroscience 2 6 4

Total beds needed for ED admits in 24 hrs

20 31 25

Predicting emergency admissions demand and create capacity to meet daily needs.

Understanding data

Smoothing flow – Can we predict our emergency demands?









OneUnderstandingdata Empowering staff

Leading management of patient flow by assertive, cooperation with care providers

To effectively manage patient’s length of stay, front line staff need assertive and cooperative communication styles, especially during times of low staffing, and increasing demanda clearly communicated knowledge of policy and organisational goals to improve whole system patient flow.

A simple communication style

model can remind staff of the

best communication methods.

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OwnInterests

Others’Interests



Checking assertiveness

The following questions can help to assess assertiveness©:

Do you express your thoughts, feelings, and beliefs in a direct and honest way?

When you differ with someone you respect, are you able to speak up and share your own viewpoint?

Do you usually have confidence in your own judgment? Are you able to refuse unreasonable requests made by friends or co-workers? Do you ask for assistance when you need it? If someone else has a better solution, do you accept it easily? Do you readily accept positive criticism and suggestions? Do you try to work for a solution that, as far as possible, benefits all parties?

© Organizational Development and Training, Department of Human Resources, Tufts University, Somerville, MA

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Barriers to assertiveness

Barriers to assertiveness can prevent solutions or actions progressing patient care.

These barriers include:

steep authority gradient steep experience gradient rank lack of confidence fear of reprisal personal agenda ambiguous policy or lack of enforcement lack of clarity about patient –centred organisational goals and vision.

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Graded assertiveness

A simple method to assist solving issues with patient’s length of stay can be used; this is called ‘graded assertiveness’. Graded assertiveness is a process of advocating and justifying a position until patient care is assured. Graded assertiveness should be used if the initial enquiry/request is unsuccessful in resolving the problem in an appropriate way.

Graded assertiveness is a process of progression through four levels of assertiveness:

1. Probe I need to know what is happening

2. Alert What is happening is preventing effective length of stay

3. Challenge The patient is not going to get timely care and treatment

4. Emergency This needs referral to a higher authority, as it is causing unnecessary delays for the patient

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By moving through the four stages of graded assertiveness, a resolution should be found for effective length of stay management.

Ultimately the patient should receive the right care, at the right time, with the right clinician with the right equipment/resources.

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Tally charts and actions plans

Variation in length of stay

Simple delay tally charts and action sheets for delays have produced significant improvements to patients’ care plans, reducing the length of stay.

Tally charts can be updated each day identifying if there are any delays in the patient’s length of stay. Action sheets stating the delay category and action can be prepared by the Ward/unit nursing staff, thus promoting ownership of patient’s clinical care. Each delay category must have a pre-defined guided intervention.

Example templates are set out on the following two pages to make additional copies.


Patient ID

Delay(refer to Action Plan categories)

Action taken

Delay Tally Sheets

Delay category Action to be taken

Delay Action Plan


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Inpatient care bundle

Care bundles are an improvement tool which makes sure a clinical process delivers the elements of care needed to optimise patient outcomes.

The care bundle approach encourages clinical teams to agree on the elements of clinical interventions and manage unwarranted variation in care delivery.

Once the care bundle is agreed, measurement can be applied to promote and manage consistent high standards of care.

A simple care bundle has been developed to assist with optimising inpatient stays. This care bundle can be converted to any clinical area and the measurement tool applied.



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OneUnderstandingdata Inpatient care bundle

Elements for a length of stay care bundle should include:

- Discharge medication

- Follow up arrangements – e.g. OPD etc.

- Day/time of discharge communicated to patient/carer

- Letter to General Practitioner

- Transport plan

The following simple codes can be used to audit whether the care bundle element has been completed:

0 – not complied

1 - complied

2 - not required.

The Care Bundle Graph tool incorporates these five elements and collects and automatically graphs audit data, on compliance with the care bundle approach.

An electronic version is located on the accompanying CD or available from the patient flow website.




TwoEmpoweringstaff Simple escalation plans for inpatient management which are action orientated

and easy for all staff to follow can produce significant benefits during bed block and by pass.

Actions must be proactive and have policy driven trigger points.

Essential to this approach is focussed, single minded leadership to resolve access issues. Accountability to the CEO is assumed to underpin and drive the escalation plans.




Escalation and contingency plans


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Short term actions that can be incorporated into escalation policies:

Review all inpatients by the patient’s clinical team

Executive grand round of all patients. This team should include Executive General Manager, Senior Clinical Lead and Senior Nurse Lead

Tracking of all inpatient delays should be enforced on all wards

Predicting Emergency Department admissions over the next 24 – 48 hours to plan bed requirements

Increase Emergency Department staff for expediting treatment of low acquity patients

Arrange one hourly Bed Manager and Lead Executive meeting

Identify single point of accountability e.g. General Manager to stop other duties and focus on issue at hand reporting directly the the CEO

Agree and review tasks every 2 hours until situation reversed.


Escalation and contingency plans


AcknowledgementsJenny Bartlett Chief Clinical Advisor, Office of the Chief Clinical Advisor

Lee MartinManager, Clinical Innovation AgencyDirector, Patient Flow Collaborative

Marcus KennedyClinical Lead, Patient Flow Collaborative

Patient Flow Collaborative TeamRochelle Condon, Improvement LeadRuth Smith, Improvement LeadFiona Dickson, Improvement LeadJohn Walker, Communications and Logistics Lead Prue Beams, Data Consultant


ContactsSupport to implement these system wide initiatives is available via the Patient Flow Collaborative team who can be contact via:

Clinical Innovation AgencyEmail: [email protected]: 9616 7022

Patient Flow Collaborative TeamLee Martin 9616 7859 Manager, Clinical Innovation

Patient Flow Collaborative DirectorRochelle Condon 9616 9026 Improvement LeadRuth Smith 9616 9025 Improvement LeadFiona Dickson 9616 9030 Improvement LeadPrue Beams 9616 7742 Data Consultant John Walker 9616 9037 Communications and Logistics Lead

department of human services five innovations to improve length of stay management and whole system...

Documents

understanding data slide

action plans

system patient flow

escalation plans discharges

inpatient care bundles

patient flow collaborative

patients length of stay

tally charts