St Vincent’s Hospital, Darlinghurst Louise Kershaw

Clinical Redesign and Decision Support Manager

of long stay patients

NEAT and NEST Strategy

This presentation

• Stranded patient project – Indications for introducing Sam to your hospital

– How to implement a Stranded Sam project

– Success factors and our results

– What Sam will not do

• Patient flow and access strategy for NEAT and NEST – Projects, programs and transformational change

– Flow and access strategic framework

– Capacity plan

– Bed allocation and emergency patient ownership

St Vincents Hospital, Darlinghurst

• Tertiary referral hospital

• 41,333 presentations in 2012 – ↑ 2.6% pa

• 45 Ambulances per day – ↑ 3.4% pa

• 36% admission rate

• 16% presentations D&A effected

• 39,175 admissions – 47% overnight

• 242 acute beds, 17 ICU, 33 MH, 10 EMU

• Statewide HLTx and BMTx services, no paeds or maternity

Stranded Sam - Methodology

• Participation in HRT Stranded Patient project

• Motivated team who met twice weekly

• Case studies of 32 patients - identified through >21 day report and operational issues

• Case studies followed up by clinical champions and problem solved

• Data analysis of long stay patients 1/1/2008 – 30/6/2011

• Key issues identified

• Ad hoc analyses and audits to support issue prioritisation

• Process redesign

• Project and change management

The team

• Bed blocked Brett Gardiner – Director Clinical Governance

• Languishing Louise Kershaw – Redesign & Decision Support Manager

• Stranded Sally Whalen – Acute Program manager

• Consult Clement Tsang – Surgery Clinical Superintendant

• Absconding Ann Morgan – Quality Manager Acute

• Rescue Rodney Smith – Patient Flow Manager

• ..... and Stranded Sam

Long stay patients - the quantum

1061

104

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Episodes Beds

<7 days

7-<14 days

14-<21 days

>20 days

In 2010 3.6% of patients took 34% of the beds Worst RSI in HRT peer group!!!

Length of stay

Issues identified

• Governance, leadership, culture, valuing and optimising scarce resources

• Discharge and care coordination

• Delays in access to ......nearly everything

• Medical team and multidisciplinary team operation

• Transition to subacute, rehab and community services

Stranded Sam objectives

• Increasing awareness of SVH staff of waste in the systems of care through targeted communication strategy

• Improving appropriateness of patient care • Improving efficiency of resource use:

– Inpatient beds – Diagnostics – ICU beds

• Recognition of patients time as valuable • Kill many of the sacred cows grazing in SVH

– Acknowledge we needed to improve – Acknowledge there was something that could be done

Communication Strategy

• Case for change – Case studies

– Quantifying the issues

– Benchmarking with HRT

• Presentations at key forums – Grand rounds

– Program and specialty meetings

– Linking with capacity plan

• Branding – Stranded Sam

• Expose waste and make it unacceptable

Languishing Lucy - LOS 67 days • 35 yo non-healing ankle # following fall in 2009, extensive surgery to (L) ankle and

surround since. High risk wound

• History of drug abuse, social and minor psychiatric – support from partner and mother

• DOS osteostomy (L) ankle and insertion of battery, internal fixation, bone graft

• Bed rest, foot elevation and IV antibiotics required postop

• Return to OT for debridement/SSG/Intergra/VAC during admission

• Patient frequently off the ward, & Tx for hypertension and tachycardia following ingestion of alcohol and other substances

• Day 21 Plastics happy for discharge with community support but Ortho recommended continued inpatient care - concern with non-compliance to therapy

• Option available for FU in community for IV ABs and wound care

• Patient discharged to community care when patient’s mental status deteriorated as a consequence of long period of inpatient care

• Currently being successfully managed in ambulatory care, wound healing

Strategies

• Patient flow business rules and implementation – ICU/HDU bed management business rules

• Report 21 day LOS in KPI set • Increased resources focussing on problem solving blocks

to patient delays • Discharge process

– Whiteboard rounds of long stay patients – Identifying target discharge date – MDT meetings - structure, process and focus

• Early identification of stranded patients • Alignment with theatre redesign project

– Getting patients to theatre on time - today’s work today

Making performance visible

Identify Stranded Sam Identify Sam early and escalate the issues

He will be more likely to have been admitted through ED and have

or more of the following

or more medical teams involved in care or review

or more allied health team members involved

or more sets of diagnostics (excluding routine pathology)

or more days waiting for review or test

one of social issues – homeless, lives alone or needs services

If your patient is heading towards being stranded

and you need help sorting out the issues

alert the Ward NUM or contact the

Patient Flow Manager 0403 197 827

Stranded patient results 2013

Number of Sams decreased slightly but now using 11 beds less

RSI 103% →

98%

Sams – the new currency

Stranded Sam supports NEAT Hospital

Success factors

• How big is your stranded patient problem? Recreate the graph – All discharged acute patients in one year – Sum separations and bed days – Create the graph

• The team – include medical staff, patient flow and executive with creativity and method

• Use case studies to challenge current practice • Focus on the opportunity cost of Stranded Sam • Keep refreshing and running the campaign

NEAT

Hospital Each day up to 3 Sam’s are stranded in the emergency

department for longer than 24 hours.

“Would you want this for

your Uncle Sam?”

NEAT AND NEST STRATEGY

How close are you to success?

• Do you perform well in most areas but missing in a couple?

• Do you need a complete organisational transformation? - are you having trouble knowing where to start?

Kotter on transformation

Establish a sense of urgency

Form a powerful guiding coalition

Create a vision

Communicate the vision

Empower others to act on the vision

Plan for creating short term wins

Consolidate improvements and produce still more change

Institutionalise new approaches

Leading Change – Why Transformation

Efforts Fail, John P Kotter HBR Jan, 2007

Performance

Accountability

External

drivers

Culture

IM&T & BI

Efficiency

BPR Lean

Focus

Change

method

Leadership

Enablers Failure causes

Strategy

Transformation

Redesign & Descision Support Strategy on a page

Patient flow and access strategy framework

Culture change Leadership and communication

Performance management

Change management

Demand management

NEAT ED team based MoC

NEAT ED Fast track

Inpatient capacity plan

Flexicare (HITH)

RED Radiology in ED

Service capacity

Stranded Sam

Theatre redesign

LOS benchmarking

NEAT ED team based MoC

Ward reconfiguration

Flow

Patient flow business rules

Bed allocation redesign

Ward patient ownership and TACT time

Surgery booking and PAC redesign

Cath lab redesign

ePatient Journey Boards

Pro

cess

red

esi

gn L

ean

Six

Sig

ma

Bu

sin

ess

Inte

llige

nce

– Q

likV

iew

rep

ort

s Change management

Performance measurement and transparency

KPI reports - QlikView

Dr A Dr B Dr C Dr D Dr E Dr F Dr G

KPI reports QlikView

Dr A Dr B Dr C Dr D

July 2011 – Link to HRT ALOS

July 2011 Capacity Management Plan

August 2012 Bed Management Project

• Value Stream Mapping 336 issues • Solution redesign based on

– Takt time – Predictability – Rounds – Standardisation in process and roles and

responsibilities to create consistency – Escalation – Accountability and responsibility

(MDT/program/executive) – SVH Capacity plan

Creating bed capacity to manage

0.0

2.0

4.0

6.0

8.0

10.0

12.0

CAR CCU MSTU X10S X7N X7S X8S X9N X9S

Discharges required per day by ward -all patients

Discharges Mon-Fri Discharges 7 days

Individual ward takt time

• Every ward provided with average admissions

by day of week

• Causes of variation include clinic days,

elective surgery list days etc

Patient Journey Board

Surgery redesign & NEST (1)

• Elective schedule changes – February 2011

• Increased in hours emergency time – February – May 2011

– Emergency orthopaedic sessions

– Refinement of emergency G session

• Communicating late start performance – April 2011

– Changes to TMS and nurse practice to allow reporting

– QlickView reports

• Changes to SVH Consent policy – April 2011

– Discontinue 1 year requirement

– Interns able to consent repeat procedures with no changes in patient

condition

• Emergency list booking process – June 2011

– Improvements to TMS Patients retained in TBA list and Emergency “wait list”

• Manage ICU and ward bed demand – ICU business rules September 2011

– Increase nurse staffing of ICU to 100%

– Business rules around prioritising, delaying and cancelling patients due to no

ITU bed

Elective list review and management– August 2011

Forward review of elective lists for unused capacity

Earlier identification of available OT capacity and reallocate unused OT time

Identification of inpatients who require theatre - September 2011

List sign off – timing & TMS changes – August 2011 – February 2012

List finalised 2 days before day of surgery & include equipment requirements

Surgical patient length of stay reports by Surgeon and Specialty and comparison to

HRT benchmarks, on time start reports by doctor – April 2012

Improve radiographer resource deployment and communication– May 2012

Redesign preadmission process including PAC – January 2012 in progress

New patient letters and process for communicating with patients

Simplified Preadmission Questionnaire (PAQ) and criteria for Preadmission Clinic

New scheduling and booking process for preadmission clinic

Scanned RFA, consent and PAQ can be reviewed remotely

Surgery redesign & NEST (2)

Impact of changes by destination ward

Trasnferred to Pre Post Total Triage to Bed requestPre Post Total Average Bed Request To Inpatient (Hours)

CORONARY CARE UNIT 4.7 4.4 4.6 4.3 3.9 4.2

10 SOUTH 4.8 4.4 4.7 5.4 5.1 5.3

7 NORTH 5.0 4.4 4.8 7.9 6.7 7.6

7 SOUTH 5.1 4.5 4.9 8.1 6.6 7.7

8 SOUTH 5.2 4.8 5.1 8.4 8.4 8.4

9 SOUTH 5.3 4.3 5.1 7.2 7.3 7.2

9 NORTH 6.8 6.0 6.5 10.9 6.7 9.6

MEDICAL ADMISSION UNIT 6.2 5.6 6.1 5.9 3.7 5.4

CARITAS CENTRE 5.0 5.4 5.1 2.9 2.2 2.8

PECC 5.9 5.7 5.8 2.8 1.6 2.6

INTENSIVE CARE UNIT 3.4 3.3 3.4 3.4 2.7 3.3

Triage to bed request Bed request to depart

ALOS overnight patients

Stranded Sam

commenced

>11 % reduction in overnight length of stay

0

500

1000

1500

2000

2500

Individual run chart time from admission to OT

Hours "+SD2" Mean

Conclusions

• A novel, memorable communication strategy assists the implementation of change strategies

• A strong message uncovering waste builds dissatisfaction with the status quo

• Sam has been instrumental in a cultural change to value bed days - long and short stay patients

• Stranded patient project needs to sit within a broader strategic program of work otherwise impact on NEAT and NEST will be negligible

Strategy Implementation

• Aligned leadership and governance

• Differentiate between cultural and process issues and treat accordingly

• Data...... data....... data

• Communication..communication..communication

• Openness and transparency about performance

• Targeted senior medical staff engagement

• Multiple projects & working parties – integrate

• Build change and redesign capacity

Questions

Louise Kershaw

0410 552568 (M)

louise.kershaw@ymail.com