NEAT

If, when and why it works well

What is the problem?• Patient 1, Laura B, 20yr female. • Direct referral from GP to Surgery (surgical expect), arrived

at 1020 and was seen by the surgical registrar at 1101, 40 minutes after arrival. She then waited 4 hours, until being referred to Medicine at 1453.

• Then followed a further 2hr wait to be seen by the medical registrar, at 1646 (6hrs and 26 minutes after arrival). The medical registrar requested a bed 1hr 10min later, and the bed was ready at 1821.

• Unfortunately she could not leave ED until the medical registrar had written up the notes, which took until 1859.

• Total length of stay in an ED bed: 8 hrs 39.

What is the problem?

• Patient 2, Kristal M, 27yr female. • Direct referral from GP to Gynaecology, arrived at 1145

and waited 6hrs for the gynaecology registrar to arrive at 1740. She was watched during this time by ED and the later by the Gynaecology house officer.

• A bed was requested immediately (1742) but was not ready until 1916, 1½ hours later. In the end, she was not moved to the ward until 2007, because a venflon had come out, and needed to be reinserted so that IV antibiotics could be given.

• Total stay in ED: 8hr 22.

What is the problem?• Patient 3, Myrna A, 69yr female. • Presented to ED with chronic leg ulcers at 1305. Seen

by ED at 1421, 1hr 15 after arrival, and was initially to be referred to vascular surgery, but because of the patient’s history was referred to General Surgery at 1832.

• In this case it took ED 5½hr to come up with a plan for this patient. She was seen by GS within an hour (1921) and immediately admitted.

• It took until 2017 to allocate a bed, and the patient left at 2041.

• Total stay in ED: 7hr 36.

What is the problem?

• Patient 4, Ross C, 52yr male. • Referred into ED by Mental Health query

overdose at 1321. He was seen immediately, and managed until 1546 (2½hrs) when he was referred to ICU.

• He was seen by ICU within 30 minutes, and further observed until a decision was made to place him in ED Observation overnight at 1856.

• As at 2100, he was still in ED Obs and likely to stay overnight. This was an appropriate patient for ED Obs if it had been available.

What is the problem?

• Patient 5, Thelma L, 91yr female. • Brought in 6 days post discharge from Internal

Medicine. Arrived at 1017, seen at 1107, and referred to Internal Medicine at 1156 (total stay at this stage, 1¾hrs.

• She then waited 3hrs 10 to be seen by the Internal Medicine Reg at 1511. A bed was requested at 1625 (1¼hr later) and allocated with 30 minutes at 1702.

• She left ED at 1737, with a total length of stay of 7hr 20.

What is the problem?

• Patient 6, Brendon S, 39yr male. • Arrived in ED at 1014, and seen at 1138

(1½hr). At 1249, ED tried to contact Gastro, but were unable to make any contact with either the registrar or consultant until 1426, as no calls were returned for the nearly 2 hrs.

• The registrar arrived 1hr later at 1536, and the patient was discharged home at 1630,

• Total stay of 6hr 16.

What is the problem?• This was a quiet day, with only 78 presentations by

2115. • Despite this, we saw

• one patient where it took ED over 5 hours to come up with a plan; • one patient, a direct referral to Gynaecology, who waited over 6

hrs for the gynae reg to arrive; • one patient who was clearly to be admitted but was passed

between surgery and medicine for a delay of 5½hrs, • an Internal Medicine patient post discharge who waited 4½hrs

from referral till bed request, • And a patient who waited 3 hrs until Gastro first responded and

then arrived, to see him. • Only one of these patients could be seen as justifiably

in ED for over six hours.

The conclusion?

• Most delays are not for clinical reasons• Delays are not good for the patient

• “We have shown that a TDP of <4h was associated with significantly shorter ED LOS… when affected by an ED LOS >= 8h, the shorter TDP was associated with a significantly higher mortality. Where ED LOS was shorter, this association was no longer significant” Mitra et al

• The delays are caused both within and from outside ED

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What is the solution?

Two verydifferent sites…

Where do we start?

• Everybody’s problem• Lead from the top• Target each area to find their problem• Get people on board by showing them how it

will make their work easier, their patient outcomes better

What are the core principles?

• Everyone (frontline staff and management) has to work together as a team

• Problem solving takes place where the work takes place

• Do not accept the status quo, and use problem solving to continuously improve performance

From what to what

• Report writing• Meetings• Management in offices• Telling• Decisions made on

anecdote• Assumptions made on

data• We can’t do it because

• Use of A3s• Actions• Managers in clinics• Coaching• Decisions informed by

data• Data tells us where to go

to see• How can we do it?

How do we change practice?

1. Break down the barriers between management and frontline staff

• Managers have to accept that they are “waste” in a lean sense, and they have to determine how they can add value...

1. Removing barriers for frontline staff2. Coaching in problem solving

How do we change practice?

2. Management working in the frontline with clinical staff to undertake problem solving

• Problem solving does not occur in the meeting room or office

1. Use data based approach to problem solving2. Verify the reasons for what the data shows by going to the

workplace

Why is it important?

• There is poor communication between managers and frontline staff, because

• Managers do not understand what the frontline work involves

• Staff are too busy to see the wastes in practices they undertake every day

• Seeing it in practice on the shop floor is “in your face” compared to looking at data and reports

How do we change practice?

3. Build a culture of continuous improvement• Continuous improvement depends on two things

1. A belief that we can make things better2. A robust problem solving methodology

• We need front-line staff doing the quality improvement work, supported by management rather than management making decisions and “telling”

What works?

• Focussing on solutions, especially solutions from elsewhere, is dangerous

• If we try to implement a fix without understanding the detail of what we are fixing, we can often make things worse

• Doing analysis and making decisions in meetings is almost always a waste of time.

• Data can only tell us where to look, not what is happening

What works?

• Change agents, preferable line managers, need to get down onto the shop floor and work directly alongside staff to solve the problems

• Management must follow through on promises

• If the A3 reaches a conclusion, it should be implemented

Conclusions

• Change is possible. It may even be “easy” but• It cannot be imposed from above• It cannot be imposed on other departments• It must change the beliefs and conditions of those

working in the front line• It is most effective if it comes from working alongside

staff on the floor and changing the practices one at a time.

Finally…

We need to understandchanges in practice,

and the effect of these changes…

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Performance to 6 hour target and volumes, Dunedin

Total patients (Dunedin) Dunedin ED