My Job?

South African Triage Scale and Acute and Emergency Case Load

Management Policy Implementation Officer

Triage?

• First come, first served• “eye-ball”• To the Letter (“inappropriate”)• “Love thy Neighbour”• Dr G Special

SATS used correctly

• ↓Waiting times• ↓Emergency Centre Length of stay• ↑Patient flow• ↑Patient and staff satisfaction• ↓Mortality (2% to 0.7%)

SATS Performance Indicator

CTS priority Target time to treat Performance indicator threshold

Red Immediate 95%

Orange 10 minutes 80%

Yellow 60 minutes 75%

Green 240 minutes 70%

Time to Triage

Triage (ambulance stretcher cases)

Seen by Doctor

• 0% Orange patients seen in under 10mins after SATS assigned

• Orange and Yellow patients are seen by doctor on average 2 hours after arrival (about 50 minutes after triage) – this is in a system where Green patients are streamed elsewhere.

Time waiting in EC

• 71% of admissions spend over 8 hours in the EC (from arrival)

• Average is 12,5 hours from arrival to ward bed

• Average wait from time seen by specialist to time to ward is 7hours.

Overcrowding

If your hospital is >90% full

OR

Over 10% of the patients in the Emergency Centre have been waiting over 8hrs from arrival to

admission

THEN...

INPATIENT MORTALITY IS INCREASED BY 30%!

Mortality risk ratio is 1.1 for each hour spent waiting in the Emergency Centre

Mortality risk ratio is 1.2 for each hour spent waiting for a doctor

Overcrowding causes• Increased patient mortality • Ambulance diversion• Increased inhospital lengths of stay�• Patients not being placed on the appropriate ward• Medical errors�• Poor infection control• Poor hospital processes• Financial losses to hospital and physician�• Medical negligence claims�• Increased staff burnout and decreased morale

“An overcrowded hospital should now

be regarded as an unsafe hospital”

No matter how few resources we havethere is always hidden capacity in the systems

Use our limited resources more effectivelyIncrease efficiencies, reduce duplication, reduce waste

Patients want:• the right treatment• without mistakes• without waiting

“Work smart not hard”

Systems Improvement

Front Door Issues – Entry Portal

GFJ:

• 20% of CHC referrals are “inappropriate”

• 40% GP referrals “inappropriate”

EC Efficiency

EC Efficiency

EC EfficiencyNursing Staff

• 44% of time is non-value added work – giving directions– pushing trolleys– answering phones– finding stock

• ie Employ 10 nurses and you will get 5,6 nurses’ worth

• ?Quality of the 56% nursing care done under pressurised and distracting conditions

• Doctors only slightly more productive...

Patient flow

Who’s closing the hospital??

Ward check

• Ward 1: 0 Beds , 5 discharges pending• Ward 2: 4 Beds, 5 discharges pending• Ward 3: 5 Beds, 3 discharges pending• Ward 4: 3 Beds, 0 discharges pending

Back Door Issues - Discharge planning

• Patients admitted on Thursdays have longer lengths of stay than those admitted on Mondays

• Patients often only leave beds at 17h00 on the day of discharge

Discharge Process

Discharge summary written and handed to nurse

Folder to pharmacy

Transport arranged

OPD appointments made

Home-based care forms filled

Patient waits in bed until medications or transport, whichever comes last

This often only happens at 12h00

or 15h00...

With Discharge Planning

Day before• Contact transport (heads

up)• OPD appointments• Home-based care forms• Intern to prepare discharge

forms for next day

On the Day• Discharge round first thing

in the morning• Transport confirmed• Patient to discharge lounge

as soon as transport confirmed

With discharge planning, discharge rounds and discharge lounge

Total length of stay shortened

Every bed hour saved:

• Reduces mortality and morbidity of patients awaiting beds

• Reduces Cost to the Hospital

‘all improvement needs a changebut

not all change is an improvement’

DMAIC

• Define the Problem and its impact on the Organization• Measure the Current Performance

• Analyze the Performance to identify Causes of this Performance• Improve the Problem by attacking its Causes

• Control the Improved Process to Maintain the Gains.

Finding ideas for change

• people providing the service• patients• guidelines (eg AECLMP and SATS policies!)• change ideas/concepts (eg lean, 6-sigma)• mapping the system• identifying underlying problem (root cause

analysis) • novel ideas (creativity) eg brain storming• best practice - sharing ideas

What Change can we make that will result in an improvement?

A little about Lean

Types of waste

Muri (overburden) – unreasonable work imposed because of poor organisation – pushing person or machine beyond natural limits. Improvement comes at the level of proactive planning.

Types of waste

Mura (uneveness): Problems inherent in systemdesign or implementation. Improvement is in smoothing out the process

Types of Waste• Muda (non-value added work): waste that becomes

apparent once system implemented– Transportation: moving products that are not actually

required to perform the processing– Inventory: all components, work-in-progress, finished

product not being processed– Motion: people or equipment moving/walking more than

is required to perform the process– Waiting: for the next step in the production– Overproduction: ahead of demand– Over processing due to poor tool or product design,

creating activity– Defects (mistakes, re-work)

Types of Waste

Use of human resources:

• Rationalisation

• Creating thinking workers

5 WHY’sWhy?

Why?

Why?

Why?

Why?

5S

• Sort• Set in order/Straighten out• Shine• Standardise• Sustain

VALUE STREAM MAPPING

10 min

30 min1 Hour

6 min

2 hour

12 min

10 min

2 min

3 hours

24 min 6 hours 40 min

VALUE STREAM MAPPING

8 min

30 min 45 min

10 min

1 hour

6 min

3 hours

24 min 3 hours 45 min

PORTERS

Porters’ Lodge

X-ray

Ward 4 Ward 1

Ward 2

Ward 3

Emergency Centre

Ward3 to X-rays

EC to Ward2

X-ray to EC

Ward 2 to Ward 3

EC to X-ray

Porters’ Lodge

X-ray

Ward 4 Ward 1

Ward 2

Ward 3

Emergency Centre

Ward3 to X-rays

EC to Ward2

X-ray to EC

Ward 2 to Ward 3

EC to X-ray

Getting ready to suture

Some other processes impacting flow

• Stock availability and placement• Pharmacy throughput• Laboratory turnaround time• Enquiries setup• Time to folder – place for bedside admission?• Statistics collection and acting on Escalation

Policies

Initiating Change

Valley of despair

Time

Rapid Cycle Change

What can we change that will result in an improvement?

How will we know that a change is an improvement?

What are we trying to accomplish?

Improving many parts of the system at once.

Wait for doctor

DischargesTriage Nursing duties

End