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6th Annual Hospital bed management and patient flow conference

25 Feb 2013

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The team

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What is the Gold Coast health Service district?

Demographics

Gold Coast

Southport

Gold Coast

Robina

Carrara

Hospital

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You pay for this……. But not for this!

Why would we go back?

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Are we Patient-centric?

3P philosophy is it right?

•Patients

•Providers

•Payers

Are we patient centric

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Distances between: Southport-Robina 20kms- 25kms 25-27 mins Southport- Pindara 6.4kms- 8.9kms 12-15 mins Robina- Pindara 13kms- 17.7kms 18-22 mins

Physiotherapy

Post-Surgery

Robina

Self- Referral

CNC Clinic

Robina

Preadmission

Outpatients

Robina

Genetic Counselling

Robina

-counselling Brisbane

Operating

Theatre

Robina

Hookwire ONLY

Southport Radiology

Riverwalk Way Robina

Physiotherapy / OT

For OP appointment

GCH Southport

Lymphosintigraphy +HW

Pindara Private Hospital

Benowa

KS Guided Core FNA

Medical Imaging

GCH Southport

Lymphosintigraphy + HW

South Coast Radiology

Chemotherapy (most)

Hormonal Treatment

GCH Oncology Southport

FNA In clinic

GCH Southport

Frozen Section -

GCH Southport

Our organisation is provider centric

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Is there a common ground through KPIs

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90 in 4

The bodies of work

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Stage 0:

Plan

Weeks 1-6 Weeks 7- 10 Weeks 11-20

Stage 1:

Diagnostics

Stage 2:

Solution

design

Stage 3:

Implementation

Weeks -4 to 0

Commencing: 11th April

Methodology

Week 15 Week 16 Week 17

w/c 9 May w/c 16 May w/c 23 May

• Sponsors and leads

checking readiness

factors to progress

strategic enablers and

phase 1

• Communications

planning (including

launch)

• KPI reporting

mechanism design

• Strategic enablers &

phase 1 solutions

commence

implementation

• Communication events

• Formalise monitoring &

reporting

• Continued

implementation and

support

• PJP Project Board

meeting

3 May

Implementation

Report signed

off

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Strategic enablers

subacute &

community care

Inpatient

care

Emergency

care

• Planning does not happen

effectively at a strategic level

• Responsibilities for bed

management are assigned

across many different roles.

This causes confusion and

impedes effective patient

flow management

• The geriatric population are a

disproportional number of ED attendances

and admissions

• The elderly are accessed blocked from

designated inpatient units

• Cat 2 waiting times exceed

QH targets of 10 min

• Cat 3 waiting times exceed

the QH target 30 min

• The current model of care for out-of-hours and weekends does

not allow for ongoing quality patient management nor efficient

discharges

• Access block is compounded by a poor rate of discharges over

weekends

• Patients do not receive allied health care over the weekends

• Pharmacy is unable to meet the demand for clinical pharmacy services,

causing medication related discharge delays and an increased risk of

medication errors

• Limited pharmacy services „after hours‟ increases the risk of medication error

• Most consultant ward rounds are not

scheduled and often occur at an

extremely fast pace

• Poor documentation from treating

teams leads to delays in patient care

activities being carried out

• Poor communication within the

multidisciplinary team

• Lack of coordinated patient care

• The transit unit is underutilised at

Southport and is not configured to be

used as a discharge unit

• Patients are not transferred to the

Southport transit unit due to delays in

prescription writing

• Robina does not have a transit unit

• Patients are staying in hospital

too long because referrals to

subacute care isn‟t starting early

enough in the patients‟ journey

• Referrals to subacute are not

comprehensive enough

• Transport delay is a major

factor in timely patient

transport both within the

organisation and home

• Patients perceive their treatment is

uncoordinated, not integrated and

not communicated effectively

• Inconsistent referral methods

across specialities and teams

causing confusion

• Delays occur in actioning

referrals and assessments

• Patient / Carer Experience surveys

indicated that there is a lack of co-ordination

and integration of care (including discharge)

• Discharge planning is fragmented and starts

too late in the patient journey

• There is lack of coordinated care and

discharge planning between staff that can

lead to delays in patients discharge

• Consistently high bed occupancy

adds complexity to management of

patient flow

• The District‟s patient flow procedure is

complex and not applied consistently

or effectively

• Medical and surgical elective

admissions are not always aligned to

capacity

• PAU is perceived to have fragmented

processes with increased patient delays for

review

• PAU lacks support from senior medical staff

• Patients and staff experience delays of up to

one week, waiting for diagnostic tests

• Patients often arrive in the medical imaging

department with patient preparation

requirements incomplete causing delays in

patient throughput.

• There is a lack of

clarity in the

accountability and

ownership of patient

and process of

referrals

• Medical officer

referrals are not

consistently responded

to in a timely manner

or by appropriate

seniority leading to

compromises in patient

safety

The diagnostic exercise identified a range of issues across the patient journey

Diagnostic Phase - Overview

Draft for discussion only – Not for distribution – Gold Coast Health Service District 10

Draft for discussion only

11

A range of stakeholders have been engaged to identify and develop solutions to

address the key issues identified in the diagnostic report

27

solution design

workshops

conducted

15

working parties

established

Leading best

practice research

69

patient interviews

conducted

More than 200 staff and external

stakeholders have contributed to the

solution design phase

Workshops

Approach to solution design

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12

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Implementation Report – How did we get here?

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This report is a documented practical guide for implementation of the identified

solutions aligned to the District goal for access block.

Post-acute care

Treatment

/care

Communication & HR

Information management & reporting

Patient flow & bed management

TransitionReferral

Inpatient care

Discharge

coordination

Care

delivery

Assess &

admit

Emergency care

DecisionTreatAssessTriagePre- present

& present

• A high proportion of QAS presentations consist of category 1 and 2

patients

• A high proportion of elderly patients present as category 2 and 3.

Generally, these patients are more likely to need an inpatient bed

• Services are fragmented and difficult

for both care providers and consumers

to navigate

• Inaccurate or inappropriate referrals

are often made due to a lack of

awareness regarding what services are

available and how they should be

accessed

• Delays between referral and transfer to

sub-acute services result increased

length of stay

• There is limited or no coordination

between service providers

• Patients and staff also experience delays

waiting for diagnostic tests and receiving test

results

• There are opportunities to improve the

utilisation of theatres across campuses

• Pre-admission clinic is perceived to have

fragmented processes with increased patient

delays for review and lacks support from senior

medical staff

• The number of

presentations at

ED is increasing,

with an

increasing

proportion of

elderly patients

presenting at ED

• Typically elderly

patients are

complex and

have multiple co-

morbidities, they

are more likely to

present to

hospital more

than once

• Several issues can routinely

impact patient care during the

assessment and admission

process, and when patients are

transferred to the ward

• Medical and surgical

elective admissions are

not always scheduled to

align to available bed

capacity

• Challenges experienced

by staff who coordinate

patient flow are

exacerbated because

relevant information is

not available to support

timely decision making

• Responsibilities for bed

management are

assigned across many

different roles. This

causes a mismatch and

impedes effective patient

flow management

• High levels of ward block impede the ability of the

District to transfer patients from the ED to an

inpatient bed and some wards are more frequently

access blocked

• Elderly patients wait longer for an inpatient bed

and also end up having a longer length of stay

• Significant delays occur waiting for inpatient teams

to review patients in the emergency department.

This exacerbates access block

• Unclear communications between patients and staff

result in patients not feeling valued or empowered

• Patients perceive that their treatment is

uncoordinated and not communicated effectively to

them

• Poor data integrity

impedes patient care

throughout the

patient journey

• Discharge planning in the District is fragmented

and starts too late in the patient journey

• Challenges related to the coordination of care

within teams impedes the discharge process

• Access block is compounded by a poor rate of

discharges on the weekends

• Failure to prepare and send patient discharge

summaries is impeding continuity of care within

the community

• Wait times for transport services provided by

QAS contribute to discharge delays from the

transit lounge

• There is a perception that the transit lounge

could be utilised to facilitate a greater proportion

of discharges from the Southport campus

This approach involved District staff prioritising a over 250 solution ideas based on

ease and impact

Solution themes

Patient flow and bed management

Care coordination and communication

Diagnostics

Pharmacy

ED cat 2 & 3

Geriatric model of care

subacute referrals

Transit lounge

Transport

Pre-admission

Out of hours rostering

Greater level of impact

21 3

Gre

ate

r e

ase

of im

ple

me

nta

tio

n

21

3

Approach to solution design

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Implementation Report

The purpose of this document is to:

• Detail the District‟s solutions to

patient flow issues

• Provide appropriate plans to guide

the implementation

• Provide a framework for managing

the implementation

• Outline benefit management

approach

• Identify key readiness criteria

•

April 2011

Stage 3: Implementation Report

Solutions Report

Diagnostic Report

Stage 0:

Plan

Weeks 1-6 Weeks 7- 10 Weeks 11-20

Stage 1:

Diagnostics

Stage 2:

Solution

design

Stage 3:

Implementation

Weeks -4 to 0

Diagnostic

Report

Solution Design

Report

Project Plan Implementation

Report

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Overview of the Implementation Report – for each solution

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Solution statement

Implement standardised and streamlined discharge process including clear roles and responsibilities to improve patient

experience, quality and timeliness of discharge

Proposed benefits and outcomes:

Reduced confusion and duplication between staff

Reduce discharge delays

Improved patient and carer experience

Earlier discharge of inpatients

Improved staff satisfaction including primary care

Leading practice:

• Best practice is a comprehensive discharge plan

developed within 48 hours of admission

• Identification of patient trajectories early and

matches patients to next step (Barwon Health)

• Re-engineering discharge incorporates Virtual

Louise for discharge education and dedicated

discharge planning work station (protected space)

• Clinical care pathways facilitate discharge by

achieving enhanced and quicker patient recovery

(Health Advisory Board, 2010)

KPIs

• Discharge by time of day

• Patient experience indicators

• Utilisation of discharge tools

• Number of patients with discharge summaries within 24 hours of discharge

• Feedback from General Practitioners

Solution design:

Implement standardised and streamlined discharge process that reflects leading

practice (should include informing patient and family of likely discharged date as

early as possible)

Implement early assessment and identification of discharge needs.

Implement consistent patient education on discharge (patient hand-outs)

Evaluate the effectiveness of tools used to facilitate discharge and recommend

changes to simplify

Review roles and responsibilities for alignment of discharge processes including

ownership of the patient (family and carers)

Measure and report adherence to streamline process and monitor effectiveness

of tools and teams

Key issues/insights:

• Patient / Carer Experience surveys indicated that

there is a lack of co-ordination and integration of

care (including discharge)

• Discharge planning is fragmented and starts too

late in the patient journey

• There is lack of coordinated care and discharge

planning between staff that can lead to delays in

patients discharge

• Poor communication between and within

disciplines.

• Team members work in silos and do not share

information with other disciplines

• Perceived inconsistency in providing information /

education to patients

Sponsor: Morven Gemmill

Solution l: Implement standardised and streamlined discharge process and toolsSolution l: Implement standardised and streamlined discharge process and tools

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Tasks Owner Dependency 1 2 3 4 5 6 7 8 9 10 11 12 Ongoing

Planning and preparation

Leadership Sponsor

Change Management leadership Lead

Determine sponsors and advocates Lead

Agree responsibilities Sponsor

Change Readiness Sponsor

Sponsor the change Sponsor

Monitor change management & stakeholders Lead

Report progress to executive sponsor Lead

Formalise working party Sponsor

Identify and agree working party Sponsor

Obtain commitment from working party members Lead

>>>>>>>…

Resource requirement plan

Review current staffing levels and services provided Lead

Develop draft staged plan for additional resoucres to meet demand for clinical

pharmacy services

Lead

Seek feedback from stakeholders regarding resource plan Lead

Resource plan endorsed Sponsor/board Board approval

Funding approved Executive Executive approval

Recruitment and deployment

Positions advertised Lead

Interviews completed Lead

Order of merit for HP3 and HP4 pharmacists finalised Lead

Appoint from order of merit Lead Executive approval

Pharmacists commence Lead

Orientate to department Lead

Deploy pharmacists as agreed in implementation plan Lead

Resources

Identify requirements in line with endorsed implementation plan Lead

Purchase required dect phones, wireless computers, lockers Lead Executive approval

Communications plan

Identify audience groups impacted by change Lead Executive approval

Determine communication needs Lead

Develop communication messages Lead

Deliver communications Lead

Gather feedback Lead

Measurement and reporting

Agree benefits Lead/MAC

Determine KPIs to support benefits Lead/MAC

Define measurement approach Lead

Develop measurement tools Lead

Measure and report progress Lead

Inpatient unit based clinical pharmacy services - implementaton Timeline: Week

1Draft for discussion only – Not for distribution – Gold Coast Health Service District

Risks:

• Failure to gain support for clinical pharmacy services will further contribute to

Pharmacy staff burnout resulting in excessive sick leave and turnover

• Lack of space at Southport

Key Solution: [summary headline of the solution topic]

Implementation team

Team role Team member Day per week Total weeks

Sponsor Jane Hancock 0

Project lead Trudy McGovern 1 8

Team member Liz Coombes 0

Team member Linda Stockwell 0

Team member Balaji Hiremagalur 0

Team member Paula Duffy – to confirm 0

Implementation team

Team role Team member Day per week Total weeks

Sponsor Jane Hancock 0

Project lead Trudy McGovern 1 8

Team member Liz Coombes 0

Team member Linda Stockwell 0

Team member Balaji Hiremagalur 0

Team member Paula Duffy – to confirm 0

Parallel projects:

PJP projects:

• Co-ordination of care and communication

• Transit Unit

• Transport

External

• Medication Services Queensland – review of

statewide medication discharge procedure (postive

impact)

• eHealth

Other resource requirements:

• Clinical pharmacy service – approx 16 FTE HP3/4/5 pharmacists to GCUH

transition to cover existing beds

• Computers, phones, lockers

KPI‟s

• Organisational KPI‟s

• Readmission rates

• Length of Stay

• Solution KPI‟s

• Medication error rate

• Time to complete medication discharge

• Quality of medication list in EDS

• Pharmacist ratios

• Patient KPI‟s

• Patient experience

Quick Wins (operational milestones thought to deliver

specific benefits within eight weeks of operation).

• Simplifying the medication discharge procedure to

reduce time and improve quality of the discharge

Dependencies:

• Medical and nursing staff to follow revised medication discharge procedures

• Adequate capacity to orientate, train and supervise pharmacists

Updated solution statements

reflecting latest thinking developed

by working parties and Sponsors

Detailed work break down

structure for the

implementation including:

• Duration of tasks (in weeks)

• Owners of tasks

• Dependencies

• Milestones

Outline business case for

the implementation

including:

• People involved in

implementing and

estimated time

commitments

• Other, non staff resources

required (eg. IT)

• Discussion of risks and

dependencies for the

implementation

• Quick wins and benefits

• Related projects

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Before any project can be mobilised, a number of key steps must be completed.

Mobilisation check list

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Checklist for Executive Sponsor Mobilisation of Solution Implementation

Project Lead identified and availability confirmed

Working party members identified and availability confirmed

Additional resources identified and confirmed

Change Readiness assessment for mobilisation:

oEnvironment

oStakeholders

oCommunication

oResources

oSchedule

oGovernance

o Risk

Funding and resource requirements defined (if applicable)

Funding and resource secured (if applicable)

Competing interests identified

Risks identified and mitigation strategies in place

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Solutions in action

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Implementation road map

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The recommended phasing of implementation starts with the strategic enablers and

quick wins, as planning and preparation starts for the next phase.

0-3 months 3-6 months 6-9 months 9-12 months 12-18 months

Prepare & Plan Implement

Prepare & Plan Implement

Evaluate, Monitor & Manage

Strategic Enablers

Evaluate, Monitor & Manage 2 - Team based care coordination and communication

1 - Patient Flow Strategy and Infrastructure

Implement

Evaluate, Monitor & Manage

3 - Bed management standard business rules

4 - Improve Category 2 and 3 emergency patient journey

5 - Early identification of Subacute patients

6 - Demand management for transportation services

7 – In-patient Unit Rounds & Communication

8 - Medical officer referrals business rules

9 - Allied health referral coordination

10 - Standard discharge process and tools

11 - Medical imaging systems realignment

12 - surgical pre-admission clinic service redesign

14 - Transit unit review and model of care development

13 – In-patient unit based clinical pharmacist

15 - Weekend activity and service alignment

Phase 1 Solutions

Phase 2 Solutions

Phase 3 Solutions

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Project Board

Project Team

Working

Party 1

Working

Party 2

Working

Party 3

Responsibilities include:

• Review and endorse

implementation plans

• Sponsor the implementation

of initiatives and supporting

solution teams

•Support solution teams and

review solution status reports

• Consider and approve

resourcing requests

• Design and implement risk

Mitigation strategies.

Responsibilities include:

• Provide program leadership and support to the assigned sponsors and project leads (responsible

owners)

• Organise and facilitate establishment of working parties

• Report overall program progress to project board and executive sponsor

• Monitor compliance with readiness assessments, timeframes and implementation plans

• Provide program management and utilise deep knowledge of hospital processes and peoples to lead

delivery of implementation activities

•Escalate overall program issues, risks and dis-benefits to the executive sponsor

Accountable Executive (Sponsor) •.

Responsible Officer (Project Lead)

Working Party Members

Managing Implementation

Consumer

on board

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So did it work for consumers?

We hit our NEAT, NEST and budget

targets……or did we miss the point!

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So what do consumers want or Complain about!!!

Consumers

• Communication

- To he listen to and respected

- To be kept in the picture

• They expect to wait!!!

Complaints

• Poor communication

• Poor treatment

• Poor access

Hospitals

• NEAT

• NEST

• Budget

• MORI

• SAC events

• Standardized mortality

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How do we measure it? Patients consented in hospital

Followed up in phone interview

Open standardised questions

Theme then classified

• 3 methodologies choosen

- Feedback after visit

- Real time interview

- PET

Measurements

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Patient Experience Trackers

Ask the same questions to staff and

patients to identify gaps

eg do you know your estimated day

of discharge

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So what have we done ? “In ED from

10am until

8.30pm-that is a

long day”

“Signage is awful”

“I was left in a soiled bed

and PJs for some time”

“The nurse to nurse

“handover” of information

about me was wrong”

Implemented

NEAT

Decluttered

and Rewritten

signs

Intentional

hourly ward

rounds

Patient

included in

hand over

So what else

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What are the main lessons learnt

•What patients want may be different to what is perceived

•Current KPI cannot capture the consumers needs

•There is significant overlap in some KPIs

•Fixing entire systems benefits both consumers and staff

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Can we Beat Disney at their own game

Can we beat Disney at their own game?

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Thank you