Wednesday 18th November 2015

Improving Flow with Institute of Healthcare Optimisation (IHO)

Variability Methodology

Session Outline

• Flow Programme Overview• IHO Methodology• Guided Patient Flow Analysis (GPFA)• IHO Flow Improvement Projects• Discussion on GPFA charts

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Where does Flow Team fit within Improvement Landscape?

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About IHO

The Institute for Healthcare Optimization (IHO) is an independent not-for-profit research, education and service organisation based in Boston, focusing on bringing the science and practice of operations management to healthcare delivery.

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Proof of Concept Approach5

Tranche 1: Building Capacity

& Capability

Tranche 2: Implementation

Tranche 3:Evaluation &

Spread

Establish Pilot Board Teams

Operations Management

Education

Patient Flow Assessment

Identify Patient Flow Redesign

Project

Implement Chosen Redesign(s): 1.Operating Theater

2.Surgical Inpatient Flow

3.Medical Inpatient Flow

Develop Scale-up Program

Disseminate Tranche 2 outcomes

Finalise Plan for Spread (within hospital boards and at a national level)

Develop tools and materials

Execute Spread

NHS Board Engagement

• June 2014 – 4 Pilot Boards begin (Tayside, Borders, GG&C, Forth

Valley)• June 2015

– Pilot Boards begin data collection for Implementation Project– 6 Mainland Boards begin initial analysis (Wave 2)

• Early 2016 – Wave 2 Boards choose implementation project– Wave 3 Boards begin initial analysis

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The Goal in Healthcare?

• To Deliver the “Right Care”• To the “Right Patient”• At the “Right Time”

Possible?? Yes, if:• We know when the patient will get sick• We know the disease, the severity and response to therapy• We can provide the right caregivers and therapies

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Variability in Healthcare

Clinical – Patients present with different diseases, different severities, and have different responses to therapy

Professional – Providers have varying levels of experience, training and innate ability

Flow – Patients arrive at various times

Natural – Random, statistically predictable, can be managed with operations management techniques (queuing theory), cannot be eliminated

Artificial – Non-random, non-predictable, unstable, must be reduced or eliminated

Sources of Variation within a Clinical Sources of Variation within a Clinical System that impact on patient flowSystem that impact on patient flow

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GPGP DischargeDischargedd

StaffStaff Skills Illness Motivation Shifts Holiday Training

ProcessProcess Unclear

Guidelines differ Complications in anaesthetics

PatientsPatients Age Race Sex Motivation Disease Education

Machines not Machines not the same the same

Supplies Supplies

Rooms not Rooms not the same the same

EquipmentEquipment

TranscriptionTranscription

Transport Transport

Applications Applications

InformationInformation

80% is within 80% is within our control!!our control!!

Our Challenge is to:

Understand the sources of variability and their effects on patient flow and then to:–Optimally manage “Natural/Uncontrollable”

Variability– Eliminate or reduce “Artificial/Controllable”

Variability

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How? Apply IHO’s Variability Methodology

What is Guided Patient Flow Assessment (GPFA)?

• Supports identification and understanding of patient flow issues in a chosen hospital(s) based on local data• Qualitative:

• Guided Patient Flow Questionnaire• Quantitative:

• Guided Patient Flow Assessment Analyses

• Identifies opportunities for improving patient flow using IHO Variability Methodology™

6. El IP. Weekday average elective admissions

7. El IP. Weekday average elective admissions

8. El IP. Weekday daily admissions

9. El IP. LoS in days10. El IP. Distribution of surgical elective admissions to wards by specialty.

12. Hosp. Weekday daily admissions run chart:•Elective •Non-elective

11. El IP. Distribution of surgical elective admissions to specialty by wards.

17. El IP. Average recovery waiting time for admitted patients by destination ward.

18*. IP Average waiting time for discharge or transfer by ward.

20. Surgical wards. Average weekday occupancy by day of week.

Elective Flow(Option 2)

14. AMU. Avg LoS for admitted patients by destination ward.

13. ED. Avg LoS for admitted patients by destination ward.

15. ED. Avg waiting time for admitted patients by destination ward.

16*. AMU. Average waiting time for admitted patients by destination ward.

19. Medical wards. Average weekday occupancy by day of week.

22. ED. Day of week avg wait time from decision to admit to admission.

23*. AMU. DOW Avg wait time for all patients from decision to admit to specialty ward. 24*. Surgical25*. Medical.

26. Hosp. LoS for unscheduled care medical patients by discharge day of week.

27. Hosp. LoS for unscheduled care medical patients by admission day of week.

28. Hosp. GP referred unscheduled care patients average LoS by day of week.

29. Hosp. GP referred unscheduled care patients average attendance time by hour

Un - scheduled Flow(Option 3)

Balancing Measures

21. Proportion of medical and surgical admissions by ward.

ScotPFA - Overview of Analysis MapOperating Theatres(Option 1)

1. OT. Weekday daily cases

• Elective • Expedient• Emergent

2. OT. Weekday daily case hours:•Elective •Expedient•Emergent

3. OT. Weekday activity average :•Elective •Expedient•Emergent

4. OT. Weekday activity average:•Day case•Non-elective IP•Inpatient

5. OT. Time of day activity/booking:•Booking*•In-room/theatre

18*. IP Average waiting time for discharge or transfer by ward.

Shows variability in theatre activity. Variation in the elective

volume is driven by scheduling patterns and

practices.

Does this variability lead to the cancellation or

delay of elective cases?

Significant number or % of emergent and expedited

cases requiring rapid access to the theatre

suggest “Re-engineering Theatres” project

opportunity

Are many low data points linked to certain days or

suggest underutilisation?

Analysis 1 - This analysis is a “line chart” showing the number of elective, expedited, and emergent cases that were performed on each non-holiday weekday in the period being

analysed.

This chart helps ascertain whether the theatres are having reasonable success at mitigating the effects of variability in

case volume on theatre workflow by matching high volume days with shorter

cases.

Evaluate if days with higher case hours affect the number of elective

cases cancelled or postponed.

Did the low data points from chart 1 correspond

with those in chart 2?

Analysis 2 - This analysis is a “line chart” showing the total hours of elective, expedited and emergent cases performed each day in the time period being analysed, as well as the averages

for each type of case over the course of the period.

Which wards have the highest average LOS or peaks in LOS?Are these wards likely to be bottlenecks, or are there other

reasons for this pattern?

Analysis 13 - This analysis is a bar chart showing the average ED length of stay for admitted patients, by admitting unit and error bars showing the 10th and 90th percentile wait times for

each day of the week.

Wards driving a high average and/or peak in ED LOS may be bottlenecks (or upstream

from bottleneck wards).

Also look at this data for Assessment Units

Analysis 15 - This analysis is a bar showing the average ED wait time for admitted patients, by admitting unit and error bars showing the 10th and 90th percentile wait times for each day of

the week.

Wards with a high average and/or peak in wait time may be bottlenecks (or upstream

from bottleneck wards).

Which wards have the highest average wait times or peaks in wait times?

Are these wards likely to be bottlenecks, or are there other reasons for this pattern?

Validation and Interpretation

• Local Engagement and Buy in• Understanding the cause(s) of variation• Local decision to choose most suitable

project options for redesign

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What is the purpose of the Guided Patient Flow Analysis

• The GPFA gives a high level overview of patient flow through hospitals• It has been designed to highlight artificial variation and patient flow issues

that IHO’s Variability Methodology™ can address• The analysis should help direct Boards towards a preferred implementation

project• At this stage it is not:

– a demand and capacity exercise– a specialty or procedure specific deep dive– an answer to everything!

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Variability Methodology

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Allows for optimal management of medical wards

leading to right-sized units and

decreased ED and acute receiving

delays

Helps ED and inpatient wards by smoothing elective

admissions and reducing

competition for beds, stress,

overload and waste

Improves theatre access, safety and

efficiency by balancing

unscheduled and scheduled flows

IHO Redesign Project Options

OPTION 1 Theatre

Reengineering

OPTION 2 Redesigning

Surgical Inpatient Flow

OPTION 3 Reengineering

Medical Inpatient Flow

Option 1: Reengineering the Theatres

Project aims:•Balancing resources and flow of time sensitive surgical cases and elective scheduled surgeries •Improve theatre access •Decrease daily operational chaos resulting from competing demands

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Option 1: Reengineering the Theatres

Activities•Retrospective data submission – 2 years•Urgency classification system - develop, implement and monitor•Prospective data collection - 3 months

– Including surgical booking time

•Standard operating procedures •IHO Modelling - present redesign options•Select a redesign option•Implement•Monitor

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Stakeholder Engagement

Option 1 Benefits

• Decreased wait time for emergent surgeries and improved compliance with desired maximal acceptable wait times

• Decreased Theatre overruns• Increased overall Theatre utilisation• Decreased hospital Acute Length of Stay (ALOS) for urgent/emergent patients• Improved outcomes for urgent/emergent surgical patients• Enable further Theatre efficiency improvement such as on-time starts, lower turnover

time, and high performance teams for elective blocks• Improved patient satisfaction relating to decreased elective case delays on day of surgery• Improved staff satisfaction and retention

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Glasgow Royal Infirmary Project 1 – June 2015Experience of Implementing a new Surgical Urgency

Classification for Theatres

EXPERIENCE BEFOREEXPERIENCE BEFORE•Inconsistent scheduling emergency cases.•Challenges to access surgery for the right patient at the right time •Competing demands between specialties•Urgency of patients not accurately recorded

UPDATED PROCESSUPDATED PROCESS•Standardised booking process and case review•Surgical Urgency captured at time of booking•Weekly ‘compliance’ metrics reviewed by clinical leads •Electronic view of all patients scheduled for emergency theatre

EXPERIENCE AFTEREXPERIENCE AFTER•Dynamic and patient focused approach to scheduling of emergency theatres•Clarification of patient demand by clinical urgency for every case•Informed discussion to schedule individual cases based on clinical need•Avoids conflicting and competing agendas•Good clinical engagement

* GRI implemented a Theatre Hub as part of a planned redesign rather than IHO project. The combination of this redesign and the rigour of IHO’s process redesign has been entirely complimentary

Process Implemented June 2015

Option 2: Redesigning Surgical Inpatient Flow

Project aims:•Smooth elective surgical flow to inpatient wards •Improve quality and safety of care on surgical wards •Decrease competition between scheduled and unscheduled flow on inpatient wards •Enhance elective surgical or medical throughput (or both) depending on the hospital’s priorities.

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Option 2: Redesigning Surgical Inpatient Flow

Project Activities:•Retrospective data submission – 2 years•Prospective data collection to quantify your true elective inpatient admission volume for the selected service(s)

– Including expected LOS, expected level of care and waiting time in recovery•Identify opportunities for smoothing elective admissions •Understanding resources required to achieve this

– Prospective scheduling options, including surgical team availability•IHO Modelling - present redesign options•Select a redesign option•Implement •Monitor

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Stakeholder Engagement

Option 2 Benefits

• Increased throughput in smoothed inpatient unit or ward• Increased placement of patients in the preferred ward with decreased

Recovery wait times and inter-unit transfers• Higher reliability in nurse : patient staffing level leading to lower

morbidity and mortality• Improved staff satisfaction and decreased use of nursing overtime• Quality improvement in terms of decreased readmissions, decreased

use of RACE teams, decreased rate of Hospital Acquired Infections (HAIs) and patient safety issues

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Option 3: Reengineering Medical Inpatient Flow

Project aims:•Alleviate medical ward bottlenecks by addressing artificial variability in admissions, discharges and transfers (ADT).

•Improve throughput in selected medicine wards by ensuring appropriate patient placement and improving the timeliness of admissions, discharges and transfers out.

•Create the opportunity to right-size medical wards to better match capacity with demand.

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Option 3: Reengineering Medical Inpatient Flow

Project Activities: •Retrospective data submission – 2 years•Admission, discharge and transfer (ADT) – Develop, implement and monitor•Prospective data collection - 3 months

– Including ready to move time•IHO Modelling - present redesign options•Select a redesign option•Implement•Monitor

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Stakeholder Engagement

Option 3 Benefits

• Increased placement of patients in the preferred units or wards / decreased boarding

• Decreased wait times in the ED and/or assessment or medical receiving units • Decreased inter-ward transfers • Improved ED and inpatient unit staff satisfaction • Potential decrease in acute LOS • Quality improvement in terms of decreased readmissions, decreased use of

RACE teams, decreased rate of HAIs and patient safety issues because patients are more likely to be placed in preferred units

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Forth Valley Royal Project 3 – June 2015Experience of Implementing a new Admission, Discharge and

Transfer criteria for medical inpatients on B32

EXPERIENCE BEFOREEXPERIENCE BEFORE•Inconsistent on lack of any criteria for transfer into or out of a ward area •Challenges to access inpatient beds for the right patient at the right time •Prolonged delays in moving patients through the hospital system from assessment unit to inpatient bed to home

UPDATED PROCESSUPDATED PROCESS•Standardised admission, discharge and transfer criteria for general medical and GI patients•Ready to move times captured at time of patient meeting set criteria•Monthly review of compliance metrics (e.g. premature transfers)•Data captured for the first time on when patients meet criteria

EXPERIENCE AFTEREXPERIENCE AFTER•Improved care planning and reduction in delays•Improved timely access from Assessment Unit into B32•Structured process to review patients daily within the ward•Spreading process across the medical inpatient wards to improve timely access to all medical wards•Good clinical engagement

Process Implemented June 2015

Summary

• IHO Project still Work in Progress– A lot of hard work– Clinical engagement and Executive commitment

essential• Boards already seeing benefits before redesign• Data crucial to improvement• A long way to go…

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Questions & Discussion on

Handouts

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