Team Presentations

1
Team Presentations
Felicity Topp and Rochelle Condon 5TH October
2004
2
Concurrent Session 1Team Presentations

• Bellarine Room 1
• Ballarat Health Service
• Goulburn Valley Health
• Western Health
• Royal Children's Hospital

3
Patient Flow Collaborative
Fiona Brew Phil Catterson Jill
OFlynn Operating Suite Emergency Department
PDU Ballarat Health Services- The Stream Team

4
Summarise Organisational Constraint areas

• BHS Constraint Background
• Culture
• Stable workforce
• Education level
• Flexibility
• History
• Medically driven organisation
• VMO mentality
• Public v Private
• Opportunity
• Current practice - ? Good / Bad / Ugly
• Cascade effect - isolation / up and downstream
  impact

5
Summarise Priority Constraint Area 1

• System Approach - Access to Theatre
• Timing of cases
• am vs pm - length of stay
• Session allocation
• emergency
• elective
• Delays
• entry
• exit

6
Diagnostic work

• Process
• Staff Involved
• Nursing, Medical, Support
• Staff Reaction
• Keen, positive
• Useful data
• Tally charts

7
Improvement Plan

• Action Plan
• tally chart presentation
• champion selection
• Strategies developed
• Identify Culture
• Paddle own canoe
• Going with the flow
• Aiming for improved stream?
• Communication
• Work practices
• Roles
• Most work in daylight hours
• Utilise DOSA unit

8
Progress

• Communication
• Centralised distribution
• Culture
• Patient focus
• Team approach - New skills
• Planning
• Work practices
• Roles
• Day surgery focus

9
Lessons learnt

• Success
• Communication
• Culture
• avoid isolation
• Work processes / practices
• strategies embedded in culture
• Future Improvements
• Education
• Frequency
• One size does not fit all

10
Desired Impact

• Recognition of cascade effect
• impact on patient flow
• global view
• Action
• purposeful
• innovative
• positive - up and downstream validation prior
• Evaluation
• patient perspective

11
Next Steps

• Consolidation
• Increased medical buy in
• Feedback
• Further development of strategies
• outcomes related to measures

12

• Questions

?
13
Patient Flow Collaborative
Kim ReadGoulburn Valley Health
14
Summarise Organisational Constraint areas

• Of the 5 Major constraints _at_ GVH, 2 constraint
  areas were prioritised due to the current
  internal efforts/projects being undertaken to
  improve patient flow
• 1. Major Bowel Surgery Admissions
• 2. Discharge Planning/Communication

15
Summarise Priority Constraint Area 1

• Bed Availability.
• Major Bowel Surgery Admissions on day prior.
• What works for us and OUR PATIENTS.

16
Diagnostic work

• Day of Surgery Admission (DOSA)rates
• Patient Interviews
• Staff Interviews
• Process Mapping

17
DOSA
18
Patient Interviews

• First Patient
• Noted what seemed to be a long wait to be seen by
  specialist after referral.
• Had support of wife and daughter when making
  decision to go ahead with surgery. Glad of their
  presence during discussions.
• Noted the effort to get surgery done in short
  period of time once decision made.
• Had bowel preparation in hospital but would have
  been happy to have this in his own home
  environment.
• Pain relief post operatively was good.
• Felt he started solids too soon after vomiting
  and subsequent naso-gastric tube.
• All went well after discharge and for follow up.
• Second Patient 
• Felt that all went quickly in relation to being
  seen and being booked for surgery.
• Was distressed and horrified with diagnosis and
  need for subsequent surgery.
• Younger female patient who requested to have
  bowel preparation at home.
• Discussed at pre-admission clinic her desire to
  be at home with her husband pre-operatively.
  Wanted to be in the comfort of her own home, and
  in her own bed. Although she had nausea with the
  bowel preparation, she would not change her mind
  about having the prep at home.
• Discussed problems with pain relief
  post-operatively.
• Had problems after discharge with nausea and
  became dehydrated.
• Required representation to Emergency Department
  for re-hydration and issues related to the drain
  tube.

19
Process Map
20
Improvement Plan

• Research bowel preparation options.
• Surgeon Involvement.
• Research processes at other institutions.
• Relationship with private hospital.

21
Progress

• Proposed process map.
• Commenced clinical guideline.
• Motel Accommodation guideline.

22
Lessons learnt

• One bite at a time.
• Involve the key players.
• Has to make a positive difference for all.

23
Desired Impact

• Satisfactory preparation.
• Patients needs met.
• Bed availability (HIPs).
• DOSA rates comparable.

24
Summarise Priority Constraint Area 2

• Discharge Planning/Communication
• potential improvement option
• Poor performance of discharge planning
  communication linked to lack of bed availability
• potential increased unplanned re-admission rates

25
Diagnostic work

• Satisfaction Surveys/Medical File Audits (R1)
• Patients/Service Providers/Clinical Staff (R2)
• Staff lack understanding of effective discharge
  planning and further hindered by lack of
  appropriate risk assessment toolslengthy
  complicated referral forms/systems.
• Random Patient Satisfaction Survey (R3)
• Patient thoughts/feelings/perception of self-care
  needs.
• Patient lack of understanding misconception
  about current day healthcare environment (e.g gt
  LOS)

26
Improvement Plan

• Review re-development of pre-admission/emergency
  admission documentation
• Implementation of streamlined internal referral.
• Review re-development of discharge summary (R4)
• Development of decision support tools-D/P(R5)
• Development of Clinical Practice
  Guidelines-Admission Discharge

27
Progress

• Improvement strategies gathering momentum
• Improved awareness of the importance of discharge
  planning at day 1 of admission to support
  clinical outcomes (R5.2)
• New Referral System Discharge Summary
  dissemination system (R6)
• - Included patients admitted from March 2004
• Included all clinical staff (acute/sub-acute ED)

28
LOS Comparisons
29
Lessons learnt

• System change alone will fail unless supported by
  culture change, which in turn is supported by
  effective education and communication support
  strategies.
• Referral system development- would repeat
  consultation process.
• Development of new admission/assessment
  documentation taking longer that envisaged due to
  complicated consultation process and variety of
  internal/external influences
• Discharge Summary review-would include internal
  satisfaction review and corresponding time with
  GP satisfaction review

30
Desired Impact

• Improved patient and carer satisfaction with the
  discharge process and health outcomes.
• Services will be integrated across the continuum
  of care.
• Length of stay will be comparable to industry
  benchmarks.
• Reduction in rate of unplanned readmissions
  within 28 days of initial separation.
• Improved processes of transition across the
  acute, sub-acute and community interfaces

31
Next Steps

• Continue development of streamlined
  admission,health assessment risk screen
  documentation to improve patient assessment
  consistency and early identification/intervention
• Ongoing education and support for staff regarding
  D/P- empower ALL STAFF to be skilled in D/P to
  improve patient journey thru healthcare continuum

32

• Questions

?
33
Patient Flow Collaborative
General Internal Medicine UnitWestern Hospital,
FootscrayG. Lane, Head of UnitH. Hasanoglu, NUM
34
Organisation
35
Background General Internal Medicine
UnitPatient Mix

• Daily average of 45 inpatients (range 25 to 90)
• Average age 79 years
• Varied ethnic backgrounds
• Several acute medical problems
• Scarcity of community support or supportive
  accommodation

36
Background General Internal Medicine Unit.
Common Problems

• Acute and chronic renal impairment
• Polypharmacy problems
• Syncope
• Obstructive lung disease
• Psychiatric diagnoses
• Self-harm
• Accommodation and community support problems

• Cardiac failure
• Ischaemic heart disease
• Cognitive impairment
• Falls
• Urinary tract sepsis
• Septicaemia
• Pneumonia
• Unstable diabetes

37
Diagnostic work A

• 2 week period of reporting by all junior medical
  and daytime nursing staff of processes which
  possibly delayed patient flow
• Recorded daily at nursing and medical handover
• Staff reactions
• Nursing cautious enthusiasm
• Medical cautious cynicism

38
Diagnostic work B

• Patient Flow Profile
• 3 patients tracked and interviewed throughout
  their admission
• Most interactions with health personnel recorded,
  including process delays
• Patients opinions sought about
• Being told what was wrong
• Being told about my treatment
• Going home
• Being followed up
• Felt to be less useful than A

39
Organisational Constraint areas
40
Organisational Constraint areas

• Delay in patients being seen for consultations
  and procedures was the 2nd highest rating process

41
Desired Impact

• 50 reduction in
• mean time
• range waiting for consultations and procedures
• ? Significant reduction in length of stay

42
Measures reflecting the effect of the constraint
on the organisation before and after test cycles

• a) Time to see patient by registrar
• b) Time to see patient by consultant

43
Pre-intervention

• Days to see patient Registrar
• Pre (n27)
• n 18
• Range 0-7
• Median 0
• Mean 1.2
• SD 1.93
• Variance 3.7

44
Pre-intervention

• Days to see patient Consultant
• Pre (n27)
• n 14
• Range 0-6
• Median 2
• Mean 1.9
• SD 1.89
• Variance 3.6

45
How Improvement Strategies were derived and
implemented

• Discussion with General Internal Medicine Unit
  staff (junior and senior) about reasons for
  delays in consultations and procedures
• Consensus on the most practical intervention
  strategy

46
Improvement Strategy

• Change to referral process
• If registrar of other unit had not seen the
  patient by the next day, the parent unit
  consultant would contact the consultant of the
  other unit

47
Outcomes

• Days to see patient Registrar
• Pre (n27) Post (n24)
• n 18 19
• Range 0-7 0-4
• Median 0 0
• Mean 1.2 0.68
• SD 1.93 1.06
• Variance 3.7 1.1
• Not seen 9 5
• by reg

48
Outcomes

• Days to see patient Consultant
• Pre (n27) Post (n24)
• n 14 9
• Range 0-6 0-7
• Median 2 2
• Mean 1.9 2.2
• SD 1.89 1.92
• Variance 3.6 3.7
• Not seen 13 15
• by cons

49
Lessons learnt

• Time intensive
• The challenges of frequent changes in junior
  staff
• ?Hawthorne effect
• Procedures often escaped reporting
• Difficult to record exact times
• Too short a study time to assess whether
  intervention would affect overall length of stay

50
What would you now do differently?

• Focus on delay to procedures rather than
  consultations
• Devise an electronic collection process of data
  by Units registrars
• Weekly audit of delayed procedures and
  consultations at Units Safety and Quality
  meeting
• Display recording sheets on all wards

51
Next Steps

• Repeat cycle within Unit, with better mechanisms
  to capture all procedures
• Ongoing frequent reminders to Unit medical staff
• Longer study period
• Remeasure LOS
• Involvement of all heads of units in the
  development of an Organisational policy on
  consultations and procedures
• Extend throughout Network
• Ongoing audit, and resources to facilitate this

52

• Questions

?
53
Patient Flow Collaborative
54
Background

• Plastic hand and maxillofacial surgery unit.
• 7 part time consultants.
• 2 registrars, 3 residents and 1 fellow.
• 2 campuses.
• Approx 2400 cases/year.
• Approx 50 hand surgery.

55
Diagnostic work

• Brainstorming sessions
• Two sessions, surgeons and other staff
• Data measurement
• Over two weeks, 4 areas collected data
• Review of Programme Measures such as LOS
• Process Maps
• 10 patients, showed extreme variation in flow
  through the system

56
Sample Data Result
57
Constraint Issue
Opening hours may not allow recovery time
Registrar may not be on campus
Surgeon/ Theatre session availability
Overbooked clinic unable to make appointment
X-ray, medical record not available.
Registrar calls theatre, admissions, bed
manager, and patient.
Inconsistent management plans
Wait for Registrar review
58
Goal setting

• Reduce patient time in ED
• Reduce plastics registrar organisational workload
• Reduce unnecessary after hours calls to registrar
• Improve reliability and utility of communications
• Reduce need for multi day bed
• Reduce delayed outpatient appointment bookings
• Simplify referral to Hand therapy

59
Improvement Plan

• Develop clinical pathway for consistent ED
  management
• Protocol for discharge whilst awaiting theatre
• Protocol for booking outpatient appointments
• Adopt SMS text service
• Protocol for when to contact and what to include
• Implement regular 'twilight' emergency lists
• DPU open to support these lists
• Op note sticker for Hand therapy referral
• 'One stop' theatre bookings

60
What's in it for plastics?

• Fewer 2am phone calls from ED about a cut
  finger.
• Less time spent on the phone.
• Organising theatre
• Waiting for ED staff to get information
• Explaining standard procedures to ED staff
• Less late night/ after hours operating.
• Downside.
• More patients clogging the corridors of
  outpatient clinic and/ or more clinic sessions.

61
What's in it for the ED?

• Uniform, simple, teachable procedure to follow
  less mistakes.
• Fewer hours spent waiting to get plastics
  registrar opinion.
• Less time spent on the phone.
• Tracking down which registrar is oncall
• Answering registrar's questions
• Easy access to outpatients clinics bookings.
• Downside.
• Possible de-skilling of ED staff.
• No account taken of individual's skills or
  abilities
• Need to overcall rather than undercall diagnosis

62
What's in it for the patients?

• Uniform, simple teachable protocol less medical
  mistakes.
• Less time waiting in hospital.
• In ED
• Prior to theatre
• Fewer theatre cancellations.
• Fewer unnecessary outpatient appointments..
• Downside.
• None

63
Progress

• Team met after hours every fortnight.
• Session 1
• Review Diagnostics Planning innovation
• Session 2
• Review work to date (pathway)
• Identify further action points
• Session 3
• Team refinements (mainly via e-mail)
• Session 4
• Final agreement for drafts and trial

64
Team Members

• Surgeons
• ED Physicians
• Nursing ED, Theatre, DPU, Ward/ SSU
• Allied Health
• After Hours Management
• Site Management
• Division of Surgery Executive

65
Team Work
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72
Progress

• Beta- testing pathway
• Start date for twilight lists
• Start date for extra outpatient sessions
• Installation of SMS software

73
Progress

• How to trial the pathway?
• Upper limb only
• Sunshine only
• Paper form and phone contact

74
Lessons learnt

• Its amazing what you can achieve with a great
  team
• Some things take longer than the 12 weeks
  implementation time
• If it's not worth doing properly, it's not worth
  doing at all.

75
Next Steps

• Complete beta testing of
• Pathway from clinical point of view
• Pathway from logistics point of view
• SMS service
• Evaluation
• HTML based pathway in ED?

76
Desired Impact

• Happy patients
• Happy staff

77

• Questions

?
78
Patient Flow Collaborative
Trevor RixonPatient Resource ManagerThe Royal
Childrens Hospital
79
The Royal Childrens Hospital Broad Constraint
Areas

• RCH operational context
• Complexity of RCH admissions process
• Communication information gaps
• Waiting list management systems
• Re-active bed management

80
Constraint Area 1Admissions Process

• Process mapping
• Multidisciplinary group follow up meetings
• Trialling revised Admissions Form
• Develop RCH Admissions Process - policy work
  practice
• Admission discharge - times days of week
• Hospital Demand Management

81
Constraint Area 2Consent

• 64 of patients admitted with no written consent
• Patient flow affected by multiple entry points
  and surgeon availability
• New booking pack and consent process developed
• Auditing to follow

82
Constraint Area 3Pre-Admission Triage

• Process mapping completed
• Surgical team engagement
• Developing multi-faceted solutions
• Pre-admission triage criteria
• Pre-admission phone calls to parents/carers
• Parent/carer-completed health questionnaire
• Review of RMO work practice
• Introduction of pre-admission clinic

83
Priority ConstraintBed Management

• No clear senior clinical involvement
• Communication gaps that impact on timely
  decision-making
• Minimal real time knowledge of available bed
  stock staffing resources
• Delays for patients in accessing beds
• Balancing staffing requirements bed allocation

84
Diagnostic Work

• Patient Resource Manager appointed (EFT 1.0)
• Determined current bed management process
  practice and service gaps
• Met with key stakeholders
• Commenced daily bed management meeting
• Developed implemented IT-based tool which
  illustrates the variation of bed management
  activity on a periodic basis

85
Improvement Plan

• Review bed management policy practice
• Interpret admissions discharge data around
  times and by specialty
• Develop an on-line bed management system
• Interpret and trend HR data e.g., nursing sick
  leave patterns rostering practices

86
Progress

• Trial of IT-based bed management template
• Very positive feedback -
• gt95 daily attendance by ward nursing staff
• Dealing with bed management issues in group forum
  allows time to identify resolve issues
• Enhanced communication between RCH
• and Royal Bank

87
Bed Management Template
88
Lessons Learnt

• Systems tools enable better understanding of
  resource requirements by all participants
• Information presented in a structured format
  ensures an agreed understanding of data
  minimises disputation of the data
• Important to acknowledge and celebrate progress

89
Desired Impact

• Ensure timely access to hospital for patients
  families
• Staff development - access to mentors champions
• Identify remove blocks to good bed management
  practice
• Increase nursing staffing efficiencies
• Provide data to assist in managing elective
• emergency demand

90
Next Steps

• Bed Meeting one venue, twice daily
• 7 days/week
• Integrate process into culture context by
  seeking involvement of key medical and allied
  health staff
• Determine if allocation of beds by specialty
  meets demand by specialty
• Determine discharge profile

91

• Questions

?
trevor.rixon_at_rch.org.au justin.king_at_rch.org.au s
ean.spencer_at_rch.org.au
92
Second Concurrent Session12.45 2.00

• How to encourage a culture of innovation Cathy
  Balding and Mary Mitchelhill
• Outpatient Department Toolkit Veronica Strachan
  and Kim Moyes
• Communication Strategies Julian Murphy and
  Sharon Neal
• Advanced Project Management Ruth Smith and
  Claire Mackinlay
• Managing Variation, Elective Emergency Lee
  Martin and Bernadette McDonald
  and Marcus Kennedy

93
Lunch

• Meet us in the next Concurrent Session at 12.45

94
Team Presentations
David Langton and Mary Mitchelhill 5TH October
2004
95
Concurrent Session 1Team Presentations

• Bellarine Room 2
• Royal Womens Hospital
• Southern Health Monash Medical Centre
• Peter MacCallum Cancer Centre
• Maroondah Hospital
• Calvary Health Care

96
Patient Flow Collaborative
Tanya Farrell Rosemary BurrellThe Royal
Womens Hospital
97
Operation Caesar

• Tanya Farrell
• Maternity Care Program Manager

98
Summarise Organisational Constraint areas

• Operation Caesar
• Variety of disciplines and locations for one
  process (including off site services)
• Wait watchers
• Lack of data to monitor attendances and FTAs
• Resources, resources, resources.

99
Summarise Priority Constraint

• Operation Caesar
• Pre Admission Clinic (Midwife PAC Anaesthetic
  PAC)
• Theatre booking

100
Diagnostic work

• Operation Caesar
• Further Process mapping,
• Documentation review,
• Review template and capacity for all Pre
  Admission clinic appointments,
• Consumer Advisory Committee representative walk
  through

101
Improvement Plan

• Operation Caesar
• Provide a guideline and revise pathway for the
  C/S process
• Revise documentation
• Streamline patient instructions and information
  provided
• Find capacity for Anaesthetic pre op review

102
Progress

• Operation Caesar
• Trial revised pathway and theatre booking form
• Revised Pre Admission templates
• AAC
• Ceased midwife pre admission role
• Patient instructions content updated and source
  of distribution centralised.

103
Desired Impact

• Operation Caesar
• Improved access to service for patients and staff
• Decrease in incident reporting
• Better use of resources

104
Next Steps

• Operation Caesar
• Complete Pathway for rest of patient journey
• Patient information, update using consumer input

105
Wait watchers.

• Rosemary Burrell
• Well Womens Program Manager

106
Summarise priority constraint

• Wait watchers
• Appointment /Booking System
• Access to ultrasound results in clinic
• Medical staff availability

107
Diagnostic work

• Wait watchers
• Process mapping,
• Restructure of clinic templates,
• Trial FTA process,
• Trial Overbooking Policy,
• FTA audit
• Consumer Advisory Committee representative walk
  through

108
Improvement Plan

• Wait watchers
• Appointment of a Gynae Clinic Coordinator
• Revision of gynae clinic appointment templates
• Confirm a FTA process and develop policy
• Implement an Overbooking policy
• Liaison with clinic/ultrasound/ultrasonographers
• FTA audit

109
Progress

• Wait watchers
• Internal reporting available in Oct 04
• Gynae Clinic Coordinator appointed
• Information from FTA audit
• Ultrasound Results access

110
Desired impact

• Wait watchers
• Improved access to service, better use of
  resources
• Reduction in variation

111
Next steps

• Wait watchers
• Consider implementing partial booking system and
  reminder call service

112
Lessons learnt

• Worked well
• Multidisciplinary approach
• Engaging medical staff
• Whole system approach
• What would we do differently
• 1 constraint only
• FTA audit completed during the diagnostic phase

113

• Questions

?
114
Patient Flow Collaborative
Andrew Driver Wendy Jupp SouthernHealth
Monash Medical Centre
115
Summarise Organisational Constraint areas

• 1. Workload
• continues to rise by approximately 2 per month
  over 20 per annum.
• Paediatric Respiratory sessions.
• 2. Equipment
• Understocked stable of endoscopes.
• No replacement plan by 2005 current stock will
  be severely stressed.
• Limited physical space.
• 3. Workforce
• No extra nursing staff, medical staff
  administrative staff.
• Non availability of anaesthetics for certain
  sessions.
• 4. Access

116
Summary Priority Constraint

• Gastrointestinal bleeding is the most common
  emergency in the gastroenterology field.
• Early recognition is the primary component of
  treatment.
• Facilitation of urgent access to endoscopic is a
  priority.
• Various levels of staff skill exist, affecting
  clinical decision making.
• Clear pathways facilitating decision making to
  improve care.
• Improved care and timely endoscopic access
  reduces length of stay.

117
Diagnostic work

• Diagnostics
• x2 patient journeys
• Involving nursing, ward management, medical, ED,
  Bed Bureau, administrative.
• Reactions
• - Variable response to the process, but
  recognition of difficulties involved. Overall
  sentiment was that the problems were caused by
  others no directly associated to the work.
• - A need to work collaboratively to further
  identify issues and move towards a resolution.
• Useful data
• - identification of where the delay was.
• - time of request to transfer to endoscopy
• - Patient journey time through medical stay it
  would be helpful to map entire medical patient
  journey identifying and understanding component
  parts to create better flow.

118
Improvement Plan

• Increase resources and service hours
• Provide decision making pathway
• Identify the need for intervention
• Establish communication procedures
• Establish bed allocation prioritisation
  principles
• Continue to Collect and collate activity data

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Improvement Plan
120
Progress

• Communication strategy / process documented
  endorsed Medicine Nursing
• If deemed the avenue to follow undertake a
  Resource costing profile
• Policy Priority requirements identified
• Continued Development Decision tree predictor
  tool

121
Outcomes

• Development and introduction of decision tree.
• Daily Medical / Nursing Unit Management meeting
  patients, demand information etc..
• Changes to formal communication processes include
  LAN paging, endoscopy bookings etc..

122
Lessons learnt

• Important to prevent information / problem
  overload.
• Tailor information to individuals that is
  relevant and timely to their sphere of control.
• All participants found to have frustrations often
  with no channels for resolution

123
Desired Impact

• Looking forward we expect
• - Better understanding of endoscopic management
  of the elective emergency demand balance
• - Accurate prediction and accommodation for acute
  endoscopic demand
• - Reduced time for patient medical journey with
  incorporated discharge planning.
• - Reduction in confusion as to decision making
  responsibility resulting in appropriate care

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Next Steps

• Small Steps frequently.
• Reconfirm buy in to process
• Continue developing the work
• Improve the entire gastro medical journey.
• To enhance interface and actions with other Units

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• Questions

?
126
Patient Flow Collaborative
Skin / Melanoma ServicePeter MacCallum Cancer
Centre
127
Summarise Organisational Constraint areas

• High volume clinical load
• Long waiting list time to theatre
• Perceived patient delays in clinic as well as
  late clinic finish time
• Multiple attendance before treatment plan
  established
• Limited resources to treat malignant lesions
  within the cancer tertiary centre due to the high
  number of patients with benign lesions

128
Summarise Priority Constraint Area 1 High Vol
Clinic Load

• Improve and systematise the initial visit to the
  clinic.
• Re allocate the human resource to meet the
  demand.
• Decrease the number of patients with benign
  presentations accessing the clinic, and increase
  resource allocation to the patients with
  malignant conditions.

129
Diagnostic work

• Audit of New Patient Presentations
• Timeframe May, June and July
• Review assessment treatment outcomes
• Audit referral source
• General Practice
• Who Participated
• Clinic staff i.e. Medical, nursing and clerical
  staff.
• Finance and Statistics staff
• 4. Staff Reactions
• All members of the team were happy to participate
  as they felt it was a positive move towards
  organising a better system
• Useful data
• Analysis of assessment outcomes demonstrated high
  numbers of patients proceeding to surgery
• Large numbers of patients were undergoing biopsy
  in clinic

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Improvement Plan

• GP Education Program
• Biopsy the patient prior to initial visit to the
  hospital
• Human Resources
• Reorganise this in order to facilitate the high
  number of patients going to theatre and post
  operative care.
• Patients who proceeded to biopsy.
• Benign result -gt Develop a standard form letter
  to be sent to the patient and referring GP.
• Malignant result - gt Patient to be called
  personally. Patient to be triaged to the
  appropriate clinic.
• Develop standards treatment pathways.
• Including follow up Currently no NHMRC
  guidelines for this group of patients

132
Progress

• 1. GP Education
• Found that over a 12 month period, 1383 new
  patient presentations from 800 different
  referrers.
• Gap in Data We were not able to allocate the 800
  into practitioner groups.
• Initial Standard Draft letter has been written
  and is currently under review by all involved
  consultants
• Outcome Initial strategy would be onerous and
  cost inefficient. Therefore this option was not
  pursued
• 2. Human Resources
• One clerical support person allocated to the pre
  operative work up process.
• Two nurses allocated to post operative wound care
  in a separate area adjacent to the main
  consulting rooms
• 3. Patient Assessment Monitoring
• Both the Consultant Surgeons and the Registrar
  are attending both Review and New Patients.
• Results in an increase in the number of patients
  being discharged.
• 4. Clinic Templates
• The clinics regularly finish on time.
• Still experiencing some delay for patients
• Need to review and further refine Clinic Template
  booking form.

133
Lessons learnt

• Absolutely essential to have good data collection
• Need to Audit on a regular basis in order to
  reallocate resources with better outcomes
• Need to design the audit carefully. For example,
  a breakdown of the outcome of patients going to
  theatre. ie. Benign versus malignant
• Need more regular team meetings, including
  Consultants, with data in order to influence
  practise change
• Include a patient satisfaction survey
• Need to develop an internal web site, including
  audit material to disseminate information easily
  and include as many people in the process as
  possible

134
Desired Impact

• Reduce the amount of time that patients wait to
  be seen in the clinic
• Reduce the number of visits to the hospital
• Concentrate scarce resources into the appropriate
  area as we are a tertiary referral centre
• Increase staff moral and satisfaction
• Develop a greater awareness of the importance of
  accurate data collection and regular review of
  work practise
• Alter the concept of change from negative to
  positive
• Develop standard guidelines that are evidence
  based

135
Next Steps

• Undertake further auditing to assess the waiting
  times and patient satisfaction.
• Develop the standard letters and implement this
  system
• Liaise with another group within the hospital to
  begin some work on reducing the number of DNAs.
• Audit the number of post operative wound care
  time allocations to possibly move toward Nurse
  Led Clinics

136

• Questions

?
137
Patient Flow Collaborative
Christine Fisch Patient Access Manager.Eastern
Health Maroondah Hospital
138
Summarise Organisational Constraint areas

• Bed Management
• Admission delays elective surgery
• Admission delays from ED
• Unable to meet 12 hour targets.
• Acute/Sub Acute
• Delayed access to Rehab and NH Beds.
• Theatre Utilization
• High rate of HIPS.

139
Summarise Priority Constraint Area 1

• BED MANAGEMENT
• Delayed Access to Beds.
• Lack of structure - bed allocation
• Inequitable distribution of workload.

140
Diagnostic work

• Sample data 5 Acute areas
• (3 Areas repeat data)
• Brain Storming 2 hour session with lunch
  provided.
• Multidisciplinary team including
• Patient Flow Collaborative - Facilitator
• Patient Access Manager
• Nurse Managers
• Allied Health
• Pharmacist
• (No medical representation)

141
Diagnostic Work (Cond)

• Staff reactions
• Committed to aim of session
• Honest
• Frustrated
• Seeking solutions
• Feeling of deja vu

142
Areas Highlighted

• HR Management
• Communication
• Collaboration Team Building
• Organisation
• E-Support
• VMOs
• Organizational Structure.

143
Areas highlighted (Cond)

• Care Planning
• Communication
• HR.
• Service model

144
Outcomes

• Identification for the need to change the current
  bed allocation processes within the organisation.
• Development of a strategy to implement a Unit
  based patient allocation process.
• Medical, Nursing and Allied Health teams to
  support this structure.

145
Expected Benefits

• Reduced LOS
• Reduced 12 hour stays in the Emergency Department
• Improved median discharge time of patients
  (Currently 1300 1400 hours)
• Improved patient care
• Improved staff morale

146
Improvement Plan

• Establish a clinical working team.
• Clinical Lead Patient Access Manager
• Nurse Manager Surgery
• Nurse Manager Medical
• Allied Health Representation (Social Work)
• Medical Registrar/Intern
• Patient Flow Collaborative - Facilitator

147
Improvement Plan (Cond)

• Map a Medical Unit ward round to use as a
  baseline.
• Process Map the Patient Access Manager for 1 day
• Review current Bed Management Policies and update
  as necessary

148
Progress

• Clinical Working Team established and first
  meeting held Monday 13th September.
• Lee Martin Rochelle invited to attended.
• Guided group

149
Next steps

• Establish Organisational Capacity Demand over 3
  months
• Retrospective data to be used.
• Appoint Clinical Leader
• Establish designated bed numbers for each Medical
  Unit.
• Establish Formal Medical Handover each morning
• Stage introduction of patient allocation to
  designated wards.

150
Lessons learnt

• Get everyone involved
• Management Executive Team
• Medical
• Nursing
• Allied Health
• Hotel Services
• Good communication at all times as project
  progresses
• Research experiences of other similar sized
  organizations.

151
Desired Impact

• Timely change to Unit Based Patient Allocation
• Success measured
• Improved LOS
• Reduction in 12 hour stays in ED
• Improved patient care
• Improved staff moral
• Retention
• Sick leave
• Equitable workloads (Medical Units)

152
Next Steps

• Ensure the current motivation across all
  disciplines continues.
• Ongoing commitment of the Clinical Working Team.