Shane Solomon

1
Welcome
Shane Solomon Executive Director Metropolitan
Health Aged Care Services 6TH July 2004
2
Introduction

• The Patient Flow Collaborative builds on the HDM
  strategy and previous collaborative work
• Todays Learning Session marks the completion of
  the Rigorous Diagnostics phase
• From here we aim to identify the key constraints
  within our health services and move towards
  implementing innovations during the coming Action
  Period

3
Rigorous Diagnostics

• Health Services have completed 12 weeks of
  rigorous diagnostics in their organisations.
• The collaborative team have made site visits and
  given support during this period.
• Rigorous diagnostics introduce a new way of
  looking at processes and data to show
• Flow
• Variation
• System Capacity

4
Rigorous Diagnostics tools

• Teams have engaged their organisations using 5
  rigorous diagnostic tools
• Process Mapping
• Tally Charts
• Brainstorming
• Consumer Interview
• Data Measures

5
Data Measures

• Data measures really help us to understand
  systems and processes
• They are not being used for benchmarking or
  measuring activity levels
• They will go across the organisation and down to
  patient streams
• They will be used to illustrate the impact and
  sustainability of system innovations
• They will promote conversation and understanding
  of how we operate

6
Support

• Health Services will receive ongoing support from
  DHS in the form of
• Preparation and dissemination of data measures
  using existing datasets
• Training in the interpretation of the data
  measures received and the development of skills
  to reproduce this analysis locally

7
The current picture in our EDs

• 13 of patients waiting gt48hrs
• 2 waiting gt72hrs
• Average length of stay in ED
• Ranges from 85mins to 8hrs across all sites
• Patient throughput in lt6hrs
• Ranges from 60 - 99

8
Program Measure- Percentage of ED Patients
Admitted to Ward in lt12 hrs

• Patients admitted from our ED in lt12hrs currently
  ranges from 65 - 100 across the system

9
Program Measure- Patient Journey Time for
Admitted Patients on Waiting List
Within the month of Mar04 Category 1 Patients
admitted from the waiting list could expect to
have a total waiting time (i.e. Ready for Care
Not Ready for Care days) between 0 and 62days
with a mean of 24days.
10
Program Measure- Length of Stay (Medical)
80 between 1 and 6 days
80 of patients (excluding sameday) at this
hospital had a length of stay between 1 and 6
days with the maximum length of stay currently at
95 days.
11
Program Measure- Length of Stay (Surgical)
80 between 1 and 11 days
80 of patients (excluding sameday) at this
hospital had a length of stay between 1 and 11
days with the maximum length of stay currently at
505 days.
12
Program Measure Average Admissions Discharges
by DOW
For the period Jul03-Mar04 the highest number of
average admissions for multiday patients was on a
Tuesday/Wednesday (66), and the highest number of
average discharges was on a Friday (69). The
lowest number of average admissions (excluding
weekends) was on a Friday (56), and the lowest
number of average discharges was on a Monday
(51).
13
Aims of the Patient Flow Collaborative

• Focus on the Patient Journey
• Use the support team to help you navigate the
  data measures
• Clearly identify the constraints and issues
• Learn from each other

14
Aim high
Good
Quite Good
The Best in the World
The Best in your Field
Very Good
15
Patient Flow Collaborative
Dr Jenny Bartlett Chief Clinical Advisor 6th
July 2004
16
Patient Flow Collaborative
The challenge is to revolutionise our
expectations of health care to design a
continuous flow of work for clinicians and a
seamless experience of care for
patients. Donald.M.Berwick President and
CEO Institute for Healthcare Improvement
17
Issues

• Excellent innovation in pockets
• Built on excellent work already undertaken
• Still long waits in ED
• Elective surgery waiting times
• Inpatient delays
• Specialist consultation
• Specialist tests
• Access to Operating Room
• Whole Hospital vs Manageable pieces

18
The Pragmatic Approach to Healthcare Improvement

• Appreciation for healthcare as a system
• Create the will to improve the system
• Locally adaptable improvement model
• Sequential building of knowledge
• testing changes on a small scale
• spread of improvements to similar sites
• Efficient and effective use of data
• strive for usefulness, not perfection

19
Model for Improvement
20
Learning in Plan-Do-Study-Act Cycles

• Build knowledge sequentially
  - a short time period, a
  shift, a unit, a few clinicians- use multiple
  PDSA Cycles
• Some reasons for changes not resulting in
  improvement
• 1. Hypothesis wrong
• 2. Change not executed well
• 3. Unexpected problems
• Use of data
  - qualitative
  data to help refine your change
  - data on sub-components of the system
  during cycles

21
Not just another Project

• Patient Journey vs Episodic Encounter
• Capacity building in your organisation
• Better way of doing business
• Efficient processes are cheaper
• Quality patient care is core business
• Spread ?Translate ? Embed new innovation and
  Improvement processes

22
Whole System thinking
An elephant is like a brush
An elephant is like a rope
An elephant is like a snake
An elephant is soft and mushy
An elephant is like a tree trunk
23
Building on the Lessons

• Emergency Departments
• Adult Intensive Care
• Acute to Subacute Patient Flow
• Safe and Appropriate Use of Blood and Blood
  Products
• Medication Safety

24
The story so far..

• Orientation Session
• Master Class Series
• Planning Group Member
• Executive Team
• Nurse Lead
• Data Analyst
• Project Facilitator

25
Pilot Work

• Each section of the program is piloted in
  Victorian organisations
• PDSA cycles feed any lessons into each part of
  the program

26
Rigorous Diagnostics completed by each team

• Program Measures
• Whole system process maps
• Brainstorming
• Patient, Relative /Carer perspectives
• Sampling Data

27

• Management works in the system, leadership
  works on the system
• Stephen Covey

28
Process

• Diagnostics delivered and analysed
• Data providing information
• If you cannot measure it, you cant manage it
• Brent James
• 1999 Executive Director, IHI
• Share innovative practices
• Use Breakthrough Methodology
• Collaborative / Rapid Cycle change /PDSA

29
Story Board Voting

• Vote for the best and most thorough Rigorous
  Diagnostics
• Stick up the Red dot supplied on the board that
  displays the Rigorous Diagnostics that get your
  teams vote
• The prize will be awarded tomorrow

30
Patient Flow Collaborative Report to Date

• Hand in a copy of the Rigorous Diagnostics at the
  Registration Desk

31
Questions
32
Prioritising Improvements

33
Rigorous diagnostics

• There are five elements to whole system rigorous
  diagnostics

34
Process maps

• Identify key areas and constraints
• prioritise these against significant wins
• List in order

35
Tally charts

• Question identified delays and prioritise them
• Make sure specific identified delay
• Identify organisational wins

36
Brainstorm

• Prioritise
• Cross check with other brainstorming
• Check you have included enough views for
  organisational review

37
Patient, carer and relative interviews

• Prioritise key themes
• For example, delays, communication issues, then
  priorities

38
Program measures

• Quick check of concerns, then prioritise areas

?
?
39
Priority Setting Tool
40
Cross Check

• Cross check all against each other
• and four against program measures

41
Organisational Aims

• Order into organisational wins

42
Process complexity and implementation index
Process Complexity Index
Low Medium High
Key
Ideal Possible Dont do
Implementation Index
Poor Medium Strong
43
Financial improvement matrix
Cost saving
High Medium low
Key
Do 2nd stage Leave
Implementation timescale and ease
Poor Medium Easy
44
Final constraints
45
Clinical work stream plans
46

• Thank you

47
Team Review of Diagnostics
Rochelle Condon Improvement Lead 6TH July 2004
48
Summary Sheet Diagnostic Tool and Top issues
49
Risks

• What are the possible risks to starting the
  project in key constraint areas?

50
Processes, Structures and Patterns

• Discuss the culture that you will need to manage
  processes, structures and patterns

51
Noers Response factor model
high
Learners
Entrenched
Capacity for change (ability to learn)
BSers
Overwhelmed
low
Comfort with change (learning readiness)
high
low
52
Noers Response factor model
high
Learners
Entrenched
Clings to narrow learnings
Learns and grows
Capacity for change (ability to learn)
BSers
Overwhelmed
Makes it up high drive but low substance
Withdraws and avoids
low
Comfort with change (learning readiness)
high
low
53
Change and learning

• Comfort Zone
• people stay here
• they dont learn
• they dont change

• Panic Zone
• people freeze, will not learn will not change

54
Change and learning
Comfort Zone
Panic Zone
55
Next Steps

• Identify Clinical Area Teams for the Key
  Constraints identified

Executive Team
Clinical Team
Clinical Team
Clinical Team
56
Breakout sessions

• Rialto 1
• Effective and efficient Bed Management
• Bernadette McDonald and Ruth Smith
• Rialto 2
• Radiology and Imaging service utilisation
• Jenny Bartlett and John DeCampo
• Rialto 3
• Operating Theatre utilisation
• Lesley Dwyer, Kim Moyes and Prue Beams

57
Breakout sessions

• Fawkner
• Preoperative and elective care
• Alison McMillan, Damien Searle and Steven Vale
• Menzies
• Emergency Department
• Marcus Kennedy and Mary Mitchelhill
• Board Room Lounge
• Length of Stay
• Lee Martin and Rochelle Condon