Welcome and overview

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Welcome and overview
Kate Harmond
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Patient Flow Collaborative
House keeping Mobile phones/Bleeps turn to
silent Rest rooms Fire Alarms Equipment on table
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Agenda

• 9.00-9.15 Welcome and agenda overview
• 9.15 9.30 Overview of collaborative
• 9.30 10.00 Project or mass movement
• 10.00 10.30 Clinical champions
• 10.30 11.00 Morning tea
• 11.00 12.30 Rigorous diagnostic phase
• 12.30 1.30 Lunch
• 1.30 3.00 Team Planning
• 3.00 3.30 Afternoon tea
• 3.30 4.00 Next steps

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Partnership agreement

• Please remember that the patient flow
  collaborative is based on a partnership and is
  tailored to your organisational leads. There are
  no passengers and no dictators we are all in it
  together.

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Questions
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Overview of the Patient Flow Collaborative
Jenny Bartlett
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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
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Diplopia
Shared vision results from a combination of good
leadership and good followership. We assume the
former and disregard the latter.
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Why Collaborate?

• Part by part improvement
• - nurses improving nursing
• - doctors improving doctoring
• - pharmacists improving pharmacy
• Working together they improve systems
• Risks of not doing this

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Issues

• Excellent innovation in pockets
• Long waits in ED
• Elective surgery waiting times
• Inpatient delays
• Specialist Consultation
• Specialist tests
• Access to OR

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Mirror mirror on the wall
How does an organisation know that its view of
reality matches that of its workforce and
consumers.
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Process

• Use Breakthrough collaborative Methodology with
  Whole system thinking
• Rigorous Diagnostics to give a base line
• Matrix diagnostics to show high level
  constraints
• Improvement plans following the diagnostic stage
• In priority order
• Tested on small scale
• Spread across organisation

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Roll out plan
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Launch of the Victorian Travelling Fellowship
Program
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Introduction to improvement science

• Kate Harmond

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Better care without delay

• Pilot site for national programme
• Measurement for improvement
• Whole systems approach
• Local control, national steer and support
• Opportunity to shine
• Star ratings

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What went well?

• Programme manager
• PR and celebrations
• Top level leadership
• User and volunteers
• Working with other agencies
• Clinical engagement

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Even better if...

• More preparation time
• Data analysis and support
• Appreciation of previous success
• Skills data base
• Managing enthusiasm
• Managing cynicism

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National support

• Client power
• Expertise
• Openness
• Tool kits
• Leadership development
• Workshops and learning labs

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Results

• Emergency waiting times
• Elective waiting lists
• Cancelled operations
• Medical out-liers
• Better use of telephones, dispensing etc
• Star ratings

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Cultural change

• Clinician champions
• Media coverage
• National and international presentations
• Recruitment
• Feel good factor
• Inclusive learning (lunch hours)

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Target practice

• Evidence for politicians
• Measurement from Mars
• Innovation from Venus
• Manufacturing models and language
• Clinical reality
• Think big, work smart

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Untapped resources

• No more patients
• Self-managed care
• Nurses and midwives
• The clerks tale
• Text and e-mail
• Critical appraisal of current practice

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Simple stuff

• Process mapping
• SPCs
• Reports, publications, presentations
• Learning programmes
• Political influence
• Managing up

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No more projects

• Systems approach
• Regular review and refinement
• Self-assessment against national measures
• Spread and rapid roll-out
• Influencing national targets
• From programmes to mass movement

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What next?

• New consumerism
• Career development
• Adding value by avoiding duplication
• Losing wait
• Appreciative inquiry
• Inspirational leadership

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Clinical Champions

• Marcus Kennedy

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Why is Clinical Leadership So Important?

• Have vision of what to change
• but may not know how (methods resources)
• Understand how the system works
• Can drive progress through
• influence with managers
• clinical professional networks
• Long term continuity

Further reading Leading Physicians through
change J Silversin, ACPE 2000
Leadership at every level J Hardacre, HSJ,
2001
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Clinician Leaders (inclusive definition) - What
are the Critical Success Factors?

• Empirically
• Frustration with status quo
• Ownership of the problem
• Passion commitment to change
• Willingness to challenge
• Protected time

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The challenge is to bring the full potential
benefit of effective health care to all this
challenge demands a readiness to think in
radically new ways about how to deliver health
care services.
Institute of Medicine, USA Crossing the Quality
Chasm
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• The chasm!
• patient expectations
• public credibility
• outcomes
• access
• resources
• equity of service
• staff recruitment/retention
• funding

The gap is growing!
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First order change
More of, or less of.the same thing
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Second order change
Stand back. Reframe. See the big picture
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Creating and Leading Innovation at Three Levels
Organisational Culture
Team
Individual
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Central truths of innovation

• Every system is perfectly designed to get the
  results that it gets
• If we want different performance, we must change
  the system
• To change the system, we must think in
  fundamentally different ways

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Creating and Leading Innovation at Three Levels
Organisational Culture
Team
Individual
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Factors That Can Drive the Business Case For
Innovation

• Patient/family expectations
• Politician/public expectations
• Competitive pressures (business environment)
• Cost containment
• Technology enablers
• Changing workforce
• Reconfiguration and capacity change
• Drive for excellence (strategic aspirations)

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• Incremental approach
• reduces threat (spread)
• increases ownership (sustainability)
• Better understanding
• redesign methods skills
• simple rules
• Showing tangible benefits
• Benefits to patients (technical)
• Now I can play more golf! - whats in it for
  me? - cultural
• Ignore the human dimensions of change and you
  will surely fail

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Rigorous Diagnostics
1. Process Maps
2. Patient flow (Programme Measures)
3. Patient and carer experience
Demand
4. Sampling data
system
5. Brainstorming
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Dimensions of innovation culture

• risk taking
• resources
• widely shared information
• specific targets
• tools and techniques
• rewards systems
• team environment
• Psychological safety

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Creating and Leading Innovation at Three Levels
Organisational Culture
Team
Individual
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Partnerships for change

• I think that people are trying to tackle
  initiatives too low in the organisation .
• you need a damn good project manager, a strong
  chief executive
• and a strong lead clinician Site visit comment

Chief Executive Board
Change team
Clinical Leaders
The partnership of these groups will provide a
effective, dynamic team
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Seven Factors ShapingTeam Performance

• Strong platform of understanding
• Shared vision
• Creative climate
• Ownership of ideas
• Resilience to setbacks
• Network activators
• Learn from experience

Source Rickards and Monger
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Team level
Executive leads

Clinical team
Clinical team
Clinical team
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Creating and Leading Innovation at Three Levels
Organisational Culture
Team
Individual
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Leadership the art of mobilising others to
want to struggle for shared aspirations
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The Leaders Third Eye

• A vision that
• Views the content
• Ensures clarity
• Projects to others (so they can see)
• Has a wide-angled lens

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A new model of leadership

• Leading others
• Genuine concern for others well-being and
  development
• Empowers, delegates, encourages critical and
  strategic thinking
• Accessible, available, approachable
• Personal Qualities
• Integrity, open to ideas, criticism advice
• Transparent honest consistent
• Decisive, charismatic in-touch, analytical
  creative thinker
• Organisational Skills
• Inspirational communicator, networked and
  achiever
• Clarifies team direction team-orientated
  problem-solving
• Unites through a shared vision
• Manages change sensitively skilfully

Alimo-Metcalfe, B. Alban-Metcalfe, R.J. (2000).
Heaven can wait, The Health Service Journal,
October 12th, 26-29.
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What do good leaders do ?

• Articulating the vision embodying values
• You must live the world you want to create.
  Ghandi
• Innovation creativity
• Working across boundaries
• Motivation
• Releasing talent
• Personal resources

Leadership at Every Level, Jeanne Hardacre, HSJ
publications 2001 Workforce development
Embodying leadership in the NHS. London NHSE 2000
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Tools and techniques for us

• build on existing creative thinking and rapid
  cycle improvement methods
• locate natural champions for innovation and
  invite them to help with clinical innovation team
  once diagnostic completed
• past innovators to serve as coaches beware not
  all innovators are good coaches

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If you think you are going to be successful
running your business in the next ten years the
way you did in the last ten, youre out of your
mind. To succeed, you have to disturb the
present.
Roberto Goizueta Chief Executive, Coca-Cola
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The K2 Paradox Change something everyday to
produce a stable routine of continuous evolution
(improvement).
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Change is inevitable, except from a vending
machine
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Questions ?
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Morning tea
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Rigorous Diagnostics
Lee Martin
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Aim of the rigorous diagnostic phase

• Overall aims
• identify constraints across the patient journey
• Engage key staff in the process ready to
  implement change
• Find any myths

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Rigorous Diagnostic phase
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Elements of the diagnostic pack

• Program measures
• Sampling data tool
• Brainstorm tool
• Process mapping tool
• Patient, carer and relative involvement tools
• Innovation intensive tool

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Elements of the diagnostic pack

• Program measures
• Sampling data tool
• Brainstorm tool
• Process mapping tool
• Patient, carer and relative involvement tools
• Innovation intensive tool

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Program Measures

• Patient Journey Time in ED (SPC chart)
• Percentage and Number of ED Admissions waiting
  lt12 hrs (SPC chart)
• Percentage of ED Throughput lt6hrs (SPC chart)
• Patient Journey Time on Waiting List (SPC chart)
• Patient Waiting Times for Admitted Patients from
  Waiting List (Pareto chart)
• Cancellations (HIPs) per 100 Admissions (Line
  chart)
• Average Admissions Discharges by day of week
  (Bar chart)
• Length of Stay Medical/Surgical/Other (Pareto
  chart)
• Number of Unplanned Readmissions within 28 days
  by day (SPC chart)

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Percentage of ED Admissions waiting lt12 hours -
Chart
For the period Jul03 to Feb04 between 59 and 86
of ED patients waiting for admission to a ward
could expect to wait less than 12hrs. The
average number of patients admitted within 12hrs
per week was 73, with a target of 95.
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Elements of the diagnostic pack

• Program measures
• Sampling data tool
• Brainstorm tool
• Process mapping tool
• Patient, carer and relative involvement tools
• Innovation intensive tool

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Sampling tool

• Two clinical areas minimum
• Request staff to identify key delays
• Chart delays for each patient each day
• Total at end of time period

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example
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Elements of the diagnostic pack

• Program measures
• Sampling data tool
• Brainstorm tool
• Process mapping tool
• Patient, carer and relative involvement tools
• Innovation intensive tool

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Brainstorm tool

• Brainstorm the delays that effect your patients

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Brainstorming tool
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Elements of the diagnostic pack

• Program measures
• Sampling data tool
• Brainstorm tool
• Process mapping tool
• Patient, carer and relative involvement tools
• Innovation intensive tool

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Process mapping tool

• Map minimum of two whole system patient journeys
• Elective Admission to Discharge
• Emergency Admission to Discharge

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• Example of Process Map

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Example of Process Map
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Example of Process Map
This is the first part of a three part process
map of which in its entirety was too detailed to
successfully display.
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A high level patient process
Patient feels unwell
Referral letter sent
Prioritised by consultant
Sees GP
Added to OP pending list
Review in clinic
Diagnostic tests
Patient attends OP clinic
Appointment sent
Added to waiting list
Patient attends for operation
transfer home
Patient attend POA
TCI letter sent
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Elements of the diagnostic pack

• Program measures
• Sampling data tool
• Brainstorm tool
• Process mapping tool
• Patient, carer and relative involvement tools
• Innovation intensive tool

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Patient,carer and relative involvement

• Small test cycles to gain consumer input
• Use the tools one to one with patients

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Elements of the diagnostic pack

• Program measures
• Sampling data tool
• Brainstorm tool
• Process mapping tool
• Patient, carer and relative involvement tools
• Innovation intensive tool

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Intensive innovation tool

• Pre-plan 6 weeks in advance
• One day event for individual health service
• Book early!
• Not needed for completing the rigorous diagnostic
  phase

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Completion of diagnostic phase

• Review all of the 5 tools together and priorities
  the constraints that are causing the most
  disruption to the larges patient group.
• Identify the clinical area team that is needed to
  carry forward the innovations from the diagnostics

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Review meeting

• Collaborative team wish to be involved
• Feedback at the first learning session

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Handy hints

• Share the work
• Gain as many views as you can
• Use this phase to find the constraints and test
  assumptions
• Enjoy the focus on patient process
• Have fun

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Questions
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Lunch
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Team planning time
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Aim of team planning time

• Dedicated time for team planning together
• Chance to network with other organizations
• Practice mapping before real event

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Tasks

• Confirm team structure and contact details
• Allocate tasks for the rigorous diagnostic phase
  against the time planner
• Process map

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Where to start
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How to get going

• Discuss tasks and what needs to be completed
  today
• Look through the templates
• Agree time for tasks to be completed today
• Remember to think about how to use these tools to
  unfreeze environment that are going to innovate
  in the next phase

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Equipment and Templatesfor team planning

• Health service project team structure
• Program measures
• Brainstorm exercise
• Patient relative and carer involvement
• Sampling data
• Process mapping equipment

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Process mapping exercise

• Whole system map
• Agree a patient
• i.e. Mrs Smith fractured Neck of femur
• Map the process from admission to discharge

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Process and flow rate
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Remember you could Photograph the process
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Delays amount to 58 hours 5 minutes in
Histopathology
Specimen arrives in department
Number allocated to specimen
Specimen entered onto laboratory database
Specimen cut up
Blocks checked
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491
105
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Fixation occurs while the steps take place and
varies between 10 min and 24 hours depending upon
the specimen type size and subsequent techniques
needed
Sections mounted under coverslips
Sections stained
Blocks cut sections placed on glass slides
Blocks embedded and checked
Blocks impregnated
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3
2
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Slides micro- scopically quality controlled
Slides labeled
Cases booked out on database
Cases placed in pathologist trays
Slides are viewed and a report dictated
5
11
2
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393
Reports taken to pathology post room
Reports are placed in envelopes
Reports are signed
Reports are printed
Reports are typed
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974
528
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95
1
3
2
4
5
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Ideas being tested and changes implemented
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Task Map a process you know really well going
to work each morning
where does it start ?

• where are the main bottle necks?
• how do you manage the bottlenecks?
• what are the 10 -15 high level process steps

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Patient processes cross many boundaries

organisational/departmental/professional
boundaries
E
B
C
D
A
output
Whole system patient journey
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Discharge delay
3HR 30MIN
DELAY
DELAY 5 HRS 30 MIN
730
1100
1200
1600
1730
1700
Nurse identifies
Enquiry made
Advised that bed
Doctor made
Patient ready
Patient left
decision to
to leave unit
patient ready to
about bed
available and ward
unit
discharge
availability
ready to accept
discharge
patient.
DELAY
8HR 30 MIN
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Any questions?
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Once Completed - Identify on Your Map the
Following

• Number of steps for the patient
• Number of times hand offs occur
• Time between each step
• Total time for process
• Queues in the process
• Steps that add value to the process
• Steps that add value to the patient
• Look for batching tasks that are left to build
  up
• Identify constraints on people and equipment
• Identify other processes that affect this process

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Good luck!!
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Next steps
Rochelle Condon
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Next steps
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For the learning session

• Story board or display of your results from
  rigorous diagnostics
• Presentation 15 mins to show other team what you
  achieved
• Project coordinators to feedback what their team
  would like on the agenda next learning session

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Questions and close
Jenny Bartlett
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Questions and Close

• Any questions for Kate, Marcus, Rochelle, Lee or
  myself
• Evaluation forms
• Remember about the travel fellowship awards
• Contact the team to start the work together and
  build the relationships

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Thank you

• Thank you to Kate Harmond and Nina Willis
• See you all on 6-7 July for the Celebration event
• Have a safe trip home