Department of Human Services Team Presentations Felicity Topp and Rochelle Condon 5 TH October 2004

Department of Human Services

Team Presentations

Felicity Topp and Rochelle Condon

5TH October 2004

Concurrent Session 1Concurrent Session 1Team PresentationsTeam Presentations

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


Patient Flow Collaborative

Fiona Brew Phil Catterson Jill O’Flynn

Operating Suite Emergency Department PDU

Ballarat Health Services- ‘The Stream Team’

Summarise Organisational Summarise Organisational Constraint areasConstraint 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

Summarise Priority Constraint Area 1 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

Diagnostic workDiagnostic work

• Process

• Staff Involved – Nursing, Medical, Support

• Staff Reaction – Keen, positive

• Useful data – Tally charts

Improvement PlanImprovement 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

ProgressProgress• Communication

– Centralised distribution

• Culture – Patient focus – Team approach - New skills– Planning

• Work practices– Roles – Day surgery focus

Lessons learntLessons learnt

• Success– Communication– Culture

• avoid isolation– Work processes / practices

• strategies embedded in culture

• Future Improvements • Education• Frequency• One size does not fit all

Desired ImpactDesired Impact

• Recognition of cascade effect– impact on patient flow– global view

• Action – purposeful– innovative– positive - up and

downstream validation prior

• Evaluation– patient perspective

Next StepsNext Steps

• Consolidation

• Increased medical ‘buy in’

• Feedback

• Further development of strategies – outcomes related to measures

Questions

?



Kim ReadGoulburn Valley Health


• Of the 5 Major constraints @ 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

Summarise Priority Summarise Priority Constraint Constraint Area 1Area 1

• Bed Availability.• Major Bowel Surgery Admissions on day

prior.• What works for us and OUR PATIENTS.


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

DOSADOSA

General Surgery DOSA Ratio

0

10

20

30

40

50

60

70

80

90

100

Jan-

03

Mar

-03

May

-03

Jul-0

3

Sep

-03

Nov

-03

Jan-

04

Mar

-04

May

-04

Jul-0

4

Sep

-04

Nov

-04

General surgery DOSA Ratio (%)

Patient InterviewsPatient 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.

Process MapProcess Map

Current Major Bowel Surgery Admission Process Map

Appointment with GPReferral to VMO Private

Rooms or Outpatient ClinicPlaced on to waiting list and

notification to patientPatient Health

Questionnaire completed

Commence bowelpreparation at 1500

hoursFleet / Golightly

Admit day prior tosurgery

Stomal Therapistappointment

Pre-Admission ClinicFBE, U&E

Theatre booking andnotification.

Diet instructions

Commence IVtherapy/fluids at

2400 hours

Fast from 2400 hoursor 0700 hours

Prepared andtransported to

Theatre

Improvement PlanImprovement Plan

• Research bowel preparation options.• Surgeon Involvement.• Research processes at other

institutions.• Relationship with private hospital.

ProgressProgress

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


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


• Satisfactory preparation.• Patient’s needs met.• Bed availability (HIPs).• DOSA rates comparable.

Summarise Priority Summarise Priority Constraint Constraint Area 2Area 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

• 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 tools+lengthy & 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 > LOS)



• 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

ProgressProgress

• 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)

http://r5.2.doc/

LOS ComparisonsLOS Comparisons

Complex Care Patients - Average Length of Stay

0

5

10

15

20

25

30

Chr ObstructAirw ay

Disease WCat/Sev CC

Chr ObstructAirw ay DisNo Cat/Sev

CC

Heart Failure& Shock W

CatastrophicCC

Heart Failure& Shock noCatastrophic

CC

Diabetic Foot Diabetes WCatastrophicor Severe CC

Diabetes W/OCatastrophicor Severe CC

E65A E65B F62A F62B K01Z K60A K60B

Ave

rag

e L

eng

th o

f S

tay

01/07/01 - 30/06/02 01/07/02 - 30/06/03 01/07/03 - 30/06/04


• 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


• 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


• 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

Questions

?



General Internal Medicine UnitWestern Hospital, FootscrayG. Lane, Head of UnitH. Hasanoglu, NUM

OrganisationOrganisation

Background: Background: General Internal Medicine UnitGeneral Internal Medicine UnitPatient Mix Patient 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

Background: Background: General Internal Medicine Unit. General Internal Medicine Unit. Common ProblemsCommon Problems

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

• Acute and chronic renal impairment

• Polypharmacy problems• Syncope • Obstructive lung disease • Psychiatric diagnoses• Self-harm• Accommodation and

community support problems

Diagnostic work: ADiagnostic 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

Diagnostic work: B 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”

Organisational Constraint Organisational Constraint areasareas

General Internal Medicine Sample Data DHS Patient Flow Collaborative May 2004

0

10

20

30

40

50

60

70

80

90

100

Type of Delay

Nu

mb

er

of

Oc

cu

rre

nc

es

of

De

lay

3 EAST Sample Data for Patient Flow Collaborative on LOS delays May 2004

0

10

20

30

40

50

60

70

80

90

100

Type of Delay

Nu

mb

er

occu

rren

ces o

f d

elay

Organisational Constraint Organisational Constraint areasareas

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


50% reduction in:• mean time • range waiting for consultations and

procedures

? Significant reduction in length of stay

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

a) Time to see patient by registrar

b) Time to see patient by consultant

Pre-interventionPre-intervention

• Days to see patient: Registrar Pre (n=27) n 18 Range 0-7 Median 0 Mean 1.2 SD 1.93 Variance 3.7

Pre-interventionPre-intervention

• Days to see patient: Consultant Pre (n=27) n 14 Range 0-6 Median 2 Mean 1.9 SD 1.89 Variance 3.6

How Improvement How Improvement Strategies were derived and Strategies were derived and implementedimplemented

• 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

Improvement StrategyImprovement 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

OutcomesOutcomes• Days to see patient: Registrar Pre (n=27) Post (n=24)n 18 19Range 0-7 0-4Median 0 0Mean 1.2 0.68SD 1.93 1.06Variance 3.7 1.1Not seen 9 5 by reg

OutcomesOutcomes• Days to see patient: Consultant Pre (n=27) Post (n=24)n 14 9Range 0-6 0-7Median 2 2Mean 1.9 2.2SD 1.89 1.92Variance 3.6 3.7Not seen 13 15 by cons


* 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

What would you now do differently?What would you now do differently?

• Focus on delay to procedures rather than

consultations

• Devise an electronic collection process of data by

Unit’s registrars

• Weekly audit of delayed procedures and

consultations at Unit’s Safety and Quality meeting

• Display recording sheets on all wards


• 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

Questions

?



Mr. Mark BaldwinPlastic Surgeon Western Health

BackgroundBackground

● 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.

● 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


Sample Data ResultSample Data Result

Constraint Issue

Patient Presents to ED

Patient DischargedTheatre

Discharged Home for Clinic. Appt

Admitted

Discharged home to wait surgery

Ward

Short Stay Unit

DPU

Out Patient follow up

Wait for Registrar review

Registrar calls: theatre, admissions, bed manager, and patient.

Inconsistent management plans

X-ray, medical record not available.

Registrar may not be on campus

Surgeon/ Theatre session availability

Opening hours may not allow recovery time Overbooked clinic

unable to make appointment

Goal settingGoal 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

Improvement Plan 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

What's in it for plastics?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.

What's in it for the ED?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

What's in it for the patients?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

ProgressProgress

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

Team MembersTeam Members

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

Team WorkTeam Work

ProgressProgress

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

ProgressProgress

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


● It’s 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.


● Complete beta testing of– Pathway from clinical point of view– Pathway from logistics point of view– SMS service

● Evaluation● HTML based pathway in ED?


● Happy patients● Happy staff

Questions

?



Trevor RixonPatient Resource ManagerThe Royal Children’s Hospital

The Royal Children’s Hospital The Royal Children’s Hospital Broad Broad Constraint Constraint AAreasreas

• RCH operational context

• Complexity of RCH admissions process

• Communication & information gaps

• Waiting list management systems

• Re-active bed management

Constraint Area 1Constraint Area 1Admissions ProcessAdmissions 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

Constraint Constraint Area Area 22ConsentConsent

• 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

Constraint Constraint Area Area 33Pre-Admission TriagePre-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

Priority ConstraintPriority ConstraintBed ManagementBed 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

• 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

Diagnostic WorkDiagnostic Work


• 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

ProgressProgress

• Trial of IT-based bed management template

• Very positive feedback - >95% 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

Date:

Expected 'Admissions'

Anticipated Beds

Required Emergency Electives O.T. ICU Green Go < 85%

Time: 0930 hours 0 YellowEarly

Caution > 85%

Occupancy 0600 hours

ED Actual 2003 Orange

Late Caution > 95%

Red Stop 100% or >

Ward/UnitTotal Bed Capacity

Beds Open

Current Census

(Actual pts. in beds)

Expected Discharges

Expected Admissions

Anticipated Transfers

IN

Anticipated Transfers

OUT Beds

Variance Iso. BedsUnstaffed

Beds

PM Staffing

Variances

ND Staffing

Variances Capacity

8 West 10 0 10 #DIV/0!7 West 23 0 23 #DIV/0!6 West 23 0 23 #DIV/0!6 East 16 0 16 #DIV/0!5 West 24 0 24 #DIV/0!5 East 24 0 24 #DIV/0!4 Main 32 0 32 #DIV/0!4 North 19 0 19 #DIV/0!3 East 22 0 22 #DIV/0!SSU 12 0 n/a 12 #DIV/0!

Medihotel 3 0 n/a 3 #DIV/0!

PICU 17 0 0 n/a 17 #DIV/0!NNU 22 0 n/a 22 #DIV/0!

EmergencyO.T.

RecoveryPSC/DMU

DSUHITH

TOTAL 247 0 0 0 0 0 0 0 0 247 0 0 #DIV/0!

ED Admissions Actual '03Actual

'04 Var. DischargesExpected

'04 Actual '04 Var.

0 0-Jan-00 0

Unexpected Admissions Actual '04

0-Jan-00

Bed Management TemplateBed Management Template

Lessons Lessons LLearntearnt

• 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


• 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


• 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

Questions

[email protected]

[email protected]

[email protected]

mailto:[email protected]










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

LunchLunch

• Meet us in the next Concurrent Session at 12.45


Team Presentations

David Langton and Mary Mitchelhill

5TH October 2004

Concurrent Session 1Concurrent Session 1Team PresentationsTeam Presentations

Bellarine Room 2– Royal Women’s Hospital – Southern Health – Monash Medical Centre– Peter MacCallum Cancer Centre– Maroondah Hospital– Calvary Health Care



Tanya Farrell & Rosemary BurrellThe Royal Women’s Hospital

‘‘Operation Caesar’Operation Caesar’

Tanya Farrell

Maternity Care Program Manager


• 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, resourcesResources, resources, resources..

Summarise Priority Constraint Summarise Priority Constraint

• Operation Caesar

– Pre Admission Clinic (Midwife PAC & Anaesthetic PAC)

– Theatre booking


– Further Process mapping,– Documentation review, – Review template and capacity for all Pre

Admission clinic appointments,– Consumer Advisory Committee

representative – walk through



• 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

ProgressProgress


– 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.



– Improved access to service for patients and staff

– Decrease in incident reporting– Better use of resources



– Complete Pathway for rest of patient journey

– Patient information, update using consumer input

‘‘Wait watchers….’Wait watchers….’

Rosemary BurrellRosemary Burrell

Well Women’s Program ManagerWell Women’s Program Manager

Summarise priority Summarise priority constraintconstraint

• Wait watchers

– Appointment /Booking System– Access to ultrasound results in clinic– Medical staff availability


• Wait watchers

– Process mapping, – Restructure of clinic templates, – Trial FTA process, – Trial Overbooking Policy, – FTA audit– Consumer Advisory Committee

representative – walk through


• 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

ProgressProgress

• Wait watchers

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

Desired impactDesired impact

• Wait watchers

– Improved access to service, better use of resources

– Reduction in variation

Next stepsNext steps

• Wait watchers

– Consider implementing partial booking system and reminder call service


• 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

Questions

?



Andrew Driver & Wendy Jupp

SouthernHealth – Monash Medical Centre


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

Summary Priority Constraint 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.

• 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.



• 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


Injec t with adren aline

Variceal Bleed

END OSCOPY

Poss ible surg ery for over sewof bleeding vessel or partial gastrectom y

Out patient repeatvariceal banding

Await brownb owel ac tion

discharge

Repeat out patient scope toch eck ulcer healing + or -H. Py lori eradicat ion

Res tore haemodynam ics tabilityEndocopy,cons ider TIP SBalloon tam penad e

Haemodynamically stable

Fluid resus unt il blood availablecons ider haem accel, N saline or coloidsTransfuse if Hb < 80 or if clinically unwellGastro med reg notify U pper GI surg reg

No rebleed Rebleed No re bleed

continue bleeding

Bleeding DU or GUMallory Weiss Tear

Presentation to ED withsignificant GI bleed

Haemodynamically unstable

Await brow nbowel action

discharge

ACUTE UPPER GASTROINTESTINAL BLEEDING ALGORITHM

PR -ve Hb stab leGas M ed reg review ? discharge

Await brownbowel ac tionD ischarge

Res tore haemodynam ic s tabilityRepeat endoscopy

Aspirin,warfarin, clopidogril

Diatherm y to bleeding vessel and orInjec t with adrenalineCont inue IV Om eprazoleGastro Med not ify Upper GI surgCom mence oral Omeprazole

THESE ARE TREATMENTGUIDELINES AND DO NOT REPLACE CLINICAL JUDGEMENT

A

ED assesm ent notify Gastro Med Reg im ediat ly IV access x 2U&E FBE clott ing LF T group and hold 4 unitsR BCRecord pos tural BP P R temp & Sao2Perform PRECGConsider C VC & IDCComm ence Om eprazole and or OctreotideCorrec t clott ing w ith FFP, platelets or Vit KAscertain risk fac tors - ETOH , NSAID, antigoagulationAspirin, W arfarinC lopidogrel

Poss ible trans fer to ward

No re bleedContinues bleedingor Re bleeds

R arely surgery

Continues bleedingor re bleeds

Variceal bandingC ont inue octreot ide 48-72 hrsOral Propranolol

ProgressProgress

• 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

OutcomesOutcomes

• 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..


• 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


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


• 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

Questions

?



Skin / Melanoma Service

Peter MacCallum Cancer Centre


• 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

Summarise Priority Constraint Summarise Priority Constraint Area 1 – Area 1 – High Vol Clinic LoadHigh 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.

1. Audit of New Patient Presentations• Timeframe May, June and July • Review assessment & treatment outcomes

2. Audit referral source• General Practice

3. 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

5. Useful data• Analysis of assessment outcomes demonstrated high numbers of patients proceeding to

surgery• Large numbers of patients were undergoing biopsy in clinic


Treatment options for New Patients. May - JulyTotal Number of Patients 100

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Biopsy 15.7% Surgery 57.8% Dermatology1%

Cryotherapy6.9 %

Topical Rx2.0%

Review 3.9 % Ref Back toGP 3.9 %

No Further Rx8.8%

Percentage


1. GP Education Program• Biopsy the patient prior to initial visit to the hospital

2. Human Resources• Reorganise this in order to facilitate the high number of patients going

to theatre and post operative care.

3. Patient’s who proceeded to biopsy. • Benign result -> Develop a standard form letter to be sent to the

patient and referring GP.• Malignant result - > Patient to be called personally. Patient to be

triaged to the appropriate clinic.

4. Develop standards treatment pathways.• Including follow up: Currently no NHMRC guidelines for this group of

patients

ProgressProgress 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

consultantsOutcome: 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.

How many patients were involved? - > All patients presenting to the clinic form August onwardsWhat staff were involved? - > Medical, Nursing, Clerical and Statistics Staff


• 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


• 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


• 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 DNA’s.

• Audit the number of post operative wound care time allocations to possibly move toward Nurse Led Clinics

Questions

?



Christine Fisch – Patient Access Manager.Eastern Health – Maroondah Hospital


• 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.

Summarise Priority Constraint Summarise Priority Constraint Area 1Area 1

• BED MANAGEMENT

– Delayed Access to Beds.– Lack of structure - bed allocation– Inequitable distribution of workload.

• 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)


Diagnostic Work (Con’d)Diagnostic Work (Con’d)

• Staff reactions

– Committed to aim of session– Honest – Frustrated– Seeking solutions– Feeling of deja vu

Areas HighlightedAreas Highlighted

• HR Management• Communication• Collaboration & Team Building• Organisation• E-Support• VMO’s• Organizational Structure.

Areas highlighted (Con’d)Areas highlighted (Con’d)

• Care Planning• Communication• HR.• Service model

OutcomesOutcomes

• 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.

Expected BenefitsExpected 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


• 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

Improvement Plan (Con’d)Improvement Plan (Con’d)

• 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

ProgressProgress

• Clinical Working Team established and first meeting held Monday 13th September.

• Lee Martin & Rochelle invited to attended.– Guided group

Next stepsNext 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.


• 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.


• 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)


• Ensure the current motivation across all disciplines continues.

• Ongoing commitment of the Clinical Working Team.

Documents

Department of Human Services Team Presentations Felicity Topp and Rochelle Condon 5 TH October 2004