PATIENT CENTERED SERVICESWorking together toward decongesting the hospital

“Managing Hospital Capacity andImproving Patient flow”

Dato’ Dr Azmi ShapieDirector Medical Development

Vision for Health:

Malaysia is to be a nation of healthy individuals, families and communities

Through, a health system that is•Equitable•Affordable•Efficient•Technologically appropriate•Environmentally adaptable•Consumer friendly

With emphasis on•Quality•Innovation•Health promotion•Respect to human dignity•Promotes individual responsibility and community participation

Towards an enhanced quality of life

Mission of MOH:

The mission of the MOH is to build a partnerships for health, to facilitate and support the people to:

attain fully their potential in health motivate them to appreciate health as a valuable

asset take positive action to improve further and sustain

their health status to enjoy a better quality of life.

8 Health services goal:

Wellness focus

Person focus

Informed person

Self help

Care provided at Home or Close to Home

Seamless, Continuous Care

Services Tailored to Individual or Group Need

Effective, Efficient and Affordable Services

6 - Quality Dimension in HC Services:

MEDICAL STAFF

LEADERSHIPORGANISATIONAL

CULTURE & VALUES

FOCUS ON PATIENT

FOCUS ON PROCESS

QUALITY

SAFETY

EFFECTIVENESSAPPROPRIATENESS

EFFICIENCY

ACCESSIBILITY

CQI

ENHANCED QUALITY OF LIFE

PATIENT CENTERED

Adopted from DDG

Challenges:

Increase workload Changing disease patterns Inadequate resources

Manpower, Financial , Physical facilities, Equipment

High expectation Patients, Providers

Increase healthcare cost

Congestion !!!

INCREASE WORKLOAD:Total number of Outpatients Attendances and Admission in MOH Hospitals – 2001 -2009

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

INPATIENT EMERGENCY SPECIALIST

Pathology Services in MOH Hospitals 2001 - 2009

Radiology Services in MOH Hospitals2001-2009

Operation Done in MOH Hospitals 2001-2009

% BOR in MOH Hospitals 2005-2009

Overcrowding and Congestion Impact on services:

Accessibility Patient centered Appropriateness Timeliness of care Efficacy Efficiency of services Effectiveness of services Safety

Quality of services !!

•Limited access•Delay•Waiting time longer•Chaos in clinical area•Physical/clinical condition•Risk of hospital infection•Complication and mortality•Frustrated and fatigue•Medical errors•Increase cost•Lost revenue

Situation inMOH Hospitals: in-patients Congestion in 5 major disciplines based on utilisation data:

BOR, ALOS, TOI. Pediatric, Medicine, Obstetrics, orthopedics, surgery

More common in the state and major specialist hospitals % congestion (services) of hospitals by functional category:

14 state hospitals Medicine-71%, pediatrics-64%, obstetrics-36%, ortho/surgery-29%

21 major specialist hospitals Medicine and pediatrics-43%, orthopedics-29%, obstetrics-19%,

surgery-14.3% 20 minor specialist hospitals

Pediatrics-35%, obstetrics-20%, medicine-15%, surgery/gynecology-5%

Situation inMOH Hospitals: out patients

Specialist clinics at 35 specialist hospitals Longer waiting time (standards - 90 minutes)

85% patients seen within 90 minutes Best performer psychiatric services

96.2% seen within 90 minutes Worst performer medical clinics

76% seen in 90 minutes

? Optimize usage of the existing facilities: Look at the ‘variability’ as source of the strain and

delay to the system The ideal healthcare system with 100% efficiency:

All patients are the same and with similar complexity/severity They all appear for care at the uniform rate All providers are equal in their ability and competency

Variability causing: Clinical stress Patient flow affected Professional stress Random variability Cannot be eliminated? beyond control? Need to be managed

Example in ED / ClinicVariability could be due to:

Time to register Time to trace records Time to trace results Time to triage Time to do imaging Time to do lab test / Ix Time to see doctor Time for decision

making – to admitted / to discharge

Time to admitted pts Time to transfer pts Within the day:

Ward rounds Tracing Ix results Discharge time Bed clearing time Assign clean bed to the

new arrival; etc Between days:

Elective surgery schedule

Within ED/Clinic: Outside ED/Clinic:

Variability:Contributing factors Hospital organisation – rules /

regulation Service fragmented Compartmentalize Operate in silo

Creating pts queues: why?? Demand exceeding services Mismatch between demand and capacity With queues make the system busy

With queues >>>>>Good utilisation??•With adequate capacity it will:

•Prevent queues •Meeting demand•Improve quality•Control costs

In the era of patient choice: Quality and timely provision of care is importance: Driving up quality, value, and productivity in HC

system: Reducing delay Changing the way we deliver care Manage process to improve services

Timeliness in the services of 1o, 2o and 3o to be improve

Doctors, nurse and all the team members have to sit down and examine how service is being provided >>>> how to be improved !!

Congestion !!Options for Solution:

Increase capacity Physical facilities Resources - manpower, money, machine

? Limiting the number of patients Rescheduling Decentralize services

Look at the process Reduce variation in process flow Optimize work process

1. Increase capacity:

Physical facilities Optimise resources

manpower, money and machine Public private integration

•Built more/bigger facilities•More equipment•More manpower•More money•But - is it sustainable ??•1Care initiative!!

2. ? Limiting the number of patients:

Rescheduling / substitution Decentralize services •Relocation of resources / services

•Offsite specialist clinics?•Shift in skill and technology

•Stand alone day care activities•Sharing of clinic between 1o & 2o •Home base / outreach programme•Self-care programme

•Different combination of services:•Location, technology and skill

•Community pharmacy•Lab testing / ECG examination•Home based infusion?•Home monitoring•Home base therapy / traction?

•Tele-consultation / tele-radiology

•Strengthen gate keeping-1o

•Referral policies•Green zone in ED•Patients flow between 1o,2o,3o care and community

•Strict admission criteria•Substitutions – look at the:

•Regrouping resources

3. Look at the process:

Reduce variation in process flow Optimize work process

•Improve work process•Operation management•Need proper study/real data•Patients flow between

•Between service stations•1o,2o,3o care and community•Gate keeping role•Regrouping resources

•New technology•Better coordination•Right staff / skill mix

Required understanding:-Variation- demand- capacity

What need to be done? Look at the practical options ?? Traditionally the model of care is:

being driven by the hospital design and the adopted process

it is centered around the staff routine and preferences Need to study and addressed the patients needs!!

Better coordination between processes

Strategies to reduce variability / delay:

Focus on the whole patient flow Plan ahead along all the patient’s flow Balance demand and capacity Keep things moving – see and treat pts in order Reducing things that do not add value to pts care Pool similar work together and share the staff

resources Keep the flow and reduce the unnecessary waiting

Adopted from NHS

1. Focus on the whole patient flow – PCS ! Referral to treatments covers most of the pt pathway, and total

time taken will depend on: Number of different teams involve Decision making process of each teams

Good to: To identify the whole pt pathway Talk to the people involves Coordinate Focus on potential bottlenecks!!

Registration process, Lab investigation, Imaging activities, Consultation with clinician, etc

2. Plan ahead along all the patient’s flow/pathway Forward planning for the need for elective and/or

HDU/ICU Ensure all the equipment is ready for the OT day Booking and scheduling in advance all the

prerequisites – lab test/imaging/results/procedures Setting a real date for discharge and planned for it Setting up pathology work process to coincide with

ward rounds Anticipate and planning for rehabilitation/therapies Coordinate/plan with other department – so that all

the support could be in place,

3. Balance demand and capacity Scrutinising demand and capacity; and taking

stocks of available resources Identify and plan for known change in capacity – eg.

staff taking leave, training, equipment down! Maximise capacity by redesign the role; Reduce DNA (did not attend) rates Plan capacity around the variation in demand and

allow for excess of capacity

•To map patients pathway•Plot volume of referrals by type of patients/time•Understand the required resources•Combine / matched the volume and resources•Develop schedules and staffing levels base on demand•Ensure daily pattern of demand is taken into account

4. Pool Similar Work Together and share the Staff Resources

Pooling referrals in line with availability of resources

Pooling the work for some of the most common and simple procedures

Pooling elements of administrative functions Pooling treatment and therapies

•Pooling is about identifying the things that being done most often•Making sure that patients, their paperwork, test and so on is not being stuck.

5. Reducing things that do not add value to pts care

Time is precious – Pts given appointment on different days for

different lab test, imaging Ix Time spent looking for equipment/records Repeating the same paperwork or diagnostic test Unnecessary appointments / followup in

outpatients Unnecessary diagnostic testy/repeating similar

test

6. Keep things moving – see and treat patients in order

If one jump queue for non-clinical reasons – those behind have to wait longer

By doing things in order – its reduce the difference in waiting time between pts.

Example of things done out of order: Blood sample got trapped at the bottom of ‘drop off

counter’ Pt was not seen in the order of referral A specialist pick up interesting cases A specialist has a longer waiting list than his colleagues Pt who missed appointment

•Seeing pts in order and doing things in order>>>>> reduce maximum waiting time

7. Keep the flow and reduce the unnecessary waiting

Reduce piling of work; Frequency in doing things; eg.

Particular test / imaging done once a week? Letters / discharge summary type once in three

days Multidisciplinary teams meet once in fortnightly Delay and time spent for decision making

•Have to reduce the step taken in doing things•Identify and cut out the hidden waits!!

PCSPatient-centered service Services to be rearranged:

To fulfilled patient’s needs To be delivered by knowledgeable and skill staff To redesigning the hospitals ? and process To break down barriers and compartment

Resources to be organised around patients Redeployment / regrouping of patients Decentralised / service nearer to patients Multi-skilled and trained personnel Patients needs teams Care protocols, task simplification, integrated records Enhanced patient’s autonomy and decision making

Immediate measures:

Optimise resource utilisation: Day care surgery – “DOSA” Day care services Offsite specialist clinic Home care Community HC programme

1Care initiative: Public private integration ?

•Issues related to resources:•Physical facility•Manpower•Money•machine•Time

•Need:•proper planning, and •need assessment

Check on next presentations!

Thank you

8 Health services goal:

Empowerment of community on HC: Wellness focus

Person focus

Informed person

Self help

Care provided at Home or Close to Home

Seamless, Continuous Care

Services Tailored to Individual or Group Need

Effective, Efficient and Affordable Services

Goal of Healthcare System:

To raise and sustain optimally the health status of individuals, families and community through: Health promotion Prevention Curative and Rehabilitative services

so as to enable all citizens to lead a socially and economically productive life, and enjoy an acceptable quality of life.

Average Length of Stay (ALOS) and Turn Over Interval (TOI): 2005-2009

0.00

1.00

2.00

3.00

4.00

5.00

ALOS TOI