Clinical Involvement

July 2015

Alfred Health

•  3 hospitals: The Alfred; Caulfield Hospital & Sandringham Hospital

•  Located in central Melbourne

•  $1B million per annum

•  Around 900 beds; 100,000 ED presentations, 95,000 inpatient events; 162,000 outpatient attendances.

•  Approximately 5000 equivalent-full-time staff made up by around 8600 people including 700 senior medical staff (200 FT and 500 PT), around 750 junior medical staff and approximately 300 nurses

•  Tertiary and Quaternary provider of: –  Heart and lung transplantation –  cystic fibrosis –  major trauma –  burns –  HIV/AIDS –  Allogeneic bone marrow transplantation –  Hemophilia –  Sexual Health –  Hyperbaric medicine –  Psychiatric intensive care

•  Home to one of the busiest emergency and trauma centres in the country,

The Alfred also has one of the largest and most advanced intensive care units in the region.

Service Profile

The Alfred

•  https://www.youtube.com/watch?v=qt-OV2I7vzI

6

Overview of Our Approach 1.  Contextualise the change process 2.  Establish a ‘guiding coalition’ that is well informed 3.  Understand the patient demand & capacity requirements of units 4.  Develop streams of care that support the patients journey 5.  Ensure we have an up to date understanding of ‘flows’ and constraints 6.  Ensure all levels of the organisation can effectively and rapidly problem solve 7.  Align the Organisation to support streams of care 8.  Empower nurse managers and medical leaders to run their ward 9.  Provide clarity of responsibility for patient care 10. Don’t ignore after hours

“Timely Quality Care” enhancing the patients experience

•  Its about excellence in patient care - performance will follow •  Its about a way of working not a project •  Everything we do is guided by six simple principles that are owned

and understood by staff

Patients will be reviewed by the inpatient team within 2 hours of being

referred for admission.

October 2013

Patients will be discharged from E&TC or admitted to the hospital as decided

by the E&TC consultant staff.

Patients will be admitted to a bed in the most appropriate clinical place,

the first time.

Patients will have their investigations, consultations and interventions

completed as soon as possible, in order

of request and in no longer than 24 hours.

Patients will be actively managed to ensure they are only in hospital

for as long as is clinically necessary.

Patients that present to the E&TC will be assessed, have treatment and investigations initiated and a

management plan in place within 60 minutes of arrival.

Whole of Hospital Changes !  Inpatient engagement & acceptance of ED’s authority !  Roster re-profiling across the in-patient units !  Bed model changes in all wards

(admission beds, SAAU’s, MAAU's & Flex beds) !  Treat in turn principle for all investigative & interventional areas !  New after-hours models ensuring safer care in this vulnerable period

1.  The  right  people  in  the  leadership  team  2.  A  shared  vision  of  the  governance  group’s  leadership    

role  in  the  delivery  of  excellent  care  3.  Strong  connec>on  between  members  and  the  capacity  for  robust  dialogue    4.  Shared  understanding  of  their  program  of  work  and  methods    

for  problem  solving  5.  Developed  informal  and  formal  processes  and  ways  of  working/communica>ng  6.  mechanisms  for  measurement  and  sharing  of  informa>on    7.  Connec>on  to  teams  outside  of  the  ward  involved  in  a  pa>ent’s  care  8.  Support  for  new  ideas  and  recognised  success  in  innova>on  9.  A  plan  for  what  they  want  to  achieve  10.  Strong  connec>on  to  the  organisa>ons  priori>es  

The  Ward  Leadership  team:  Building  a  ‘Guiding  Coali>on’  

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1.  Patients will be actively involved in their treatment and have opportunity to influence the wards operations

2.  Patients will be reviewed twice daily by their treating team(s) 3.  Patients will have an up to date treatment plan at the time of admission including an

expected date of discharge with any deviation from that plan brought to the attention of the primary consultant

4.  There will be a monthly management meeting, chaired by a head of unit (or designated consultant) and interdisciplinary in nature

5.  Ward level metrics will be regularly reviewed by the interdisciplinary ward management team (per 4 above) to ensure timely quality care, that is safe for staff and patients alike & be within existing resources. These will be made available to ward visitors

6.  There will be a clear mechanism to communicate with all staff 7.  There will be a clear process for escalation of patient safety and ward management

issues 8.  All staff (including visiting staff) will know where to access patient and management

information as it will be consistent across all wards 9.  There will be a clear process for welcoming & managing visitors to a ward

Excellence in Ward Governance

These  ward  governance  groups  will;    1.  Deliver  on  strategic  priori>es  2.  Manage  their  wards  well  and  deliver  on  the  TQC  ward  governance  principles  3.  Connect  the  various  opera>onal  teams  &  staff  that  u>lise  the  ward  4.  Meet  the  expecta>ons  set  by  the  Na>onal  Standards    5.  Effec>vely  communicate  and  consult  with  pa>ents  6.  Sponsor  innova>on  at  the  ‘point  of  care’,  and  spread  innova>on  to  other  areas  7.  Consider  and  evaluate  ward  prac>ce    8.  Build  an  improvement  culture  and  ward  leadership  capability    9.  Engage  in  interdisciplinary  research  and  translate  research  into  prac>ce  

Wards  are  governed  by  an  interdisciplinary  team  which  take  responsibility  for  improving  the  pa8ent  experience  and  consistency  of  prac8ce    on  the  ward.  They  are  the  point  of  connec8on  for  the  organiza8on  to  the  wards  and  for  the  ward  staff  to  the    organisa8on  

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Ward Teams Radiology Pathology Pharmacy

Community and

Ambulatory Services

Outpatients

13

Business Services

Building  Leadership  Capability  across  Alfred  Health  

Theatres E&TC, ED & HITH

Developing our Leaders • Role Based programs- 2013-2015 • Outline role expectations and links to strategic directions

–  Unit Heads first - greatest need –  Nurse Managers- shared framework and empower –  Lead (business services)-often ignored –  Associate Nurse Managers –our daily leaders and future

leaders Next step –  Allied Health – and system transformation Shift to Team/Interdisciplinary focus ( integrated with ward

governance project)

Develop great leaders Build a common view and expectations of leaders, common language and framework. Develop strategic thinking, build and deepen relationships with peers, test ideas, problem solve. Unit Heads and Nurse Managers

3 domains – Self leadership – Team leadership – System leadership

Program DESIGN Prework – conversations and testing 3 day off site program – Start with the person, shift between team and system thinking – CEO, CFO, COO in conversation – Leader from outside – Mindfulness/resilience

Title Unit of measure

Legend Legend Legend Legend

Legend Legend Legend

PRELIMINARY Legend Legend Legend Legend Legend

1 Footnote

Source: Source 16

Alfred Health’s Theatre Optimisation

Utilisation Reduce the proportion of time when lists are staffed, but not being used. Consolidated across sites. 1

Eliminating first case delay. A late start means a first case’s surgical start after 8:40am for an AM list or after 1:40pm for a PM list

Reduce the time required for each surgical case, by improving faster set-up, parallel processes? Target turnaround time.

On time starts 3

Clinical productivity 4

List construction - lists that are start late or finish early. Creating all day lists vs half day sessions - same unit. Identifying complex cases/overruns

Most cases should turnaround in 15 minutes or less – any turnaround results in unused theatre time

Turnaround

Scheduling 2

5

Scorecards - Utilisation, On time starts, Time out. Block mapping.

Visual Management 6

About us...... 19 OR'S + 2 PR- 3 sites Most Specialities Site 1 - 10 OR's 60:40 Emerg Site 2 - 6+2 Dedicated Elective Site 3 - 3 Community Hospital

Title Unit of measure

Legend Legend Legend Legend

Legend Legend Legend

PRELIMINARY Legend Legend Legend Legend Legend

1 Footnote

Source: Source 17

How are we doing?

Utilisation Target utilisation 85% - May 91% 1

May 76 % of cases commenced on time

Surgeon Preference Card / Surgical Tray and Set up redesign project. Reduction in CSS EFT

On time starts 3

Clinical productivity 4

Reduced 21 sessions inc staff. 13% increase in throughput within scheduled hours across AH Cancellation rate <4%

Turnaround Target achieved for standard cases ICU transfers still need work Turnaround

Scheduling 2

5

Ongoing........ keeping it interesting......maintaining the impact. Visual Management 6

Junior medical Staff involvement - crucial

•  Weekly meeting with Advanced Trainees •  Moving to open meeting with Adv Trainees and all other JMO’s •  Improve the training experience •  Identify issues •  Some Project leadership

Current State

Drug  Chart  re-­‐Writes    Average  No.  Nightly  =  2.5  (Baseline  20/11/12  -­‐>  15/07/13)  =  4.0  

(Baseline  20/09/12  Overnight  Tracking)  =  42    

Medical  Cannula  Inser5ons    Average  No.  Nightly  =  2.4  (Baseline  20/11/12  -­‐>  15/07/13)  =3.6  (Baseline  20/09/12  Overnight  Tracking)  =12  

Medical  Venepunctures    Average  No.  Nightly  =  0.1  (Baseline  20/11/12  -­‐>  15/07/13)  =0.9  (Baseline  20/09/12  Overnight  Tracking)  =5  

Admissions    Average  No.  Nightly  =  17.9  (Baseline  20/11/12  -­‐>  15/07/13)  =  4.8  (Baseline  20/09/12  Overnight  Tracking)  =  2*  *NB:  Admissions  Med  Reg  not  tracked  

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

2009-2010 2010-2011 2011-2012 2012-2013 2013-2014

ICU discharge mortality by time of day

How are we doing ?

Time within the Emergency & Trauma Centre

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep

-14

% E

D P

rese

ntat

ions

< 4

Hou

rs

% ED Patients < 4 Hours Average Lower Control Limit Upper Control Limit

Relative length of Stay

50

55

60

65

70

75

80

85

90

95

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Rel

ativ

e St

ay In

dex

Relative Stay Index (Source: Health Round Table HED)

Relative Stay Index Average Lower Control Limit Upper Control Limit

Safety

0

20

40

60

80

100

120

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Stan

dard

ised

Mor

talit

y R

ate

Standardised Mortality Rate (Source: Health Round Table HED)

Standardised Mortality Rate Average Lower Control Limit Upper Control Limit