PFC 2005 - Medical flow: Patient Flow Collaborative - Victorian Government Health Information, Australia

PFC 2005 - Medical flow

Aim

To remove unnecessary delays, transfers and complexity for patients who are hospitalised.

Change Concepts

Implement six key building blocks for effective length of stay management:

Nurse facilitated discharge
Discharge date and length of stay agreed on admission, and planned at Pre-Op
Medication scripts written on admission for discharge
Delays tracked and managed
Single assessment - develop a single assessment tool which can be used across all assessment stages, build on quality of assessment not on comprehensive multiple assessments
Discharge letter and summary faxed or emailed to GP on discharge (pre-written/automated system)

Review delay days and variance between Expected Date of Discharge and Actual Date of Discharge at ward meetings each changeover of staff until improvement then at regular intervals

Review ward rounds (see rigorous diagnostic process maps)

Re-design to promote daily ward rounds by surgical and medical clinicians early in the day
Establish number of discharges needed per day and at what time of day by division, service, unit and ward
Review whiteboards beginning of day and plan next steps

Grand rounds with managers and clinicians to be performed weekly

Ward rounds to be process mapped by ward staff to highlight areas for improvement, namely processes, communication channels and procedures

Predict admission rates and discharge rates, providing each specialty team with actual numbers of admissions and discharges per day

Integrate performance schedules into each specialty with monthly targets

Authorise Resident or registrars to discharge all day every day

Pharmacy, Pathology and Radiology given daily lists of inpatients waiting tests (traffic light tool) reviewed daily as a minimum and prioritised linked to a scheduling system

Community care providers engaged at earliest point in admission process to promote planning for transfer, contact with GP on admission

Nurse initiated assessment for community transfer

Nurse training course for Intravenous Antibiotics and rehydration therapy available for community and mental health services hospital in the home

Pharmacy services redesigned to accept electronic prescriptions via email or fax

Tracking system that shows capacity and demand for pharmacy service

Implement medication reconciliation

Develop long stay action team to progress potential problems with patient's experience/prolonged care

Implement lead person on each ward to champion discharge and length of stay planning - ownership by all staff on unit

Implement lead nurse to train all front line staff in effective management of patients stay and how to progress delays

Identify as an organisation key recurrent 'real' delays and progress to executive team

Implement Multidisciplinary team meetings as needed, no fixed formula for this multidisciplinary team should be flexible to meet needs of patients admitted

Develop nursing structure to promote 'pull' systems for length of stay management.

Strong nurse lead to review length of stay daily
Nurse trainer to work with frontline staff to empower them to deal with delays
Each ward to have length of stay champion
Each ward to have trouble shooting guide for management of delays in patients length of stay
'Safety valve' procedure for management of bad news, terminal or at risk
Patients to be agreed with all wards to provide time for patients needs

Regular meetings and communication to GPs, community care providers and nursing homes for example daily email, fax weekly summary of inpatient transfers

Allied health staff to be provided with priority patient lists each day and to be allocated to a specialty or specialist area to escalate discharge process, single referral to allied health

Flex staff and wards to incorporate closing wards or opening as medi hotels

Agree admission criteria for community care and sub acute services

Agree 7-day week admissions with community/subacute

Trouble shoot hotline for subacute for after hours to prevent readmissions

Develop single referral, assessment and transfer documents between community, subacute and acute services

Implement discharge/admissions area and track usage

Target discharge time for patients to go home that is suitable to patient and hospital needs

Develop nurse champion to liaise with nursing homes and residential care managers

Develop Chronic Disease management team

Inpatient to meet out patient chronic disease team
Training in condition management before patient leaves hospital started at earliest point of inpatient care
Chronic disease management service, manage care from day of discharge

Patients who have been flagged as concern for re-admission by nursing team telephoned within six hours of discharge to check transfer to home and tracked

List of contacts given in handbook or on PC to ward staff of community services

Afternoon or evening discharge round done by nurse and registrar to make sure all expected discharges are completed

Direct Admission to medical team via medical registrar or consultant instead of emergency attendance via phone call or protocol

Effective bed management

Bed management policy to be agreed
Bed management to be a 24/7 activity by bed managers or night staff
Escalation policy to incorporate progression (red amber green) with actions and responsibilities
Bed management meetings to be daily via conference calls with all wards
Simple system for identifying bed numbers to be available i.e. 1) bed occupied 2) bed being cleaned 3) bed available
Bed managers to progress grand rounds
Bed managers to hand over between morning, evening, night responsibility to next bed manager

Rapid response cleaning team available each day to be called by bed manager if a ward can not turn round an available empty used bed

Escalation policy to include bed availability that must be available after 5.30pm

Overall capacity and demand for inpatients to be carried out reduction in variation of admission to be targeted

Smoothing of variation of elective admissions to be progressed once emergency variation mapped

Seasonal variation to be predicted and management systems in place four weeks before large seasonal change

Daily monitoring of long stay patients (those over 10 days) by senior multi-disciplinary team including hospital management

Junior medical staff (or nurses) routinely given conditional authority to discharge patients if specific test results are normal

Hospital provides transport home for patients if they are able to care for themselves at home and would otherwise occupy an inpatient bed

Patients and families informed of approximate discharge time by 8pm on the evening prior to discharge

Lower acuity 'swing beds' available for patients awaiting transfer to post-acute facilities

Bed management system showing real time occupancy with estimated arrival and waiting times of incoming patients and expected departure times of current patients

Monitor proportion of beds made available within one hour of the discharged patient physically leaving the bed

Centrally monitor number of beds available for occupancy at all times

Review time and mechanism ward/unit receive routine tests needed to ensure discharge

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Key Change Principles

Implement system that monitors steps in process and tracks delays

Develop integrated medical service between primary and secondary care teams

Manage resources to provide right patient, right place, right time, right resource, right staff member

Program Measures

Average Admissions & Discharges by day of week (Bar chart)

Length of Stay - Total/Medical/Surgical/Other (Pareto chart)

Number of Unplanned Readmissions within 28 days by day (SPC chart)

Example Case Study Measures

Average Admissions & Discharges by day of week (Bar chart)

Elective v Emergency
Medical v Surgical

Daily Admissions and Discharges by Elective/Emergency (SPC charts)

LOS by Day of Admission (Bar for year sample)

HDM Monitoring

Provides complete monitoring of health services for monthly/quarterly and 6-monthly KPI/KRA performance, with comparisons to targets (where applicable) and the previous year

Includes a mixture of provisional data provided by health services and data from ESIS/VEMD/VAED

Encompasses ED processes, Elective Surgery Services, ICU/CCU, Patient Flow and Exit Block indicators

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Resources