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

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Patient Flow Collaborative II - Outpatients

Patient Flow Collaborative 2005

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PFC 2005 - Surgical flow

Aim

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

Change Concepts

Implement seven 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
- Delays tracked and managed
- Written protocol used across episode of care for all patients
- Discharge letter and summary faxed or emailed to GP on discharge
- GP advised on admission
Review delay days and variance between Expected Date of Discharge and Actual Date of Discharge at ward meetings daily, weekly
Review ward rounds (see rigorous diagnostic process maps)
- Re-design to promote daily ward rounds by surgical and medical clinicians
- Establish number of discharges needed per day and at what time relevant to operating capacity
- Review ward white boards at beginning of day and action plan
Review admissions following public holidays, major events, school holidays, conference weeks etc. Day Case patients to be booked for operations following public holidays allowing inpatient build up to be managed
Grand rounds with managers and clinicians to be performed weekly to progress management issues
Ward rounds to be process mapped by ward staff effectively to highlight areas for improvement, namely processes, communication channels and procedures
Predict admission rates and discharge rates providing each specialty team with actual numbers per day
Integrate performance schedules into each specialty with monthly targets
Resident or registrars with authority to discharge all day every day
Medical referral for complex patients, pre-operative with co-management during inpatient stay, i.e. fluid/blood/meds etc.
ICU handover protocols
MET team calls
Handover promoted flexibility between ward and theatre
Pharmacy, Pathology and Radiology give daily lists of inpatients waiting tests (traffic light tool)
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Community care providers engaged at earliest point in admission process to promote planning for transfer
Nurse initiated assessment for community transfer
Nurse training course for Intravenous Antibiotics and rehydration therapy available for community and mental health services
Pharmacy services redesigned to accept electronic prescriptions via email or fax
Tracking system that shows capacity and demand for pharmacy service
Develop long stay action team to progress potential problems with patient's experience
Implement lead person on each ward to champion discharge and length of stay planning but ownership by all
Implement lead nurse to train all front line staff in effective management of patient's 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 with needs of patients admitted
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
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
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/medi hotels
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
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 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 surgical team via bed management process, surgical registrar or consultant instead of emergency department attendance
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 at least six weeks before large seasonal change
Link beds, theatre
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Key Change Principles

Develop whole process management strategy for elective patients that incorporates out patients, pre operative assessment, queue management, validation, theatre activity and length of stay management
Develop and implement organisational policies

Measures

Program Measures

Patient Journey Time on Waiting List (SPC chart)
Patient Waiting Times for Admitted Patients from Waiting List (Pareto chart)
Hospital Initiated Postponements per 100 Admissions (Line chart)
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)
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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
ESIS Indicators:
- % Elective Cat 1 Admitted within 30 Days
- Total on Waiting list
- Average Cat 2 Waiting Time
- Hospital-Initiated Postponements per 100 Admissions
- % Cat 2 Waiting > 90 Days [QUARTERLY]
- Number of Admissions from the Waiting List
- Total Elective Separations

HDM Supplementary Data

Hospital performance
- Peer group performance charts
- Bar charts showing how hospitals stack up against each other and time series charts showing how they have performed within their peer groups in recent years.
- Waiting times of admitted patients by hospital. Useful source of procedural level data.
Hospital Exception Reports - From June 2003 onwards
- Provides useful information on where individual hospitals are not meeting demand
Control Report and Supplementary Report
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