Transcript Document

“Making the front door work!”
Mark Poulden
Lead Consultant in Emergency Medicine
Andrew Carruthers
Directorate Manager Medicine
ABM University NHS Trust
COMPETING DEMANDS & TARGETS
Emergency
Department
95% 4 hour
Reduce LOS
Evidence
based clinical
effectiveness
Reduce
emergency
admissions
Waiting time
IP/OP/DC
ED Saphte
scores within
acceptible
limits
Achieve
EWTD
targets
Reduce
DTOCs
Reduce
cancellations
due to lack of
bed
Financial
Stability
Where do we start?
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Remember the patient
We work hard and don’t succeed
We don’t work together
It feels like a mammoth
task…..so do nothing
New approach to team-work
What do you do – can it be done
differently
How Did it start?
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2.
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4.
5.
6.
Accept that 95% was hospital (system) not ED
target.
Realisation that it should drive/derive from
better patient care.
Streaming patients in the hospital as well as at
the front door – learning and sharing things
previously thought of as separate!
Form following function – processes changed
before the geographical change – do not wait
until the new build
A leap of faith that this could work WITHIN
current recurrent resources – it would
otherwise never have been done
Along came WECAC…………..
Bro Morgannwg Emergency Services
Transformation (BEST) programme:
Ingredients for success
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Strong, enthusiastic clinical leadership
Supported and driven by committed management
team
Executive champion
Mapping processes/pathways: identifying
constraints, delays, duplication
Focus – determine what will make a difference,
not what may be interesting…….
Use information/tools/techniques/evaluation
Learn from others/share good practice
Small step changes (PDSA cycles), Theory of
constraints, LEAN methodology etc.
Key Diagnostic Work
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Process Mapping
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7 day ED analysis
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From September 2004 – over 5000 individual breaches
analysed
In patient flow analysis
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August 2004 – yielded limited information
Breach analysis
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Key elements of process mapped during August / Sept
February 2005 – helped understand admission / discharge
gap
In patient ‘snapshot’ audit
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May 2005 – helped understand issues associated with
clinician review, diagnostic delays and discharge planning
Collaborative approach
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Model for
improvement
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Specific aims
Measurement –
where are the
problems?
What will lead to
improvement?
Ask why? - all the
time
Plan-Do-Study-Act
cycle
Simple things
Incremental change
Improvement
Success factors
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Streaming
Frontload Decision
Makers
Clinical Pathways
Some easy wins
Access to diagnostics
Clinically driven IM&T
Minimise Duplication
Joined up working
Continual Processing
Bed management
Discharge planning
Bringing Together Individual PDSA’s
January 'Perfect Week' comparisons
Daily percentage - month run chart
100.00
'Perfect week'
95.00
91.06%
90.00
85.53%
85.00
80.00
75.00
70.00
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Monthly av. daily attendance (POW)
170
165
160
2000
155
2001
150
2002
145
2003
140
2004
135
2005
130
125
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Monthly % compliance (POW)
100
98
96
2000
94
92
90
88
86
2001
84
82
80
2005
2002
2003
2004
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Princess of Wales
Emergency Department
Reception Sieve & Sort
Self presenting patient books in at reception
Reception staff stream patient according to following
YES
Print card in BRATZ
Give red card
Send to BRATZ
YES
Print card in BRATZ
Give orange card
Send to BRATZ
YES
Print card in minors
Give green card
Send to minors
YES
Print card in minors
Advise patient to sit in main
wait
Give advice leaflet
NO
Does patient have active chest pain
NO
Is patient adult with any of following:GP referred major
Short of breath
Collapse
Abdominal pain
Self Harm
Pain requiring analgesia
Causing concern
Not on minors criteria
NO
Is patient under 5 year old
Or
Any child NOT on BDM criteria
Or
Any chemical eye injury
Or
Any minor injury with ongoing bleeding,
pain requiring analgesia, or any deformity
Barn Door Minor – ALL OF
Walked in
Definite history of injury
Injury to limb or face
Only one body part affected
Patient comfortable
OR
Obvious primary care complaint
Early Success – Minors Streaming
Weekends
60
14
50
12
No. of Patients
Before
No. of Patients
Weekdays
40
30
20
10
10
8
6
4
2
0
0
<1 hr
1-2hrs
2-3hrs
3-4hrs
4-5hrs
>5hrs
<1hr
1-2hrs
3-4hrs
4-5hrs
>5hrs
4-5hrs
>5hrs
Waiting Time
80
30
70
60
25
No. of Patients
After
No. of Patients
Waiting Time
2-3hrs
50
40
30
20
20
15
10
5
10
0
0
<1hr
1-2hrs
2-3hrs
3-4hrs
Waiting Time
4-5hrs
>5hrs
<1hr
1-2hrs
2-3hrs
3-4hrs
Waiting Time
BRATZ
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Triage removed
Team
All patients for assessment
Assessment
Initiate treatment
Initiate Investigations (Recipe Book)
Who can see
Where can go
BRATZ Issues……..
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Big investment
Safer
Increase use of XR
Difficult
How much time
24/7
Peak times
Consultant & middle grade shortages
Traditional Patient Pathway
Arrive & Book in
Triage
Emergency Dept SHO
Have a think
Do some tests
Consultant Discharge
Do take homes
Results available
Take homes ready
Specialty Tests
Transfer to “ology” ward
Have a think
Refer to Specialty
Can go home
Care package cancelled
Serum rhubarb
Plan “senior review”
Seen by consultant “ologist”
Seen by Specialty SpR
Refer to “ologist”
Decision to Admit
Seen by on call consultant
Transfer to MAU
Process
Segregated Silo
Working
Uniform Efficient
Collaborative Team
Clinical Pathways - Duplication
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High Impact (numbers/problems/evidence)
Multi-specialty
Diagnostic support
Beware “best fit”
Documentation from front door
Pooled juniors – 1st one completes
Added value at each step
New Patient Pathway
Arrive & Book in & streamed to appropriate area/service
Discharge as planned
Active bed management
Care Pathway with EDD
Discharge planned inc TTH & care
Senior decision maker plans care
“Prescribed” investigations
Seen by appropriate team
Team “dooer”
Transfer to appropriate bed
Process developments……
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Generic doctors or doctors with
generic skills?
Clerking quality
Teamwork vs work avoidance
Clinical responsibility (senior &
junior)
Communication with primary care
Rapid Diagnostics
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Access to diagnostics where
decisions can be made on admission
and discharge
Access to urgent out patient tests
Dedicated slots each day for previous
days admissions
Access to tests 7 days a week
IM&T PDM (Patient Duration Monitor)
What PDM has delivered
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Introduced data entry as part of
clinical process
Real time view of department status
Visual aid to pre-empt potential
breaches
Patient whereabouts
Clinical usefulness
And demonstrated potential…
PIMS+: Using technology as a tool
to improve clinical processes
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Traffic light concept
Live view of Inpatients by:
• ward
• expected date of discharge (EDD)
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Driven by simple, easy to use ADT
functions
Helping to manage the discharge process
Managing beds in a live environment
The potential to use live information to
streamline other processes
IM&T next steps……..
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Dependance
Accuracy & timeliness
Confidentiality
ETOC – time/rapid enough
Stepwise EPR or wait???
Clinically useful vs beancounting
Bed Management
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Bed finding
Critical level of
occupancy
Forecasting tools
(ADT matching)
Real time bed
monitoring
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Not just
walking the
wards
Trend of Patient Attendance
Patient Numbers
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1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Discharges
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Ward rounds/discharge decisions
7days a week
Discharge planning from day 1 (pull
rather than push)
Pharmacy
Discharge lounges
Early social care involvement
Discharge facilitators
In hospital process…….
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Nurse facilitated
Weekend/OOH plan
Specialist nurse (DN, Resp, Card)
Patient to ward vs doctor to patient
Specialist vs generalist
Tertiary transfers
Elderly Care PDSA / NH Ward
rounds?
Processes had to be in place BEFORE
building work started – to compensate
for the loss of space/facilities
Clinical Decision Units
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No size fits all (28 beds/trolleys?)
Personalities
Agreed clinical pathways
Rapid turnover - Continual “processing”
Multispecialty including ED
Joined up working
24hrs / 7 days a week / 365 days a year
Location & Design
“By defining the top 10 presenting symptoms and
developing pathways most hospitals could improve the
care of 80-90% of their emergency admissions”
Ambulatory
48 Hr
24 Hr
4 Hr
Minors
CDU next steps…
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CDU size
Suffers from effectiveness
Ineffective when inappropriate
Ambulatory evolution
Role of ACP vs OCP
Knock on effect on ward (LOS &
dependency)
Capacity Issues – bed occupancy
Midday Bed Occupancy - Princess of Wales Hospital
All Acute Specialties, exl. Paediatrics and Obstetrics
April to November 2003
Average % Occupied
Beds - 95%
Occupance Level as
recommended by the All
Wales Capacity Working
Group - 85%
01
/0
4/
20
03
15
/0
4/
20
03
29
/0
4/
20
03
13
/0
5/
20
03
27
/0
5/
20
03
10
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6/
20
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24
/0
6/
20
03
08
/0
7/
20
03
22
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7/
20
03
05
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8/
20
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19
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8/
20
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02
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30
/0
9/
20
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14
/1
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20
03
28
/1
0/
20
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1/
20
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25
/1
1/
20
03
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
% Occupied Beds
% Empty Beds
g0
O 4
ct
-0
4
Pe Dec
rfe -0
ct 4
w
ee
M k
ar
-0
Pe
M 5
rfe ay
ct
fo 05
rtn
ig
A u ht
g0
O 5
ct
-0
D 5
ec
-0
Fe 5
b0
Ap 6
r-0
Ju 6
n0
Au 6
g0
O 6
ct
-0
D 6
ec
-0
Fe 6
C
DU b
O 07
pe
ni
ng
Au
Percentage
95% target…
Results Against Compliance Target
100%
95%
90%
85%
80%
92%
Nov
2008
75%
70%
Timescale
What’s worked for us
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No single factor responsible for improvements
• Combined impact of multiple changes to processes including:
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Changes to ED working
• PDM – live information / breach prevention
• Sieve and Sort / See and Treat
• Majors assessment
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Changes to Acute Assessment processes
• Acute Care Physician
• ED interface improvements
• Improvements in diagnostics and discharge
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Changes to inpatient flow management
• PIMS+
• Estimated dates of discharge
• Transfer teams / discharge pull
Resource Issues
Effective resources?
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Clinical engagement and lead from the start – involving
several Directorates;
High profile Executive input and robust senior management
leads;
Process issues addressed – detail (e.g. when Trop T
taken/analysed) and staffing (identifying when required);
Empowering staff and encouraging PDSA cycles – have a go!
Reorganisation of job plans, leading to introduction of 2nd
Acute Care Physician;
Reorganisation of Directorate structures to improve
communication and remove any perceived barriers
Streaming – senior presence at extended triage, ambulatory
streams, 24 and 48 hour areas, and also ward based working
Availability of “live” data – after breach takes place is too late!
Changes to geographical layout – bringing three separate
areas together
Analyse impact – daily, weekly and monthly information –
keep on top of things!
Cannot be seen in isolation……..
Hawthorne Effect
 Sustainability
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(March madness)
Knock on effects
 Generalisation
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Challenges for DECS
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Consistent initial assessment &
streaming
pathway.
Realistic configuration of all UCS –
safe, sustainable & clinically effective
vs politically driven.
Balanced capacity.
Suitable & timely services for an
ageing population.