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Department of Human Services

ToolkitLength of stay

A toolkit of the Patient Flow Collaborative

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Toolkit Length of stay


Introduction

Goals of the toolkit

Overview and strategy

Health service team

Processes

Data

Resources

Diagnostics and tools

Introduction

What are the aims of the toolkit?

The patient flow collaborative aims to remove unnecessary delays in the patient process, effective management of length of stay is essential to this aim. The toolkit will provide tools, resources and techniques to promote innovation in effective length of stay management.

How should we implement the concepts in the toolkit?

Clinical innovation teams should use the ideas and concepts to promote creativity and discussion for adaptation to local context.

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What is the length of stay management toolkit?

Effective management of the patient, the process and all the resources needed for effective, timely treatment are essential to good patient care. This toolkit has been designed to promote discussion, thinking and innovation in the management of length of stay for our patients.

Who should use this toolkit?

The toolkit is designed to be used by anyone who is responsible for inpatient stays.




Introduction

The length of stay management toolkit is based on whole system thinking and includes a whole of hospital perspective to managing length of stay.

Goals

Specific goals of the toolkit are:

• Provide ideas or solutions to remove length of stay constraints

• Build organisational wide best practice in flow management

• Provide diagnostic tools

• Provide resources to assist with identifying solutions

Feedback

This first version of the toolkit will stimulate further versions containing tools, resources, case studies and good news stories developed by the Patient Flow Collaborative Teams. Feedback is welcome and will be incorporated into the subsequent versions.

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Introduction



Health service team

Processes

Data

Resources


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Effective management of patients length of stay is seen as one of the most important and complex elements to hospital care.

Continuous patient flow building blocks

Individual patient

Unit/team

Organisation

Introduction



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Organisational

Policy organisation wide policy for admission and discharge practice, escalation and bed management policy

Data show organisation length of stay, admissions and discharges

Communication organisational wide knowledge of effective management of length of stay

Organisational building block

Introduction



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Processes

Data

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Unit/team

Unit/Team

Operational processes – processes that are simple and effective

Ownership – all staff team empowered to flow patient to next step

Data – monitoring of length of stay and delays

Leadership – senior leaders who can champion effective and efficient processes

Tracking systems – pull process monitoring

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Individual patient building blocks

Individual patient building blocks

Informed – Information given as soon as possible

Involved – Discussion around process and planning

Empowering – Owning the process, champions who care and process

Introduction



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Tracking length of stay

If you do not have the information you can not manage process at any level.

Simple Access databases can be effective

Introduction



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Tracking length of stay

D e l a y A c t i o n S i m p l e A 4 s h e e t t o r e c o r d d e l a y s a n d t a k e a c t i o n , t h u s p u l l i n g t h e p a t i e n t t o t h e n e x t s t a g e .

D e l a y A c t i o nD e l a y A c t i o n S i m p l e A 4 s h e e t t o r e c o r d d e l a y s a n d t a k e a c t i o n , t h u s p u l l i n g t h e p a t i e n t t o t h e n e x t s t a g e .

P a t i e n t D e l a y r e a s o n

L e e W a i t i n g r a d i o l o g y



D e l a y r e a s o n

A c t i o n t o b e t a k e n

R a d i o l o g y p h o n e r a d i o l o g y m g r

o n e x t : 3 2 5 6



D e l a y r e a s o n

A c t i o n t o b e t a k e n

R a d i o l o g y p h o n e r a d i o l o g y m g r

o n e x t : 3 2 5 6

Simple A4 sheet to record delays and agreed action plans

Introduction



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Health service teamIntroduction

Once an efficient and effective organisational system has been developed to manage length of stay a skilled, trained and dedicated individual/team will be needed to manage the overall system.

Engagement of each individual is essential to manage effective length of stay.

Checklist for effective length of stay

• Whole of organisation strategy

• Clear reporting

• Executive ownership

• Each unit empowered to play their part

• Clear monitoring and data

Roles and responsibilities

•Organisation lead

•Manager within each unit

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Health service teamHealth service team

Clear reporting to health service manager/director of operations with simple escalation policy

Innovations

Develop daily tracking

Develop discharge policy and protocols

Review ward rounds, plans and who discharges

Track patient process, develop action plans and procedures

Issues/constraints

No clear data for all patients

No clear authority to discharge

Waiting for discharge

Waiting for next step

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Processes

Admission Discharge

Review Present Process

• Push system X

• Good data on organisation LOS X

• Multiskilled team to manage LOS X

• Integrated admission/discharge process X

• Monitoring linked to innovation X

• Systematic process X

• Owned by all X

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Processes

Admission Discharge

Identify essential building blocks Tracking

Nurse facilitated discharge

Medication written on admission where possible

Single assessment used by all

Discharge letter and summary faxed or emailed to GP. Build capacity for patients who need extra time as an inpatient.

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Data

Suggested Measures

•Length of Stay – Total/Medical/Surgical/Other (Pareto chart – 80% rule)

•Average length of stay by specialty/procedure (compare to HDM or HRT benchmark figures)

•Average length of stay by day of admission (Bar for year sample)

•Average admissions & discharges by day of week (Bar chart)

• Elective v Emergency

• Medical v Surgical

•Delayed discharges:

• Total delayed patients per week for one year

• Total delayed patients per week expressed as bed days for a year

•Number of patients waiting for transfer to sub-acute split into Rehab/GEM and Residential Care

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

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Resources

Taken from the Patient Flow Collaborative Change Package.

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

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Resources


• 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 speciality 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

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Resources


• Handover promoted flexibility between ward and theatre

• Pharmacy, Pathology and Radiology give daily lists of inpatients waiting tests (traffic light tool)

• 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

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Resources


• 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 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 speciality 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

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Resources


• 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

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ResourcesTaken from the Patient Flow Collaborative Change Package.

• 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

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Resources


• 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 lists and predicted increase in elective (emergency capacity and demand)

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• Tally chart for delays and action plan

• Rigorous diagnostics hand book

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