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Department of Human Services
Patient Flow Collaborative
Lee MartinCollaborative Director
Welcome and overview
House keepingHouse keeping
• Informal – ask lots of questions• Phone/Bleep• Restrooms• Refreshments• Partnership approach• No knows all the answers• Fire alarms
AgendaAgenda
8.45 - 9.00 Welcome and registration
9.00 – 9.30 Overview of day,
9.30 – 10.00 Project Coordinator role and key roles of health service team
10.00 - 10.15 Morning tea
10.15 – 11.30 Introduction to self assessment and questions
Capability building
11.30 – 12.30 Whole system thinking
12.30 – 1.15 Lunch
1.15 – 2.45 What is your behavioural style? What is your learning style?
How do we help others to learn?
2.45 – 3.00 Afternoon tea
3.00 – 4.00 Game: Variation - capacity and demand,
Critical chain project management, reporting/presenting skills
Conference calls, Site visits, Score your team
4.00 – 4.15 Feedback and discussion
AimsAims
• To tackle key constraints in the patient process identified by each health service
• To promote and facilitate the development of service improvement skills within each health service
Patient Flow CollaborativePatient Flow CollaborativeKeyOS Orientation SessionLS Learning SessionC/Call Team Conference Calls
SustainSustain
Patient Flow CollaborativeProject Plan
Feb Apr SeptJulJun
LS25 Oct
Dec
LS38-9Feb
Mar
LS419-21April
2004
Feb
2005
OS2th
April
OctMarJan Apr Jun Jul
LS519 July
Diagnostic phaseTest cycles and implementation Action phase:
Enable spread
HealthImprove-
mentSchool
Embed sustainability and mainstreamTrainingphase
Engage HealthServices
May
LS16 -7July
Celebration
Aug Nov MayJan
Site visitsC/Call
7-11 March
Site visitsC/Call
23-28 May
ActionLearningSession
ActionLearningSession
ActionLearningSession
ActionLearningSession
ActionLearningSession
9 Jun
Site visitsC/Calls
23-27Aug
ActionLearningSession
6 Sep
ActionLearningSession9 Aug
Site VisitsC/Calls3-8 May
Site visitsC/Call 15-
20 Nov
ActionLearningSessionJan 04
ActionLearningSession3rd Dec
Site Visits
Nurse LeadTraining1 April
DataTraining17 Mar
PGMTraining
5 Mar
InnovationAssociates
Training30 Apr
InnovationAssociates
Training29 Oct
ProjectTeam
TrainingDay 1
29 Mar
MainstreamAction Plan
Report
InnovationAssociates
Training29 Apr
ProjectTeam
TrainingDay 227 Apr
ExecutiveTeam
Training31 Mar
Key componentsKey components
• Rigorous diagnostics
• Innovations
• Spread and Sustain
• Mainstream
Learning ProgramLearning Program
• Master classes• Self assessment• Learning sessions• Mentors• Action learning sets• Change package
Partnerships HDM and CIAPartnerships HDM and CIA
Assistance
• Strategic Workforce Planning• Nurse Policy Unit• Planning Group from field• Health Services
Health Service StructureHealth Service Structure
Executive team
Clinical
team Clinical
team Clinical
team
MethodologyMethodology
• Breakthrough Collaborative
• Whole system improvement
• Constraints theory
• Adult learning principles
Expectations Health serviceExpectations Health service
• Sampling data• Engaging health service at all levels• Report to the website monthly• Learning sessions & Conference calls• Spread and sustainability of innovation• Embed innovations approach within
the organisation
Expectations HDM/CIAExpectations HDM/CIA
• Improvement skills training• Diagnostics• Data – SPC’s• Action learning sets• Master class series education• Networks of innovation• Spread of innovation• Site visits
Internal Communications Internal Communications strategystrategy
• To assist unfreezing
• Spread motivation
• Raise morale
• Increase public confidence
• Increase staff pride
RisksRisks
• NO Executive commitment
• Too big too soon
• Rigorous diagnostics not completed properly
• Human dynamics of change not processed
• No Project Coordination
• Lack of organisational readiness
Questions
Department of Human Services
Coordinators Role
Coordinators roleCoordinators role
• Discussion around what is the key roles for the project coordinator and your experience of doing this
Partnerships for changePartnerships for change “I think that people are trying to tackle initiatives too low in the organisation .…
you need a damn good project manager, a strong chief executive
and a strong lead clinician” Site visit comment
The partnership of these groups will provide a effective, dynamic team
Team levelTeam level
Executive team
Clinical
team Clinical
team Clinical
team
Questions
Department of Human Services
Self assessment
Project coordinator self Project coordinator self assessmentassessment
Learning ProgramLearning Program
• Learning sessions• Action learning sets• Self Assessment• Change Package• Mentors• Master classes
AimsAims
• To tackle key constraints in the patient process identified by each health service
• To promote and facilitate the development of service improvement skills within each health service
Self assessment formsSelf assessment forms
Questions
Department of Human Services
Capacity and Demand
Lee MartinCollaborative Director
Department of Human Services
An elephant is like a brush
An elephant is like a rope
An elephant is like a snakeAn elephant is
soft and mushy An elephant is like a tree trunk
GP Acute
Sub acute
Residential
Ambulanceattends
ED
Elective
HomeDeaths
Transfers
HomeDeaths
Transfers
Whole system health care
EquilibriumEquilibrium
EvaporationRiver flows in
River flows outWater level stays the same
Activity
Did Not AttendCancellationsDeaths
Demand
Queue keeps utilisation 100%Queue keeps utilisation 100%
EvaporationRiver flows in
River flows outWater level stays the same
Activity
Did Not AttendCancellationsDeaths
Demand
Manchester HIP Crash 230103 KS© 2002 Crown copyright
Variation mismatch = queue
time
Demand Capacity
Queue
Can’t pass unused capacity forward to next week
Sources of variationSources of variation
Demand• numbers of patients presenting• clinical conditionCapacity• number of practitioners• time available• Equipment etc
Moment of truthMoment of truth
• Even if average demand = average capacity
then• variation in demand
– + variation in capacity = queue !
• is system causing queue?
1. Demand > capacity1. Demand > capacity
Time
waiting numbersIf Demand
> Activity or Capacity
Rare situationCommon belief
Effect of variation on flowEffect of variation on flow
1 2 3 4 5
Carve out results in churnCarve out results in churn
Demand
Capacityactivity
Bottleneck
Sick patients do not go away - they get sicker
Capacity carve out: specialisationCapacity carve out: specialisation
Demand
Bottleneck
CapacityHands
Heads
Legs
Feet
Backs
Arms
Number of specialists432Su
rgeo
n 1
432Phys
icia
n 1
5 Rad
iolo
gist
Number of appointmenttypes
urgentsoon
routine
routine
urgent soon
Flexi-sig
Colonoscopy
ERCP
OGD
routine
urgent soon
The size of the carve out
x
x
x
x
x
x
x x
x
x
x
x
x
x x
xx
x
xx xxx
x
x xxx
xxxxx xx
xx
xx
x xx
xxxxx xx xxxx
xx x xxx
xx
xx
x
xxxx
x
xx
xx
73 queues
Carve out: 2 & 3 careCarve out: 2 & 3 care
Clinic
LaserClinic
Research
ClinicTheatre
TheatreAdmin
Paedsclinic
Angios
teaching
SoonRoutine
Follow
SoonRoutine
SoonRoutine
Follow
SoonRoutine
Follow
Urgent Urgent Urgent Urgent Urgent
SoonRoutine
Follow
Urgent
SoonRoutine
Follow
Urgent
SoonRoutine
Follow
Urgent
SoonRoutine
Monday Tues Friday Sat SunThursWed
Recognising vicious circleRecognising vicious circle
More beds( & staff)
Less frequent ward rounds More
consultants & staff
More variation
More confusion
LessQuality
Length of stay
Number of admissions
More GPvisits How do we
reverse this ?
More readmit’s
Where should we focus change Where should we focus change effort ?effort ?
• ‘smooth’ elective admissions?• ‘smooth’ all discharges?• reduce length of stay ?• reduce test turnaround times?• improve quality to reduce re-
admissions?• more beds?
• if so, how many?
See “today’s” demand See “today’s” demand “today”“today”
• So we never let the queue get out of hand– set the capacity at 80% of the fluctuation in
demand– flex the capacity to meet the demand
• annualised hours
Advanced access
Where do we get ‘extra’ capacity from?Where do we get ‘extra’ capacity from?
• Map process• re-design process• measure bottleneck
– demand/capacity/activity/backlog
• analyse data - reduce variation• continue to measure and analyse• apply Statistical Process Control (SPC)
Improvement ToolsImprovement Tools
• Process map• Understand data• Reduce complexity• Reduce variation• Reduce carve out• Manage patient flows - pull not push• 80% improvements (Pareto)• Maximise capacity• PDSA• Constraints theory• Lean thinking
Whole system improvement Whole system improvement toolstools
• Structures • Process • Patterns
© Paul E. Plsek
General medical ward round - Monday 28th of April 2003
MAU9.00-9.08 2 patients
Cuckmere ward9.14 - 9.17
1patient
Berwick ward9.17-9.302 patients
Wilmington ward11.23-12.209 patients
Folkington ward10.40-11.156 patients
East Dean ward9.37-10.227 patients
Summary:Duration of ward round = 3 hours and 20 minsWards visited = 6Patients seen = 26
DME post take ward round- Saturday 26th April8.55am MAU
5 patients
10.05am Gardner ward
2patients
10.30am Newington
Ward 1 patient
11.10am CCU
1 Patient
11.00am James Ward
1 patient
10.45am Baird Ward
1 patient
11.20amBenson Ward
1 patient
11.30amMurray ward
1 patient
Back to MAU for 11.50am
Summary:Duration of ward round = 2 hours and 55minutesNumber of patients seen= 13Number of wards visited= 8
% New appointments resulting as DNAs per week April 2001 to February 2003
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
08-A
pr-0
122
-Apr
-01
06-M
ay-0
120
-May
-01
03-J
un-0
117
-Jun
-01
01-J
ul-0
115
-Jul
-01
29-J
ul-0
112
-Aug
-01
26-A
ug-0
109
-Sep
-01
23-S
ep-0
107
-Oct
-01
21-O
ct-0
104
-Nov
-01
18-N
ov-0
102
-Dec
-01
16-D
ec-0
130
-Dec
-01
13-J
an-0
227
-Jan
-02
10-F
eb-0
224
-Feb
-02
10-M
ar-0
224
-Mar
-02
07-A
pr-0
221
-Apr
-02
05-M
ay-0
219
-May
-02
02-J
un-0
216
-Jun
-02
30-J
un-0
214
-Jul
-02
28-J
ul-0
211
-Aug
-02
25-A
ug-0
208
-Sep
-02
22-S
ep-0
206
-Oct
-02
20-O
ct-0
203
-Nov
-02
17-N
ov-0
201
-Dec
-02
15-D
ec-0
229
-Dec
-02
12-J
an-0
326
-Jan
-03
09-F
eb-0
323
-Feb
-03
Week Ending
% N
ew D
NA
s
% New DNAs
Mean =10.8%
UCL =14.9%
LCL =6.6%
Between Apr 01 and Feb 02 Hastings could expect to see between 7% and 15% of new appointments result in a DNA outcome per week with a weekly average of 11%.
From Feb 02 Hastings can expect to see between 6% and 14% of new appointments result in a DNA outcome per week with a weekly average of 10%.
Apr-01 to Jan-02 Feb-02 to Feb-03
9.8%
5.6%
14.0%
Christmas/ New Year 2001
DNA marketing campaignGP surgeries & OPD Feb 2002
Christmas/ New Year 2002
Football World Cup June 2002
Summer holidays
Out Patient services
% Patients waiting over 4 hours in A&E
0%
5%
10%
15%
20%
25%
30%
35%
07-A
pr-0
2
21-A
pr-0
2
05-M
ay-0
2
19-M
ay-0
2
02-J
un-0
2
16-J
un-0
2
30-J
un-0
2
14-J
ul-0
2
28-J
ul-0
2
11-A
ug-0
2
25-A
ug-0
2
08-S
ep-0
2
22-S
ep-0
2
06-O
ct-0
2
20-O
ct-0
2
03-N
ov-0
2
17-N
ov-0
2
01-D
ec-0
2
15-D
ec-0
2
29-D
ec-0
2
12-J
an-0
3
26-J
an-0
3
09-F
eb-0
3
23-F
eb-0
3
09-M
ar-0
3
23-M
ar-0
3
06-A
pr-0
3
20-A
pr-0
3
04-M
ay-0
3
18-M
ay-0
3
01-J
un-0
3
15-J
un-0
3
29-J
un-0
3
13-J
ul-0
3
27-J
ul-0
3
10-A
ug-0
3
24-A
ug-0
3
Week Ending
% W
aiti
ng
Ove
r 4
Ho
urs
% Over 4 Hours
Mean
UCL
LCL
Year End Targets
Between 01 April 2002 and 31 March 2003 8% and 30% of patients attending A&E department could expect to wait more than 4 hours.
The average number of patients waiting over 4 hours per week was 19%
Between 01 April 2003 and 31 August 2003 0% and 12% of patients attending A&E department could expect to wait more than 4 hours.
The average number of patients waiting over 4 hours per week was 6%
Changes in process - dramaticreduction in waiting times
Theory of ConstraintsTheory of Constraints
• Step 1 -Identify the constraint• Step 2 -Exploit the bottleneck• Step 3 -Subordinate everything else to
the bottleneck• Step 4 -Elevate constraint - bring in
extra capacity• Step 5 -Once bottleneck solved, look for
the next bottleneck in the system
Case Study MeasuresCase Study Measures- Inpatient- Inpatient
• Total, Emergency and Elective Admissions (Daily/Weekly Multiple Line chart)
• Daily Admissions and Discharges by Elective/Emergency (SPC charts) • Avg Elective and Emergency LOS by Day of Admission (Bar for year
sample) • Average Inpatient Discharges + Deaths (DOW Stacked Bar for year
sample)
Length of Stay (Total) Length of Stay (Total) - Chart- Chart
80% of patients (excluding sameday) at this hospital had a length of stay between 1 and 8 days with the maximum length of stay at 238 days.
Average LOS by Day of AdmissionAverage LOS by Day of Admission- Chart- Chart
y = x2 – b
f = ma?
“attractor”
Tossing a Rock or a Bird?Tossing a Rock or a Bird?
© 2000 Paul E. Plsek
Transfer the change ideas, not the Transfer the change ideas, not the solutionssolutions
Solution / change in healthcare
organisation A
Change idea Change idea
Solution / change in healthcare
organisation B
A range of restructuring, process and systems redesign, and transformation
Improvement model
Act• what changes are to be made?
• next cycle?
Plan• objective• questions and predictions (why)• plan to carry out the cycle (who, what, where, when)
Study
•complete the analysis of the data
•compare data to predictions
•summarise what was learned Do
• carry out the plan• document problems and unexpected observations• begin analysis of the data
What are we trying to accomplish?How will we know that a change is an improvement?What change can we make that will result in improvement?
Bull whip effectBull whip effect
• increasing demand distortion down process– effect on intermediate care ?– effect on sub-acute?– effect on administration staff ?– effect on primary care ?
Adopter CategorisationAdopter Categorisation
Innovators
EarlyAdopters
EarlyMajority
LateMajority ‘Rear guard’
Source: Rogers
2.5% 13.5% 34% 34% 16%
Process complexity and implementation indexProcess complexity and implementation index
Low Medium HighP
oor
M
ediu
m
S
tron
g Key
Ideal
Possible
Don’t do
Process Complexity IndexIm
plem
enta
tion
Ind
ex
FinancialFinancial improvement matrix improvement matrix
High Medium lowP
oor
M
ediu
m
E
asy Key
Do
2nd stage
Leave
Cost savingIm
plem
enta
tion
tim
esca
le a
nd e
ase
Stories
Primary care – 3 million overspend implemented
one A4 tracking sheet and saved 2,000 per ward per day.
Average older person stay 39 days down to 19 days
Stories
ED – tracking all patients through in 75 minutes average
No category ones, none seen immediately
Staff morale raised, development program in
place covered by Clinical Director
for all staff
Australian Sample Data Surgical Ward
16 days
No clear care plan = 96Awaiting Radiology tests = 53
Not reviewed by home unit = 28No Discharge Plan = 22
Outlier patient not seen by unit yet = 14Late decision to D/C = 10
Awaiting ACAT assessment = 10Awaiting ACAT referral = 9Waiting r/v another unit = 9Waiting for Rehab bed = 9
Department of Human Services
Behavioural and learning styles
What is your styleWhat is your style
Expressive Amiable
Direct Driver Analytical
ExpressiveExpressive
• Verbal• Motivating• Enthusiastic• Gregarious• Convincing• Generous • Influential• Dramatic• Animated
AmiableAmiable
• Patient• Loyal• Sympathetic• Relaxed• Mature• Considerate• Stable• Trusting• Team person
Direct DriverDirect Driver
• Action oriented• Decisive• Problem solver• Direct• Assertive• Risk taker• Competitive• Independent• Determined
AnalystAnalyst
• Controlled• Orderly• Precise• Disciplined• Deliberate• Cautious• Diplomatic• Accurate• Fact finder• Systematic
ExerciseExercise
• Corners of the room are sign posted• Move to the corner of the room that
reflects your style
Positive and Negative Positive and Negative perceptions of Expressiveperceptions of Expressive
• Verbal inspiring• Ambitious• Energetic• Enthusiastic• Confident• Friendly
• Talkers • Overly dramatic• Impulsive• Undisciplined• Excitable• manipulative
How to work with expressive How to work with expressive people betterpeople better
• Tell who first• Be enthusiastic• Allow for fun• Support their creativity• Talk about people and goals• Handle the details for them• Value feelings• Keep fast paced
Positive and Negative Positive and Negative perceptions of Amiableperceptions of Amiable
• Patient• Respectful• Willing• Agreeable• Dependable• Concerned• relaxed
• Hesitant• Wishy washy• Pliant• Conforming• Dependant• Unsure• Laid back
How to work with amiable How to work with amiable people betterpeople better
• Tell why and who first• Ask instead of telling• Draw out their opinions• Explore personal life• Define expectations• Strive for harmony
Positive and Negative Positive and Negative perceptions of Direct Driverperceptions of Direct Driver
• Decisive• Independent• Practical• Determined• Efficient• Assertive• Risk takers• direct
• Pushy• One man/woman
show• Tough• Demanding• Dominating• Insensitive• Cuts corners
How to work with direct How to work with direct driver people betterdriver people better
• Tell what and when first• Keep fast paced• Don’t waste time• Be business like• Give some freedom• Talk results• Find shortcuts
Positive and Negative Positive and Negative perceptions of Analystperceptions of Analyst
• Accurate • Conscientious• Serious• Persistent• organised
• Critical• Picky• Moralistic• Stuffy• stubborn
How to work with analyst How to work with analyst people betterpeople better
• Tell how first• List pros and cons• Be accurate and logical• Provide evidence• Provide deadlines• Give them time, don’t rush or
surprise
Under stressUnder stress
analytical•will withdraw
driver•will become autocratic
amiable•will submit
expressive•will become offensiveor sarcastic
Fears about changeFears about change
analytical•not enough information•making a wrong decision•being forced to decide
driver•loss of control•failure•lack of purpose
amiable•damaged relationships•confrontations•not being recognised for efforts
expressive•being ignored•being asked for detail•being linked with failure
Change and learningChange and learning
Panic Zone•peopleclose up•they freeze•they don’t learn
Comfort Zone•people stay here•they don’t learn
•they don’t change
Discomfort Zone
Change and learningChange and learning
Comfort Zone
PanicZone
•uncertainty•learning
Change learning and comfort: Change learning and comfort: people respond differentlypeople respond differently
• some feel it’s an adventure and are excited and stimulated
• some feel it is a mission or a duty• some feel it is a forced march and are
fearful and cautious• some feel overwhelmed, depressed and
demotivated
Noer’s Response factor modelNoer’s Response factor model
Entrenched
Overwhelmed BSers
Learners
Comfort with change(learning readiness)
Cap
acity
for
chan
ge(a
bilit
y to
lear
n)
highlow
low
high
Noer’s Response factor modelNoer’s Response factor model
Entrenched
Overwhelmed BSers
Learners
Comfort with change(learning readiness)
Cap
acity
for
chan
ge(a
bilit
y to
lear
n)
highlow
low
high
Clings to narrow learnings
Learns and grows
Withdraws and avoids
‘Makes it up’high drive but low
substance
Can apply to individuals, groups, Can apply to individuals, groups, departments, directorates or departments, directorates or organisationsorganisations
Entrenched
Overwhelmed BSers
Learners
comfort with change(learning readiness)
Cap
aci
ty f
or
chan
ge
(abili
ty t
o learn
)
highlow
low
high
Clings to narrow
learnings
Learns and grows
Withdraws and avoids
‘Makes it up’high drive but low substance
Overwhelmed - Overwhelmed - low comfort with low comfort with change, low capacity for changechange, low capacity for change
Withdraws and avoids• avoids confronting real issues• retreats into old patterns that
are perceived as safe• hopes that things get better• engages in passive /
aggressive behaviour• avoids thinking about or
planning for the future
Overwhelmed:Overwhelmed: low comfort with change, low comfort with change, low capacity for changelow capacity for change
How overwhelmed feel• unhappy or depressed• frustrated, anxious, powerless• bruised self esteem• fearful of mistakes and failure• needs approval, reassurance and stability
What is needed• help in coping with stress, fear and frustration• phased transition and success loaded
challenges
Entrenched - Entrenched - low comfort with low comfort with change, high capacity for changechange, high capacity for change
Clings to narrow learning• blames and complains• acknowledges need for
change but resists changing• works harder than ever at
previously successful behaviour
• tries to ride it out until things return to normal
Entrenched:Entrenched: low comfort with low comfort with change, high capacity for changechange, high capacity for change
How entrenched feel• frustrated, anxious, angry• unrealistically confident that past skills are
valid• reluctant to take risks
What is needed• understanding and help in coping with anger
and frustration• phased transition with a bridge from old to
new
BSer - BSer - high comfort with change, low high comfort with change, low capacity for changecapacity for change
‘Makes it up’ - high drive but no substance
• jockeys for positions of influence• presses for quick solutions and
actions• may initially come across as a
beacon in the darkness - ultimately becomes transparent
• often fools superiors
BSers: BSers: high comfort with change, low high comfort with change, low
capacity for changecapacity for change
How BSers feel• comfortable with need for change• compelled to do something - anything!• frustrated with the ‘confused’ and ‘whining’• confident in ability to function in any situation
What is needed • close supervision and close monitoring• assignments which are safe for the
organisation and push the employee
Learner -Learner - high comfort with change, high comfort with change, high capacity for changehigh capacity for change
Learns and grows• finds silver linings behind
dark clouds• finds humour in difficult
situations• is very aware of both
strengths and weaknesses• expands boundaries of their
comfort zone
Learners:Learners: high comfort with change, high high comfort with change, high
capacity for changecapacity for change
How learners feel• comfortable with need for change • challenged, stretched, optimistic• in control of own destiny / positive thinker• not afraid of short term mistakes and setbacks
What is needed • protection, latitude, air time• developmental roles and assignments with
impact• rewards and reinforcements
How leaders can helpHow leaders can help
Entrenched - find ways to let go of old and comfortable and learn skills
Overwhelmed -provide help and support during neutral zone of their transition
BSers - identification (uninformed optimist and the true hard core) and development
Learners - create an organisation to develop, select and preserve learners
Leading your team
Remember to consider your teams behavioural styles:
•Analytical/processing
•Amiable/supporting
•Expressive/enthusiastic
•Driver/controlling
Variation game
Project management
Vs
Critical chain project management
And finally
•Presentations
•Conference calls
•Site visits
•Scoring your team
Team scoring card
Feedback and close
Department of Human Services
Welcome and overview
Rochelle Condon
Patient Flow Collaborative
House keeping
Mobile phones/Bleeps turn to silent
Rest rooms
Fire Alarms
Equipment on table
Agenda
9.00-9.15 Rigorous Diagnostics – How are we going?
10.15-10.30 Morning Tea
10.30-12.00 Working with groups
Project Plans
Constraints Theory
Prioritising Innovations
12.00-12.30 Lunch
Aim of the rigorous diagnostic phase
Overall aims• Identify constraints across the patient journey• Engage key staff in the process ready to
implement change• Find any myths
Rigorous Diagnostic phase
Elements of the diagnostic Elements of the diagnostic packpack
• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative
involvement tools• Innovation intensive tool
Elements of the diagnostic Elements of the diagnostic packpack
• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative
involvement tools• Innovation intensive tool
Program Measures Program Measures
• Patient Journey Time in ED (SPC chart)• Percentage and Number of ED Admissions waiting <12 hrs (SPC chart)• Percentage of ED Throughput <6hrs (SPC chart)• 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 – Medical/Surgical/Other (Pareto chart)• Number of Unplanned Readmissions within 28 days by day (SPC chart)
Patient Patient Journey Time in ED Journey Time in ED - All Presentations Chart (mth)- All Presentations Chart (mth)
Within the month of Nov03 patients presenting to this Emergency Department can expect to have a journey time from arrival to departure between 0 and 1287mins with an average of 356mins.
Percentage of ED Admissions waiting <12 hours Percentage of ED Admissions waiting <12 hours - Chart- Chart
For the period Jul03 to Feb04 between 59% and 86% of ED patients waiting for admission to a ward could expect to wait less than 12hrs.
The average number of patients admitted within 12hrs per week was 73%, with a target of 95%.
Number of ED Admissions waiting <12 hours Number of ED Admissions waiting <12 hours - Chart- Chart
For the period Jul03 to Feb04 between 134 and 252 of ED patients waiting for admission to a ward could expect to wait less than 12hrs.
The average number of patients admitted within 12hrs per week was 193.
Percentage of ED Throughput <6hrs Percentage of ED Throughput <6hrs - Chart- Chart
For the period Jul03 to Feb04 between 59% and 76% of ED patients waiting (I.e. from Arrival datetime to Departure datetime) could expect to wait less than 6hrs.
The average number of patients waiting less than 6hrs per week was 76%, with a goal of 100%.
Patient Journey Time for Admitted Patients Patient Journey Time for Admitted Patients on Waiting Liston Waiting List
- Chart (Cat1)- Chart (Cat1)
Within the month of Jul03 Category 1 Patients admitted from the waiting list could expect to have a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 52days with an average of 19days. Note: Median waiting time would be 13days.
Patient Journey Time for Admitted Patients Patient Journey Time for Admitted Patients on Waiting Liston Waiting List
- Chart (Cat2)- Chart (Cat2)
Within the month of Jul03 Category 2 Patients admitted from the waiting list could expect to have a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 300days with an average of 86days.
Patient Journey Time for Admitted Patients Patient Journey Time for Admitted Patients on Waiting Liston Waiting List
- Chart (Cat3)- Chart (Cat3)
Within the month of Jul03 Category 3 Patients admitted from the waiting list could expect to have a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 883days with an average of 229days.
Patient Waiting Times for Admitted Patients Patient Waiting Times for Admitted Patients from Waiting Listfrom Waiting List
- Chart- Chart
80% of admitted patients from the waiting list for the 02-03 financial year had a total waiting time (i.e. Ready for Care + Not Ready for Care days) between 0 and 103 days with a maximum waiting time of 1504 days.
HHospital Initiated Postponementsospital Initiated Postponements per 100 Admissions per 100 Admissions - Chart- Chart
Hospital Initiated Postponements reporting methodology = The number of cumulated postponements over the entire patient waiting time, reported on the month of admission.
Average Admissions & Discharges by DOW Average Admissions & Discharges by DOW
- Chart- Chart
The highest average admissions for Multiday patients occur on Mon (79), and the highest average discharges occur on Fri (83). The lowest average admissions and discharges very clearly occur on the weekend. These numbers exclude Sameday admissions and discharges.
Length of Stay (Total) Length of Stay (Total) - Chart- Chart
80% of patients (excluding sameday) at this hospital had a length of stay between 1 and 8 days with the maximum length of stay at 238 days.
Length of Stay (Medical) Length of Stay (Medical) - Chart- Chart
80% of patients (excluding sameday) at this hospital had a length of stay between 1 and 7 days with the maximum length of stay at 232 days.
Length of Stay (Surgical) Length of Stay (Surgical) - Chart- Chart
80% of patients (excluding sameday) at this hospital had a length of stay between 1 and 10 days with the maximum length of stay at 238 days.
Length of Stay (Other)Length of Stay (Other)- Chart- Chart
80% of patients (excluding sameday) at this hospital had a length of stay between 1 and 6 days with the maximum length of stay at 67 days.
Number of Unplanned Readmissions within Number of Unplanned Readmissions within 28 days28 days- Chart - Chart
For the period Jul03 to Feb04 we could expect to see between 0 and 39 unplanned readmissions within 28days of discharge.
The average number of patients with an unplanned readmission within 28days is 18
Percentage of ED Admissions waiting <12 hours Percentage of ED Admissions waiting <12 hours - Chart- Chart
For the period Jul03 to Feb04 between 59% and 86% of ED patients waiting for admission to a ward could expect to wait less than 12hrs.
The average number of patients admitted within 12hrs per week was 73%, with a target of 95%.
Elements of the diagnostic Elements of the diagnostic packpack
• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative
involvement tools• Innovation intensive tool
Sampling toolSampling tool
• Two clinical areas minimum• Request staff to identify key delays• Chart delays for each patient each day• Total at end of time period
ExampleExamplePILOT EXAMPLE Example of creation and process of delay tally chart
Surgical ward identified delays total numbers – Example
Day No clear
care plan Awaiting tests: MRI, CT, Bone scans
No planned discharge date
Home unit not reviewed
Boarder- not seen x unit before 0900 bed meeting
Boarder- not seen x unit before 0900 bed meeting
Late decision to discharge
Waiting for assessment
Waiting for ACAT referral
Waiting for rehab bed
Waiting for review by other unit
Waiting acute bed at another hospital
No weekend discharge plan so covering RMO says no
Monday 5 1 3 0 0 0 1 1 0 0 1 0 0
Tuesday 3 3 1 0 2 2 2 0 0 0 0 0 0
Wednesday 11 4 2 1 1 1 1 0 0 1 0 0 0
Thursday 6 3 0 0 1 1 2 0 0 1 2 0 0
Friday 9 4 0 0 1 1 1 0 0 1 1 0 0
Sunday 8 1 0 0 2 2 0 0 0 0 1 0 0
Monday 8 5 0 12 2 2 0 1 0 1 3 0 0
Tuesday 4 6 1 12 1 1 0 0 2 1 1 0 0
Wednesday 11 5 2 0 0 0 0 1 2 0 0 0 0
Thursday 10 2 3 3 1 1 1 1 2 0 0 0 0
Friday 1 3 0 0 0 0 0 1 2 1 0 0 0
Saturday 0 1 0 0 0 0 0 2 1 1 0 0 0
Sunday 6 4 3 0 0 0 0 2 0 0 0 0 0
Monday 2 4 4 0 2 2 1 1 0 1 0 0 0
Tuesday 9 7 3 0 1 1 1 0 0 1 0 0 0
Total 93 53 22 28 14 14 10 10 9 9 9 0 0
Elements of the diagnostic Elements of the diagnostic packpack
• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative
involvement tools• Innovation intensive tool
Brainstorm toolBrainstorm tool
• Brainstorm the delays that effect your patients
Brainstorming toolBrainstorming toolBrainstorm Whole system constraints tool
Order of
constraint
Description of constraint
Effect on majority or
minority of total points
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Key Minority – small number of patients affected Majority – majority of patients affected
Elements of the diagnostic Elements of the diagnostic packpack
• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative
involvement tools• Innovation intensive tool
Process mapping toolProcess mapping tool
Map minimum of two whole system patient journeys
Elective Admission to DischargeEmergency Admission to Discharge
Surgical Process Map Surgical Process Map Fractured Neck of FemurFractured Neck of Femur
85 yr old woman lives aloneDaughter & Son
Home HelpMeals Services
Diabetic (Public patient)
Found by Home Helpin the bathroom
on the floor
Supervisor travelsto the home
location
Ambulance rungby Supervisor
Home HelpContact Supervisor
Surgical Process Map Surgical Process Map Fractured Neck of FemurFractured Neck of Femur
Ambulance Arrives
Triage•Ambulatory Services•Information to Nurses•Assign Category
* Issue
Ambulance flowdirection
Patient transferred intothe ambulance
HospitalEmergency Dept.
Clerical Registrationfrom RELS / PT / AMB running sheet/transfer letter
History & labelsgenerated
History & Labels transported to the cubicle area
Nurses / CC contactrelatives (or patientliaison nurse)
Patient moves toa cubicle
Handover Ambulance Cubicle Nurse Staff
Patient moved from trolley cubicle bed
AMB/ Nurse/ PAC
Medical staffpick up patient
care fromcomputer system
I min
2 min
Medical Officerassigned and Nursingcare commenced
RIV by ED DR& assess – physical
Transported to X-Ray
Bed Managerallocates a bed – contact wardupdated HAS
HAS Request for a bed lodged
Patient have X-RayTaken in Plain Film
Room
X-RayFill in slips
X-Ray slip -manualWalk to slot to queue
Radiographerprioritises requests andassigns categories
Patient transportedBack to ED cubicle
Interim Rx Plan Written
Analgesia andGen. Nurse Careand Relatives in.
Nurse Initiated Analgesia
Commenced IV cann.ECG / Bloods
RIV by careCo-coordinatorNurse Risk assessment
Ward rings Bed Manager.Notifying Bed
available
Ward contact time negotiated to transfer the patient to theward
Referral to receiving Orthopaedic UnitRegistrar
Paged by ED DR
Wait for response
ED DRR/V’s X-Rays
Diagnosisconfirmed# NOF
Control Clerk calls for EDA totransport patientX-Ray
Bloods sent to labsvia centraldistribution area(shute)
BloodsFill in slips
Basic protocol forcare commenced
* Radiographer ring ED/page/loud speaker requestTransport of patient
Policy &Procedures Myths
3½-4 hrs
* myth
ED + /
Theatre process
Patient still waitingFor
Ortho UnitRIV
Clinical Co-coordinator
Arranges EDN to transport patient
Ortho RIVUndertaken
Clinical Co-coordinatorHandovers viaPhone to ward
Exit ChecklistDone by Nurse
Checked byCl. Co-coordinator
Patient R/V’dBy medical
team
Arrives to wardAnd transferred
To bed
Patient preparedFor transferto the ward.
Patient moved to The ward
Notes/X-Ray/ Exit Checklist Ortho Unit
Contact TheatreTo make a booking
Rx Plan written
Histories
Filing
Order
Investigation
Check IV(EDA/NurseTransport)
By who Ward Documentation
And ExpectedL.O.S.
AssessmentNursing•Obs•Anal•Risks
Medical RegistrationAuto. RIV’s
Ortho patients
8-10 hrs
Surgical Process Map Surgical Process Map Fractured Neck of FemurFractured Neck of Femur
48 hrs
52 hrs
Patient transferredto ward
Anaesthetist RIV’spatient night prior
Patient has furthermedical investigations
done to her
Patient consented for theatre
Patient transferredto theatre
Further medicalinvestigations ordered and
done
Ward round every day
Patient waitingtill theatre time
Patient medically fit
Post op care per Care Plan
Discharge planX 2 weekly reviews
Referral sits inTrack officefor Triage
Aged CareRehab
Consultantsdecide
Care Plan
Patient StandbyPhysio
and O.T.
Electronic Referral
To rehab. ByDr.
3-4 days waiting Ref/RIV)
(Rest waits for a bed)
Discharged To Rehab
Ward
Room
10
days – 2
w
eeks
Theatre
Surgical Process Map Surgical Process Map Fractured Neck of FemurFractured Neck of Femur
Elements of the diagnostic Elements of the diagnostic packpack
• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative
involvement tools• Innovation intensive tool
Patient,carer and relative Patient,carer and relative involvementinvolvement
• Small test cycles to gain consumer input
• Use the tools one to one with patients
Elements of the diagnostic Elements of the diagnostic packpack
• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative
involvement tools• Innovation intensive tool
Intensive innovation toolIntensive innovation tool
• Pre-plan 6 weeks in advance• One day event for individual health
service• Book early!• Not needed for completing the rigorous
diagnostic phase
Completion of diagnostic Completion of diagnostic phase phase
• Review all of the 5 tools together and priorities the constraints that are causing the most disruption to the larges patient group.
• Identify the clinical area team that is needed to carry forward the innovations from the diagnostics
Review meetingReview meeting
• Collaborative team wish to be involved • Feedback at the first learning session
Handy hintsHandy hints
• Share the work • Gain as many views as you can• Use this phase to find the constraints
and test assumptions• Enjoy the focus on patient process• Have fun
How are you going?Questions?
Department of Human Services
Morning Tea
Working with GroupsWorking with GroupsAims of the sessionAims of the session
• To help to prepare for group meetings
• Be aware of what facilitation skills to use and when
• Examine your own communication style, and understand personal communication preferences
Think of a group you enjoyed Think of a group you enjoyed and did not enjoyand did not enjoy
A group you enjoyed
What made you enjoy it?
What made you not enjoy it
A group you did not enjoy
In an effective groupIn an effective group
• Clarity• Informal• Everyone participates• Everyone listens• Free expression• Free disagreement• Decisions - consensus
In an in-effective groupIn an in-effective group
• Dominated by few• Never hear ideas, comments• Real agenda lost• No follow up actions
Stages for group Stages for group developmentdevelopment
Forming Storming Norming Performing Adjourning
FORMINGFORMING
• Effort in defining goals• Sizing up• Keep feelings to themselves• Very polite• Aware of boundaries and hierarchies
STORMINGSTORMING
• Questions – who is responsible for what, leadership, goals, directions
• Jockeying for position• Withdrawal – if values not aligned
NORMINGNORMING
• Acceptance• Ground rules are set• Difference is valued• Everyone belongs
PerformingPerforming
• Effective• Efficient• Learning – collective and individual• “Less me – more we”
AdjourningAdjourning
• End of project• Well defined• Mainstreaming plans set• Sustainability of efforts• Mourning/ celebration
FacilitatingFacilitating
EXPLORE ACTION
learning agreementsperspectives decisionsoptionsexperience
What facilitation style?What facilitation style?
• doing nothing
Gentle • silence
Intervention • support
Supportive • questions to clarify
• questions to move
• suggesting choices
Persuasive • suggesting paths
Forceful • sharing ideas
Intervention • suggesting actions Directive • guidance
• choosing for the group • directing
Communication StylesCommunication Styles
• Adapt and flex your style• What is your style?• Over to you!
SummarySummary
• A snapshot of working with groups• Key players • Be aware of human dimensions• Future Learning Sessions &
communications
Project Plans 5-11
Apr12-18Apr
19-25Apr
26-2Apr/May
3-9May
10-16May
17-23May
24-30May
31-6Jun
7-13Jun
14-20Jun
21-27Jun
Process mapping
Sample data
Patient carer involvement
Brainstorm session
Review program measures
Book site visit with CIA team
Display for Learning session 6/7 July 2004
Presentation for Learning Session 6/7 July 2004
Organisational Rigorous Organisational Rigorous DiagnosticsDiagnostics
Step 1
Step 2
Step 3
Step 5
Case Study – constraint data
Clinical area- diagnostics and innovation
Back to the Beginning
Organisational wide- diagnostics
Clinical Stream data
Step 4
Process complexity and implementation indexProcess complexity and implementation index
Low Medium HighP
oor
M
ediu
m
S
tron
g Key
Ideal
Possible
Don’t do
Process Complexity IndexIm
plem
enta
tion
Ind
ex
FinancialFinancial improvement matrix improvement matrix
High Medium lowP
oor
M
ediu
m
E
asy Key
Do
2nd stage
Leave
Cost savingIm
plem
enta
tion
tim
esca
le a
nd e
ase
Theory of ConstraintsTheory of Constraints
• Step 1 -Identify the constraint• Step 2 -Exploit the bottleneck• Step 3 -Subordinate everything else
to the bottleneck• Step 4 -Elevate constraint - bring in
extra capacity• Step 5 -Once bottleneck solved, look
for the next bottleneck in the system
Model for ImprovementModel for Improvement
Act Plan
Study Do
What are we trying to accomplish?
How will we know that a change is improvement?
What change can we make that will result in
improvement?
Adopter CategorisationAdopter Categorisation
Innovators
EarlyAdopters
EarlyMajority
LateMajority ‘Rear guard’
Source: Rogers
2.5% 13.5% 34% 34% 16%
Questions?