Patient Flow Study: Maximizing Capacity to Meet Acute Care Service Demands. Janet Templeton BN MN Elizabeth Kennedy BN MN

Transcription

1 Patient Flow Study: Maximizing Capacity to Meet Acute Care Service Demands Janet Templeton BN MN Elizabeth Kennedy BN MN

2 Overview Background Planning Implementation Project Management Challenges and Lessons Learned Conclusion

3 Eastern Health RHA Largest healthcare organization in NL (>1 billion) Over 12,000 employees Catchment area of over 290,000 Tertiary services to province Full continuum of services offered in over 80 sites - acute care, cancer care, mental health, long term care, and community based services Over 2 million ambulatory care encounters per year

4 Background Where we were Completed a review of services as former HCCSJ in 2002 Implemented many changes Evidence in CIHI/Hay comparative studies supporting successes Unable to move forward to achieve further successes Frustration being experienced at points of entry, transfer and exit by health care team Engaged physician leaders within program leadership teams

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6 Efficiencies achieved City Hospitals (HAY /CIHI comparison ) Indicators HAY Review 2001 Canada 2001 HAY /CIHI 2007 Canada 2007 LOS days Cost per weighted case dollars 2,713 2,095 3,421 3,421 ED worked hours per visit Worked Hour per med/surg day

7 Opportunities for Improvement Indicators HAY Review 2001 Canada 2001 HAY/CIHI 2007 Canada 2007 Ambulatory Care Sensitive Conditions (rate) NA NA Potential days saved for LOS improvements (%) ALC Days - percentage

8 Human Resource Planning More than 30 occupations have critical HR planning challenges 20 of these groups have targeted recruitment and retention strategies in place Includes nurses, allied health professionals, diagnostics, skills trades and managers Almost 30% of EH s workforce are RNs RN labour market nationally and internationally is fiercely competitive

9 Age demographic EH region Patients Age Distribution City Hospitals V o l u m e >85 Age

10 Population Health Indicators Population Health Status EH NL Canada Self Reported Disease Conditions yrs 65yrs yrs 65yrs+ EH NL Can Arthritis Asthma BMI (score 30+) Diabetes Leisure time/ Physical Activity High BP

11 Bed Reduction Profile After the 2002 HAY reduced beds from 1054 to the current level of approximately 971 operated beds. A reduction of 83 beds in the city hospitals. Operating on average 978 beds Beds In Operation City Hospitals Beds Year Beds

12 Occupancy Rates High volume high demand service should be at 85% (IHI) Critical Care areas should be at 75% (IHI) Medicine is 97%, Surgery is 93% and Critical care is 84% These are crisis management numbers Occupancy Rate by Program City Hospitals Medicine Surgery Cardiology Critical Care Mental Health CHP/WHP Rehab 2005/ / /08

13 Why an 85 % Occupancy rate? Optimal care comes when the right patient is receiving right care at right time in the right setting Requires flexibility to meet the demand for service Need to have the ability to respond to unpredictable demands for service Ability to unclog bottlenecks in system-operating in crisis mode

14 ALC needs ALC patients take up 66 bed equivalents in the city hospitals but in: Medicine 18% or 34 beds Surgery 13% or 24 beds ALC By Category End Of Life Care Transfer to LTC Consulted Rehab Discharge Planning Other reasons Waiting other Hospital Community Resources / /08

15 Hospitals of St. John's Adult Surgery Priority Performance Summary Report Priority I II III IV V VI Target Time Frame Surgery in 1week (e.g. AAA) Surgery in 1-3 weeks (e.g. Cancer surgery Bladder, Breast, Bowel) Surgery in 3-6 weeks (TURBT, Discectomy) Surgery in 6wks-3 months (Urology procedure) Surgery in 3-6 mos (Joint replacement, Cataracts, Hernias, Lap Choly, elective CABG) Surgery in 6-12 mos (Breast Reduction) Completed cases within recommended time frame (%)

16 Hospitals of St. John's Adult Surgery Priority Performance Summary Report Priority Target Time Frame Completed cases within recommended time Patient waiting beyond target Timeframe I Surgery in 1week (e.g. AAA) 87% 91% II Surgery in 1-3 weeks (e.g. Cancer surgery Bladder, Breast, Bowel) 57% 70% III Surgery in 3-6 weeks (TURBT, Discectomy) 55% 73% IV Surgery in 6wks-3 mos (Urology procedure) 59% 67% V Surgery in 3-6 mos (Joint replacement, Cataracts, Hernias, Lap Choly) 90% 42% VI Surgery in 6-12 mos (Breast Reduction, 77% 56%

17 Cardiac Surgery Example Cardiac Surgery Wait List January February March April 2008 Number waiting Surgeries Completed

18 Waiting time to move from the ED to an Inpatient Bed Patient flow impeded with high occupancy Patients wait from 3.0 to 6.3 hours on average to move to their inpatient bed Patient safety issue Wait Time for Admitted Patients to Transfers to an IP Bed 7 6 Hours SCM HSC Expon. (HSC)

19 Issues and Symptoms of the Problems Recruitment Challenges Occupancy Rates WT for surgery ALC indicators Wait time in the ED for admitted Population profile

20 Solutions/ Recommendations Short Term (1-6 months) Service reduction for summer 2008 Initiate international recruitment Implement attendance management program Implement new collective bargaining models* Competitive salaries and associated benefits* Competitive recruitment packages*

21 Solutions/ Recommendations Short Term (1-6 months) Conduct an operational review for patient flow Fully implement electronic appropriateness of admission screening tool (MCAP review process) Utilizing Personal Care Homes for short term increased level of care (e.g. for convalescent care)*

22 Solutions/ Recommendations Medium Term (6-18 Months) Increase enrollment of nurses* Increase supply of select Health Care providers* Skill mix review in community and acute care

23 Solutions/ Recommendations Medium Term (6-18 Months) Enhance home care/ home support resources* Enhance rehab services in LTC, regional facilities and community* Set priorities and move forward with LTC redevelopment plan* Establish incentives to work in LTC and Rural areas*

24 Long Term Solution / Recommendations Population health needs based human resource plan Develop provincial health services plan* Undertake long term planning for infrastructure requirements* Allocate budget by evidence not crisis management*

25 Background In mid 2008, Eastern Health determined a need to study patient flow through their city hospitals (SCM 220 beds & GH 356 beds) The objective was to improve access and overall patient care processes from entry into the system through to discharge In March 2009, a study was commissioned in partnership with Siemens Global Solutions Healthcare Consulting to help identify opportunities for improvement and to achieve further efficiencies across the system

26 Implementation 22 Reports delivered (+ Summary Report) Current state views, assessments and recommendations for all clinical and support departments Based on extensive interviews with front line staff and management and a review and evaluation of existing processes and documentation Over 160 employees interviewed across the organization Recommendations validated by Management

27 Implementation Sometimes the implementation may seen insurmountable Or have some holes in the process But..

28 Getting Started Diving into it Steering Committee Executive sponsor Project sponsor Project management expert Change management strategy Other support

29 Project Structure Executive Sponsor Senior VP Patient Flow Recommendations Steering Committee Chair: Senior VP Members: 3 VP: Medical, Medicine/ER, and Critical Care/Surgical; Clinical Efficiency PD and Clinical Chief R&D Lead Jennifer Penney Project Sponsor Liz Kennedy Project Manager Justyna Waclawek Resource Group Management Engineering Research/Knowledge Transfer Clinical Efficiency Decision Support Quality DI Working Group Xxx, co-chairs ER Working Group Xxx, co-chair (s) OR Working Group Xxx, co-chair (s) C/ CC Working Group co-chair (s) In-Patient Working Group Xxx, co-chair (s)

30 Steering Committee Responsibilities High Level Demonstrate continued support and commitment Maintain up to date knowledge of project status and activities to ensure presentation of a united front when communicating Project Level Approve project approach and plan Validate key messaging for all stakeholders Assist with managing the resistors Establish accountability and monitor compliance in achieving recommendations in the designated time frame Approve implementation of high priority recommendations that require additional funding.

31 Steering Committee Approval Process High priority level recommendations requiring additional funding will be presented to the SC for approval prior to proceeding with implementation planning.

32 Project Manager PM Dedicated full time resource Responsibilities Approach Develop and lead the execution of the project plan to meet deliverables Providing status reporting, Manage operational and strategic risks, issues and resolutions Facilitate working sessions and disseminate related findings / results Standardized documentation Quick turn-around times Relationship building Consistent messaging Two-way communication

33 Research and Development Support R & D Lead 80% Dedicated to the Patient Flow Project Experience leading projects designed to support evidence informed practice Responsibilities Literature reviews Data collection and analysis Chart reviews/audits Evaluation Development and monitoring of Key Performance Indicators Cross Dept. Liaison Administrative support to the working groups.

34 Implementation Scope and Objectives Phase I - Planning Develop project plan and documentation Engage appropriate stakeholders Review recommendations and classify by implementation ease and priority level Assign responsibility Phase II - Implementation Determine implementation approach Determine implementation timelines Facilitate implementation Phase I Planning/ Classification March-June 2010 Timelines Phase II Implementation May 2010

35 Implementation OR Pre-Admission OR Bookings Day Surgery, OR, PACU Physicians, DI, Lab, Booking Clerk Physicians, Administrative, Wait Time Clerk Booking Clerks Inpatient Units, Portering Housekeeping, Pharmacy, Physicians

36 Getting Started be adventurous Change is constant and affects the entire organization. Change brings with it chaos and stress which must be acknowledged and dealt with in order to make the organization effective.

37 Change Management Change Management Phases Prepare for Change Align and Engage Stakeholders Integrate and Maintain Changes Approach rooted in CM Best Practices Early and sustained engagement Two-way communication Members of all areas across the Dept., including administrative staff, technicians, clinicians and management Review to be performed by staff directly impacted by recommendations Opportunity to make additional recommendations Opportunity to cross-reference with other Depts./Programs Obtain stakeholder support and buy-in Mitigate resistance to change outcomes Ensure that the changes are sustainable

38 Communications The Communication Plan will provide an overall approach and tactical plan for effectively communicating the activities and status updates to stakeholders objectives Identify: Audiences that need to receive communications Audience specific key messages Communication vehicles (e.g. method and/or format) Strategic communication scheduling /sequencing of messages Ensure Messages and Delivery methods are: Targeted, relevant, timely, consistent, informative and effective Ensure the communication process is: Aligned with the project plan Continuously evaluated for ongoing improvements and adjustments outcomes Awareness of the Patient Flow Study Recommendations Implementation Project Understanding of the objectives, goals and benefits of project Regular updates throughout the transition process

39 Working Group Success Getting Started Provide constant communication in the organization Acknowledge, appreciate, and understand different work cultures Provide ample support throughout the change process to make the transition easier for staff Acknowledge, address, and seriously consider external forces affecting the organization under change (nursing shortages) Choose the right people

40 Getting Started Choosing the Group: Theoretical Framework Diffusion of Innovation Theory Innovators Early Adopters Early Majority Late Majority Laggards

41 Getting Started Diffusion of Innovation Theory Knowledge Persuasion Decision Implementation Confirmation

42 Getting Started Model: Plan, Do, Study, Act (PDSA) 1. Plan objectives, data, indicators. 2. Do implement. 3. Study evaluate, summarize, reflect. 4. Act continue, revise, refine, and monitor.

43 Project Plan Project Kick-off SC Kick-off SC Approval SC Approval SC Approval SC Approval Project Planning 22 weeks weeks Working group Chair(s) Meetings 8 weeks Phase I Working group Kick-Off Meetings 10 weeks Recommendations Review and Classification 12 weeks Phase II Implementation x weeks WEEK Monthly Steering Committee Meetings

44 Classification Process Recommendations will be reviewed, classified and tracked using the Status Sheet

45 Project Status Overall Project Status Deliverables Key stakeholders identified and engaged Program Directors and Clinical Chiefs Support Departments Corporate communications IM/IT Key project documents developed and validated with stakeholders Recommendation Classification Status Sheets Kick-Off Presentations Project Status Reporting Project status reported monthly to the Steering Committee On track Associated issues have been identified and managed Associated issues have been identified and mitigation plans are pending

46 Working Group Progress Map Chairs Identified Chairs Meeting Working Group Kick-Off Classification Meeting 1 Classification Meeting 2 Class. Meet 3 Critical Care Diagnostic Imaging In-Patient Units Emergency Department Long Term Care Ambulatory Clinic Services Operating Rooms Health Info. Services and Informatics Environmental Services Mgmt. Engineering Palliative care Pharmacy Physiotherapy Portering Technology Laboratory Rehab Program

47 Challenges Engagement Validation Data errors Scope of Project Time constraints Culture change status quo, we ve heard this before.

48 Lessons Learned Include resources required for implementation in original budget Project lead Potential cost of recommendations Develop communication plan Clearer expectations of outcome and recommendations more specific

49 What Went Well Navigating through difficult waters Executive Sponsor Data validation process ownership! Resource Group Co-Chairs

50 Next Steps Evaluation Plan within working groups and entire project Prioritize recommendations that have budgetary implications Maintain change Celebrate successes