European Care Pathways Conference 2013

Transcription

1 European Care Pathways Conference 2013 Peter O Neill Director π 3 Solutions Senior Lecturer, Department of Management, Monash University, Australia Ian Gibson Director π 3 Solutions Jo Egan Director π 3 Solutions

2 Improve bed management and patient flow within the acute and sub acute services and the interface between the services.

3 Major health system with approximately 1,000 beds in acute, sub-acute and mental health services. Internationally recognised teaching hospital. Vital statistics approximately 100,000 inpatient admissions 200,000 specialist outpatients clinic attendances 80,000 allied health outpatient clinic attendances 70,000 emergency department attendances

4 One major acute hospital providing a range of specialist services is supported by two major sub acute hospitals. Three sites began as separate hospitals now operate as part of an integrated health service Acute services facing long delays in transfer to subacute while there was a perception that beds at subacute are not always full. In fact they were. Subacute services includes: Geriatric assessment and management Rehabilitation, under or over 65 Spinal Fast Track Stroke

5 Victorian Health Priorities framework ( ) outlines radical changes to the delivery of health. Key directions for improvement include: improving patient flow through the health system improving hospital service quality and safety clinical and hospital administration and best practice. Subacute services must change and adapt to satisfy the consumers if this framework is to be delivered effectively.

6 Overall ranking Quality of care Access Efficiency Equity Long healthy lives Health expenditure per capita (US$) Netherlands $3,837 UK $2,992 Australia $3,357 Germany $3,588 NZ $2,454 Canada $3,895 USA $7,290 Source: Davis K, Schoen C, and Stremikis K, June 2010, Mirror, Mirror on the Wall: How the Performance of the U.S. Health care System Compares Internationally, 2010 Update, The Commonwealth Fund.

7 Case study use complex real world situations for investigate complex operational issues in customising cellular delivery of services. Interviews with 12 key managers responsible for the patient flow. Process mapping Quantitative analysis Discrete event simulation

8 Changes in population and acuity have not been matched with changes in services models. Possible issues with process of transferring and / or mismatch of demand and capacity. System is very complex and struggles to run smoothly due to the varying dynamics of the acute and subacute services. Bed movements are predominately reactive based on day to day service pressures or patient needs. Dysfunctional systems leads to tension between the staff at the variou sites and blame culture.

9 Inpatients referral by Specialist Triage by Care Coordinator Geriatric Evaluation and Management Stream as inpatient Waiting List for Geriatric Evaluation and Management Aged Care Registrar assessment Family or aged residential placement Aged Care Assessment & Waiting List of Aged Residential Care Return to Home or Aged Residential Care

10 Analysis of time from decision to refer to Sub Acute Admission Mean 5.4 days Maximum 31 days Admission delays up to 31 days

11 Analysis of Sub Acute Length of Stay for Aged Care with / without Catastrophe Mean 21 days Maximum 120 days Length of stay up to 120 days

12 Operation research modelling and analysis methodology used in many sectors for over 40 years. Enables understanding and evaluation of options to improve of complex systems i.e. Forecasting the impact of changes in clinical pathways on patient flow Estimating the space, staffing and equipment needed to deliver services Understanding the impact of changes in clinical pathways on patient flow

13 Discrete event simulation 2005 Study by US Institutes of Medicine and Engineering identified DES as a method appropriate for improving health care. Source: Build a better health care systems: A new engineering-healthcare partnership survey of papers on DES in health care concluded DES offers perhaps the most powerful and intuitive tool for the analysis and improvement of complex health care systems. Source: Jacobson, Sheldon H., Hall, Shane N. and Swisher James R 2006, Chapter 8 Discrete-Event Simulation of Health Care Systems Patient Flow: Reducing Delay in Healthcare Delivery Springer

14 Analysis of complex and dynamic systems Interactions between variable demand, resources available, operational rule & clinical requirements when they change with time Available of resources Changes of technology, regulation or practice Testing of options for improvement to the operational system is difficult or impossible Develop collaborative whole system view by stakeholders Quick analysis - analyse 12 months operations in minutes Communicate how system will work Animation, metrics and visualisation Design of new systems or analysis of performance of existing systems

15 Variable demand Process based on clinical pathways and resource requirements Metrics of the performance of the system Variable staffing and spaces Histograms of resource use by shift

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17 7/08/2013 Group Urgency Disposition Age Estimated demand Admitted Admitted Admitted Admitted Admitted Admitted Admitted Admitted , Admitted , Admitted Admitted , Admitted , Admitted , Admitted , Admitted 85+ 2, Admitted Admitted , Admitted , Admitted , Admitted 85+ 2, Admitted All Not Admitted All Not Admitted Not Admitted , Not Admitted , Not Admitted Not Admitted Not Admitted , Not Admitted , Not Admitted , Not Admitted , Not Admitted Not Admitted , Not Admitted , Not Admitted , Not Admitted , Not Admitted 85+ 1, Not Admitted , Not Admitted All 9, Did not w ait All - 41 Isolation Admitted All Mental Health Admitted All 1,071 Total ED attendance 107,837 17

18 Acute

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20 DES study shows proposed changes would save 5,400 beds days per annum

21 Volumes in the acute services are higher than sub acute improvement in acute would provide greatest benefit. Top 6 DRGs have 10% of admissions and 20% of LOS If investigations or overnight medical cover is required patients must remain in the acute as sub acute sites do not provide these services.

22 Triage 30% do not lead to admissions Variability in referrals from 220 to 280 per month Assessment Multiple assessments waste staff time and cause delays Process Variation in process time from decision to refer to actual admission average wait of 5 days, range of 1 to 29 days Acute care Simplifying and standardising the referral process. Process improvement for the high volume DRGS based on clinical pathways can improve the system capacity.. Overnight medical cover is needed at all sub acute sites given the acuity of patients.

23 Centralise and standardise referral and decision making Investigate root cause of high volumes of referrals not leading to admission Improve functionality of e- referral system Simplify referrals of Aged Care patients Improve communications between acute and sub acute staff Improve pathways for four high volume DRGS Rationalise Aged Care Assessment and Social Work Assessments Rationalise referrals to sub acute sites Improve pathways for rehabilitation with or without catastrophe Re-classify wards as generic aged care and rehabilitation

24 Pathways Process People Inspire Integrate Improve π 3 Solutions People People Pathways developed with simulation Inspire Inspire Integrate Integrate Improve Improve Process Process Improvement Improvement

25 We cannot solve our problems with the same thinking we used when we created them. - Albert Einstein