Improving Patient Flow John Ash

Director of Patient Flow

www.qualitysummit.ca

#QS14

Faculty/Presenter DisclosureFaculty: [John Ash ]

Relationships with commercial interest: • Not Applicable

Disclosure of Commercial SupportPotential for Conflict(s) of Interest: • Allscripts Patient Flow will be discussed as a part of this presentation.

Allscripts Patient Flow was purchased by E-Health Saskatchewan, and is being implemented by multiple regions across the province as directed by the province.

Mitigating Potential Bias• The approach discussed was established based on literature review and best

practice.

• The approach discussed has been adopted by the provincial Hoshin on ED waits and Flow.

Regina Qu'Appelle Health Region

Under the medium growth scenario the City of Regina would grow at a rate of 2,500 people per year exceeding 226,500 in 2020 and 258,000 in 2035.

In the last 14 years the overall population that RQHR serves has grown 2.7 per. However people 85 years old and older have doubled.

2009 to 20013 Saskatchewan's population grew more than 80,000

1. Regina Qu'Appelle Health Region, Health Status Report, 2010 POPULATION, EMPLOYMENT AND ECONOMIC ANALYSIS OF REGINA June 2010

The Problem : Population Growth +

242,827 245,784

246,877

243,767

246,889

252,366 253,809

266,386

230000

235000

240000

245000

250000

255000

260000

265000

270000

2003 2004 2005 2006 2007 2008 2009 2010

Co

ve

re

d P

op

ula

tio

n

Regina Qu'Appelle Health Region Covered Population

2003-2010

The Problem : Unhealthy Population +

High saturated fat & high sugar diets, smoking, recreational drug use, alcohol use, lack of exercise are pre cursors for chronic disease

• 35% of 18y/o over population overweight (BMI 25% or greater)

• 21.5% of 18y/o over population obese (BMI > 30) *70% of the burden of illness and injury is attributable to chronic disease.

1.2010 RQHR Health Status Report

The Problem : Increasing Demand =

RQHR ER visits have increased 15.1% and admissions from the ER have increased 13.9% over past 5 years

RQHR EMS transports to ER have risen 15% over the past 5 years

Demand for urban LTC, Convalescence beds and Homecare spaces and support has increased

= Poor Patient FlowSummary 2012/13

Regina Qu'Appelle Health Region: Occupancy 120-130% Admitted ED patients awaiting IP bed

Pasqua and Regina General combined norm: 20-25 Peak 60+

Use of overflow ER space 2012-2013: monthly occurrence Use of hallways for inpatient care: 9 designated spots ED Admission decision to placement in IP bed (Wave Time):

30+ hours

Effective patient flow is achieved by providing safe quality care to the patient without delays or waste.

Environmental scan highlighted leading practices: IHI, Advisory Board International, and other health jurisdictions including Fraser Health, Australia, UK, Germany.

….Finding A Solution

Primary Care

Acute Care

Community Care

RQHR: First Steps

Dedicating patient flow as area of focus: Resources/Structure Centralized bed management supported by clear business workflows,

policies, and integrated technology Allscripts Patient Flow Software implementation & business process

redesign Real Time Demand Capacity Management (RTDC)

Governance structure, standard work, and accountability framework for patient flow: Everyone's responsibility

Develop a Long-term strategy based on best practice

From – To

Primary Care

Acute Care

Community Care

Making a Long Term Plan to Long Term Problem

• Understanding and identifying opportunities through data & value stream mapping

• Initial focus - in hospital - to improve ER overcrowding, achieve surgical targets & reduce over-capacity

• Long term – full patient journey

The Solution = A Strategic Approach to Patient Flow

Care Planning

Patients are involved with care team and contribute to the development and delivery of their care plan/timeline

Care plans and discharge planning are considered standard work & patients are well informed / prepared for discharge

Short Term Initiatives: RQHR RPIW’s: Physician communication of Target Discharge Date (TDD) and

Care Plan; Multidisciplinary rounds Provincial RPIW: Repatriation Clinical Pathway development: RQHR and Province

Governance

Standard work for leaders at all levels specific to patient flow – respond quickly & effectively to patient flow issues

Short Term Initiatives: Establish Department of Patient Flow Establish Patient Flow Senior Leadership Steering Committee (medical /

administrative), Operational Leadership Team (Service Line Dyads and KOTs) Defined Roles and Accountabilities for Senior Leaders and Managers Implement Real Time Demand Capacity (RTDC) roles & responsibilities for:

• AM/PM unit huddles• Bed meetings• Multidisciplinary rounds

Standard Work

Standard work is imbedded in the organization & leaders hold themselves & teams accountable

Core business clearly understood by staff and quality standards for each service line

Short Term Initiatives: Finalize standard work for:

• Multidisciplinary team meetings• Unit huddles / bed meetings• Bed management

Revise policy / procedure for use of OCP beds Develop system level capacity response framework

to replace OCP

Load Leveling

System demand is leveled where possible – surgical & clinic (i.e. Endo) targets are achieved with increased throughput while limiting overall system disruption

Operating room case complexity is factored into booking process

Short Term Initiatives: Surgery Slate Leveling Assessment of Outpatient Clinic Admission Patterns LOS targets

Demand & Capacity Planning

System Capacity Response Framework with adjustments made to address recurring capacity demand mismatches

Short Term Initiatives: Establish capacity response framework based on unit level escalation

triggers Develop tools to predict demand a week in advance – for frontline unit

managers / charge nurses Create additional bed spaces through bed reallocation; short stay surgical

and medical units; convalescent beds

Escalation

Negative capacity identified and mitigated ahead of time to limit impact.

Unpredicted demand managed through interim plans at unit level.

Short Term Initiatives: Implement RTDC standard work including:

• Unit level capacity plans to manage demand capacity mismatches in conjunction with physician & physician leaders

• Review of unit level plans to identify system barriers• System response to address system barriers

Implement unit level demand capacity plans linked to system capacity response framework

Quality and Safety

Patient, staff safety and quality patient care at the core of every decision. Zero defects. Zero unplanned readmissions.

Patient, Staff and Physician engagement are supported by patient outcomes to drive system change.

Short Term Initiatives: Current Lean activity – Mistake Proofing & RPIWs Improve bed management processes to limit patient movement through:

• Allscripts Patient Flow Software• Bed management/allocation process review

A best practice and literature review has highlighted a “systems approach” will result in sustainable improvement to overall patient flow

RQHR has integrated the findings of best practice into the development and implementation of its patient flow strategic framework

Annual work plan Integration with lean activity

Summary

Reduced Admit No Bed #’s: Combined norm 10-16 Periods of zero ANB

Reduce System Wide Occupancy 92%-98% norm Improved Wave Time: 6-8 hours All 9 IP hallway beds permanently closed Infrequent use of ED overflow space ER Overcrowding: Seen as system issue Cooperative culture to managing occupancy Improved accountability and visibility

Outcomes

Framework adopted by the provincial Hoshin : ED Waits and Flow.

Outcomes

Questions

Questions?Contact Me:

John Ash Regina Qu'Appelle Health Region,

Director of Patient Flow john.ash@rqhealth.ca

www.qualitysummit.ca

#QS14