improving provincial waiting time: hip and knee arthroplasty
DESCRIPTION
Alberta Health ServicesTRANSCRIPT
1 1
Taming of the Queue
March 29, 2012
Improving provincial waiting time for
Hip & Knee Arthroplasty through reduction in LOS
Jane Squire Howden
Co-Chair, Provincial Hip & Knee Working Group
Bone & Joint Strategic Clinical Network
2 2
What have we done?
Developed a quality improvement approach
that is being used to ensure evidence based care
continuum implemented in 12 arthroplasty
sites across Alberta to reduce wait times and
Improve Quality
3 3
Spread the Integrated Care Path across Alberta
Target improvements in:
√ Efficiency: Length of stay
√ Accessibility: Waiting times
√ Safety: Adverse events; surgical safety checklist
√ Appropriateness: Patient mobilization; antibiotics
√ Acceptability: Patient satisfaction
√ Effectiveness: Pain control; on-time first case
setup
4 4
• Quarter over quarter improvement in LOS
oFrom 6.4 days (F08/09) to 5.1 days (F10/11 Q4)
• Reductions in both acute care LOS and transfer LOS
• 8000 actual bed days have been saved combined
with an increased volume of 901 cases province wide
• Projected bed days saved for F11/12 – 11500
• Improvements in accessibility, acceptability, safety,
• Effectiveness, efficiency & appropriateness
Measurable Progress June 2010 – May 2011
5
Physician A
Agency F
Physician W Primary Care Group
Service 467
Service 311
For Profit Rehab.
Agency Y
Public Rehab
Service 222
Service 1
Service 179
OLD: Patient Navigation Path
6 6
Hip and Knee Care – History
• Alberta Health Services and Alberta Bone, Joint Health
Institute and Alberta Orthopedic Surgeons developed an
evidence-based Hip and Knee Replacement Continuum
• Pilot project to test the continuum was 2005 – 2006
• Edmonton, Calgary, and Red Deer implemented the
continuum
• Continuum implementation spread to all sites that are
doing Hip and Knee Replacements
• Provincial Hip and Knee Working Group provide
leadership
7
NEW: Integrated Hip & Knee Care Path
Multi-faceted Systematic Evidence-based
Increased Community Care
Community Care Hospital Care
8
• Fully implement the Integrated Care Path
• To improve waiting time for Hip & Knee
Arthroplasty
• Improvement in Length of Stay across
province
• To improve Quality and Safety indicators in
each site
• Eliminate waste & reinvest savings
Goal
9 9
Measure Performance
10 10
A step toward sustainability
eliminate waste and reinvest to improve
16000
bed days
$12 000 000
11 11
Spread the Integrated Hip and Knee Care
Path Across Alberta
Balanced Scorecard
Monitors Improvement
B A S E L I N E
12
It’s all about the “How”
13
Process
• The use of a collaborative model to:
o engage 12 hip and knee arthroplasty front line teams
Alberta-wide
o develop and implement a quality improvement
scorecard & plans to achieve a targeted goal
o support evaluation and ongoing monitoring of
improvement indicators
• Team leads report progress monthly to the Provincial Hip
and Knee Working Group
• Face to face meetings 2 x’s per year with all team
members province-wide
14 14
Providers are the secret to sustainability
Engage and support providers as they are the solution
What front line providers know:
ohow ‘it really works and doesn’t work’ - they treat the
people
owhat is practical ‘on the ground’
The front line providers are: RN’s Surgeons, Anesthetist,
Internal Medicine, Occupational Therapy, Physical Therapy,
anyone that works directly with the patient.
15 15
Providers are the secret to sustainability
Engage and support providers as they are the solution
What front line providers may not think about:
oProviders’ individual decisions actually drive total
access, quality and cost of ‘the system’
oThere is a ‘continuum of care’ that is connected.
oWhat happens in one part affects all parts up and
downstream
oTeams are essential – within and across the continuum
oTeams working with data can drive major improvements
16 16
Using Measurement in Quality Improvement
17
First steps to managing Wait times
The Bone & Joint Clinical Network worked with ABJHI to develop 5
year strategic plan to address wait times & achieve 14 week waiting
time targets.
• Determined one set of Wait Times Rules - what is being measuring
and how will it be measured starting with Family Doctor referral
• Transparency – all arthroplasty surgeons in the province provided
ABJHI with waiting time data so that “true demand” could be
captured
• Waiting list clean up – methods to achieve this consistently across
province
• Modelling to manage pent up demand (backlog), then steady state
requirements to meet demand across province.
18 18
Keys to Success
• Use of bottom-up approach more successful vs.
top-down approach
• Multidisciplinary team participation & buy in.
• All team members have the same “authority” in
decision making
• Evidence based decision making
19 19
• Front-line staff determined improvement
strategies to meet the target
• Look across the continuum of care
• A small change can have a big impact
• Data is the basis for all decisions.
• This is not a research project, the data does
not have to be perfect to be usable.
Keys to Success
20 20
Keys to Success
• Regular meetings that require teams to report on
activity.
• No judgment, support the teams to achieve
goals through sharing successes and ideas to
resolve challenges.
21 21
Length of Stay
Efficiency Results
Average length of stay based on administrative data
22 22
Mobilization Day 0
Appropriateness Results
“Mobilization Day 0” - patient weight-bearing at bedside with assistance and use of aids on day of surgery.
Mobilization Day 0 not tracked for 3 of 11 sites
23 23
Wait time from Referral to Surgery (T0 – T2)
Accessibility Results
0
50
100
150
200
250
300
350
400
450
500
Alberta 1 2 3 4 5 6 7 8 9 10 11
Days
Sites
Current
Baseline
T0-T1 Wait Times data collected from surgeon office or central intake clinic data sets
T1-T2 Wait Times data from administrative data sources
24 24
5-Year Plan to Reduce Waits
South
Calgary
Central
Edmonton
North
0
10
20
30
40
50
60
Baseline F2011/12 F2012/13 F2013/14 F2014/15 F2015/16
90
% W
ait
Tim
e (
Wee
ks
)
14 Weeks from
Decision to Surgery
25 25
• From June 2010 to October 2011 11,384 acute care bed days
were saved, equating to over $8.5 million dollars to be
reinvested
• In 2011/12, nearly 1300 additional arthroplasty cases where
completed to assist in reducing wait times. 80% of patients are
now meeting the wait time target compared to 65% in 2010/11.
• Final goal of 90% of patients having their surgery completed in
14 weeks by 2015/16 is on track.
Measurable Progress
