nicola ryan, royal perth hospital - improving the journey – paasport to better outcomes
DESCRIPTION
Nicola Ryan, Senior Project Officer – Clinical Service Redesign, Royal Perth Hospital delivered this presentation at the Clinical Redesign & Process Mapping conference. This conference provides case studies of succesful redesign projects to assist delegates in identifying the root causes of issues impacting patient journeys and then develop and implement sustainable change processes to improve the way health care is delivered. Find out more at www.healthcareconferences.com.au/clinicalredesign13TRANSCRIPT
PAASPORT TO BETTER OUTCOMES
• Nicola Ryan, Senior Project Officer
• Dr. Gavin Teague, HOD Anaesthesia, Project Lead
• Professor Krishna Boddu, Service Director,
Executive Sponsor
Improving the Patient
Journey
Key Drivers for Change at RPH
• Universal Drivers
• State and National Health Reform & Targets
• Clinical Services Plan
• National accreditation
• Activity Based Funding/ Management
Identify stakeholders
Sub- group: Pre Operative Assessment
Leader: Gavin Teague/Simon Wall/Penny
Toomey
Governance:
Reports to the Elective Patient Journey Task
Force who in turn report to START
KPI’s:
· Cancellations
· DNA’s
· Number of visits pre op
· Number of investigations requested?
· Number of referrals to other specialties?
Desirables:
· Establish multidisciplinary clinic assessment
for high risk pts
· Pathways for referrals
· Review rostering of anaesthetists – buddied to
specialty teams - same anaesthetist in theatre
reviews pt in clinic?
Issues identified from previous
redesign projects
0
10
20
30
40
50
60
Request for WaitlistRegistration
Pre – Admission Journey
Admission Theatre Post – operation care & discharge
Frequency of Issues
Journey Location of Issues
RPH Elective Surgery Patient Issues by Journey Group Mapping from 2009 redesign project
RPH Pre-admission Assessment
Service (PAAS) • Located adjacent to RPH
• Currently assesses all elective surgical patients for
• Orthopaedics
• Plastics
• Urology
• Vascular
• General Surgery
• Booked admissions
• Limited capacity for walk ins
• 2 anaesthetists; 1 clinical nurse; 2 registered nurses; 1
preadmission clerk
• 30 patients a day on average
• Runs a high risk assessment clinic (2 afternoons a week)
Clinic and Pre-operative
Assessment • Inconsistent booking
practices; potential for loss
of documentation
• Complex patients were not
identified early in the
process
• Patients not “Ready for
Care” at end of PAAS
• No triage process
• Short lead in time for
patient assessment and
optimisation
• Poor medication advice
Project Aims
• Patients having a seamless surgical
experience
• Enhanced satisfaction of patients/
families and staff
• Reduction in cancelled cases and
waiting times
• Impart redesign and change
management skills to hospital staff
• Improve data collection practices
• Continuous monitoring of KPIs
Choosing a methodology
Courtesy of Hannah
Moss and Sam Green
DOH Western Australia
How to choose
methodologies when faced
with a choice?
• Suitability of methodology to
problem
• Available resources
• Need for data
Using the DMAIC Process
• Process Mapping
• Voice of the staff
• Voice of the patient
• Voice of the organization
Challenges of Engagement
WE HAVE ALREADY DONE THIS!
NOT MORE FOUR HOUR RULE!
RESOURCES
YOU CAN’T CHANGE THE
CULTURE!
IT WON’T WORK
NOTHING WILL
CHANGE
I THINK WE DO
A GREAT JOB!
I see you are doing the
important work
When
do I find
time to
do
this???
Challenges of Engagement
Defining the problem
We engaged over 100 stakeholders from across
the hospital through participation in:
5 Process Mapping sessions
Numerous 1:1 discussions
2 Root-Cause-Analysis sessions
We logged 89 issues,
10 root causes and delay reasons
We also asked our patients what they
thought of the Pre-Admission process
Define - Process Map for
Preadmission
Themes Arising from Mapping
• PAAS appointments <2 weeks prior to DOS resulted in
increased cancellation rates on DOS
RPH: Time from seen in PAAS to Day of Surgery
Measure - What is the Problem?
This line
represents the 2
week mark
Most patients are falling within
the <2 weeks boundary
Measure- Data Collected from Electronic
Booking System until Aug 2013
Pts on EBS GEN SURG ENT OPHTHALMOLOGY UROLOGY VASCULAR
PTS ON LIST 187 130 469 606 41
NO OF PT CANCELLED
26 (14%) 20 (15%) 93 (20%) 113 (19%) 11 (27%)
CANCELLATIONS 28 (15%) 30 (23%) 130 (27%) 150 (25%) 12 (29%)
KNOWN REFERRAL
184 (98%) 0 (0%) 120 (26%) 59 (10%) 10 (21%)
CONSENTS 178 (95%) 124 (95%) 461 (98%) 573 (95%) 24 (59%)
CAT 3' s CONSENTED
61 (100%) 74 (92%) 346 (98%) 209 (97%) 4 (44%)
What is the Problem?
You told us that a lack of management of anti-coagulants cause day
of surgery cancellations…
PATIENT UNFIT - In ED PreOP
- High INR
- High potassium/ renal
review
- Fluid overload
- Didn’t stop Warfarin
- Didn’t stop Clopidogrel
- UTI
- For LA needs – needs
GA
- Ankle swollen
In the month of September 2 patients did not
stop taking their anti-coagulant medication
and their surgery was cancelled on the day
Measure - What is the
Problem?
Pre-admission Patient Journey - Junior Doctor Consult Times
08:15 08:30 08:45 09:00 09:15 09:30 09:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 11:45 12:00 12:15 12:30 12:45 13:00 13:15 13:30 13:45 14:00
JMO
JMO
JMO
JMO
JMO
JMO
JMO
JMO
JMO
JMO
JMO
JMO
JMO
Note that while clinic appointments begin
from 8:00am, most Junior Doctors are
unable to attend the clinic until after
10:30am due to work on wards
Measure - What is the Problem?
RPH: Control Chart for time from arrival to
departure pre-admission clinic
• VOP – patients complained about wait times (the average
patient waits at least 165 minutes)
• VOS – staff complained about wait times
• VOO – inefficient use of resources
Measure- PAAS Activity 2012/13
What is the Problem?
Patient did not report (DNR) to Pre-admission appointment…
This means a
loss of clinicians
time due to
waiting for
patients who do
not arrive.
There is great variation
in DNRs across specialty
It is not clear
at this stage
why patients
DNR
Data Fair
Data Fair
• Outcomes:
– Voice of Registrar
– Social Work
– Pathology
– Breast Clinic
– Displays
• Anaesthesia
• Theatre
• Pre-admission
Analyse- Root Causes
1. Why do we have limited patient info prior to pre-
admission?
• No state-wide consent process for release of patient
information
• No minimum data set for referrals
• Lack of standardised process for distribution of Health
Questionnaire
2. Why do we only use 76% of our pre-admission
capacity?
• Low activity days
• No centralised allocation for use of sessions
• No formal process for filling cancellations
• Some sessions left empty due to unpredictable
Analyse- Root Causes
3. Why is patient wait in pre-admission 165mins?
• Pre-admission often includes 3 different
appointments
• Conflicting role demands: Junior Doctors
• Lack of processes to accommodate variation in
workload and staffing
4. Why can’t clinicians see if patients have
attended pre-admission?
• Pre-admission appointment only recorded in EBS
for approx 50% patients
• Use of recording systems (TOPAS)
• Lack of formal data entry processes
• Insufficient training in relevant programs
Solution Generation
• Early distribution of Patient
Health Questionnaire
• Triage Nurse
• Removal of surgical JMO and
replacement with nurse case
managers
• Pharmacist
• Physiotherapist
• Walk in model of care – 50/50
• Patient PAASport
• Standardized pre-op
investigations by specialty
• Inclusion of GP
• Telephone screening
Templates for standardised
letters to GP
Pre-admission PAASport
Developed by
Professor Krishna Boddu
• System of checklists
• Must be checked off at each
point of the patient journey
before the patient can move
onto the next step.
• Ensures efficiency and provides
a system for accountability.
• A coded medical record
document remains in the
patient notes
Theatre Management System
• Electronic capture of the pre-
anaesthetic assessment
• Improves communication
between anaesthetists
• Improved legibility
• Electronic capture of
anaesthetic Hx.
• Potential for communication
across sites
Telephone Screening
• Development of a screening tool
• Reduction in number of patients requiring a face to
face preadmission assessment
• More efficient use of existing resources
The project timeline has been extended to accommodate
successful embedment of solutions
Excellence
“We are what we repeatedly do
Excellence, therefore is not
an act but a habit”
- Aristotle
Questions?