qi: “just do it!” emergency medicine residents july 31st, 2003 jamie jones, qi consultant, qihi...

QI: Just Do It!Emergency Medicine ResidentsJuly 31st, 2003

Jamie Jones, QI Consultant, QIHIDr. Sarah McPherson, PGY-5

Quality & ChangeAbout process NOT performanceNew way of practicing care NOT top down changeIts about redesigning the system we work in NOT working harder

My QI ExperienceIs it important to teach residents HQI?What is the best way to teach residents HQI?Does the Emergency Medicine program adequately teach HQI?If not, how could we do a better job at teaching HQI skills?

The Answers to My Questions1. Do Residents need to learn HQI?Absolutely YES.

Knowledge of QI principles and skills is not innate.Residents need to know how to make their workplaces and the care they provide to patients better. Residents are part of the frontline staff and are therefore uniquely able to identify potential areas for improvement in the healthcare system.

2. What is the best way to teach residents QI?

Many different approachesAfter reviewing the literature and discussing with other residents and medical staff, I think that..

Theory should be taught and then practicedEvery resident should be involved in a yearly, small scope project to utilize skills firsthandThe format should be encouraged to be group based to minimize excess workloads and to teach teamwork skillsDedicated time should be given to the teaching of QIRegular evaluation of QI education

3. Do the Emergency residency programs adequately teach QI? Maybe.

In the last 4 years we have had a 1 day QI workshop and 1 core rounds session (2 hrs) addressing QA/QI theoryFew QI projects have involved residents; even fewer have been initiated by residents

4. How could we do a better job at teaching HQI?

I propose that we should start a structured program for HQI so that all residents get to be involved.

What are the Goals of our Proposal?To challenge residents to regularly ask the following questions:

Why do we do what we do?How do we know that what we are currently doing works well?How do we identify specific parts of a process that require improvement?How can we change to do our work better?

To develop a system where residents, attending physicians, and other members of the health care team can work together on clinical and educational improvements

To continually improve care delivered by residents

To teach residents the principles and clinical skills of HQI and the improvement model (PDSA)

QI in ED Residency ProgramSchedule and Content:3 Scheduled QI Days each year:July 31st - Setting the context for QI in Emergency Residency programsMid-September 03 - Moving forward with measurementMid-January 04 - Successes & Holding the Gains

Schedule and Content:

July 31 03 Major principles of QIteam based philosophyculture of changeThe Improvement ModelBrainstorm ideas and develop resident projects

Schedule and content:

Mid-September 03 PDSA Cyclesmoving forward with testingmeasurement & graphing

Schedule and content:

Mid-January 04 Share Successes How will we hold the gains? How will we spread successes?

What the IOM said..Trying harder will not work anymore

Only redesign of our health care systems

Crossing the Quality Chasm, May 2001

What is Best Care?S - SafeT - TimelyE - EfficientE - EffectiveE - EquitableP - Patient Centered Its a STEEEP Climb to Quality!Adopted from D. Ballard, Baylor Healthcare Organization

To become a national leader in the delivery and measurement of quality health care.Calgary Health Region Goal:

Individual clinical departments/programs are ultimately responsible and accountable for quality of care.

QIHI

Does not own quality

A support service to provide consultation & information for decision-making

Integrative Process for QI ProjectsQuality Issues/ProblemsFront Line StaffManagementExecutivePortfolio/DepartmentalQuality Councils(Multidisciplinary)Clinical Enhancement TeamClinical Enhancement PhysicianQI ConsultantQI Data CoordinatorHealth Record AnalystData/Systems AnalystQI TeamQIHI ResourcesRegionalQuality CouncilQI TeamQI Team

QI MethodologyHealthcare Quality ImprovementPractical 11 step problem solving process

The Improvement Model Plan - Do - Study - Act

Methodologies require QI teams Tools & techniques

QI PrinciplesEmpower front line employeesFocus on processStructured problem solvingPatient focusedDecisions based on data

More QI PrinciplesReliance on toolsEmphasis on visual presentationPromote innovation, learning and reasonable risk takingCycle for learning and improvement

Trial and Learn Plan - Do - Study - Actmeasuring results and acting on themRe-evaluate and Continuous Improvementact, capture the gain and start all over

*

HealthcareQuality Improvement Model

STEP 2:

COLLECT BACKGROUND

DATA

STEP 1:

FORM TEAMS

STEP 3:

DEVELOP PROBLEM/ISSUE

STATEMENTS

STEP 4:

DIAGRAM THE PROCESS

STEP 5:

DETERMINE ROOT CAUSES OF

PROBLEMS/ISSUES

STEP 6:

VERIFY CAUSES WITH DATA

STEP 7:

CRITICAL REVIEW OF THE

LITERATURE

STEP 8:

DEVELOP AND SELECT THE

SOLUTIONS

STEP 9:

PLAN, TEST, IMPLEMENT THE

SOLUTIONS

STEP 10:

MEASURE RESULTS

STEP 11:

RE-EVALUATE AND

CONTINUOUS IMPROVEMENT

Getting Started

Getting Focused

Analysis

Decision Making

Implementation

Measurement

Continually Improve

A Few Required Understandings... Does baseline data support there is a problem?

What are we hereafter?Does everyone on team understand the aim?

Do we understand our process?

Does data support there is a problem?

Background DataImportant to have issue supported with data Greater confidenceUnderstand issueGreater degree of belief

Background DataCollect data-Many ways to gathersurveysnew performance dataexisting dataqualitative & quantitative

Background DataOrganize dataDisplay data

graphical display of data is key to sharing the messagea picture is worth a thousand words

e.g. histograms, run charts, Pareto charts

Data Drives DecisionsMeasurement is for learning NOT for judgementResearch: Just in case measurementQI: Just enough measurementMeasures tell a story; Goals give a reference point

DATA ContdMeasurement helps teams:manage, learn & improve work processescommunicate & understand the current process & the changes in process

But, Im not a statistician!

Thats ok - its easier than it looks!Random samplingPen & paper are fine - dont wait for information systemUse qualitative data, rather than waiting for quantitativeCollect useful data, not perfect dataPlot your data over time Run Charts

EKG Turnaround TimeWest Roxbury Center (1/22/89 - 2/3/89)32 data points 916 1 415 813 113 161417 7 220 2 2 218 317 21420 1 1 2 7 1 215 2Average = 8.3 daysDr. Peter Norton

Run chart of EKG Turnaround TimesDr. Peter NortonDaysEKGs

Chart1

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Annotated Run ChartsRun charts:simplify the datafocus attention on trends & rangesare attention gettinghelp us evaluate the effect of change activities

Annotated Run ChartPlot small samples frequently over time

What are we hereafter?

Does everyone on the team understand the aim?

Issue StatementWhy is an Issue Statement important?To focus the project on the biggest issuesTo ensure all team members are on the same pageTo avoid Scope CreepTo begin thinking about measurement

Issue StatementThree components of an Issue StatementDirectionIncrease, improve, decrease, removeMeasure# of days, weeks, hoursCost, wait times, errors, availabilityProcessadmission processpatient teaching

Issue StatementReasons for MeasurementBefore/after measures are important to quantify improvementWhat gets measured tends to get results

Issue StatementExamplesDecrease the number of patient complaints about length of stay in ED waiting rooms.Increase, by 25%, the number of patients expressing satisfaction with care experience.Reduce lab turn around times by 50%.

Paramedic downtime estimated at $500,000Source: Calgary Herald 01/24/03Calgary taxpayers spent at least $500,000 paying paramedics to wait in line to drop patients off at Calgary hospitalswe are very concerned about the number of hours ambulances are tied up in emergency rooms

EMS Official Demands Province Provide CureCourtesy: Calgary Sun 01/04/03its just that the health region needs capacity and EMS needs fundingI think the province is dragging their feet and theres a need to address this politicallywe need to look at more efficient ways of using existing resources

Ambulance Delay LingersCourtesy: Calgary Sun 02/21/03Ambulances are waiting more than one-third longer at hospital emergency wardsthe concern we have is we have fewer ambulances available and spread across a larger area --- it will take us longer to reach people and we dont want it to happen

Frustration Shared byPatients and StaffCourtesy: Calgary Herald 02/08/03Im not sure theres always evidence the patient is compromised (by a long wait), but it certainly is extremely uncomfortable to be in pain for too long or to be worried and anxious for too long

Issue StatementExercise:At each table, work as a group to develop an issue statement for the following problem:EMS has long wait-times in ED hallways

Issue StatementGoals:Reduce turnaround time for paramedic units from arrival at ED triage to being available for next call; without negatively impacting ED waiting room patients while maintaining safe, effective & high quality patient care.

Understanding Work as a Process

HQI - Focus on ProcessConsider Juran and Demings 85/15 rule:At least 85% of problems can be dealt with by improving systems; only 15% are the direct result of people.

Diagram the ProcessAllows you to analyze how a process functions (or doesnt!)Most processes were never designed they just developed40 60% of everything that is done in a large complex process is non-value addingHow can you possibly improve something unless you know how it works?

Diagram the ProcessFlowchartstool used to diagram the processmacro or microExamples

Micro FlowchartPROF Bed Flow (ED - Unit 72 - OR)Macro FlowchartED Consultant Process

PATIENT TRANSFER PROCESSFMC EMERGENCY -to- PLC HOSPITALISTFind a bedArrange transferTransfer1. FMC ED doc: decision to admit2. FMC ED doc: checks PLC census3. FMC ED doc: pages PLC Hospitalist4. PLC Hospitalist: calls FMC ED doc5. PLC Hospitalist: calls PLC Admitting (bed assigned immediately1)6. PLC Hospitalist: calls FMC ED doc to accept transfer7. PLC Admitting: calls & faxes FMC ED UC to advise bed information8. FMC ED doc informs FMC ED UC1. Pt. Transport: dispatches vehicle2. Pt. Transport: arrives FMC3. Pt. Transport: collects chart/patient4. Pt. Transport: receives report5. Pt. Transport: transports patient6. Pt Transport: arrives PLC Admtg7. PLC Admitting: registers patient8. Pt. Transport: transport to unit9. Pt. Transport: check-in with UC10. Pt. Transport: report to RN11. PLC UC: pages Hospitalist1. PLC Hospitalist: calls report to inpatient unit 22. PLC Hospitalist: books Patient Transport3. FMC ED UC: puts PLC fax on pt chart4. FMC ED doc: writes order5. FMC ED RN/UC: completes transfer checklist6. ED RN: completes Admission Sheet7. ED RN: gives Admission Sheet to ED UC8. ED UC: enters into Log Book9. Admission Sheet to FMC Admitting10. FMC Admitting: calls PLC Admitting11. PLC Hospitalist: informs PLC Admitting12. PLC Admitting: assigns bed13. PLC Admitting: calls FMC Admitting14. FMC Admitting: advises ED UC15. ED UC: advises RN16. ED RN: phones report to PLC unitNotes: red indicates new steps indicates eliminated steps

Family Medicine - Results

Chart3

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20.0791666667

30.1548611111

40.0618055556

50.0784722222

60.1215277778

70.1416666667

80.1715277778

90.3652777778

100.2569444444

110.1736111111

120.0729166667

130.1319444444

140.2611111111

150.1701388889

160.1944444444

170.0833333333

180.0909722222

190.2006944444

200.0875

210.1534722222

220.0826388889

230.0645833333

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260.0930555556

270.0819444444

280.4527777778

290.1104166667

300.0979166667

310.125

320.3131944444

330.0777777778

340.2173611111

350.1763888889

360.1284722222

370.1423611111

380.1354166667

390.1305555556

400.3111111111

410.1069444444

420.0944444444

430.4777777778

440.0923611111

450.0861111111

460.15

470.1708333333

480.1

490.1791666667

500.1395833333

510.0583333333

520.09375

530.1006944444

540.0791666667

550.2034722222

560.1270833333

570.1048611111

580.1243055556

590.0770833333

600.08125

610.0534722222

620.1805555556

630.1354166667

640.0597222222

650.1159722222

660.0673611111

670.0944444444

680.1180555556

690.1319444444

700.1715277778

710.1277777778

720.0854166667

730.0777777778

740.0430555556

750.1402777778

760.1083333333

770.0465277778

780.0972222222

790.2041666667

800.15625

810.1006944444

820.05

830.0645833333

840.0659722222

850.0611111111

860.1034722222

870.0479166667

880.0520833333

890.05625

900.0604166667

910.0798611111

920.0694444444

930.0513888889

940.1048611111

950.0555555556

960.2256944444

970.16875

980.0638888889

990.0625

1000.0506944444

1010.0611111111

1020.0673611111

1030.0256944444

1040.0958333333

1050.0506944444

Change 1

Change 2

Target

Change 3

Special cause identified; protocol not followed in these transfers.

Baseline

Patient Case

Hours

'Decision to Admit' -to- 'Transfer Complete'

All RunChart

All RunChart

10.0743055556

20.0791666667

30.1548611111

40.0618055556

50.0784722222

60.1215277778

70.1416666667

80.1715277778

90.3652777778

100.2569444444

110.1736111111

120.0729166667

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150.1701388889

160.1944444444

170.0833333333

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200.0875

210.1534722222

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290.1104166667

300.0979166667

310.125

320.3131944444

330.0777777778

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360.1284722222

370.1423611111

380.1354166667

390.1305555556

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420.0944444444

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460.15

470.1708333333

480.1

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500.1395833333

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520.09375

530.1006944444

540.0791666667

550.2034722222

560.1270833333

570.1048611111

580.1243055556

590.0770833333

600.08125

610.0534722222

620.1805555556

630.1354166667

640.0597222222

650.1159722222

660.0673611111

670.0944444444

680.1180555556

690.1319444444

700.1715277778

710.1277777778

720.0854166667

730.0777777778

740.0430555556

750.1402777778

760.1083333333

770.0465277778

780.0972222222

790.2041666667

800.15625

810.1006944444

820.05

830.0645833333

840.0659722222

850.0611111111

860.1034722222

870.0479166667

880.0520833333

890.05625

900.0604166667

910.0798611111

920.0694444444

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950.0555555556

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990.0625

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1030.0256944444

1040.0958333333

1050.0506944444

&C&"Arial,Bold"&18TRANSFER TIMES PROJECT: FMC EMERGENCY TO PLC HOSPITALIST2001 / 2002

&L&8&F&D&R&8Prepared by: J. Robinson210-9238

Change 1

Change 2

Target

Change 3

Special cause identified; protocol not followed in these transfers.

Baseline

Patient Case

Hours


All RunChart Data

0.1510706019

0.1125816993

0.09634661840.072037037

0.0794117647

&C&"Arial,Bold"&18TRANSFER TIMES PROJECT: FMC EMERGENCY TO PLC HOSPITALIST2001 / 2002


Change 2:n=15,8 'special cause cases' removed from mean

Change 2: n=23 (all cases)

Baseline -Apr/May/Jun 2001

FMC Admittingremoved

Hospitalists doingmany steps

Removeduplicate steps

Mean - All Cases Included

Mean - CC2 'Long Cases' Removed

Mean Transfer Times by Change Cycle

For tbpi manual

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&C&"Arial,Bold"&14TRANSFER TIMES PROJECT 2001: FMC EMERGENCY TO PLC HOSPITALIST


Target

Baseline

Change 1

Between

Change 2

Patient Case

Hours

TRANSFER TIMES: 'Decision to Admit -to- 'Transfer Complete'

day,eve,nt

CC Patient NumberOverall Patient Number'Dec to Admit' -to- 'Complete'With Change 2 'Problem Cases' Removed

Baseline111:471:47

221:541:54

333:433:43

441:291:29

551:531:53

662:552:55

773:243:24

884:074:07

998:468:46

10106:106:10

11114:104:10

12121:451:45

13133:103:10

14146:166:16

15154:054:05

16164:404:40

17172:002:00

18182:112:11

19194:494:49

20202:062:06

21213:413:41

22221:591:59

23231:331:33

24241:191:19

25251:141:14

26262:142:14

27271:581:58

282810:5210:52

29292:392:39

30302:212:21

31313:003:00

32327:317:31

33331:521:52

34345:135:13

35354:144:14

36363:053:05

37373:253:25

38383:153:15

39393:083:08

40407:287:28

41412:342:34

42422:162:16

434311:2811:28

44442:132:13

45452:042:04

46463:363:36

47474:064:06

48482:242:24

Change 11494:184:18

2503:213:21

3511:241:24

4522:152:15

5532:252:25

6541:541:54

7554:534:53

8563:033:03

Between1572:312:31

2582:592:59

3591:511:51

4601:571:57

5611:171:17

6624:204:20

7633:153:15

8641:261:26

9652:472:47

Change 21661:371:37

2672:162:16

3682:50

4693:10

5704:07

6713:04

7722:03

8731:521:52

9741:021:02

10753:22

11762:362:36

12771:071:07

13782:202:20

14794:54

15803:45

16812:252:25

17821:121:12

18831:331:33

19841:351:35

20851:281:28

21862:292:29

22871:091:09

23881:151:15

Change 31891:211:21

2901:271:27

3911:551:55

4921:401:40

5931:141:14

6942:312:31

7951:201:20

8965:25

9974:034:03

10981:321:32

11991:301:30

121001:131:13

131011:281:28

141021:371:37

151030:370:37

161042:182:18

171051:131:13

"Revisited"11061:47

21072:44

31082:53

41091:06

51101:41

61111:44

71123:18

81132:15

91141:46

101151:43

111163:51

121171:20

131181:44

141193:49

151201:08

161211:20

171222:23

181232:20

191241:29

201252:13

211262:35

221271:14

231281:34

241291:18

"Special Cases Removed"

AverageAverage

Baseline3:37Baseline

Change 12:42Change 1

Change 22:1836%Change 21:4352%

Change 31:5447%Change 31:4153%

Review 12:0343%

B-3 difference1:4347%

transfers/wk8

13:45patients time saved per week

per year715hrs Emerg saved per year

pt days30days Emerg saved per year

red line & boxes displaced to compensate when copying to powerpoint

&C&"Arial,Bold"&12PATIENT TRANSFERS: FMC EMERG TO PLC HOSPITALISTS - 2001/02

&L&8&F,&A&R&8J.Robinson, 210-9238

Special cause identified;protocol not followed in these transfers.

Baseline

Change 1

Change 2

Change 3

Review 1

Patient Case

Hours


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0.0722222222

0.1375

0.09375

0.0736111111

0.0715277778

0.1604166667

0.0555555556

0.0722222222

0.1590277778

0.0472222222

0.0555555556

0.0993055556

0.0972222222

0.0618055556

0.0923611111

0.1076388889

0.0513888889

0.0652777778

0.0541666667

&C&"Arial,Bold"&12PATIENT TRANSFERS: FMC EMERG -to- PLC HOSPITALISTS, 2001/02

&L&8&F,&A&R&8J.Robinson, 210-9238

Change 2:n=15,8 'special cause cases' removed from mean

Change 2: n=23 (all cases)

Baseline -Apr/May/Jun 2001

Remove FMC Admitting

Hospitalists domany steps

Removeduplicate steps

ReviewJan '02

Hours

All Cases

No 'Spec Cause'

Mean Transfer Times by Change Cycle

Baseline

Baseline

Change 1

Change 1

Change 2

Change 2

Change 3

Change 3

Review 1

Review 1

0.1510706019

0.1125816993

0.0963466184

0.072037037

0.0794117647

0.0855034722

PtTrans Response

PtTrans Response

490.1791666667

500.1395833333

510.0583333333

520.09375

530.1006944444

540.0791666667

550.2034722222

560.1270833333

570.1048611111

580.1243055556

590.0770833333

600.08125

610.0534722222

620.1805555556

630.1354166667

640.0597222222

650.1159722222

Change 1

Change 2

Target

Patient Case

Hours


Change 3 Data

BaselineChange 1Change 2Change 3Review 1

Day11%30%6%25%

Evening33%17%47%33%

Night56%52%47%42%

Change 3 Data

000

000

000

000

000

&L&8&F,&A&R&8J. Robinson, 210-9238

Day

Evening

Night

Percent

PATIENT TRANSFERS: FMC EMERG -to- PLC HOSPITALISTSProportion by Shift

CC 2 Data Analysis

PATIENT TRANSPORT RESPONSE TIMES

Datemins

3-Jan-0220

4-Jan36

4-Jan44

5-Jan15

5-Jan14

7-Jan40

7-Jan34

7-Jan45

7-Jan24

8-Jan36

8-Jan35

8-Jan31

9-Jan95

9-Jan40

9-Jan47

9-Jan26

9-Jan27

10-Jan8

10-Jan33

10-Jan62

10-Jan16

10-Jan28

12-Jan16

12-Jan19

12-Jan20

13-Jan51

13-Jan18

13-Jan23

13-Jan19

13-Jan15

13-Jan63

13-Jan12

15-Jan26

15-Jan43

15-Jan58

17-Jan45

17-Jan33

18-Jan47

19-Jan27

19-Jan39

21-Jan37

21-Jan7

21-Jan46

21-Jan14

22-Jan14

23-Jan29

23-Jan35

24-Jan15

24-Jan20

26-Jan21

26-Jan7

27-Jan43

27-Jan70

28-Jan10

28-Jan8

29-Jan32

29-Jan40

30-Jan24

30-Jan27

31-Jan16

31-Jan15

31-Jan15

31-Jan14

31-Jan11

1-Feb21

2-Feb46

2-Feb27

3-Feb30

3-Feb33

3-Feb23

3-Feb32

4-Feb51

4-Feb5

6-Feb6

6-Feb5

7-Feb19

8-Feb8

9-Feb73

9-Feb31

9-Feb31

10-Feb36

10-Feb19

11-Feb20

11-Feb22

12-Feb20

12-Feb20

13-Feb16

13-Feb9

13-Feb1

15-Feb13

15-Feb16

16-Feb40

18-Feb57

18-Feb20

19-Feb19

20-Feb23

22-Feb18

22-Feb21

22-Feb30

24-Feb27

25-Feb26

26-Feb45

27-Feb43

27-Feb6

28-Feb35

28-Feb44

average28

max95

min1

median26

there are more transfers here than in the project data; all fmc to plc transfers are represented here whereas our project data only represents PLC Hospitalists patients

Change 2 Data

CHANGE CYCLE 3: December 8'01 - January 8'02

#Hospita-listDateData from FMC EDData from HospData from PLC AdLast NamePHNAdmit FMC EDDec to AdmitDec to Admit ShiftED doc calls Hospi-talistAdmis-sion Sheet to ED UCHospitalist requests bedPLC faxes ED w/ bedED RN phones reportHospitalist Books Pt Transport"Dec to Admit" -to- "Pt Transport booked"Vehicle dispatchedActual Pick UpCom-pletion"Dec to Admit" -to- "Com-pletion"Hospitalist Notified by Unit"Dec to Admit" -to- "Hospitalist Notified"Booked to Completion

1Dec-10xJurcevic59423120021:36e21:3621:5122:120:3622:1022:1722:571:2123:502:140:45

2TrainorDec-10xxBischoff35846051122:28e22:2822:4922:5522:490:2122:4623:2123:551:270:121:4424:00:001:06

3Dec-11xLai64879772015:37e15:3715:4115:440:0716:2116:4817:321:5517:452:081:48

4Dec-11xBearshirt4456768006:38n6:386:466:400:027:107:258:181:408:201:421:38

5KassamDec-13xxKluczeweski23:00n23:0023:0823:4723:000:0023:0223:370:141:14"no medical beds"1:14

6BryantDec-16xBeregszaszi23013221019:41e19:4119:4620:390:5820:4221:3222:122:3122:302:49"first call to PLC Admtg - no staff; patient mrsa positive"1:33

7Dec-17xBarclay34529480016:04e16:0416:1016:090:0516:0516:3617:241:2018:102:061:15

8ConradieDec-18xLeys1:30n1:301:551:590:295:366:106:555:25"FMC ED reports PLC accepted care 0130, but hospitalist delayed until 0600 to sleep"; Hospitalist provided no id to PtTransport4:56

9Dec-19xFrancis71411160014:00d14:0015:2515:491:4916:3017:0918:034:03unexplained delay between "Dec to Admit" and "Pt Transport Booked" = 01:492:14

10Dec-20xLinddlad42151900021:50e21:5022:0322:030:1322:0822:3623:221:3223:451:55"Admitting would not confirm bed until unit here was called to confirm availability"1:19

11Dec-20xWindrem94494061122:00e22:0022:0522:050:0522:0722:5423:301:3023:501:501:25

12KassamDec-20xxMurphy26135181023:20n23:2023:4023:4323:290:0923:320:110:531:131:24

13KassamDec-20xxDerhakhsham23:30n23:3023:4023:4323:300:0023:360:180:581:281:28

14KassamDec-21xxClaggette9203729112:00n2:001:102:122:150:152:262:493:371:373:451:451:22

15KassamDec-21xLarsen6439637003:00n3:003:092:123:030:033:073:023:370:373:450:450:34

16KassamDec-21xxSchwaier2186519004:15n4:154:204:124:220:075:235:416:332:186:402:252:11

17Jan-03xOgle10773301022:42e22:4222:5022:440:0222:5423:1423:551:130:301:4824:00:001:11

day1count1717count12

evening8average0:181:54average1:551:36

night8max1:495:25max2:49

min0:000:37min0:45

Incomplete Data

1NixonDec-12xDuncanno datan23:4023:4723:510:0023:560:140:570:000:00

2StassenDec-16xxGrantno datan0:300:450:490:000:501:081:440:000:00

3CullyDec-18xDowningno datan23:402:0023:440:0023:460:201:030:000:00

4CullyDec-19xHerdmanno datan2:402:532:360:004:325:025:450:000:00"Hospitalist provided no id data to PtTransport"; hi volume transfers delayed transport

5CullyDec-19xMumcuogluno datan4:314:251:280:006:036:307:130:000:00"Hospitalist provided no id data to PtTransport"; hi volume transfers delayed transport

6CullyDec-19Iversonno datan6:086:105:580:006:026:307:170:000:00"Hospitalist provided no id data to PtTransport"; hi volume transfers delayed transport

7KassamDec-21xHuttonno datan1:102:120:00not transported by PT0:000:00PT arrived at FMC to find patient no longer there - unknown how pt was transported

Transfers not Reported by Hospitalist, FMC ED, PLC Admitting (I.e. extracted from Pt. Transport dbase only)

823-DecMyers

926-DecDebniak

1026-DecGalloway

1127-DecWiegle

1228-DecGuo

1328-DecHufnagel

1430-DecHarcus

1531-DecReviczkw

161-JanNelson

173-JanMurray

184-JanStimson

194-JanSingh

205-JanPachal

215-JanBonderoff

227-JanDunsmoor

237-JanScheunert

247-JanMcRae

258-JanLalande

268-JanLo

278-JanAlexander

288-JanGacek

Between cc1-cc2

CHANGE 2 DATA November 7 - December 7, 2001

#Hospita-listDateFMC EDHospPLC AdLast NamePHNAdmit FMC EDDec to AdmitDec to Admit ShiftED doc calls Hospi-talistAdmis-sion Sheet to ED UCED UC requests bedPLC faxes ED w/ bedED RN phones reportHospitalist Books Pt Transport"Dec to Admit" -to- "Pt Transport booked"Vehicle dispatchedActual Pick UpCom-pletion"Dec to Admit" -to- "Com-pletion"Hospitalist Notified by Unit"Dec to Admit" -to- "Hospitalist Notified"

1Gatzke10-NovxxxManyshots0:2014:19day14:1914:5615:0514:320:1314:3415:1415:561:3716:161:57

2Gatzke10-NovxxxDionne94866398:3514:45day14:51015:210:3615:2416:1317:012:1617:583:13

813-NovxxPopham58127021:01evening21:2321:4121:4721:230:2221:2522:1022:531:520

913-NovxxSamson944337322:00evening22:0222:1522:030:0322:0622:2123:021:0223:441:44

11Hakes14-NovxxxMunro948667011/14/01 3:153:00night3:003:154:123:080:084:204:575:362:366:053:05

12Bryant14-NovxxxNicholson66056160011/14/01 23:2011/14/01 23:10night23:0523:1823:3011/14/01 23:140:0423:2323:3811/15/01 0:171:0711/15/01 0:201:10

1314-NovxWilkinson35302512111/13/01 21:302:00night2:052:203:061:063:263:394:202:20

16Conradie24-NovxxxCuthbert921804023:1011/24/01 22:30evening22:5323:2011/24/01 22:550:2523:520:0911/25/01 0:552:2511/25/01 1:303:00

17Conradie24-NovxxIwazyk007339317:3822:00day22:0822:130:1322:2722:3123:121:1211/25/01 0:182:18

1826-NovxxHewitt5:4511:05day11:1511:150:1011:3011:5112:381:3314:153:10

1926-NovxBrown64226xx8:2013:15day13:3513:3813:210:0613:5114:0414:501:35

2027-NovxxJohn63325188019:551:10night1:111:291:150:051:422:002:381:282:391:29

2127-NovxxSharpe3549291119:3519:40evening19:1719:5019:5120:170:3721:0221:2922:092:2922:372:57

22Cran5-DecxxXie, Guang34616153023:2912/5/01 23:17night23:1823:3023:3512/5/01 23:200:0323:2423:4612/6/01 0:261:09

23Cran6-DecxxGullacher8343392005:10night5:105:115:225:210:115:275:426:251:15

count15

average0:17average1:43

max1:06max2:36

min0:03min1:02

3Cran12-NovxxMeads948695311/12/01 18:302:30night2:352:550.11805555563:260:563:504:315:202:50patient transport not booked by Hospitalist

4Cran12-NovxxBaylis948696111/12/01 19:432:10night2:152:550.12152777783:281:183:504:315:203:10patient transport not booked by Hospitalist

5Kassam13-NovxxGuyong925646211/12/01 22:550:20night0:200:471:511:313:203:444:274:07patient transport not booked by Hospitalist

6Kassam13-NovxxKing936171511/13/01 16:560:09night0:090:470.03472222221:541:451:572:383:133:04patient transport not booked by Hospitalist

713-NovxxWiggins100457211/13/01 10:1514:45day14:4515:2015:501:0515:5215:5816:482:0317:090.1patient transport not booked by Hospitalist

10Kassam13-NovxxHudson948525211/12/01 20:142:30night0:203:400.15833333333:421:124:395:105:523:22patient transport not booked by Hospitalist

1414-NovxRothwell95681022011/13/01 17:422:00night2:054:042:045:576:076:544:54no comments received, assume as others

15Cully19-NovxxHarrendance34773608012/31/99 11:2517:05day17:10unaware0.802083333319:492:4419:5120:0620:503:45patient transport not booked by Hospitalist

count15

Incomplete Data

Samis7-NovxDobruk92392970:460:491:101:51

Cully28-NovxChebrehiwet23:2023:162:112:293:08

Cully28-NovxxOrr911261321:4123:2023:152:533:043:4423:16

28-NovxOstafichuk932227821:0521:3123:1223:3511/29/01 0:170.0270833333

28-NovxKok949339821:4121:5521:510:260:4911/29/01 1:310.1236111111

Cully29-NovxSitu94911363:503:433:464:154:52

Jeanine Boyarchuk:orange denotes transfers where Hospitalist did not contact Patient Transport

Change 1 Data

CHANGE 2 DATA November 7 - December 7, 2001

#Hospita-listDateFMC EDHospPLC AdLast NamePHNAdmit FMC EDDec to AdmitDec to Admit ShiftED doc calls Hospi-talistAdmis-sion Sheet to ED UCED UC requests bedPLC faxes ED w/ bedED RN phones reportHospitalist Books Pt Transport"Dec to Admit" -to- "Pt Transport booked"Vehicle dispatchedActual Pick UpCom-pletion"Dec to Admit" -to- "Com-pletion"Hospitalist Notified by Unit"Dec to Admit" -to- "Hospitalist Notified"Booked to Completion

1Gatzke10-NovxxxManyshots0:2014:19day14:1914:5615:0514:320:1314:3415:1415:561:3716:161:571:24

2Gatzke10-NovxxxDionne94866398:3514:45day14:51015:210:3615:2416:1317:012:1617:583:131:40

3Cran12-NovxxMeads948695311/12/01 18:302:30night2:352:552:503:260:563:504:315:202:50patient transport not booked by Hospitalist1:54

4Cran12-NovxxBaylis948696111/12/01 19:432:10night2:152:552:553:281:183:504:315:203:10patient transport not booked by Hospitalist1:52

5Kassam13-NovxxGuyong925646211/12/01 22:550:20night0:200:471:511:313:203:444:274:07patient transport not booked by Hospitalist2:36

6Kassam13-NovxxKing936171511/13/01 16:560:09night0:090:470:501:541:451:572:383:133:04patient transport not booked by Hospitalist1:19

713-NovxxWiggins100457211/13/01 10:1514:45day14:4515:2015:501:0515:5215:5816:482:0317:090.1patient transport not booked by Hospitalist0:58

813-NovxxPopham58127021:01evening21:2321:4121:4721:230:2221:2522:1022:531:5201:30

913-NovxxSamson944337322:00evening22:0222:1522:030:0322:0622:2123:021:0223:441:440:59

10Kassam13-NovxxHudson948525211/12/01 20:142:30night0:203:403:483:421:124:395:105:523:22patient transport not booked by Hospitalist2:10

11Hakes14-NovxxxMunro948667011/14/01 3:153:00night3:003:154:123:080:084:204:575:362:366:053:052:28

12Bryant14-NovxxxNicholson66056160011/14/01 23:2011/14/01 23:10night23:0523:1823:3011/14/01 23:140:0423:2323:3811/15/01 0:171:0711/15/01 0:201:101:03

1314-NovxWilkinson35302512111/13/01 21:302:00night2:052:203:061:063:263:394:202:201:14

1414-NovxRothwell95681022011/13/01 17:422:00night2:054:042:045:576:076:544:542:50

15Cully19-NovxxHarrendance34773608012/31/99 11:2517:05day17:10unaware19:1519:492:4419:5120:0620:503:45patient transport not booked by Hospitalist1:01

16Conradie24-NovxxxCuthbert921804023:1011/24/01 22:30evening22:5323:2011/24/01 22:550:2523:520:0911/25/01 0:552:2511/25/01 1:303:002:00

17Conradie24-NovxxIwazyk007339317:3822:00day22:0822:130:1322:2722:3123:121:1211/25/01 0:182:180:59

1826-NovxxHewitt5:4511:05day11:1511:150:1011:3011:5112:381:3314:153:101:23

1926-NovxxBrown64226xx8:2013:15day13:2013:3513:3813:210:0613:5114:0414:501:351:29

2027-NovxxJohn63325188019:551:10night1:111:291:150:051:422:002:381:282:391:291:23

2127-NovxxSharpe3549291119:3519:40evening19:1719:5019:5120:170:3721:0221:2922:092:2922:372:571:52

22Cran5-DecxxXie, Guang34616153023:2912/5/01 23:17night23:1823:3023:3512/5/01 23:200:0323:2423:4612/6/01 0:261:091:06

23Cran6-DecxxGullacher8343392005:10night5:105:115:225:210:115:275:426:251:151:04

count23

day730%average0:44average2:181:34

evening417%max2:44max4:54

231214night1252%min0:03min1:02

Incomplete Data

Samis7-NovxDobruk92392970:460:491:101:51

Cully28-NovxChebrehiwet23:2023:162:112:293:08

Cully28-NovxxOrr911261321:4123:2023:152:533:043:4423:16

28-NovxOstafichuk932227821:0521:3123:1223:3511/29/01 0:170.0270833333

28-NovxKok949339821:4121:5521:510:260:4911/29/01 1:310.1236111111

Cully29-NovxSitu94911363:503:433:464:154:52

Jeanine Boyarchuk:orange denotes transfers where FMC UC indicated that Hospitalist did not contact Patient Transport; Transfer #14 appears to also fit this category

Baseline

BETWEEN CC1 and CC2 (non-test patients) October 17th - November 6th, 2001

DateLast NamePPR or PLC #Admit FMC EDDec to AdmitDec to Admit ShiftED doc calls HospitalistAdmis-sion Sheet to ED UCED UC requests bed from PLCPLC assigns bedED RN phones reportED UC books Pt Transport"Dec to Admit" -to- "Pt Transport booked"Vehicle dispatchedActual Pick UpCompletion"Dec to Admit" -to- "Com-pletion"Hospitalist Notified by Unit"Dec to Admit" -to- "Hospitalist Notified"Booked to Completion

117-OctCorasinitiTeresa101070110/17/01 2:10night10/17/01 3:50

218-OctCherniwchanMary Anne360645610/18/01 3:35night10/18/01 3:3510/18/01 3:5010/18/01 3:540:1910/18/01 4:1010/18/01 5:1810/18/01 6:062:312:12

322-OctCannellCarlos910340610/22/01 20:45evening10/22/01 20:4510/22/01 22:201:3510/22/01 22:3810/22/01 23:0610/22/01 23:442:591:24

422-OctZeebRose134704610/22/01 23:30night10/22/01 23:4810/23/01 0:060:3610/23/01 0:2010/23/01 0:4410/23/01 1:211:511:15

523-OctTitmarshRamon340276510/23/01 23:15night10/23/01 23:1510/24/01 0:050:5010/24/01 0:1110/24/01 0:3710/24/01 1:121:571:07

624-OctFjeldstromSonya230373310/24/01 2:35night10/24/01 2:440:0910/24/01 2:4810/24/01 3:0410/24/01 3:521:171:08

725-OctJuhnMartina Sara427628310/25/01 0:10night10/25/01 1:0710/25/01 0:1010/25/01 1:541:4410/25/01 3:1310/25/01 3:4710/25/01 4:304:202:36

825-OctUrbainMargaret734447210/25/01 0:15night10/25/01 0:1510/25/01 1:4510/25/01 1:411:2610/25/01 2:3610/25/01 2:5610/25/01 3:303:151:49

92-NovBannanMargaret767824611/2/01 22:45evening11/2/01 23:130:2811/2/01 23:1811/2/01 23:3511/3/01 0:111:260:58

104-NovMacKinnonTheresa929334511/3/01 23:50night11/4/01 12:1511/4/01 1:0511/4/01 1:051:1511/4/01 2:0311/4/01 2:0111/4/01 2:372:471:32

average2:291:33

Incomplete Data

18-OctEaglesonJames541381010/18/01 3:1510/18/01 3:3710/18/01 3:3910/18/01 4:0810/18/01 4:43

22-OctOrbanLaszlo947897710/22/01 0:4010/22/01 1:4510/22/01 1:4810/22/01 2:0910/22/01 2:46

26-OctGeruygPieter913177010/26/01 1:2310/26/01 1:3210/26/01 2:3610/26/01 2:5610/26/01 3:30

26-OctBlaischuckShannon896832310/26/01 0:3710/26/01 1:0410/26/01 1:3610/26/01 1:5310/26/01 2:27

3-NovYeeTeddy948423511/4/01 9:0511/4/01 21:3411/4/01 21:3811/4/01 21:5411/4/01 22:34

3-NovLalondePhyllis248046511/3/01 9:0511/3/01 21:3311/3/01 21:3711/3/01 22:0311/3/01 22:46

jmr:report tried 0320 (no one available), 0330 (no answer), and again at 0350

jmr:not prospectively collected so unavailable from charts unless noted

jmr:chart not pulled





Pivot Baseline

DateLast NamePHNAdmit FMC EDDec to AdmitDec to Admit ShiftED doc calls Hospi-talistAdmis-sion Sheet to ED UCED UC requests bedPLC assigns bedED RN phones reportED UC books Pt Transport"Dec to Admit" -to- "Pt Transport booked"Vehicle dispatchedActual Pick UpCom-pletion"Dec to Admit" -to- "Com-pletion"Hospitalist Notified by Unit"Dec to Admit" -to- "Hospitalist Notified"Booked to Completion

9-OctCates8:3015:40evening10:4915:4015:4015:4216:1716:200:40No Record-EMS?

9-OctDick12:4019:05evening19:2319:4019:4220:2020:3721:001:5522:2622:4223:234:1823:454:402:23

10-OctMacIntyre20:470:04night23:450:040:300:391:202:362:322:333:033:253:214:003:560:49

11-OctThomson12:4521:15evening21:0021:1521:1521:2021:2521:300:1521:2621:5522:391:2421:251:09

11-OctTernes93746020013:132:29night2:292:452:452:55unavail3:090:403:414:014:442:151:35

14-OctKinakin19:2510:00day10:0010:0510:0510:2010:5911:051:0511:0011:4012:252:2514:454:451:20

14-OctParnell53995931012:4523:30night23:4523:590:020:16unavail0:220:520:230:511:261:541:401:541:04

15-OctDuFour9961589202:454:55night4:555:275:316:526:587:192:248:268:389:484:532:29

17-OctCora23:451:51night1:512:122:152:162:253:552:044:134:154:543:030:59

day11%average1:23average2:563:481:28

evening33%median1:05median2:444:181:14

night56%

missing data

9-OctHoare61028091019:2821:55unavail21:5521:5622:15unavailprivate veh.No Record-private veh.

time elapsed from step to step

9-OctCates7:100:000:000:020:350:03

9-OctDick6:250:180:170:020:380:170:231:260:160:41

9-OctHoare2:270:010:19

10-OctMacIntyre3:170:260:090:411:160:300:22

11-OctThomson8:300:150:000:050:050:050:290:44

11-OctTernes13:160:000:160:000:100:320:200:43

14-OctKinakin14:350:000:050:000:150:390:060:400:45

14-OctParnell10:450:150:140:140:010:280:35

15-OctDuFour2:100:000:320:041:210:060:211:070:121:10

17-OctCora2:060:000:210:030:010:091:300:180:020:39

average7:040:050:150:040:190:210:321:320:400:220:423:17

median6:470:000:150:010:120:170:210:320:240:42

avg step percent of time (to Booked)16%4%21%24%35%100%

avg step percent of time (to Completion)8%2%11%12%18%23%13%24%112%

7.6923076923

35%24%21%16%4%

0

0

0.0504050926

0.0498263889

13

&C&"Arial,Bold"&12FAMILY MEDICINE COLLABORATIVETRANSFER TIMES - FMC ED to PLC HOSPITALISTS

CHANGE CYCLE 1

&L&8JRobinson&F&D&10

jmr:appears to be inaccurate

jmr:calculation is -3 minutes - - impossible

jmr:calculation is -4 minutes - impossible

jmr:calculation is - 5 minutes - impossible

jmr:for this case, use Dec to Admit time versus ED doc calls hospitalist

jmr:only two cases, eliminate from calculations

jmr:"PLC unable to take patient until after 0700h"

jmr:"bed will not be ready until 12:00" - note in chart dated 1100h

Bar Proportion Delay

FMC Chart #FMC Admit DtFMC Disch DtDecision Admit ED to IPTime Dec to Admit to DischCalc ED Phys Assess TimePLC Chart #Admit to PLCDischargeHoursBookedAppointmentPickup"Dec to Admit" - to - "Pt Transport Booked"DispatchActual PickupTime Dec to Adm to Actual Pick-Up (P-D)CompletionTransport TimeDec to Adm to PLC Admit TimeTime Dec to Adm to CompletionTime Dispatch to Pick-Up (O-N)Booked to Completion

040811202-Apr-2001 11:5902-Apr-2001 21:3002-Apr-2001 20:48420202591402-Apr-2001 22:3503-Apr-20011.0802-Apr-2001 21:2902-Apr-2001 23:0002-Apr-2001 22:150:4102-Apr-2001 21:3202-Apr-2001 21:460:5802-Apr-2001 22:350:491:471:470:141:06



066921004-Apr-2001 10:0804-Apr-2001 18:3004-Apr-2001 11:104400601856804-Apr-2001 12:4207-Apr-2001-5.804-Apr-2001 11:3704-Apr-2001 13:1504-Apr-2001 12:300:2704-Apr-2001 11:5304-Apr-2001 11:550:4504-Apr-2001 12:390:441:321:290:021:02



100578909-Apr-2001 14:1310-Apr-2001 02:3309-Apr-2001 23:301830833911110-Apr-2001 02:5509-May-20010.3710-Apr-2001 01:3210-Apr-2001 03:1510-Apr-2001 02:302:0210-Apr-2001 01:5810-Apr-2001 02:152:4510-Apr-2001 02:540:393:253:240:171:22

033831509-Apr-2001 22:1210-Apr-2001 02:4010-Apr-2001 01:30700889678910-Apr-2001 02:5712-Apr-20010.281:270:00




114347614-Apr-2001 22:4515-Apr-2001 03:4515-Apr-2001 00:1021525632832215-Apr-2001 01:3021-Apr-2001-2.2515-Apr-2001 03:1215-Apr-2001 04:4515-Apr-2001 04:003:0215-Apr-2001 03:4215-Apr-2001 03:323:2215-Apr-2001 04:200:481:204:108:001:08

037057716-Apr-2001 04:0417-Apr-2001 00:5016-Apr-2001 22:5511528004981717-Apr-2001 00:4813-May-2001-0.0316-Apr-2001 23:4517-Apr-2001 01:3017-Apr-2001 00:450:5017-Apr-2001 23:5617-Apr-2001 00:061:1117-Apr-2001 00:400:341:531:458:000:55



921200619-Apr-2001 22:1420-Apr-2001 02:5920-Apr-2001 01:259532897242420-Apr-2001 03:2620-Apr-20010.452:010:00





036878124-Apr-2001 14:2425-Apr-2001 01:091356940734425-Apr-2001 01:3528-Apr-20010.4325-Apr-2001 00:2625-Apr-2001 02:0025-Apr-2001 01:1525-Apr-2001 00:2825-Apr-2001 00:5425-Apr-2001 01:360:420:261:10





940992830-Apr-2001 15:1001-May-2001 01:2311113424601-May-2001 00:1309-May-2001-1.1701-May-2001 00:5301-May-2001 02:3001-May-2001 01:4501-May-2001 00:5601-May-2001 01:1201-May-2001 01:500:380:160:57

072021501-May-2001 20:3502-May-2001 01:3002-May-2001 00:20700271112502-May-2001 01:1308-May-2001-0.2802-May-2001 00:5702-May-2001 02:3002-May-2001 01:450:3702-May-2001 00:5902-May-2001 01:140:5402-May-2001 01:530:390:531:330:150:56

041519202-May-2001 18:1002-May-2001 23:4502-May-2001 23:3015305869429103-May-2001 00:4808-May-20011.0502-May-2001 23:5303-May-2001 01:3003-May-2001 00:450:2303-May-2001 23:5503-May-2001 00:080:3803-May-2001 00:490:411:181:198:000:56

082733104-May-2001 16:3504-May-2001 22:5904-May-2001 22:006040192474504-May-2001 23:0917-May-20010.1704-May-2001 21:5604-May-2001 23:3004-May-2001 22:4504-May-2001 21:5804-May-2001 22:260:2604-May-2001 23:140:481:091:140:281:18



941233105-May-2001 21:5506-May-2001 02:591155941233106-May-2001 07:2712-May-20014.4706-May-2001 06:1206-May-2001 07:4506-May-2001 07:0006-May-2001 06:1306-May-2001 06:3506-May-2001 07:110:360:220:59


107597812-May-2001 14:3012-May-2001 21:40180921332212-May-2001 22:1324-Jul-20010.5512-May-2001 21:0612-May-2001 22:4512-May-2001 22:0012-May-2001 21:0912-May-2001 21:3012-May-2001 22:130:430:211:07





937503817-May-2001 17:3018-May-2001 00:4017-May-2001 23:307075865685218-May-2001 01:2112-Jun-20010.6817-May-2001 23:5518-May-2001 01:3018-May-2001 00:450:2518-May-2001 23:5918-May-2001 00:361:0618-May-2001 01:220:461:511:528:001:27




085220222-May-2001 08:5922-May-2001 20:501487136667322-May-2001 20:5826-May-20010.1322-May-2001 19:3922-May-2001 21:1522-May-2001 20:3022-May-2001 19:4622-May-2001 20:1622-May-2001 20:570:410:301:18





063517925-May-2001 22:4026-May-2001 07:3026-May-2001 03:402300219708526-May-2001 06:1203-Jun-2001-1.32:320:00




942501304-Jun-2001 18:0505-Jun-2001 00:5504-Jun-2001 22:0017535942501305-Jun-2001 01:1615-Jun-20010.3504-Jun-2001 23:2304-Jun-2001 01:0004-Jun-2001 00:151:2304-Jun-2001 00:0105-Jun-2001 00:132:1305-Jun-2001 00:133:162:130:120:50

024699811-Jun-2001 09:5211-Jun-2001 16:0511-Jun-2001 14:5075118438359211-Jun-2001 18:3612-Jun-20012.523:460:00

020603516-Jun-2001 11:3016-Jun-2001 21:5016-Jun-2001 21:1931560468414816-Jun-2001 23:2318-Jun-20011.5516-Jun-2001 22:1316-Jun-2001 23:4516-Jun-2001 23:000:5416-Jun-2001 22:3516-Jun-2001 22:421:2316-Jun-2001 23:230:412:042:040:071:10

098565926-Jun-2001 01:5226-Jun-2001 06:4526-Jun-2001 04:001653588931626-Jun-2001 07:3701-Jul-20010.8726-Jun-2001 04:5726-Jun-2001 07:1526-Jun-2001 06:300:5726-Jun-2001 06:0526-Jun-2001 06:472:4726-Jun-2001 07:360:493:373:360:422:39

004157326-Jun-2001 20:3026-Jun-2001 23:4526-Jun-2001 22:159055230493927-Jun-2001 02:1927-Jun-20012.5726-Jun-2001 23:3627-Jun-2001 02:1527-Jun-2001 01:301:2127-Jun-2001 01:2627-Jun-2001 01:413:2627-Jun-2001 02:210:404:044:060:152:45

044151829-Jun-2001 22:4530-Jun-2001 15:1530-Jun-2001 13:2511065943579630-Jun-2001 15:4906-Jul-20010.5730-Jun-2001 14:2730-Jun-2001 16:0030-Jun-2001 15:151:0230-Jun-2001 14:3030-Jun-2001 15:041:3930-Jun-2001 15:490:452:242:240:341:22

average2:352:57average0:403:371:32

median1:082:21median0:423:021:26

April-May count51

57count47count4853

> 3:0010

Order of diagnostics waiting diagnostic results RN busy (cant get tests done) UC busy/UC forgets to page Waits to page consultant (nights) MD delay in re-assessing patient after diagnostic results are backTriage DelaysMacro Flowchart ED Consult Process More diagnostics ordered level of experience of responding consultant Is it appropriate service? ordering of further tests prior to admit so dont have to wait for tests on ward transfers care to another service many ED patients to assess returns to OR/Clinic/Unit to d/c patientsConsult Delays

Diagram the ProcessReasons to flowchartDevelop common understanding of processGet a complete pictureEasily identify issues in the processduplication of effortsources of delaysnon value adding activitiesRedesign the processCommunicate changes to the process

Diagram the ProcessAnalysis of Flowchart / Process RedesignCan it be standardized?Does every step or activity add value?Is there duplication of work?Is it possible to simplify?

Exercise - Diagram the ProcessIn your group, create a flowchart of: EMS arriving at triage through to treatment space & transfer of care to RNSuggestions:use a post-it note for each stepfind a large space on which to work

The Improvement ModelPDSA

Trial and Learn Plan - Do - Study - Actmeasuring results and acting on themRe-evaluate and Continuous Improvementact, capture the gain and start all over

*

HealthcareQuality Improvement Model

STEP 2:

COLLECT BACKGROUND

DATA

STEP 1:

FORM TEAMS

STEP 3:

DEVELOP PROBLEM/ISSUE

STATEMENTS

STEP 4:

DIAGRAM THE PROCESS

STEP 5:

DETERMINE ROOT CAUSES OF

PROBLEMS/ISSUES

STEP 6:

VERIFY CAUSES WITH DATA

STEP 7:

CRITICAL REVIEW OF THE

LITERATURE

STEP 8:

DEVELOP AND SELECT THE

SOLUTIONS

STEP 9:

PLAN, TEST, IMPLEMENT THE

SOLUTIONS

STEP 10:

MEASURE RESULTS

STEP 11:

RE-EVALUATE AND

CONTINUOUS IMPROVEMENT

Getting Started

Getting Focused

Analysis

Decision Making

Implementation

Measurement

Continually Improve

Framework for Trial & LearningImprovement Model PDSA

The model consists of two parts: 3 questions & a cycle for learning and improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in I improvement?

Improvement CyclePDSA

Facilitates the use of teams to make improvementsProvides a framework for the use of effective measurement and use of improvement toolsEncourages planning to be based on evidence-based theoryEmphasizes and encourages learning (trial and learn)Empowers people to take actionCreates the will for improvement

Improvement Model PDSA

BreakthroughResultsTheories, hunches,& best practicesLearning and improvementPDASPDASPDASPDASTheories, hunches,& best practicesLearning and improvementPDASPDASPDASPDASRapid and repeated use of the cycle helps teams build knowledge sequentially

Use the PDSA Cycle forTesting or adapting a change ideaImplementing a changeSpreading the changes to the rest of your system

Hip Fracture Project Orthopedics and EDPurpose of Project: Reduce (ALOS) in ED for all hip fracture patients by 50%Fracture hip patients receive surgery within 24 - 48 hoursScope & Boundaries: All hip fracture patients at FMC site.Improvement Objectives: Optimize time to surgery to ensure patients receive high quality care with positive outcomesAddress co-morbidity factors prior to discharge.

PDSA Cycle 1Act:: Implement checklist to ensure streamline care of hip # pts.Study: Chart review of all # hip patients in ED. Does checklist decrease LOS in ED? Plan: Test feasibility of utilizing guidelines in ED Do: - Use Guidelines to develop a checklist for hip # pts in ED

Hip fracture checklist streamlines care = LOS in ED.

Improved communication between ED and Orthopedics

awareness of flow (ED to OR) PDSA 1 Learning's:

PDSA Cycle 2Act: Continue with PROF (Pre-Operative Fracture) bed until November 30, 2002Study: Findings - ALOS in ED & time to OR Plan: Test feasibility of having a designated PROF bed. Can anesthesiology assist with surgical clearance in timely manner? Do: - Create a designated bed for hip fractures on unit 72 - Work with anesthesiology to assist with surgical clearance

A designated bed (PROF) for hip #s enhances flow of patients from ED to OR

Right staff is caring for the right patient in the right bed

Pre-op delays are reduced PDSA 2 Learnings:

PDSA Cycle 3Plan: Work on effectiveness & efficiency of flow for hip # across continuum of careDo: Follow all hip fracture patients admitted to the FMCStudy: Chart & bed utilization review (ALOS in ED; Time to O.R.; ALOS as inpatient; patient outcomes)Act: Refine the flowchart = communication amongst care providers

Progress to date: ALOS in ED: ALOS in ED: 13 hours < 5 hours Time from admit to O.R: 5-7 days 17 - 24 hours Inpatient ALOS: 21 days 12 days Direct admits bypassing EDHip Fracture Project Orthopedics and ED

Run Chart: Hip # Patients (FMC)

BASELINE

Target in ED

Target to O.R

PDSA 1

PDSA 2

PDSA 1: ED Checklist EstablishedPDSA 2: PROF Bed OpenedPDSA 3: communication/awareness

Pt. To ICU d/t co-morbidity

PDSA 3

Chart2

26.536

896

932

1313

1316

824

817

1675

147

818

1056

1331

926

12.512

1736

12.535

1132

1050

9.568

3617

15.313

1212

584

512

924

731

414

715

215

511

514

428

210

415

615

510

442

227

715

48

47

319

526

618

28

319

310

521

221

1031

724

35

326

Hours in ED

Hours to OR

Patient Case Number

Hours

ALOS in ED; Time to O.R.

Sheet1

Case #Hours in EDHours to OR

1.026.536.0N/A

2.08.096.0N/A

3.09.032.0N/A

4.013.013.0N/A

5.013.016.0N/A

6.08.024.0N/A

7.08.017.0N/A

8.016.075.0N/A

9.014.07.0N/A

10.08.018.0N/A

11.010.056.0N/A

12.013.031.0N/A

13.09.026.0N/A

14.012.512.0

15.017.036.0

16.012.535.0

17.011.032.0

18.010.050.0

19.09.568.0

20.036.017.0

21.015.313.0

22.012.012.0

23.05.084.0

24.05.012.0

25.09.024.0

26.07.031.0

27.04.014.0

28.07.015.0

29.02.015.0

30.05.011.0

31.05.014.0

32.04.028.0

33.02.010.0

34.04.015.0

35.06.015.0

36510

37442

38227

39715

4048

4147

42319

43526

44618

4528

46319

47310

48521

49221

501031

51724

5235

53326

Sheet1

26.536

896

932

1313

1316

824

817

1675

147

818

1056

1331

926

12.512

1736

12.535

1132

1050

9.568

3617

15.313

1212

584

512

924

731

414

715

215

511

514

428

210

415

615

Hours in ED

Hours to OR

Patient Case Number

Hours

Run Chart: Hip # Patients

Sheet2

Sheet3

Mention that we didnt have time to OR in baseline data on individual cases; however we did have the mean time to OR as within 5-7 days prior to initiation of test cycles.

Emergency Triage ProjectChallenge: at-risk patient population in triage line-ups and waiting rooms triage practices targeted for QI11 step HQI methodology PDSATrial and Learn for change ideas: sequential building of knowledge breakthrough results

REDIS Snapshot Over Capacity

Site Core Teams(FMC, RGH, PLC)Ideas to Test: Rapid assessment of line-up by RN Promote information/security in waiting room Consistent communication Re-allocate resources D.I. patients at triage desk ED patients presenting x 2 at triage

Criteria for a Good Action PlanSMART Planspecificmeasurableaction orientedresponsibilities definedtime lined

Rapid Triage AssessmentTest cycles:nurse educator to assist assessing line-uppost-it notes > 5 patients in line-up or PRNone day/one nurse spread dedicated chair for sicker patientsre-allocate staff

Rapit Triage - Graph

317

319

216

418

323

216

629

421

526

419

Rapid Triage

Normal Triage

Minutes

Mean Time to Primary Assessment at RGH Triage

Sheet1

Rapid TriageNormal Triage

2001Oct. 5317

Oct. 15319

Nov. 7216

Nov. 10418

Nov. 13323

Nov. 18216

Dec. 10629

Dec. 14421

2002Jan. 9526

Jan. 12419

Sheet2

Sheet3

Re-evaluate and Continuous ImprovementPDSAPlanDoStudyActact, capture the gain and start all over

Exercise : Create a Plan for a PDSA CycleWhat is the objective of this cycle?What change are you testing?What is your prediction?Details of the planWho ?What ?Where ?When?How?

Anyone who has never made a mistake has never tried anything newAlbert Einstein

Create a PDSA Cycle for EMS Delays

Go forth and work.

Questions?

Simplify the data - runcharts are easy to understand

Attention getting - easy for people to see the impact of change!3Simple method to improve performance

3 fundamental questions that provide a framework for trial & learning approach

Focus on the questions, thus emphasis on framework for learning, the use of data and design of small trialsDevelop Plan - 5 Ws - who, what , when, where, why & howDo: trial on small scalecollect dataStudy:Compare the results of the test with the predictions madeDATA - different methods of capturing;- ease of collecting data- plotting data- special causeAct: Turn the learning's into action

Next PDSA Creates an environment of reasonable risk taking

BEFORE going to next slide:

TALK ABOUT CHANGE - CREATIVITY

Think outside of the boxChallenge your boundariesi.e. direct admits were being admitted through ED.

Increased waiting timesIncreased number of critical incidentsIncrease number of patient complaintsstaff anxiety and concern

Recommendations - communication Re-assessments Initiating labs at triage

Challenge the boundaries:triage window was boundary - move beyond it

Communication - P.A. system (comfort level for some initially - spread to others)

Involve pertinent team members - one at a timeRe-evaluated purpose of resuscitation room -

They are patient care areas that can be utilized for sicker patients until another bed is available

Use of huddles to communicate test cycles & learning

Plotting data over to time to communicate success

qi: “just do it!” emergency medicine residents july 31st, 2003 jamie jones, qi consultant, qihi...

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