visual communication services – alfred template neat within the hospital culture, strategy and how...

VISUAL COMMUNICATION SERVICES – ALFRED TEMPLATE

NEAT within the hospital Culture, strategy and how to embed timely quality care

or

Don’t mention the war!

ACI/NSW Health/ECI Seminar, Sydney, 13th December 2013

A/Prof Harvey Newnham,Clinical Program Director Emergency & Acute Medicine,Director of General Medicine,Alfred Health, Melbourne


How are we doing?

Improved Much the same Worsened No idea

1. Quality of patient care in your sphere of influence in 2013 compared with 2011 is ……………..?

2. In what way do you feel the 4h NEAT approach to date has contributed to quality of care?


Survey of Directors of Victorian

General Medical Units

September 2013

Certainly has led to increased focus on patient through put and we have implemented some practice change to improve thisFocus on KPI's to the detriment because we are treating a performance measure as an objectiveThe 4 h NEAT target has been a catalyst for some positive changes although there are balancing negative effectsHave noticed very little difference in realityIt has helped focus on what was previously very poor and unpatient centred performance.

Pressure on JMS to discharge patients and to transfer patients to ward regardless of clinical management requirementsIt has been challenging to maintain the high standard of patient care but feel we have achieved this.Shorter ED length of stay and earlier contact with the treating team has lead to benefits overall

There have been stress points with ED at times and some tensions that we have had to resolve Pressure leads to deterioration in behaviours General medicine is looking closer at internal structure and perhaps not filling gaps in other services as it was previously We have been better accepted by ED people

The registrars feel more stressed and there has been some pressure put on them by ED staff which they have found difficult to manage Resources allocated to assist with achieving targets We have had to operate within existing budget It has helped focus on gaps in rostering

Consistent practice, excellent senior staff input, wonderful nurses and junior medical staff with great nursing leadershipVery happy with care once they get in.


The Zen of HealthcareIt’s not about what happens.

It’s about what you do with what happens.

Modified from Aldous Huxley


Working in healthcare:

What’s not to like?The people:

Smart,

Experienced,

Committed,

Ultimately want to do the best job they can for our patients

Very substantial Resource

High degree of public, political and administrative Engagement


Context of NEAT:Essential problems in delivery of careFor many patients we don’t know what to do.

When evidence exists it is often not applied.

Fidelity of execution.

Our health system is tweaking an historical model of care rather than designing its own future

Solution: Design and create a comprehensive system for delivering health care.

Richard Bohmer “Designing Care” 2009

All just too hard


Don’t mention the war(However will we win?)

It’s not about 4 hours – pebble in a pond


It’s not about working harder

E &TC cubicle occupancy May to August 2011, 2012, 2013

2011

2012 2013

2009

Which department would you prefer to work in?


Timely Quality Care (TQC) Transforms the way we treat our patients to

ensure they all receive timely, quality care consistent with their clinical needs

Is a whole of health service change that involves everyone (clinicians, managers and support staff)

Changes how we assess and treat our patients from the moment they arrive to the time they are discharged

It is about excellence in patient care


It is a new paradigm‘It is no longer tenable that a good practitioner can provide the best care other than as part of an effective team within a well organised health care delivery system.’

Translated into medicalese: We can enjoy what we do, use our skills to provide effective care,

have a manageable workload and maintain reasonable remuneration, if we learn how to be part of an effective team.

Management speak: We want everyone to work at the mid-upper level of their

competency. We all need to

• work differently or • be paid less or • get off the bus.


The Good News

The best innovations happen within the tightest constraints

Paraphrased from Clayton Christensen, in ‘the Innovator’s Prescription’


Our Timely Quality Care Journey


Alfred Health

3 hospitals: The Alfred; Caulfield Hospital & Sandringham Hospital Around 900 beds; 90,000 ED presentations, 92,000 inpatient events;

170,000 outpatient attendances. Approximately 5000 equivalent-full-time staff made up by around

7000 people State-wide services for trauma, burns, heart & lung transplants, HIV /

AIDS, hyperbaric service, cystic fibrosis, haemophilia, Melbourne Sexual Health Centre

$900 million per annum Strong General Medicine

Highest bed-day user

The Journey starts:

Harvey H Newnham, Pieter De Villiers Smit, Martin J Keogh, Andrew M Stripp, Peter Cameron MJA 2012 p101

In August and September 2010, four of us (H H N, P De V S, M J K, A M S) undertook an investigative tour of 13 emergency hospitals in the United States and the United Kingdom to observe innovative approaches to patient flow pathways from the emergency department (ED) to inpatient wards and consider their potential for use at Alfred Health


The Journey towards Timely Quality Care

E&TC and Acute/GenMed in same program

Site visits US & UK 2010

In house conversations

Individual unit developments –

AMU model of care etc, E&TC modifications

Formation of Whole of Hospital TQC Steering Group

Data, and more data

Site visits to Perth Hospitals

Importance of engaging HMOs

Draft principles established for whole of hospital approach

Stakeholder input into principles

Sign off by HOUs of principles

Travelling roadshow by COO

E&TC Design sessions

Launch of daytime TQC Nov 2012

Formation of Hospital at Night steering committee late 2012

–Conversations about hospital at night–Draft principles established–Stakeholder input–Promulgation of hospital at night plan–Launch of hospital at night (ie 24h TQC) Feb 2013

Ongoing monitoring by steering group


TQC – Craft group specific approaches to implementation


Leadership Workshop


Concerns must be voiced and taken seriously


GENERAL MEDICINE DESIGN WORKSHOP


Key Whole of Hospital Changes

Trust The Emergency physicians’ decision to admit The inpatient team to promptly provide appropriate

care The investigative/interventional services to deliver in

24 hours (treat in turn) Management to apply resources according to system

design/priorities based on accurate data Adjust rosters/work patterns to ensure staff are available

when required Match bed capacity to the time of highest demand and

ensure patient goes to the correct bed first time admission beds, SAAU’s, MAAU's & Flex beds

Develop safe after hours/overnight teams


Triage has become Streaming

3 minute assessment maximum ATS allocated (? is it still relevant)

Patients streamed to either: Resus & Trauma: RITZ:

Prioritise Cat 2 & AV to front of queue Everyone else treat-in-turn

Fast Track: Treat-in-turn


Upfront Senior Decision making for all patients….

RITZ (Rapid Intervention & Treatment Zone)

Consultant led assessment team Determine interim management and

disposition plan “Treat in turn” principle instead of

“triage & wait”


Safety is OK


Dr Foster global health comparator

Alfred Health


Bypass: Our Doors are Always Open

The Alfred


NEAT 4h KPI July 2011–March 2013

NHPA website Sept 2013

The AlfredTarget 75%


Patient Access as per NEAT

Acute General Medicine Patient Pathway

*Via call to streaming APT registrar & nurse.

With interim orders DIRECT ADMITfrom community,

clinic or other hospitalvia call to *lead

consultant

RITZ

HOMEor

CH, SH, HITH, private hospital

E & TC

Team ATeam B

Ward 4GMU

4 Identical teams A-DConsultant (8-12/1600*pm)APT (8-1700)BPT (8-2130)2 x Interns (8-4 & 11-1930/2130)Daily consultant ward round

*Lead Consultant

Patient

Team CTeam D

Ward 4AMUStreaming

APTStreaming

nurse

AAU

ESSU Cubicles

As at 2nd December 2013


TQC GenMed % E&TC Admitted <4hJune-November 2013


Staff Experience – 12 months on…….


What NEAT is showing usBefore NEAT

Good Doctor + Experience + Resources = Best Care

Doctor: custodian of knowledge, skills and application of these to the individual patient

Organisation: provider of resources

After NEAT

Health care delivery organisation manages….

Practitioners - typically in multidisciplinary teams

Knowledge base - decision support and practice-based evidence

Processes of care – reduced variation and delays, outcome orientated

to provide best healthcare outcomes at affordable cost

Adapted from Richard Bohmer “Designing Care” 2009


10 Big Ideas Future Hospital Commission 2013: “the most important statement about the future of British medicine for a generation”

“Hospitals must offer “seven-day care, delivered where patients need it”.

It's time to build a new movement for generalism, not specialism—”generalists are the undervalued champions of …acute hospital service”.


Major Gaps

Practice-based evidence is in its infancy in our systemCan’t implement change unless monitoring systems are good enough to

learn from mistakes and measure failure

Integration is essentialThe divide between hospital and community care leaves us impotent

regarding demand management


Where next?PM’s & weekends

Treat-in-Turn expansion Cardiology

Gastroenterology

Patient discharge pathway

Matching staff with workload (volume and time)

New ward governance models

Standardisation of ward rounding

How many admitting units do we need?


ConclusionsDon’t mention the war – it’s not about the 4 hour KPI!

It’s not about working harder -

• It is about leadership, teamwork, design, and reducing variation

• Hospitals are full of smart people, we need to create the environment/culture that allows them to achieve their potential

It is about quality and excellence in care – quality saves time and money

It is a journey that your staff have to travel with you

Let’s get the job done and move on to address the bigger issues


Acknowledgements

Martin Keogh – Services Director, Emergency and Acute Medicine

Andrew Stripp – Chief Operating Officer

De Villiers Smit – Director Emergency Services

Peter Hunter – Program Director of Aged Care and Rehabilitation

Andrew Way – CEO

Bill Johnson – Program Director Surgical Services

Amy McKimm – Redesign manager

Many, many others


GenMed Team Staffing Dec 2013+

8am

12pm

5pm

7.30pm

9.30pm

WEEKDAYS WEEKENDS

APT BPT INTERN BPTCONCONA B C DA A B C D A B C D A B C D A B C D A B C D

1pm

INTERN


“Culture Eats Strategy for Breakfast”

Pre TQC Post TQC

You can’t remove triage Don’t bring back triage

That’s ED’s problem The hospital working more as a team

I was the wall Thanks for the referral I’ll see them on the ward

At night I see what’s on my list and just get on with it

We have a night team and meet at 9 for handover

Frequent unnecessary overnight calls to on-call staff

The After Hours Clinical Lead can decide

What training overnight Its great to get support, mentoring and education after hours

I would never ask a registrar to do one of my jobs

I’m not alone.

This is just about government targets ???? not so sure now


Re-thinking E&TC Practices & Processes

Completely change triage Move from triage to streaming model

More timely care to reduce E&TC occupancy

Upfront senior clinical decision making “Treat in turn” instead of “triage and wait

New team structures Clarity of Roles & Responsibilities

E&TC to use their authority to admit Reduce need for negotiation & delay

Time based targets five years on: The WA perspective

and other lessons.

Dr Mark Monaghan

What has this been about?

Enhancing access to care for acute patients and making access to care a central component of excellent clinical care.

Replacing processes that are burdened with waste and protectionism, and thereby reducing morbidity, length of stay and mortality.

Creating a more effective system to cope with increasing demand.

Instilling the concept that hospital beds are a valuable resource that we as clinicians have a responsibility to utilise in the most efficient way possible.

What has this been about?

Key achievements – WA Program

Implementation of large scale, statewide change program

Establishment of redesign capacity across the system

Invested over $40M in solutions Leading the nation in emergency access reform

Where are we now?

In terms of numbers and targets, the WA State NEAT performance in high 70‘s, with our tertiary site performance stalled or deteriorated slightly.

Where are we now?

From a hospital clinician perspective it has created an improved work environment that persists despite challenges in maintaining tertiary performance.

The concept of the need to flow patients efficiently has been embedded to a significant degree. It is part of our language now.

A quick scan of the data

Presentation numbers compared to ED hours of care

Access block and mortality

Beds saved for ED presentations at Tertiary hospitals

What happened in 2012?

Transition from project teams to hospital executive ownership.

Consequent lack of drive of solutions and solution review.

Significant ED demand. Ministerial focus on NEST.

So what did we do about this performance trajectory?

We attempted to rally managerial and clinician engagement, however we were struggling to know where to start.

The Minister for Health commissioned an external review –The Bell Review.

The Bell Review

Daily accountability /core business Data Bed management structure/ outliers/ the

clinician’s role Consultant lead service-weekend performance Align multi-professional teams for timely

treatment and decision making ED discharge stream perfomance, decreased

patient moves within ED.

The Bell Review

Capacity audit analysis. 25-30%, half of which is under hospital control.

Simplified points of access to specialties. Acute unit structure and staffing. “a safe haven”,

with focus on inclusion rather than exclusion criteria.

Appropriate IT solutions

The Bell Review

Essentially, the take home message was that if you want this to be successful, you have to get serious and run it like a professional business should run.

What has happened since

Executive restructuring was already occurring in several of our tertiary sites. This is occurring across all tertiary sites now.

This includes leadership training, greater time allocation to divisional heads, JDF changes to incorporate NEAT accountability (eg FSH).

What has happened since

Bed management disassembling and increased clinician involvement.

Services to provide seven day structure –endpoint being equivalent discharge rates to weekdays

Data/CapPlan utilisation for daily clinician bed management.

Some real accountability and ownership is being seen at a hospital level.

Some general observations to consider

ED versus Inpatient reform. Flogging the discharge stream The admission stream dilemma. Direct admissions, inpatient occupancy and the

core role of the ED The future of NEAT The ministerial drive effect

Thanks

visual communication services – alfred template neat within the hospital culture, strategy and how...

Documents

melbourne slide

rostering slide

overall slide

health care

quality of care

alfred health

quality of patient care

delivery of care