Wednesday 18 th November 2015 Improving Flow with Institute of Healthcare Optimisation (IHO) Variability Methodology.
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Wednesday 18th November 2015
Improving Flow with Institute of Healthcare Optimisation (IHO)
Variability Methodology
Session Outline
• Flow Programme Overview• IHO Methodology• Guided Patient Flow Analysis (GPFA)• IHO Flow Improvement Projects• Discussion on GPFA charts
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Where does Flow Team fit within Improvement Landscape?
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About IHO
The Institute for Healthcare Optimization (IHO) is an independent not-for-profit research, education and service organisation based in Boston, focusing on bringing the science and practice of operations management to healthcare delivery.
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Proof of Concept Approach5
Tranche 1: Building Capacity
& Capability
Tranche 2: Implementation
Tranche 3:Evaluation &
Spread
Establish Pilot Board Teams
Operations Management
Education
Patient Flow Assessment
Identify Patient Flow Redesign
Project
Implement Chosen Redesign(s): 1.Operating Theater
2.Surgical Inpatient Flow
3.Medical Inpatient Flow
Develop Scale-up Program
Disseminate Tranche 2 outcomes
Finalise Plan for Spread (within hospital boards and at a national level)
Develop tools and materials
Execute Spread
NHS Board Engagement
• June 2014 – 4 Pilot Boards begin (Tayside, Borders, GG&C, Forth
Valley)• June 2015
– Pilot Boards begin data collection for Implementation Project– 6 Mainland Boards begin initial analysis (Wave 2)
• Early 2016 – Wave 2 Boards choose implementation project– Wave 3 Boards begin initial analysis
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The Goal in Healthcare?
• To Deliver the “Right Care”• To the “Right Patient”• At the “Right Time”
Possible?? Yes, if:• We know when the patient will get sick• We know the disease, the severity and response to therapy• We can provide the right caregivers and therapies
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Variability in Healthcare
Clinical – Patients present with different diseases, different severities, and have different responses to therapy
Professional – Providers have varying levels of experience, training and innate ability
Flow – Patients arrive at various times
Natural – Random, statistically predictable, can be managed with operations management techniques (queuing theory), cannot be eliminated
Artificial – Non-random, non-predictable, unstable, must be reduced or eliminated
Sources of Variation within a Clinical Sources of Variation within a Clinical System that impact on patient flowSystem that impact on patient flow
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GPGP DischargeDischargedd
StaffStaff Skills Illness Motivation Shifts Holiday Training
ProcessProcess Unclear
Guidelines differ Complications in anaesthetics
PatientsPatients Age Race Sex Motivation Disease Education
Machines not Machines not the same the same
Supplies Supplies
Rooms not Rooms not the same the same
EquipmentEquipment
TranscriptionTranscription
Transport Transport
Applications Applications
InformationInformation
80% is within 80% is within our control!!our control!!
Our Challenge is to:
Understand the sources of variability and their effects on patient flow and then to:–Optimally manage “Natural/Uncontrollable”
Variability– Eliminate or reduce “Artificial/Controllable”
Variability
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How? Apply IHO’s Variability Methodology
What is Guided Patient Flow Assessment (GPFA)?
• Supports identification and understanding of patient flow issues in a chosen hospital(s) based on local data• Qualitative:
• Guided Patient Flow Questionnaire• Quantitative:
• Guided Patient Flow Assessment Analyses
• Identifies opportunities for improving patient flow using IHO Variability Methodology™
6. El IP. Weekday average elective admissions
7. El IP. Weekday average elective admissions
8. El IP. Weekday daily admissions
9. El IP. LoS in days10. El IP. Distribution of surgical elective admissions to wards by specialty.
12. Hosp. Weekday daily admissions run chart:•Elective •Non-elective
11. El IP. Distribution of surgical elective admissions to specialty by wards.
17. El IP. Average recovery waiting time for admitted patients by destination ward.
18*. IP Average waiting time for discharge or transfer by ward.
20. Surgical wards. Average weekday occupancy by day of week.
Elective Flow(Option 2)
14. AMU. Avg LoS for admitted patients by destination ward.
13. ED. Avg LoS for admitted patients by destination ward.
15. ED. Avg waiting time for admitted patients by destination ward.
16*. AMU. Average waiting time for admitted patients by destination ward.
19. Medical wards. Average weekday occupancy by day of week.
22. ED. Day of week avg wait time from decision to admit to admission.
23*. AMU. DOW Avg wait time for all patients from decision to admit to specialty ward. 24*. Surgical25*. Medical.
26. Hosp. LoS for unscheduled care medical patients by discharge day of week.
27. Hosp. LoS for unscheduled care medical patients by admission day of week.
28. Hosp. GP referred unscheduled care patients average LoS by day of week.
29. Hosp. GP referred unscheduled care patients average attendance time by hour
Un - scheduled Flow(Option 3)
Balancing Measures
21. Proportion of medical and surgical admissions by ward.
ScotPFA - Overview of Analysis MapOperating Theatres(Option 1)
1. OT. Weekday daily cases
• Elective • Expedient• Emergent
2. OT. Weekday daily case hours:•Elective •Expedient•Emergent
3. OT. Weekday activity average :•Elective •Expedient•Emergent
4. OT. Weekday activity average:•Day case•Non-elective IP•Inpatient
5. OT. Time of day activity/booking:•Booking*•In-room/theatre
18*. IP Average waiting time for discharge or transfer by ward.
Shows variability in theatre activity. Variation in the elective
volume is driven by scheduling patterns and
practices.
Does this variability lead to the cancellation or
delay of elective cases?
Significant number or % of emergent and expedited
cases requiring rapid access to the theatre
suggest “Re-engineering Theatres” project
opportunity
Are many low data points linked to certain days or
suggest underutilisation?
Analysis 1 - This analysis is a “line chart” showing the number of elective, expedited, and emergent cases that were performed on each non-holiday weekday in the period being
analysed.
This chart helps ascertain whether the theatres are having reasonable success at mitigating the effects of variability in
case volume on theatre workflow by matching high volume days with shorter
cases.
Evaluate if days with higher case hours affect the number of elective
cases cancelled or postponed.
Did the low data points from chart 1 correspond
with those in chart 2?
Analysis 2 - This analysis is a “line chart” showing the total hours of elective, expedited and emergent cases performed each day in the time period being analysed, as well as the averages
for each type of case over the course of the period.
Which wards have the highest average LOS or peaks in LOS?Are these wards likely to be bottlenecks, or are there other
reasons for this pattern?
Analysis 13 - This analysis is a bar chart showing the average ED length of stay for admitted patients, by admitting unit and error bars showing the 10th and 90th percentile wait times for
each day of the week.
Wards driving a high average and/or peak in ED LOS may be bottlenecks (or upstream
from bottleneck wards).
Also look at this data for Assessment Units
Analysis 15 - This analysis is a bar showing the average ED wait time for admitted patients, by admitting unit and error bars showing the 10th and 90th percentile wait times for each day of
the week.
Wards with a high average and/or peak in wait time may be bottlenecks (or upstream
from bottleneck wards).
Which wards have the highest average wait times or peaks in wait times?
Are these wards likely to be bottlenecks, or are there other reasons for this pattern?
Validation and Interpretation
• Local Engagement and Buy in• Understanding the cause(s) of variation• Local decision to choose most suitable
project options for redesign
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What is the purpose of the Guided Patient Flow Analysis
• The GPFA gives a high level overview of patient flow through hospitals• It has been designed to highlight artificial variation and patient flow issues
that IHO’s Variability Methodology™ can address• The analysis should help direct Boards towards a preferred implementation
project• At this stage it is not:
– a demand and capacity exercise– a specialty or procedure specific deep dive– an answer to everything!
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Variability Methodology
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Allows for optimal management of medical wards
leading to right-sized units and
decreased ED and acute receiving
delays
Helps ED and inpatient wards by smoothing elective
admissions and reducing
competition for beds, stress,
overload and waste
Improves theatre access, safety and
efficiency by balancing
unscheduled and scheduled flows
IHO Redesign Project Options
OPTION 1 Theatre
Reengineering
OPTION 2 Redesigning
Surgical Inpatient Flow
OPTION 3 Reengineering
Medical Inpatient Flow
Option 1: Reengineering the Theatres
Project aims:•Balancing resources and flow of time sensitive surgical cases and elective scheduled surgeries •Improve theatre access •Decrease daily operational chaos resulting from competing demands
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Option 1: Reengineering the Theatres
Activities•Retrospective data submission – 2 years•Urgency classification system - develop, implement and monitor•Prospective data collection - 3 months
– Including surgical booking time
•Standard operating procedures •IHO Modelling - present redesign options•Select a redesign option•Implement•Monitor
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Stakeholder Engagement
Option 1 Benefits
• Decreased wait time for emergent surgeries and improved compliance with desired maximal acceptable wait times
• Decreased Theatre overruns• Increased overall Theatre utilisation• Decreased hospital Acute Length of Stay (ALOS) for urgent/emergent patients• Improved outcomes for urgent/emergent surgical patients• Enable further Theatre efficiency improvement such as on-time starts, lower turnover
time, and high performance teams for elective blocks• Improved patient satisfaction relating to decreased elective case delays on day of surgery• Improved staff satisfaction and retention
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Glasgow Royal Infirmary Project 1 – June 2015Experience of Implementing a new Surgical Urgency
Classification for Theatres
EXPERIENCE BEFOREEXPERIENCE BEFORE•Inconsistent scheduling emergency cases.•Challenges to access surgery for the right patient at the right time •Competing demands between specialties•Urgency of patients not accurately recorded
UPDATED PROCESSUPDATED PROCESS•Standardised booking process and case review•Surgical Urgency captured at time of booking•Weekly ‘compliance’ metrics reviewed by clinical leads •Electronic view of all patients scheduled for emergency theatre
EXPERIENCE AFTEREXPERIENCE AFTER•Dynamic and patient focused approach to scheduling of emergency theatres•Clarification of patient demand by clinical urgency for every case•Informed discussion to schedule individual cases based on clinical need•Avoids conflicting and competing agendas•Good clinical engagement
* GRI implemented a Theatre Hub as part of a planned redesign rather than IHO project. The combination of this redesign and the rigour of IHO’s process redesign has been entirely complimentary
Process Implemented June 2015
Option 2: Redesigning Surgical Inpatient Flow
Project aims:•Smooth elective surgical flow to inpatient wards •Improve quality and safety of care on surgical wards •Decrease competition between scheduled and unscheduled flow on inpatient wards •Enhance elective surgical or medical throughput (or both) depending on the hospital’s priorities.
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Option 2: Redesigning Surgical Inpatient Flow
Project Activities:•Retrospective data submission – 2 years•Prospective data collection to quantify your true elective inpatient admission volume for the selected service(s)
– Including expected LOS, expected level of care and waiting time in recovery•Identify opportunities for smoothing elective admissions •Understanding resources required to achieve this
– Prospective scheduling options, including surgical team availability•IHO Modelling - present redesign options•Select a redesign option•Implement •Monitor
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Stakeholder Engagement
Option 2 Benefits
• Increased throughput in smoothed inpatient unit or ward• Increased placement of patients in the preferred ward with decreased
Recovery wait times and inter-unit transfers• Higher reliability in nurse : patient staffing level leading to lower
morbidity and mortality• Improved staff satisfaction and decreased use of nursing overtime• Quality improvement in terms of decreased readmissions, decreased
use of RACE teams, decreased rate of Hospital Acquired Infections (HAIs) and patient safety issues
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Option 3: Reengineering Medical Inpatient Flow
Project aims:•Alleviate medical ward bottlenecks by addressing artificial variability in admissions, discharges and transfers (ADT).
•Improve throughput in selected medicine wards by ensuring appropriate patient placement and improving the timeliness of admissions, discharges and transfers out.
•Create the opportunity to right-size medical wards to better match capacity with demand.
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Option 3: Reengineering Medical Inpatient Flow
Project Activities: •Retrospective data submission – 2 years•Admission, discharge and transfer (ADT) – Develop, implement and monitor•Prospective data collection - 3 months
– Including ready to move time•IHO Modelling - present redesign options•Select a redesign option•Implement•Monitor
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Stakeholder Engagement
Option 3 Benefits
• Increased placement of patients in the preferred units or wards / decreased boarding
• Decreased wait times in the ED and/or assessment or medical receiving units • Decreased inter-ward transfers • Improved ED and inpatient unit staff satisfaction • Potential decrease in acute LOS • Quality improvement in terms of decreased readmissions, decreased use of
RACE teams, decreased rate of HAIs and patient safety issues because patients are more likely to be placed in preferred units
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Forth Valley Royal Project 3 – June 2015Experience of Implementing a new Admission, Discharge and
Transfer criteria for medical inpatients on B32
EXPERIENCE BEFOREEXPERIENCE BEFORE•Inconsistent on lack of any criteria for transfer into or out of a ward area •Challenges to access inpatient beds for the right patient at the right time •Prolonged delays in moving patients through the hospital system from assessment unit to inpatient bed to home
UPDATED PROCESSUPDATED PROCESS•Standardised admission, discharge and transfer criteria for general medical and GI patients•Ready to move times captured at time of patient meeting set criteria•Monthly review of compliance metrics (e.g. premature transfers)•Data captured for the first time on when patients meet criteria
EXPERIENCE AFTEREXPERIENCE AFTER•Improved care planning and reduction in delays•Improved timely access from Assessment Unit into B32•Structured process to review patients daily within the ward•Spreading process across the medical inpatient wards to improve timely access to all medical wards•Good clinical engagement
Process Implemented June 2015
Summary
• IHO Project still Work in Progress– A lot of hard work– Clinical engagement and Executive commitment
essential• Boards already seeing benefits before redesign• Data crucial to improvement• A long way to go…
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Questions & Discussion on
Handouts
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