Beyond Overcrowding: Western Canadian Forum on Innovation ... 1 SK Multi... · Kaizen Event Process Identify the changes required to implement the new process(es) such as staffing,

Beyond Overcrowding: Western Canadian Forum on Innovation and Evidence-based Decision Making in

Emergency Care

October 26 & 27, 2007

Presenters

� Suann Laurent , Senior Vice President, Health Services, Sunrise Health Region, and

� Dawn Calder , Executive Director, Medical Administration, RQHR

1. Multi Region Program Objectives

2. The Journey

3. Pilot Project

4. Lessons Learned

5. Next Steps

Agenda

Challenges:� Lack of timely access to beds at the tertiary care centers and the home

� region inpatient units

� Patient transfer processes are not standardized� Inconsistent exchange and availability of patient information within region

Charter: Improve the flow of patients between regions by providing coordinated and timely access to care appropriate to their needs.

Objectives:� Develop a full understanding of patient flow between tertiary care centers and home

regions care centers. � Develop viable ideas/solutions to optimize the flow of patients between the regions.

� Implement pilot solution(s), measure and document the improvement outcomes

Multi-Region Patient Flow Project:Challenges, Charter & Objectives

Project Overview

� Analyzed and documented current processes for patient movement between the four health regions and RQHR tertiary acute care

� Identified staff, process, information and policy issues that prevent effective patient flow

� Identified leading practices

� Redesigned patient transfer process and piloted it in Sunrise Health Region

The Journey

Current State Assessment – 1 day in each region(June 14/15, 2006)

� interviewed 108 stakeholders in 5 regions

� reviewed current processes, forms and performance data

� summarized findings

The Journey

Developed current state value stream maps – two fulldays for Design Team (June 28/29, 2006)� conducted training session – learned about Lean, Six Sigma and

other tools

� developed value stream maps

�from Home Region ED to RQHR ED

�from Home Region Inpatient to RQHR Inpatient

�from RQHR Inpatient to Home Region Inpatient

�from RQHR Inpatient to Home Region Homecare

�from RQHR Ambulatory Care to Home Region Homecare

�from Home Region Inpatient to RQHR ED

Multi Region Patient Flow:Current State Value Stream Map

The Journey

� Data collection (September 2006)

� Leading practices document (September 2006)

� Data analysis (early October 2006)

Objectives / Outcomes:

� Review the data analysis of the Current State Value Stream Map (cVSM)

� Identify root causes of inefficient patient transfers within the Multi Region

� Identify solutions to address the root causes using a variety of techniques

� Prioritize the solution using a Prioritization Matrix

1. Hi Benefit / Lo Effort 2. Hi Benefit / Hi Effort

3. Lo Benefit / Lo Effort 4. Lo Benefit / Hi Effort

� Identify project(s) to pilot

Identified over 200 solutions

Selected -a hybrid of two projects - the best attributes of bo th projects

Identified and developed project charters for 7 Hi Benefit / Lo Effort projects

Future State Workshop

Root Causes Analysis Example

� Proactive patient education through a patient pamphlet, physician transfer document to expedite defining the target discharge date (TDD) and communication of the discharge plan and date with physician and regions

� Comprehensive Use of RQBedline Across Southern Health Regions

� Maximize Internal Regional Health Authority Capacity

Identified Projects

Identified Projects

� Collaborative Policies, Procedures and Standardized Forms between tertiary care and the regional health authorities

� Efficient use of existing technology – telehealth and teleradiology

� Central Coordination of EMS Transfers

RHA ED TO RQHR EDRHA IP TO RQHR ED

Management of care in home region

Electronic Health Record

Specialists see pts. In timely manner

MRI/Nuclear med in some home regions

Sharing specialist supportMobile team and resources

Standardized info sharing

Central EMS coordination

Use all available technology

Specific support to EMS to EMS arrivals

pt. holding/assessment area

7-day /week tertiary services

Use bedline for referrals to ED

1

3

5

1 3 5

Effort

Ben

efit

Prioritization Matrix Example

Solutions Priority Matrix

5> 6 months

Outside the scope of the Multi Region

e.g. Need SaskHealth Approval

Extremely High

>$20,0005Extremely

Highabove 30%>$20,0005

33 – 6

months

Other departments require within

the Multi Region e.g. IT

Moderate$10,000 -$20,000

3Moderate10% - 30%$10,000 -$20,000

3

1<3 monthsWithin the

Scope of Multi Region Team

Little<$10,0001Little0% - 10%<$10,0001

RankingProject

TimeframeProject

RequirementsEffort

Project Cost

RankingBenefitEstimated Improve-

ment

Cost Savings

Ranking

Ranking Reference

The Journey

Pilot Project Goals:

� To ensure physicians and staff in SHR and RQHR are aware of and using RQBedline when appropriate.

� To provide timely and appropriate information to referring regions and RQHR on the use of RQBedline.

� To manage patient expectations for transfer process.

� To standardize policy, protocol and set of information to travel with patients.

KAI•ZEN

Kaizen – Rapid Improvement Event – three full days forKaizen Team (December 5 – 7, 2006)

� Kaizen – Is a rapid improvement event usually lasting from 2 – 5 days

� Kai – Take Apart

� Zen – Put Together/Make Better

Kaizen Event Process

� Identify the changes required to implement the new process(es) such as staffing, roles, training, policies, procedures and information.

� Identify the activities that need to be completed to prepare for a pilot of the new process(es) in one selected health region.

� Trial and verify the applicability of the pilot project materials in the clinical settings

� Develop metrics and targets to measure the success of the pilot project

� Finalize the pilot project logistics

Kaizen Accomplishments

Pilot Project Goal 1: To ensure physicians and staff in SHR and RQHR are aware of and using RQBedline when appropriate.

Activities� Developed education material (presentations) to roll out to

physicians and nurses� Developed an awareness poster and a tear pad to be

placed in hospitals, clinics and physician's offices� Developed a comprehensive communication plan on how

to inform various stakeholders

Kaizen Accomplishments

Pilot Project Goal 2: To provide timely and appropriate information to referring regions and RQHR on the use of RQBedline.

Activities� Revised Bedline Case File� Developed a Call Process Swim Lane � Developed a Fax Disposition for Physicians� Created a Data Base for reporting� Identified data points for each stakeholder� Developed an education tool for Bedline staff

Kaizen Accomplishments

Pilot Project Goal 3: To manage patient expectations for transfer process.

Activities� Developed and verified patient transfer fact sheet and

poster for hospitals waiting rooms � Modified the EMS satisfaction survey� Revised the roll out plan (pilot marketing plan)� Made contact list of Team members

Kaizen Accomplishments

Pilot Project Goal 4: To standardize policy, protocol and set of information to travel with patients.

Activities� Modified and trialed NISS Inter-Agency Referral Form� Contacted NISS for pre-approval regarding the revision of

the NISS form� Received a confirmed reply date from NISS� Developed an audit form to track usage and improvements

in communication� Incorporated education needs required for new form into

the Pilot PowerPoint

After the first Kaizen Day!!!

Upon Completion of the Kaizen!!!

Post Kaizen Accomplishments� Received feedback from NISS about changes to form� Finalized Draft Form� Executed Marketing Plan (SHR)

• News Release• Articles• TV show scripts• Website Uploads

� Received Board & MAC endorsements (SHR)� Transitioned Calls to Switch Board (RQHR) � Completed Education Plan

• RQHR Nurse • Sunrise Nurse • Sunrise MD/staff • Bedline • RQHR UC

Pilot ResultsResults originated from:� 6 Sunrise Care Centers

• Canora• Esterhazy• Kamsack• Melville• Preeceville• Yorkton

� 38 Sunrise Referring Physicians� 2 Regina Inpatient Care Centers

• Regina General Hospital• Pasqua Hospital

� Participation included: RQHR & SHR Inpatient units, RQHR & SHR EDs, EMS, SHR & RQHR Physician Groups, RQHR SWADD team and RQBedline

Pilot Results (Output)

82%8.3 %Percentage of patients who accessed RQHR tertiary care through RQBedline

Pilot ResultGoal * / Baseline

Metrics

14 minutes30 minutes*Cycle time from call to RQBedline from MD in Sunrise to time connected with RQHR MD

9:13 hours14:21 hoursOverall Cycle time - From Sunrise MD call to patient registration in RQHR facility

Pilot Results (call volume)

Regional Call Volume to RQHR Bedline

0

20

40

60

80

100

120

April May June July Aug Sept Oct Nov Dec Jan Feb Mar

Months

Cal

l Vol

ume

Sunrise

Cypress

Five Hills

Sun Country

Pilot Results (Process)

Pilot Result

Goal* / Baseline

Metrics

81%90%*% and actual number of patients who were sent to ER for assessment and subsequently admitted, where the referring facility was advised by RQBedline that patient was admitted in Regina

65 -70%50%-75%*# of NISS Pilot Interagency Referral Forms faxed at time of departure

25%0%# and % of fully completed NISS Pilot Interagency Referral Forms

Pilot Project CommentsQuotes from Sunrise referring MDs in Health Matters titled "Sunrise soars with pilot":"I hope other doctors are using it because I wouldn't want to go back to the old way. I would sometimes spend half an hour on the phone trying to get a hold of a specialist. The RQBedline seems to sort that that out. The process is much more efficient.“ ……. Dr. Van Zyl

"I was worried that I wouldn't be able to contact the specialists that I wanted to consult with, that I would have to use whomever was available. Instead I have found that the RQBedline is excellent.“……Dr. Soumbasis

The final paragraph of the article is:

"Rural physicians in Sunrise already give the pilot a thumbs up.Both Soumbasis and Van Zyl call the RQBedline 'excellent' and both agree, this pilot has wings."

Lessons Learned – What Went Well

� Physician and staff education – through various medium (+ office staff)

� Dedication of design team members

� Use of data and data analysis expertise

� Consultants’ guidance and coordination

� Regular status call

Lessons Learned – What Went Well

� Kaizen – accomplished a lot

� Capacity building

� Developed relationships and network

� Many good ideas generated

Lessons Learned – What Did Not Go Well

� Completion rate of some forms and surveys

� Tight timeframe for education

� Patient and physician satisfaction not quantitatively measured

The Project Plan

Kaizen - Rapid Improvement Event (December 5 – 7, 2006)

Future State Value Stream Maps (October 17/18, 2006)

Data analysis (October, 2006)

Data Collection and Synopsis of Evidence (September 2006)

Develop Current State Value Stream Maps (June 27/28, 2006)

Current State Assessment – 1 day in each region (June 14/15, 2006)

Activities

Rollout to remaining regions

Evaluate pilot and lessons learnedDevelop sustainability and rollout plan (May 9, 2007)

Pilot between two regions – Eight Weeks (February 1 – March 31, 2007)

Activities

Next Steps

� Finalize Sustainability Plan metrics – to be reviewed quarterly by South Regions’ Forum +/or Steering Committee

� Integrate patient satisfaction survey into HQC continuity of care survey

� Finalize the NISS Inter-Region Form with SAHO

� Design a roll-out plan specific to each region:• Cypress• Five Hills• Sun Country

� Coordinate with RQHR on go live date

� Celebrate

Questions