EDOC (2)

1. Hossam Elamir,TQMD, MBBCh Quality & Accreditation Office, MKH

2. Quality Definitions The Global Situation Causes The Local Problem EB Solutions 2

3. Dont kill me (no needless deaths) Do help me & dont hurt me (no needless pain) Dont make me feel helpless Dont keep me waiting Dont waste resources - mine or anyone elses Berwick, D. M. (2005) 3

4. This situation continues for days at the moment. According to one of ED senior physicians: What is the meaning of quality!The patient died! We would save her live if she was transferred a little bit earlier to inpatient. 4

5. EDOC: institutional resources available are insufficient to meet the basic service needs of emergency patients. Patient Boarding: a known practice in which patients are held or "boarded" in emergency departments waiting for inpatient beds in the hospital. Blum et al. (2006) 5

6. Access block: A situation when.. patients who were admitted or planned for admission but discharged from the emergency department (ED) without reaching an inpatient bed, transferred to another hospital for admission, or died in the ED .total ED time exceeded 8 hours. ACEM. (2013) Prolonged EDLOS: was defined as 4 hours in the UK, 4-6 hours in Canada and 8 hours inAustralia. Horwitz et al. (2010) 6

7. LM: a management practice based on the philosophy of continuously improving processes by either increasing customer value or reducing non- value adding activities (Muda), process variation (Mura), and poor work conditions (Muri). (p.365) Radnor et al. (2012) 7

8. Vs 8

9. One of the fittest athletes in the world His body fat is 3% less than supermodels = 16 9

10. Womack & Jones (1996) Toussaint & Gerard (2010) 1. Specify value from the customers perspective 1. Focus on patients (not the hospital or staff) and design care around them 2. Identify the value stream for each product/service provided 2. Identify value for the patient and get rid of everything else (waste) 3. Make the product/service flow uninterruptedly and standardise processes around best practice 4. Create pull systems between all steps where continuous flow is impossible 3. Minimise time to treatment and through its course 5. Manage towards perfection by systematically eliminating waste to achieve an ideal process 10

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13. For every complex problem, theres a solution that is simple, neat,and wrong H L Mencken 13

14. Donabedian,A. (1966) Inputs Structure 14

15. Current Beds Number Beds number after expansion Access block 15

16. Observation of all patients visited ED during 7 days (27 Nov. 3 Dec. 2014) Design CapacityTotal time= 35 X 7 =245 bed days 245 X 24 hours = 5880 bed hours 16

17. Patient Arrival Triage Doctor room Observation room Lab/Rad request Lab/Rad done Lab/Rad result/report ED doctor Consultation request Unit doctor Admission/ discharge decision Patient transfer 17

18. Total visits to ED in 7 days 6383 100% Didn't go to observation 4633 73% Shouldn't go to observation 316 18% Stayed less than 6 hrs 1224 70% Stayed more than 6 hrs 210 12% Other 1750 27% Didn't go to observation 73% Stayed less than 6 hrs > 95% Stayed more than 6 hrs < 5% Other 27% Provide their needs in the primary healthcare centers 18

19. 0 50 100 150 200 250 300 350 LOS intervals Missed variables > 1:00 1:00 - < 2:00 2:00 - < 3:00 3:00 - < 4:00 4:00 - < 5:00 5:00 - < 6:00 > 6:00 7 232 340 247 168 94 210 136 19

20. 90.42% Aggregated LOS time of observation room visits who deserve to be observed (1434 patients)= 221.53 days 100% Total calculated ED time by design capacity= 245 days 32.63% Aggregated time of all patients with LOS > 6 hours (210 patients)= 79.95 days 20

21. 0 10 20 30 40 50 60 70 80 90 100 Total ED observation room LOS Major waste time 1078.98 hrs 1918.95 hrs 21

22. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% time-to-review-radiology- report time-to-review-lab-results time-to-get-radiology-report time-to-receive-lab-report time-to-execute-radiology time-to-reply-consultation time-to-transfer-pt-after- admission-decision 561.17 hrs 143.42hrs 143.52hrs 22

23. Inputs Solutions: Ambulance diversion 1ry Healthcare centres to manage non- urgent cases (e.g.: catheter change, blood collection) Closed ED area with security Proper triaging Fast track 23

24. Minimal structural requirement to make it efficient and accommodate the numbers Control room 24

25. Throughput (process) Solutions: Reply consultation promptly Use POC U/S Execute Radiology promptly Report Radiology promptly 25

26. Output Solutions: Effective discharge service Bed crisis management protocols Bed manager Set time target to all staff: EDLOS < 6 hrs wait times < 30% of total EDLOS No patient boarded in ED > 45 mins Initiation of crisis protocols should be zero 26

27. Every system is perfectly designed to get the results it gets. "If we keep doing what we have been doing, we'll keep getting what we've always gotten"an expensive, high-tech, inefficient health-care system. P. Batalden D. Berwick 27

28. Berwick, D. M. (2005), My right knee, Annals of Medicine ACEM. (2013) Policy on StandardTerminology. Melbourne, Australia: The Australasian College for Emergency Medicine Blum et al. (2006) Report From a Roundtable Discussion: Meeting the Challenge of Emergency Department Overcrowding/ Boarding. Washington, DC, USA: American College of Emergency Physicians Horwitz et al. (2010) US Emergency Department Performance on WaitTime and Length ofVisit. Ann Emerg Med Radnor et al. (2012) Lean in healthcare:The unfilled promise? Soc Sci Med Guttmann et al. (2011) Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 28

EDOC (2)

Documents

bed hours

total ed time

emergency department

hours inaustralia

bed days

dont waste resources

helpless dont

inpatient beds