Thinking Out of the Box Ambulatory Service in Hospital Authority Dr. Woon-Leung NG Department of Medicine & Geriatrics United Christian Hospital 1
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Thinking Out of the Box Ambulatory Service in
Hospital Authority
Dr. Woon-Leung NG
Department of Medicine & Geriatrics
United Christian Hospital
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Thinking Out of the Boxo
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Thinking Out of the Blue
NOT
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2006
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Conventional • Ask for more IP beds
• Ask for more manpower
• Ask for more resources
• Ask colleagues to work harder
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Conventional • Ask for more IP beds
• Ask for more manpower
• Ask for more resources
• Ask colleagues to work harder
Counter-intuitive • Cut IP beds
• Convert to Ambulatory
• Cut wastages
• Challenge colleagues to work smarter
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Reforms
• Reduce In-patient Beds
• Redesign an ambulatory care centre (UACC)
• Recruit a dedicated ambulatory care team
• Reconfigure our service model
• Reducing Avoidable Hospitalization
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Prevent Avoidable Hospitalization
eeResults
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A&E Admissions (MED 1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals
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Average no. of IP beds per day (MED 1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals
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IP bed occupancy rate (%) MED (1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals
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Total IP bed days occupied - MED (1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals
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Graph 1 – AE Adm Graph 2 – IP Beds
Graph 3 – Occupancy Rate Graph 4 – Total IP Bed Days
"A statistic should tell a story." -- Margaret Thatcher
Think Substitution
Think Ambulatory 1st
Think “Back”
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Think Substitution
Think Ambulatory 1st
Think “Back”
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Think Substitution - IP Bed is not the only Option
• IP bed is expensive
• IP bed cannot be expanded indefinitely
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Day Medical Care Ambulatory Care in Internal Medicine
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Nurse-Led Service •Drug infusion / injection
•Transfusion / Chemo Rx
•Catheter Care
•Special dynamic tests
• Insulin tolerance test
• Autonomic function test
Medical Procedures Endoscopies
Bone marrow
Lumbar Puncture
Biopsies
Abdominal &
Pleural tap / Bx
(USG-guided)
Day Cardiac Procedures •Cardiac cath / Change of pacemaker
•Pre-procedure education and consent
Rheumatology •Biologic Rx
•Joint Injections
•Musculoskeletal
Ultrasound
Medical Consultation
For Complex Care •Supported Discharge
•Drug titration
•Conjoint programme with AED
Multi-disciplinary Service •TIA clinic
•Cognitive clinic
•Autologous BMT workup
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IN OUT
Ambulatory Care
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Alternatives
Life or organ threatening illness
Access to Specialist Services
Ambulatory Care To Reduce
Avoidable Hospitalization
Fast-tracked Ambulatory Procedures
Early Discharge
Prolonged
IP Rx AED Admission For Mx of
Wax and Wane Medical Conditions
Ambulatory
& Community
Intervention
to prevent
Admissions In-Patient
Procedures
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Think Substitution – Alternative Pathways
• Create timely and organized service to address patient needs
• Standardized and Protocol-Driven
• Tailored to individuals
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“I just remove everything that isn’t part of the Statue.”
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Hospitality
HK$ 4,680
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Hospitality
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Workup of a Lung Mass
Workup of a Lung Mass
Traditional IP Pathway
• Admitted to MED through AED
• Initial Workup in ward, review results,
• Consult Respiratory team
• Further arrangement for workup
Workup of a Lung Mass
Traditional IP Pathway
• Admitted to MED through AED
• Initial Workup in ward, review results
• Consult Respiratory team
• Further arrangement for workup
Ambulatory Pathway
• Arranged to be directly assessed by Respiratory team specialist at Ambulatory Care Centre
• Preliminary workup initiated at AED
• One-stop counseling, workup, ± procedure
Think Substitution – Bottleneck
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• Eliminate everything that is not value-added to patient care or that can be replaced
• Hotel Service
• Waiting (in hospital)
• Non-value added processes that consume the time and expertise of professional staff (Bottleneck)
“I just remove everything that isn’t part of the Statue.”
Think Substitution – Elimination
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Think Substitution
Think Ambulatory 1st
Think “Back”
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International Experience
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http://www.institute.nhs.uk/ambulatory_emergency_care/public_view_of_ambulatory_emergency_care/ambulatory_emergency_care_homepage.html
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Think Ambulatory 1st
• Every emergency admissions would be considered as having ambulatory care potential unless there was clear evidence to the contrary
• For those where existing services cannot adequately provide the ambulatory alternative, there can be further exploration
Think Substitution
Think Ambulatory 1st
Think “Back”
Gallerie dell'Accademia, Florence
Prevent Avoidable Hospitalization
Purpose
Policy
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Position & Priority
Michael Porter
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Protocols
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Patient Journey
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Passion
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Collaborations • Rapid access to Diagnostics: Imaging, Pathology
• Other supporting services: nursing, allied health, community healthcare support, transport
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Curriculum
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Career Pathway
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Critical Mass
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Community Acceptance
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Corporate Direction
Think “Back”
So we fix our eyes not on what is seen, but on what is unseen, since what is seen is temporary, but what is unseen is eternal.
2 Corinthians 4:18 , Bible
Deal with issues at the back
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