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TO ACUTE CARE SERVICESA practical toolkit for use in public hospitals

Developed by the Clinical Excellence Commission

Clinical Excellence Commission

IMPROVING PATIENT ACCESS


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Dear reader,

As you are no doubt aware, the flow of patients through an acute hospitaldepends upon a complex set of relationships between many departments,

services and people. Achieving improvements in the way patients move

through such a complex system requires a coordinated approach to admission,

treatment and discharge of patients based on core principles of system

engineering. It requires hospitals to untangle the complexity of their existing

processes so they can understand where the key bottlenecks exist within their

clinical units. It also requires a fundamental commitment to providing safe,

effective, efficient and timely care where services are designed first and

foremost according to patient needs.

Successfully improving flow across an organisation requires an extraordinarylevel of commitment to a complex and exhaustive change process. It also

requires acknowledgement that there may, at times, be a requirement to tackle

issues that have previously been sacred cows within your organisation. For

these problems to be solved, leaders in your organisation must be committed

to this change process in very practical ways. Appropriate time and resources

should be allocated to ensure the improvement process is successful. A realistic

assessment of the number of individuals and teams needing dedicated time

away from their usual clinical duties to commit to the change process should be

made, and steps taken to ensure that they have the capacity to do so.

This Toolkit is designed to be an aid to you and your organisation shouldyou choose to embark upon the journey to improve patient access to acute

services. The Toolkit is a compilation of strategies and ideas from multiple

sources including:

The NSW Institute for Clinical Excellence Patient Flow and

Safety Collaborative

NSW Health documents and projects

Access projects within New South Wales Public Hospitals

Weekend Discharge project

Effective Discharge Planning Framework

Emergency Department Access projects including the Rapid Emergency

Access Team (REAT) and Emergency Medical Unit (EMU) projects

Operating Theatre project

Best practice sites identified during consultation with Area Health Services (AHS)

Other local, national and international experts, literature and projects

reporting success in improving patient flow.

Particular acknowledgement is made of the contribution of leaders of the

modernisation process within the UK National Health Service (Helen Bevan,

Kate Silvester, Richard Lendon, Ben Gowland, Karen Castille and many others)

to much of the thinking contained in the Toolkit. Similarly, the Australian

members of the Access Improvement Taskforce listed at the end of this


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document have all contributed greatly to ensuring that locally applicable

solutions are contained within this document.

The Toolkit is aimed at hospitals providing acute adult medical and surgicalcare, although many of the principles may be applicable in obstetric, paediatric

and mental health services. The Toolkit does not specifically address flow issues

for these streams of patients.

The level of evidence for many of the interventions described in the Toolkit

is Level II, Level III or Level IV. The interventions described however, have

been shown to produce results at least at a local level. The Toolkit does not

claim to be a comprehensive list of effective strategies and interventions.

Rather it seeks to describe an approach that your organisation could adopt as

it starts to redesign its patient care processes, and to describe some practical

interventions that have been found to be useful in organisations elsewhere.

If an intervention isnt included this does not mean that it is ineffective or

that its use is not recommended. Similarly, interventions that have worked

elsewhere may not be suitable, or may need to be adapted, for your institution.

Careful analysis of your local data needs to form the basis upon which you

determine which interventions are most appropriate to implement locally. This

preliminary analysis of local data is discussed in Section 2.2 - Review data to

understand hospital activity and performance.

We believe that the principles contained in this Toolkit can be applied to

small-scale (local clinical unit level) to large-scale (whole hospital) redesign

programs. The complexity and resource requirements may differ according

to the size of the project, but the fundamentals of removing barriers to

efficient patient flow through providing care based on the needs and experience

of patients as they travel through the organisation will remain the same

regardless of the project size. We hope that you will find this Toolkit useful as

you embark upon redesigning how patients interact with your health service.

Lastly, I would like to acknowledge the work of the team at the Clinical

Excellence Commission that have put this toolkit together. Louise Kershaw,

Director of the Patient Flow and Safety Collaborative, has assembled a vast

array of interventions that have been shown to improve patient access toacute services and was a key driver in the writing of this toolkit. Together,

Louise, Lorraine McEvilly and Celia Mahoney have worked tirelessly to manage

the Patient Flow and Safety Collaborative and to produce the final toolkit. My

deepest thanks go to these extraordinary individuals.

Best wishes and good luck,

Dr. Rohan HammettDirector

Healthcare Improvement Projects

NSW Clinical Excellence Commission

March 2005


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HOW TO USE THIS TOOLKIT 6

1. INTRODUCTION 7

2. PLANNING THE IMPROVEMENT WORK 11

2.1 Identify and define the problem 12

2.2 Review data to understand hospital activity and performance 12

2.3 Engage clinicians and convene the redesign team 14

2.3.1 Leadership 14

2.3.2 Team members 15

2.4 Diagnostic Work 16

2.4.1 Understanding the current systems and processes 16

2.4.2 Tools for understanding processes 17

2.5 Determine your aim 192.6 Designing and implementing changes 20

2.6.1 Identify interventions to implement 20

2.6.2 Practical ideas for effecting change 21

2.6.3 Implementation plan 22

2.7 Analyse the Results 23

2.7.1 Methods of measurement 23

2.8 Communicating the change 24

2.8.1 Key factors for successfully managing change 25

Case study - Western Sydney AHS -Neck of Femur Patient Flow Group 26

Checklist prior to starting your improving access project 34

3. INTERVENTIONS 35

3.1 General strategies 36

3.1.1 Shared work plans, practices and scheduleswithin multi-disciplinary teams 36

3.1.2 Develop multi-disciplinary evidence based pathways 37

3.1.3 Relative performance table 37

3.1.4 Convene a redesign team 38

3.1.5 Improve communication systems 383.1.6 Referral to specialist services 39

3.1.7 Service level agreements 39

3.1.8 Managing capacity to respond to need for services 39

3.1.9 Minimise variation in capacity to provide care 40

3.1.10 Change to 7 day a week services 40

3.1.11 Buffer beds 40

3.1.12 Smoothing variation in elective activity 41

3.1.13 Develop advanced nursing roles 41

3.1.14 Up-skilling peripheral hospitals for complex patient needs 42

3.1.15 Align staff specialist/consultants work to maximise efficiency 42

3.1.16 Bed management system 43

3.1.17 Centralised bed authority/bed co-ordinator 43

3.1.18 Regular multi-disciplinary bed meetings 45

Contents


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3.1.19 Teleconference bed updates 45

3.1.20 Clinical prioritisation of patients 45

3.1.21 Reconfigure beds to reduce outliers 46

3.1.22 Over Census Policy 46

3.1.23 Guidelines and protocols for test ordering 47

3.1.24 Review permissions to order tests 48

3.1.25 Prioritise tests for Emergency Departmentor patients waiting for discharge 48

3.1.26 Allocated time for emergency cases 48

3.1.27 Appropriate information on request form 49

3.1.28 Patients attending for tests 49

3.1.29 Stratified test ordering 50

3.2 Emergency patient flow 51

3.2.1 Pre-bypass hospital early warning system 51

3.2.2 Streaming techniques 53

3.2.3 Alternate admission processes 53

3.2.4 Develop alternate services to prevent ED presentation 54

3.2.5 Advanced nursing and allied health practitioner roles 54

3.2.6 Fast Track 54

3.2.7 See and Treat 55

3.2.8 Lean thinking 56

3.2.9 Clinical pathways around presenting problems not diagnoses 57

3.2.10 ED access to day surgical list bookings 57

3.2.11 Communications clerk 583.2.12 Emergency medicine unit 58

3.2.13 Flag and case manage frequent attendees 58

3.3 Improving Flow of Emergency Surgical Patients 59

3.3.1 Clinical guidelines or pathways 59

3.3.2 Team briefing and debriefing sessions 60

3.3.3 Emergency department physician admission rites 60

3.3.4 Review existing demand for emergency operating theatre time 61

3.3.5 Prioritisation protocol 61

3.3.6 Prioritisation team 61

3.3.7 Pre-operative placement of patients waiting for OT 61

3.4 Medical strategies 62

3.4.1 Medical assessment and planning unit 62

3.4.2 Day only admission ward for ED patients 62

3.4.3 Flag and case manage frequent medical admitted patients 62

3.4.4 Trial at home program 63

3.4.5 Improve appropriateness of admission 63

3.4.6 Safety risk assessment 63

3.5 Improving communication 64

3.5.1 Improving communication with GPs and community nursing 643.5.2 Generic transfer/discharge to hospital form for

all residential aged care facilities (nursing homes) 65

3.5.3 Link discharge from ward time with admissionfrom Emergency Department time 65


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3.5.4 Scheduled transfers 65

3.6 Improving discharge processes 66

3.6.1 Discharge risk assessment form 66

3.6.2 Admission and discharge plan 67

3.6.3 Criteria driven discharge 67

3.6.4 Nurse activated discharge 67

3.6.5 Monday morning audit 68

3.6.6 Weekend discharge pharmacy 68

3.6.7 Multi-disciplinary Discharge Meetings 69

3.6.8 Informing patients and carers about their discharge 70

3.6.9 Discharge checklist 70

3.6.10 Estimated day of discharge 71

3.6.11 Estimated length of stay table 71

3.6.12 Compare the estimated date of discharge

to the actual date of discharge 72

3.7 Aged care 73

3.7.1 Aged care assessment team (ACAT) 73

3.7.2 Transitional care beds 73

3.7.3 Community transitional care beds 73

3.7.4 ComPacks service model 74

3.7.5 Purchase transitional care beds 74

3.7.6 Direct emergency admission protocol 74

3.7.7 Dependant care stream of patients managed

by specialist nurse practitioner 74

3.7.8 Walking assistance program 75

3.8 Elective Patient Flow 75

3.8.1 Quarantined elective surgical beds 75

3.8.2 Criteria driven discharge 75

3.8.3 Surgical pathways and estimated day of discharge (EDD) 76

3.8.4 Increase day of surgery admission rates and

manage performance outliers better 76

3.8.5 Audit all theatre delays or cancellations 763.8.6 Surgical peri-operative liaison nurses 76

3.8.7 Medihotels 77

3.8.8 Flexible staffing 77

3.8.9 Align leave of multi-disciplinary surgical teams 77

3.8.10 Clinical teams operating pooled referrals 77

3.8.11 Clinical pathways 77

3.8.12 Improve completion of consent forms 78

3.8.13 Marking operating site 78

3.8.14 Improve compliance with fasting requirements 78

3.8.15 Predict surgical case length accurately 78

GLOSSARY OF TERMS 79

ACKNOWLEDGEMENTS 80


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How to use this ToolkitThe Improving Patient Access Toolkit is divided into the following sections:

Introduction to patient flow

Planning the improvement work

Diagnosing flow problems in your organisation

Key elements of an access improvement project

Interventions/change ideas

The Toolkit has been designed with the intention that you should adopt a

systematic approach to improving patient flow across your organisation. To do

this, you should start at the beginning of the Toolkit and work your way through

the different stages of designing and implementing a successful redesign

program. However, should you simply want change ideas and strategies to

implement, you should go directly to the interventions section where there are

detailed descriptions of many specific changes you can test.

Throughout the document you will find the following icons that will guide

you to useful resources.

Key to icons:

Tool available on CD Rom

Hospitals where interventions are in place

Resource available on the internet

Bookmark link within document


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1. IntroductionIntroduction to the principlesof managing patient flow

During the course of a single treatment journey a patient will interact with

dozens of clinicians and clinical and non-clinical services that have the potential

to impact on their care. There are multiple steps and handovers that need to

occur smoothly for the patient to receive optimal care in as timely a manner as

possible. At key points in a hospital where many patients are interacting with a

single service (e.g. in the emergency, radiology, and pathology departments or

in the operating theatres) there is great potential for delays in the treatment of

one patient to result in flow-on of delays to other patients and to other services

throughout the hospital. Like a pebble causing ripples on a pond, relatively

small delays in the treatment of one or two individuals may have significant

ramifications for flow of patients across the whole organisation.

It is vital that hospitals have an understanding of the key groups of patients

they treat, and the type of care required to produce optimally efficient

management of flow of these patients. Interestingly, in most acute hospitals

patients fall into one of three categories:

Category 1- short stay patients with an average

length of stay (ALOS) of less than 48 hours

Category 2 multi-day patients with an ALOS of less than 10 days

Category 3 patients with an ALOS greater than 10 days.

It is useful, in planning service delivery, to think of how services can be

arranged to optimise flow for these three groups of patients. As can be seen inFigure 1, the majority of patients fit into category 2 (ALOS


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For category 3 patients (ALOS > 10 days) strategies focussed on

prevention of adverse events, improved liaison with community care

providers and case management may all help prevent the extreme lengths ofstay often seen in these patients.

In general, the types of services required to ensure optimal flow for each

category of patient will be similar almost regardless of the specific clinical

condition that has brought them into hospital. For example most category 1

patients require some simple diagnostic tests, short-term intravenous therapy

of some sort and some nursing care or monitoring for a short period of time.

If services are redesigned appropriately, much of this care could be provided

in facilities other than the acute hospital e.g. ambulatory care units, nursing

homes, general practice, or the patients home.

Similarly, the patients in category 2 will require diagnostic services, medical and

nursing management and planning to provide appropriate support post-discharge.

Much of this care can be planned before admission for elective patients, or very

early during their admission for emergency patients. The key constraint areas of

the hospital (e.g. radiology, pathology, operating theatres, intensive care) can

plan how many of these patients will require their services based on historical or

prospective data to minimise delays to their treatment. This will enable a matching

of capacity and demand that will improve the efficient flow of these patients and

prevent delays that increase length of stay and result in flow-on effects across thewhole organisation.

Figure 1

250

200

150

100

50

0

Category 2 | take a day off clinically unnecessary

ALoS and it has a dramatic effect

Category 1 |prevent admission

Category 3 | these patients may have more

complex support needs

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay | Medical Patients

Length of stay (days) | Average LoS = 7.24 days

Source | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals


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The importance of managing variation

Many of the delays that plague patients attempting to access acute services

are not due to inadequate resources, but rather the result of the variation withwhich these resources are utilised. For example, many hospitals have extensive

waiting lists for outpatient clinic appointments. When an analysis is undertaken

of the number of clinic appointment times available, it is often the case that the

current clinical capacity actually matches the demand for the service, except

that every time there is a public holiday or a conference, the outpatient clinic is

cancelled and as a result a waiting list is produced. If clinics were rescheduled

rather than cancelled this would not occur.

Similarly, the variation in the number of patients a hospital admits for

elective surgery may in itself be contributing to waiting lists, access blockand surgical cancellations. The graph shown in figure 2 below is taken from a

hospital that on average admitted 49.7 patients every day. In the top part of

the graph you can see that the number of patients admitted varied between

24 and 78 on any single day. To ensure it could provide enough beds for all

patients on 99.9% of days, this hospital required 78 beds to be kept open for

elective admissions. In the bottom part of the graph the same average number

of patients were admitted (49.7) but, by reducing the variation in the number

of patients admitted (38-70 cf 24-78), the number of beds required to ensure

availability for 99.9% of patients was reduced to 68.

Figure 2

80

70

60

50

40

30

20

80

70

60

50

40

30

20

Total Admissions |April-November

Standardised Admissions |April-November

78 beds

required each

day to give

99.9% chance

of admission

68 beds

required each

day to give

99.9% chance

of admission

Daily bed requirement reduced from 78 to 68

Admissions

Average = 49.7

UPL = 67.9

AdmissionsAverage = 49.7

UPL = 78.1

Source | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals


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Thus if we manage the variation in the way we provide our services, we will

find greater capacity to deliver services in an efficient manner. Interestingly,

in most hospitals elective activity varies far greater than emergency activityon a daily basis. Similarly, there is often far more variability in the number

of patients discharged than the number of patients admitted. Both of these

processes (number of elective patients admitted and number of patients

discharged) can be managed by the organisation itself. Understanding the

management of variation in service delivery is crucial to smoothing the flow of

patients through acute hospitals.

Gaining a greater understanding of the way in which patients move into,

through and out of the organisation and the bottlenecks that are hindering

efficient movement will assist in understanding which changes should bemade to gain improvement. To do this effectively an organisation will need to

examine its own data to identify patterns in activity that need to be redesigned.

The resources below contain more detailed descriptions of the information

contained in this introduction and can be referred to in order to gain a greater

understanding of the key principles of managing patient flow. The Toolkit may

then be utilised to redesign the way a patient travels through the system.

Improving patient flow

www.steyn.org.uk/

Queuing theory (NHS website)

Patient flows, waiting and managerial learning paper (NHS)

www.cognitus.co.uk/healthcare.html#1

NHS Flow Management Wizard

www.natpact.nhs.uk/demand_management/wizards/big_wizard/

index.php?page=/demand_management/wizards/big_wizard/Step_

4/Basic_Queuing_Theory.php

Foundations of demand and capacity (NHS presentation)

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2. Planning the

improvement workSuccessful implementation of changes will depend on effectiveproject management throughout the period of the project.Project steps

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review data to understand

activity and performance

Identify and

define the

problem

engage clinicians and

convene the redesign team

complete baseline

diagnostic work

determine the aim

identify interventions to trial

design and implement

the changes

analyse the results

communicate

the changes

build in accountability to

help sustain changes


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2.1 Identify and define the problemBefore commencing work, it is useful to try to sum up the problem you wish

to improve in one sentence e.g. reduce or eliminate access block, improve

discharge processes for medical patients, or decrease delays in transferring

patients between hospitals. Identify the problem from the patients perspective

and use terms that describe their experience. This will help clarify the core

objective of the work you are about to undertake and prevent your project

from suffering from a diffuse, poorly directed lack of purpose.

The amount of work and degree of change required will vary depending on

the scope of the project. Significant improvements to patient access to acute

services may be produced by implementing change at local departmental level,

service, ward or across an entire hospital.

2.2 Review data to understandhospital activity and performance

It is vital that characteristics of patient populations and their flow through

the system are understood. The following is a general list of data that will help

in understanding patient flow in the organisation and may be obtained from

the Patient Access System (PAS), Disease Index (DI), Emergency Department

Information System (EDIS) or the Health Information Exchange (HIE). Only

extract the data needed to help understand that part of the system of interest.

Use the data to highlight problems or to prove the changes implemented are

making a significant improvement.

1 Numbers of access block patients by day at 12 MD, 4 pm and 8 pm. This

will identify within-day variation in demand for services that will assist

with planning staffing needs throughout your organisation.

2 Number of beds used daily by ED status (admitted and discharged from

ED, admitted through ED, not admitted through ED) at peak times (12 MD

and 4 pm). This will assist in identifying the bed requirements for each

clinical department to deal with their emergency patient load. It should be

utilised in conjunction with an analysis of elective admissions by clinical

department to plan appropriate bed allocation.


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3 Count the number of beds required to cover a given proportion of days

(e.g. 95% of days). This will help you to understand the size of the

improvement required to eliminate access block in your organisation.

4 Number of access block patients for each day of week. This will identify

the between-day variation in demand for services to assist with planning

schedules for clinical activity and staffing.

5 Percentage of overnight access block patients who reach a ward bed

before midday. This will help identify any problems related to turnover of

available beds.

6 Distribution of specialties for access block patients (% bed use by

Consultant Medical Officer specialty). This will help identify departments

in which redesign processes might be most useful, or in which there may

be a need for additional resources to improve flow.

7 Percentage bed base by Consultant Medical Officer specialty (Emergency

and non-emergency bed distributions). This will enable a current appraisal

of bed utilisation and management of bed allocation on a data-based

rather than historical basis.

8 Outliers by Consultant Medical Officer specialty and ward bed days used.

This will identify the degree of disorganisation of current bed management

practices and provide a focus to case management models to improvelength of stay for these patients.

9 Emergency overnight medical discharge rate by day of week (% weekend

discharge). This will characterise variation in discharge practices across

days of the week. It should be done for a 12-month period. Note the peaks

in discharge prior to public holidays. Readmission rates after these public

holidays usually do not change despite the high discharge rates suggesting

that these patients really were ready for discharge. You can check these

readmission rates in your own organisation.

10 Elective overnight admission rate by day of week. This will show thevariation in elective services in your organisation. If this variability can be

minimised it will, of itself, create extra bed capacity in your organisation.

11 Analysis of length of stay against benchmark by Consultant Medical Officer.

This will help identify variation in clinical practices that may be contributing

to delays for patients. These can be addressed by the clinical unit manager.


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For access to or assistance with extracting the above data, contact the hospital

case mix manager (or person who collates data for reporting to the health

department). They will have access to the data and the skills and knowledgeto extract this data or will be able to suggest other sources of assistance.

Alternatively your executive sponsor will be useful in securing the services of

an appropriately skilled person to do this.

Access Blocked Patient Analysis 2002-2003 (NSH)

Hospital Flow Measurement Guide (IHI)

www.qualityhealthcare.org/IHI/Topics/Flow/PatientFlow/

EmergingContent/HospitalFlowMeasurementGuide.htm

2.3 Engage clinicians andconvene the redesign team

2.3.1 LeadershipEffective leadership is crucial to maintaining a focus on improving the

patient experience. The team should include:

someone with the skills, energy and enthusiasm to lead the project,

strong medical and nursing leadership at all organisational levels,

clinician managers who are effective champions for the project. They have

an important role in spreading improvements to other departments and may

be required to performance manage individual variance,

individual clinician leaders who participate and use their influence to

support change amongst their colleagues,

leaders with a clear vision of the project who can sell this vision to others.


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2.3.2 Team members

When bringing together a project group or a redesign team ensurethere is a mix of administration, medicine, nursing and allied health

representation relevant to the projects aims. Enthusiasm and interest in

the project are essential qualities to look for in team members. They should

also have an operational role in the processes to be changed. Many sites

that have successfully improved patient flows have also actively involved

consumers in the work of their teams, in a manner appropriate to the

context of the organisation.

Team members also need to take the following roles:

2.3.2.1 Executive sponsor

Previous experience has demonstrated that effective sponsorship at an

executive level is crucial to successful implementation of organisational

change. Executive sponsors need to be at Area Health Service level or

executive level in a facility i.e. Director of Clinical Services or Hospital

Executive Director and be:

someone with enough influence in the organisation to oversee the change,

someone prepared to set aside time for the project.

2.3.2.2 Clinical leaders

Most projects require a nursing lead and a medical lead. They should be

someone who:

understands the processes of care,

is able to provide technical expertise in order to produce solutions that are

technically proper, ethically sound and effective,

can provide effective leadership,

is an opinion leader who can influence his/her peers to produce

improvement in existing systems of care delivery.


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2.3.2.3 Project co-ordinator

Someone who: understands not only the details of the system, but also the various effects

of making change(s) in the system,

has the necessary skills, including computer literacy, project management

and high-level organisational skills,

ideally has some experience in change management, process mapping and

Clinical Practice Improvement (CPI) techniques.

2.4 Diagnostic Work

2.4.1 Understanding the currentsystems and processes Identify what the main streams of activity are within the service where

you are seeking improvements e.g. elective day of surgery admission

stream, emergency medical admit and discharge from ED, elective medical

procedure admissions.

Identify what the key processes and issues are within those streams, using a

variety of means that collect patient and staff perspectives of the problem.

Use interviews, focus groups, patient journeys and process mapping.

Review:

current or recent projects, their aims and outcomes to date,

current policies and procedure manuals,

currently available data.

Measurement for Improvement, Improvement LeadersGuide (NHS)

www.modern.nhs.uk/improvementguides/

measurement/


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2.4.2 Tools for understanding processes

2.4.2.1 Process mapping

The flow of patients through hospital, whether as emergency admission,

ED presentation, outpatient or for an elective procedure, involves multiple

processes, many of which may be repeated approximately the same way for

every patient. Even very complex procedures may be standardised, based on

sound scientific practice. This can help to reduce variation and inefficiency

caused by poor communication and redundant complexity. Process mapping is

a technique to identify inefficiencies; redundant steps in clinical workflow;bottlenecks or blockage points where time or resources are wasted.

Improving Patient Flows - Guide to Process Mapping(Institute for Clinical Excellence)

Improvement Leaders Guide to Process Mapping, Analysis andRedesign 2002 (NHS)

Easy Guide to Clinical Practice Improvement 2002 (NSW Health)

2.4.2.2 Patient journeyTracking a patients journey through the healthcare system is a simple way

to understand where problems lie and how the service looks through the eyes of

a patient. Any member of staff can do this by shadowing a patient through the

system and keeping a time log of activities. Alternatively, ask a patient or their

carer to write a diary of their experience. The patient journey may be used to

verify findings of the process mapping exercise and will allow identification of

any waits and delays in real time.

Patient Journey Tools (Institute for Clinical Excellence)


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2.4.2.3 Understanding major bottlenecks

For those bottlenecks identified in the process mapping, you should auditthe reasons for patients waiting and measure the waiting times involved. For

example you could record the time from request for diagnostics to the time

results are reviewed by the referring team.

decision requestresult

available

review

report

The time in between each of these steps can be useful to highlight what

works well, what is causing problems, and opportunities for improvement.

Other tools such as Fishbone (Ishekawa or Cause and Effect) Diagrams and

Pareto charts may be useful to determine what the underlying causes of the

problem are. Refer to the NSW Health Clinicians Toolkit.

Clinicians Toolkit (NSW Health)

2.4.2.4 Patient flow audits

Greater than 14 day audit do a walk around of all patients with a length of

stay greater than 14 days. Ask if they are sick, are they waiting for something,

why have they not been able to go home?

Discharge Delay Data Collection Worksheet(Western Sydney Health)

Monday audit review all patients who are discharged on Monday. Ask thefollowing questions. Were they medically stable on Saturday or Sunday? Why

werent they discharged earlier? e.g. lack of services, waiting for a test,

waiting for review by medical officers.

Discharge Audit Tool (RNS Hospital)


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2.5 Determine your aimDevelop a statement about the aim of your project. An aim is used to keep

the team focused on what it is trying to achieve and provide a measure for the

projects success.

Based on your diagnostic data, determine aims that include:

the percentage improvement you will work towards achieving,

the time within which you will achieve the aim.

Example:To have less than 10% of 75 year old patients experiencing four hour

access block within six months.

It is important to note a few key points about these aims:

1 Use the diagnostic work to find what is important to the different

stakeholder groups involved. Engage the team with something that matters

to each of them.

2 Once the issues the team wish to address are clear, set aims at hospital

and departmental level that act as levers to engage change at ward and

individual clinician level.

3 Make the aims SMART i.e. specific, measurable, achievable, results

orientated and time scheduled.

The aims should describe:

what is expected to happen,

the system to be improved,

the setting or sub-population of patients,

goals.

Develop Your Aims from your Diagnostics Presentation(Institute for Clinical Excellence)


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2.6 Designing and implementing changes

2.6.1 Identify interventions to implementOnce problems and issues have been identified and prioritised a decision

needs to be made regarding what changes you will implement to achieve the

aim. Go to Section 3 of the Toolkit which has a range of ideas, suggestions and

changes implemented in other organisations. Read through the interventions

listed in the appropriate section and download any references or tools. At

a redesign team meeting agree on a list of interventions you wish to trial

or implement, based on the results of your diagnostic work. It is important

to focus on interventions relevant to those significant problems identified

during your diagnostic analysis. Look for the common sense solutions before

introducing radical change. Many of these will emerge during process mapping

and redesign activity.

In some cases, a decision to implement a particular strategy may be made

straight away. This is appropriate where there is a high level of confidence

from the diagnostic work and evidence from other organisations where it is in

place, that it will effect an improvement. However other interventions will

need to be trialled, adapted to local context and evaluated for effectiveness

before a decision to implement is made. Clinical Practice Improvement (CPI)

methodology is a useful tool for trialing interventions.

Easy Guide to Clinical Practice Improvement Methodology(NSW Health)

PDSA Worksheet (Institute for Clinical Excellence)


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2.6.2 Practical ideas for effecting change

Create a culture where change is encouraged and people are willing to trysomething new.

Use cases that actually happened in your hospital to demonstrate process

and system problems affecting patient outcomes to foster organisational and

individual will to change.

Publicise the findings of the diagnostic work to highlight problem areas and

engage clinical staff and management.

Use success stories to create an expectation that change can occur.

Establish a process in your hospital or department to keep up to date withthe current best practice.

Use incentives, e.g. wards with high morning discharge rates given priority

for receiving extra staff.

Acknowledge and celebrate success when it is achieved.

This should help to create a culture where things change/improve constantly so

that a state of change/improvement becomes the stable state.

Improvement Leaders Guide -

Managing the Human Dimension of Change (NHS)www.modern.nhs.uk/improvementguides/human

Organisational Change, a Review for Healthcare Managers,Professionals and Researchers (NHS)

www.sdo.lshtm.ac.uk/pdf/changemanagement_review.pdf

Making Informed Decisions on Change (NHS)

www.sdo.lshtm.ac.uk/pdf/changemanagement_booklet.pdf

Quality collaboratives: Lessons from research(The Nordic School of Public Health)

Improvement Leaders Guide - Spread and Sustainability, 2002(NHS)


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2.6.3 Implementation plan

Once you have a list of interventions you plan to trial, create animplementation plan including a breakdown of the interventions into lists of

tasks you need to complete in order to implement the intervention. Brainstorm

potential barriers and plan to proactively manage these. Many of the barriers

to change that will be encountered relate to poor communication. Give all

appropriate people the opportunity to be involved. The implementation plan

should be specific with individuals accountable for completion of work by a

specific date. The following example is an excerpt from an implementation

plan that describes a few of the actions that may be required to implement

nurse initiated X-rays.

Figure 3

Example | Implementation plan

Planned step Action

required

Identified

barriers

Strategies

to overcome

barriers

Individual

responsible

and by when

Introduce

nurse

initiatedX-ray

Write a

protocol

detailingindications

for nurse

initiated

X-ray

Radiology

apprehension

re servicegetting

overwhelmed

Joint working

group to

develop theprotocol and

guidelines for

when RN can

initiate

Training

programme

in draft by DrSarah Jones

04/04/04

Develop

a form

specifically

for this

purpose

Nurses

not having

confidence

to make the

decision due

to lack of

information

Training by

radiology and

emergency

departments

for nurses

to ensure

they feel

skilled and

supported

in decision

making.

Joint working

group chaired

by and

supported by

Peter Brown.

First meeting

06/05/04

Work with

radiology

department

to develop

agreed

guidelines

Doctors

concern over

the quality of

the service

Involve the

ED doctors in

the protocol

development

Set up

monitoring

systems


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2.7 Analyse the resultsThe team should determine how to measure the progress of their work and

develop a strategy to achieve this. Avoid the temptation to spend so much time

collecting or pursuing perfect data that the improvement work doesnt get

started. Measurement plays the following important roles.

Key measures are required to assess progress on your aim.

Specific measures can be used to learn more about the problems that exist

within the system.

Balancing measures are needed to assess whether the system as a whole is

being improved. Data from the system (including from patients and staff) can be used to

focus improvement and refine changes.

2.7.1 Methods of measurementDifferent methods may be used to gain measures, both qualitative and

quantitative, to provide the information described above.

Clinical measures of patients health

Documentation of behaviour

Questionnaires

Interviews

Assessments

Summary of databases

Chart audits

Observations


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Once process mapping is complete it usually highlights areas requiring further

information gathering or audit. This will help the team to fully understand the

nature and size of the problem to be addressed and prioritise the area to work on.

Measurement Strategy Worksheet(Institute for Clinical Excellence)

Measurement Presentation - Helen Ganley (NSH)

Weekend Discharge Audit Report (RNS Hospital)

SPC for Beginners - Powerpoint Presentation (NHS)

www.modern.nhs.uk/InnovationandKnowledge

Group/7338/SPC_for_beginners_web.ppt

Patient Perceived Needs Survey (NICS)

2.8 Communicating the changeFor these projects to work smoothly there needs to be good communication

with individuals, departments, patients, providers, management and clinicians.

As interventions are implemented, display information about the changes

that have been made and the results achieved in a clear graphical format. Show

performance against targets.

Every individual in the healthcare team including nurses, doctors, allied

health professionals, administrators, managers, secretaries, cleaners, foodservices and porters, play a significant part in the patients journey. They will

all offer a different and valuable perspective. Remember, if people know what

is going on and are actively involved, they will have greater ownership of the

problem and the solutions.

Identify data and measures that have shock value and use them to gain

acknowledgement of the problem and engagement of staff in the need for

change. Identify all those who have some role to play in the care processes that

you aim to change and be open and share information with them.


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2.8.1 Key factors for successfully managing change

Evidence suggests that the following factors all significantly improve thechances of a project making an effective and sustainable impact.

An organisational will and commitment to change the system to, first and

foremost, meet the needs of the patients.

Visible commitment from executive and senior management.

Local ownership of solutions to the problems encountered by local clinical

and management teams.

Resources committed to the redesign process, including personnel

experienced in change management to facilitate this locally. A core multi-disciplinary team who drive change, facilitated and supported

by a project coordinator.

Medical, nursing and allied health engagement, leadership, and participation

in the team.

Investigation and data analysis of existing issues and problems utilising

tools such as extensive process mapping and redesign of inefficient

processes of care.

Rapid implementation of strategies that have been shown to be effective in

improving flow in similar hospitals.

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Case study - Western Sydney AHS -

Neck of Femur Patient Flow Group:Contact Details: Maria Lingam [email protected]

Rosio Cordova [email protected]

Team Members

Cathie Whitehurst Executive Representative

Celine Hill Team Leader, Trauma Program Manager

Rosio Cordova Facilitator, Quality Manager

Maria Lingam Clinical Nurse Consultant (Orthopaedics)

Narelle Allen Clinical Nurse Educator (Orthopaedics)

Gail Hook NUM, D4A (Orthopaedics ward)

Robert Dowsett Director ED Westmead

Gayle McInerney Director ED Auburn

Geoff Shead Surgery Stream representative

Randolph Gray Orthopaedic Registrar

Elizabeth Stafidas Surgical Support Services representative

Peter Landau Staff Specialist, Geriatric Medicine

Sue Voss Anaesthetics Consultant

Linda Gutierrez Trauma Data Manager

Dr John Fox Director, Orthopaedics Unit, Westmead Hospital

Dr Roger Brighton Director, Orthopaedics Unit, Blacktown Hospital

The Aim

According to evidence-based best practice, patients with fracture of the

neck of femur (NOF) should have early surgery (within 24 to 36 hours) once a

medical assessment has been made.

The aim of the project was to increase by 25% the current rate of patients

with NOF fractures (those patients who were identified clinically fit and not

requiring extensive diagnostic tests) having an operation within 24 hours by

January 2004.


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Background

Analysis of data previous to project commencement (Jan 02 to Jun 03)identified that only 42% of patients with neck of femur fracture were

reaching theatre within 24 hours.

Furthermore, an audit on patients who didnt go to theatre within 24 hours

demonstrated 30% didnt do so because they were unfit and/or required extensive

diagnostic tests such as bone scan and Magnetic Resonance Imaging (MRI).

Based on the analysis, it was evident that we were able to improve

access to theatre for those patients who were delayed for other reasons

than identified above.

Project Development

A multi-disciplinary team was formed with representatives of key

stakeholders including cross campus representation to facilitate transfer of

knowledge and expertise. A number of tools were used to determine the nature

and extent of the problem and to identify how change could be achieved within

the resources available.

A brainstorming exercise took place in order to identify the current patient

journey (Figure 7 - page 32). This identified the following issues:

Patients with NOF fracture were in most cases referred for geriatric review

before seeing the Orthopaedic registrar: especially in cases where there is

pain but X-ray is normal and patient is able to walk.

Geriatric review only occurs during working hours. Patients presenting after

hours have to wait until next day.

Orthopaedic review only occurs until 9pm, if a call is made after that

time then the patient will wait in ED until the next day to be seen by the

Orthopaedic registrar. The Anaesthetist can request further medical review, delaying operating

time (which can take an extra day).

Patients from district hospitals usually wait longer due to the lack of bed

and/or incomplete documentation.

Customer expectations were collected anecdotally. Expectations from the

following customers and service partners were noted:

Patients wanted to receive prompt and adequate treatment and staff

expressed their will to provide patients with efficient services.


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A cause effect analysis (Figure 4) assisted the team in identifying the priority

areas requiring attention. The team decided to focus on issues surrounding

accessibility and assessment. The issues surrounding patients fitness and co-morbidities was something the team was unable to influence. There was a

similar issue with insufficient operating theatre times, as this required the

provision of major financial resources.

Figure 4

PatientOperatingtheatre

Assessment Accessibility

NOF patientswaiting morethan 24 hoursfor operation

Incomplete patientdocumentation

upon transfer

No specialisednursing review in ED

Booking times

Geriatrician review vsOrthopaedic review

No beds available

Disorganised booking times

Orthopaedic review vsAnaesthetist review

Patient requiresMRI or Bonescan

Patient ismedically unfit NOF not considered for

emergency theatre

Theatre availablity

Lack of OT timeFamily refuses operation

Action

The following interventions were implemented in order to simplify the

current patient flow process (Figure 5). Timeframes, responsibilities and

performance measures were assigned to various members of the team. Key

strategies focused on redesigning the current process.


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Figure 5Issues Intervention implementedPatients referred

for geriatric review

before seeing the

Orthopaedic Registrar.

Once ED Registrar reviews tests and admission is

identified, then the ED Registrar calls the Orthopaedic

Registrar as well as informing the Geriatric Registrar.

Geriatric review

only occurs during

working hours.

In absence of the Geriatric Registrar, the Medical Registrar

can review the patient after hours or weekends.

Orthopaedic review only

occurs until 9pm, if a

call is made after that

time then the patient

will wait in ED until the

next day to be seen.

ED Registrar is able to organise transfer of patients to

the Orthopaedics Ward upon confirmation of fracture.

The Anaesthetist can

request further medical

review, delaying

operating time.

Anaesthetist review occurs at the beginning of the diagnostic

process rather than at the end, upon admission to the ward.

Patients from district

hospitals wait longer for

operation due to the lack

of bed and/or incomplete

documentation.

Checklist is used upon transfer of NOF patients from district

hospitals to ensure documentation is complete. This reduces

delays to theatre due to incomplete documentation.

District hospital patients are returned to the hospital

of origin after operation for post-operation treatment.

This reduces long waits in ED due to the lack of bed, as

this has been quarantined in the hospital of origin.

Disorganised

booking times.

Orthopaedic Registrar will book theatre when diagnosis is

confirmed either before 9pm or between 7am-7.30am as this

would help in organising lists and prioritising theatre patients.

No specialised nursing

review in ED.

The Clinical Nurse Consultant (Orthopaedics) is called upon

patients ED admission to start the care management process

rather than waiting until the patient is admitted to the ward,

i.e. this assists early identification of what the patient requires

in terms of protection of skin integrity, rehabilitation etc.

Education sessions were conducted at various shifts in ED to

raise awareness among staff.

Data collection. The current data collection form was modified to allow capture

of information on reasons why the patient is delayed in going to

theatre within 24 hours.


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Results

Data was collected pre and post project implementation. A comparisonof the data showed that an average of 70% of patients with neck of femur

fracture reached theatre within 24 hours during the seven months of project

implementation compared to 42% before the project (refer to Figure 6).

Overall, the rate of NOF fracture patients going to theatre within 24 hours

increased by 28%.

A further positive outcome of the project was that it crossed departmental

boundaries in order to achieve what is best for the patient.

Figure 6

100%

50%

0

Rate

NOF Project

UCL = 100%

Mean = 70.1%

LCL = 24.4%

Pre-project mean 42%

Jan 02 - Jun 03 Jul 03 - Jan 04

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Figure 7

NOF Fracture Patient Flow (pre-project)

Yes

Patientpresentsto ED-Triage

Admissionrequired?

Yes

No

Time recorded & triagecategory provided

Patient isadmitted MRN is produced

JRMOmedicalassessment

Time is recorded prospectivelyTests include X-ray & bloodpathology tests

In ED X-ray order is putin X-ray box & pick upby X-ray staff

Test resultsreviewed inED by SeniorED Doctor

Patient senthome

Geriatricreviewneeded?

Is geriatricadmissionrequired?

Geriatricianinformed or Med.reg called afterhours

Some # missed.Patients maybe recalled

Patient maybe admitted

to Orthoward duringthe night if

X-ray showsfracture

Yes YesSpecialtests for hippain ordered

Fracture ofhip?

Medicalmanagement

Seen bythe Orthoregistrar

Patientrequiresadmission toOrtho ward?

No

No

Yes

Op theatre booked at timeof diagnosis before 9pm orbooked at 7am next day

Is bedavailable?

No

Wait in ED

Is fractureconfirmed?

Yes Fit forOT?

Yes OTavailable?

Yes Rejected byanaesthetist?

Yes Ward(medicalassessment)

No

Ward

(specialtests)

No

Ward

(medicalmanagement)

No

Ward

(OT rebookdaily)

No

Patient has

operation

Yes

Seen by

the Orthoregistrar andfollows asper 1

Time to be recordedby Ortho registrar

Time of diagnosis& mode to berecorded

Time Orthoregistrar is calledto be recorded byGeriatric registrar

Booking timerecorded inOp theatre,operating timeincluding start& finish times

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Figure 8

NOF Fracture Patient Flow (post-project)

ED Nurse callson Ortho CNC

ED Nurse ordersan X-ray

Confirmation ofNOF fracture

Nurse suspectsNOF fracture

Patient presentsto ED-Triage

ED Registrar reviewpatient & order bloodtests & ECG

ED Registrar tocall the NOF team(Ortho Registrar andGeriatric Registrar)

Patient admittedto D4A

Book theatre atthe same time

Obviousfracture?

Is patient fitto theatre?

Anaesthetistsagree withNOF team?

Further investigation,other teams revieware requested

Patient goesto theatre

Yes

Yes

No

No

Yes

Time recorded & triage category provided

MRN is produced

CNC to review patients needs

skin integrity, rehabilitation etc

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Checklist

prior to starting yourimproving access project

Organisational commitment secured

Principles of change understood

Diagnostic work

Scope of project defined

Engagement of stakeholders

Convene project team

Project aim agreed with team

Defined project plan

Potential interventions identified

Measurement strategy in place

PDSA cycles planned


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3. InterventionsAn intervention is a change, idea or strategy that is designed to improveoutcomes for patients, staff and the organisation. These interventions are

tried and tested ideas and may produce dramatic improvements in patient

flow in an organisation where they have not previously existed. However, these

fixes may not produce long-term sustained improvement unless a structured,

organisation-wide redesign process occurs. It is likely that long-term gains will

only be sustained by adapting an organisational approach to matching service

capacity and demand and smoothing variation in activity as outlined in the

general interventions below.

The interventions are divided into three sections:

General strategies

Emergency patient flow

Elective patient flow

The layout for each intervention is as follows:

Intervention title- a short description of the intervention and key elements ofimplementation.

Tools to assist with implementing the intervention are containedin the attached CD. A tool is anything that is of practical use inimplementing the change. This may be a checklist, Powerpointpresentation or file.

A hospital or organisation where the intervention is in place- not a comprehensive list as these interventions are often inplace in many sites.

Resources These are links to websites or referencedocuments that contains more detail on the intervention orany reported results.

Bookmark link within document.


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3.1 General strategiesThese interventions have a whole of organisation or hospital scope, may

be applied to many different types of patients or are applicable in many

different settings.

Tools - Patient Flow

www.ihi.org/IHI/Topics/Flow/PatientFlow/Tools/

A common cause of miscommunication and delay is a lack of clarity among

all members of the multi-disciplinary team about what should be done

(therapy) and when (urgency). It can cause delays in the patient receiving the

most appropriate care or treatment and non-compliance with evidence based

best practice.

3.1.1 Shared work plans, practices and schedules withinmulti-disciplinary teams

Coordinate ward rounds, team meetings and case conferences and publicise

regular meeting times to maximise opportunities for communication regarding

patient management. Leadership from senior clinical staff is pivotal to the

viability of scheduled multi-disciplinary meetings as it requires all team

members to attend and be punctual. Consider rescheduling meetings if the

team is on call, to minimise interruptions. Allocate responsibility to one person

to communicate changed times or cancellations.

Royal Prince Alfred Hospital

Where possible have consistency in work practices. For example use thesame forms across areas that share staff or use similar layout of equipment in

treatment rooms. Shared referral criteria, documentation and clinical protocols

will make the patient journey safer and reduce the margin for error.

Royal North Shore, Prince of Wales,Hornsby and Albury Hospitals

Multi-Disciplinary Assessment Form (RNS Hospital)

Draft National Medication Chart (Safety and Quality Council)

www.safetyandquality.org/index.cfm?page=Action&anc=Health%20R

eform%20%2D%20Safety%20and%20Quality%20Action%20Areas


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3.1.2 Develop multi-disciplinary evidence based pathways

To provide consistent, streamlined patient care, develop evidence basedpathways for high volume ED presentations and/or admissions. Or to save time,

borrow someone elses and convene a multi-disciplinary team to modify them

to meet local needs.

www.mja.com.au/public/issues/180_06_150304/suppl_contents_

150304.html

www.cochrane.org/index0.htm

www.nicsl.com.au/projects_projects_detail.

aspx?view=6&subpage=28

www.nicsl.com.au/knowledge_literature.aspx

TASC Chest Pain and Stroke Pathways (Nepean Hospital)

Nepean, Gosford, Royal North Shore and Dubbo Hospitals

3.1.3 Relative performance tableProvide feedback to individual clinicians and wards on their performance

on key indicators e.g. unplanned readmission rates. Where performance or

improvement is inconsistent between departments or clinicians, consider

making this information publicly available. This does not have to involve large

amounts of data and can use measures relevant to the department and changes

being implemented (e.g. number of operations delayed due to incomplete

consent forms by surgeon, weekend discharge rate by ward and/or physician).

Wyong, Dubbo and Royal North Shore Hospitals

Western Australian Audit of Surgical Mortality AnnualReport 2003 pp 38-41

www.waasm.uwa.edu.au/


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3.1.4 Convene a redesign team

Whenever change is being considered in a process or system, convene ateam who will take ownership and drive the change and communicate it to

others. Ensure participation from all groups that have active involvement in

the system. At the process mapping workshop identify participants who appear

to take ownership of the issues and the problems that are identified. Include

someone from each of the key stakeholder groups including representation

from upstream and downstream of the processes of concern. The redesign

team will prioritise the problems (waits, bottlenecks etc.) identified during the

operations review and process mapping sessions. Measure, where necessary, to

detect at which steps in the process delays occur. This data is used to inform

the team in their redesign of the process.

Redesign Team Success - Who to involve to ensure success -Powerpoint Presentation (Institute for Clinical Excellence)

St George, Liverpool, Albury and Dubbo Hospitals

The Clinicians Toolkit, Easy Guide to Clinical PracticeImprovement (NSW Health)

Link to engage clinicians and convene the redesign team

3.1.5 Improve communication systems

Review suitability of existing information technology (IT) systems, paging

systems, number and placement of telephones or computers. Try innovative

solutions such as:

Communication clerks.

Personal Digital Assistants solutions such as electronic reminders, electronic

guideline documents etc.

Other IT solutions such as point of care ordering systems.

Staff exchange between wards, departments or hospitals.

Scheduled multi-disciplinary case meetings.

Team briefing or debriefing sessions.

Link to Improve Discharge Processes

Link to Surgical Strategies

Link to Emergency Department Strategies


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3.1.6 Referral to specialist services

Develop alternate methods for referral to specialist services e.g. fax oremail. Establish a common departmental email address that is accessible to all

members of the specialist team so that on call rosters do not need to be known

by those who are referring patients.

Privacy note:Our advice from NSW Health is that it is acceptable to send

patient information necessary for a referral using AHS email servers but that

confidential information should not be sent through commercial email providers.

3.1.7 Service level agreementsDevelop and implement internal and external service agreements. Internal

service level agreements may for example be established between ED and

wards around agreed time to transfer, or with radiology regarding time to

report available. External agreements may be used to facilitate patient

transfer between tertiary referral/base and peripheral hospitals. Include

peripheral hospitals in a process mapping session looking at patient flow

between the hospitals. Develop an area clinical services and bed management

plan that includes transfer and clinical criteria protocols that have been

agreed with peripheral hospitals. Broker management (including bedmanager) and medical staff agreement for base hospitals to take patients

not able to be managed by peripherals and peripherals to take patients not

requiring base hospital level support. Include inter-hospital transfers in the

bed management prioritisation protocols.

Wollongong, Albury, St George and Calvary Hospitals

Link to Management of Hospital Beds

3.1.8 Managing capacity to respond to need for services

Capacity refers to the ability of an organisation to provide a specific volume

of service and is determined by the resources it has and the efficiency with

which the resources are used. Demand for health care is fairly consistent and

predictable. Introducing variation and unpredictability into capacity to provide

care (e.g. not providing seven day a week diagnostic or allied health services)

causes waits and delays.


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3.1.9 Minimise variation in capacity to provide care

Use staggered accrued days off (ADO) instead of hospital wide ADOs.Reschedule vital clinics so that they are not cancelled when there is a public

holiday.

3.1.10 Change to seven day a week services

Change to seven day a week services and reward those that provide this.

Look at services such as radiology, imaging and allied health to ensure there is

weekend access, especially for those patients waiting for discharge who cannot

leave until they have been seen by one of these services. Ensure all inpatientsreceive a medical review seven days per week if they are sick enough to

require a bed in hospital, they are sick enough to have daily review of their

management plan.

3.1.11 Buffer beds

Buffer beds are used to supply capacity at those times when historical data

predicts there will be an increased need for beds. Commonly they will be

opened on Monday, Tuesday and Wednesdays, or evenings. These are the timeswhen demand for elective surgical beds is greatest and access block is likely to

be at its highest level.

St Vincents Health, Victoria


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3.1.12 Smoothing variation in elective activity

Where there are waiting lists, or difficulty in managing operating theatreavailability, smooth the system wide flow of elective surgery admissions. Data

on demand for operating rooms can be used to work with surgeons to adjust

the scheduling of surgical patients. Do a small test first, limiting or capping

elective surgical admissions within a defined unit with one specialty:

1 Identify the average daily number of elective surgical admissions.

2 Limit the admissions for the day to the average daily number of elective

surgical admissions (may take less but not more than the average).

3 Analyse the results of the test and use this information to work with

surgeons to adjust scheduling of surgical patients.

Case for Improvement, Institute for Healthcare Improvement

www.qualityhealthcare.org/QHC/Topics/Flow/

NHS Improvement Leaders Guide to Matching Capacity and Demand

www.modern.nhs.uk/improvementguides/capacity

3.1.13 Develop advanced nursing roles

Further develop specialist roles for nursing or allied health staff. Review the

skill mix in your team, where gaps exist, consider who may be able to fill them

and the education and training required. Where appropriate, consider models

where nurses have ultimate responsibility for patient management. Develop the

role of enrolled nurses to be accredited to take on more responsibilities.

Redesign Tip

During the redesign process identify those bottlenecks that

occur as a result of patients waiting for one member of themulti-disciplinary team. Review the tasks performed by that

team member. Ask:

1. Can any of these tasks be performed

by another team member?

2. Will that team member require additional

training or education in order to perform

the tasks safely and effectively?

3. What additional communication processes need to be

established to ensure coordination of care?


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Management of hospital bedsThe management and coordination of placement of patients

in appropriate inpatient beds is a complex and challenging

logistical exercise. However, it is critical to achieving best

outcomes for patients and a harmonious low-stress working

environment for staff.

3.1.16 Bed management system

Use a centralised bed management system with seven-day bed management/

patient flow personnel responsible for all admissions and transfers.

3.1.17 Centralised bed authority/bed coordinator

Assign a person to act as the centralised bed authority for each shift in

smaller hospitals (fewer than 200 beds). Ensure they have access to up to

date bed information. Assign a location or group of individuals to act as the

centralised bed authority in larger hospitals (more than 200 beds). The team

should be informed of all admissions and discharges and can help find the most

effective way to bring patients into beds for both elective and emergency

procedures/treatment. Key responsibilities of the centralised bed management

team include convening multi-disciplinary bed meetings, diagnosing issues

around bed management and coordinating development and implementation of

strategies to realign bed stock and bed management processes.

Bed Management Information Sheet (St George Hospital).Example of two strategies that facilitate the discharge ofpatients at St George.

Projected activity report template (St George Hospital).


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The patient flow or bed management team

Each hospital should have a core patient flow management

team with operational responsibility for bed management,

including the following people:

Bed manager/patient flow managerwho has the support

of the executive for decision-making and communicates with

units about placements and anticipated bed needs. This person

should have networking skills and credibility with senior clinical

staff. The role will also serve as a conduit for all direct patient

admissions and have a watching brief on other avenues of

admission outlined in alternate admission processes.

Nepean Hospital

Executive sponsor A senior manager (e.g. Director of

Clinical Services, Director of Nursing or hospital Executive

Director) who ensures high-level support and action where

needed to drive change.

Medical leaderto provide input into bed managementmeetings and coordinate weekend discharge ward rounds.

They should have the seniority and influence to follow-up with

specialist clinicians if a patient seems to be inappropriately

occupying an inpatient bed. They should convene/attend

meetings of senior staff to ensure that extra ward rounds or

reviews take place if required.

RNS Hospital

Weighting the WaitPowerpoint Presentation (RNS Hospital)


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3.1.18 Regular multi-disciplinary bed meetings

Convene a morning multi-disciplinary meeting to discuss the bed situationfor the day. Identify the pressures in the system, plan for admissions and

discharges to occur at an appropriate time and brainstorm ideas to prevent

access block. This meeting should also improve communication, as each

department will be aware of the facility wide difficulties. Also called bed

parliament or bed huddle.

3.1.19 Teleconference bed updates

Set up regular teleconference meeting times during the day to update bedstatus and help co-ordinate flow throughout the hospital.

3.1.20 Clinical prioritisation of patients

Wards have ownership of their specialty beds and decision-making

responsibility for accepting patients for admission to the ward with strict rules

for prioritisation and acceptance of patients for admission as agreed with the

central bed management authority. Use of a uniform prioritisation system

promotes equity of access and provides a logical basis for prioritising need. Usethe following decision making hierarchy for admitting patients:

1 Retrieve outliers

2 Accept own specialty patients from ED

3 Accept own specialty transfers from lower service level hospital

4 Bring in elective patients

5 Accept other specialty patients from ED

Redesign tipUse this intervention to decrease outliers. Adapt the protocol

above or develop your own guidelines for prioritising patient need.

St Vincents Health, Victoria


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Case study

St Vincents Health made significant improvements in their

access block, length of stay and elective surgery cancellation

rates by implementation of ward bed ownership and patient

admission prioritisation rules. They also introduced:

a structured process for admitting patients,

planned weekend bed closures and extended opening,

multi-disciplinary team discharge meetings,

services such as a medihotel and awaiting placement

ward to prevent patients from being admitted and

occupying a bed earlier than necessary when coming in for

elective surgery.

3.1.21 Reconfigure beds to reduce outliers

The evidence is that outlying patients (those that are accommodated on

a ward not catering to the patients requirements for specialist nursing care)

have poorer outcomes and longer length of stay. Understand each specialties

bed capacity in relation to the demands placed on them. The number of beds

in each specialty in a hospital is usually historically determined rather than

related to the volume required by patient activity. Reduction of the number

and incidence of outliers becomes more difficult as occupancy rates increase.

Reduce bed occupancy by introducing strictly controlled buffer beds.

Link to Buffer Beds 3.1.11

3.1.22 Over census policy

An over census policy is based on the premise that it is better to have one

extra patient on a ward than 15 extra patients in an ED. The bed manager visits

all units to identify available beds and staff assigned to them. An assessment of

ward staff capacity to safely take additional admissions is made. Each patient

waiting admission in the ED is assigned to an inpatient hallway bed and no unit

will be assigned more than two over census patients. Establish strict criteria

for selecting and prioritising these patients (e.g. must have stable vital signs).If considering this intervention, negotiation with your organisations nursing

establishment is essential prior to implementation.


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3.1.24 Review permissions to order tests

Develop protocols for ordering specific tests. Nurse initiated X-ray in the EDcan help fast track patients and ensure test results are available when the patient

has their initial medical assessment. In the case of a patient entering ED with

pneumonia, a nurse initiated chest X-ray at triage can decrease time to antibiotics.

Pathology Traffic Light Protocol (Lyell McEwin Hospital, SA)

Radiology Traffic Light Protocol (Northern Sydney Health)

Hornsby, Coffs Harbour, Canberra and RNS Hospitals

Rational Investigation Ordering Collaborative Project

www.nsahs.nsw.gov.au/teachresearch/cpiu/rio_project.shtml

3.1.25 Prioritise tests for emergency department orpatients waiting for discharge

Introduce a simple system such as coloured stickers or different coloured

pathology form for emergency department or discharge pathology.

Sydney, Wollongong, Albury and Dubbo Hospitals

Post-op Hip/Knee Stamp (Wollongong Hospital)

3.1.26 Allocated time for emergency cases

For specialty procedures that have waiting lists such as CT and ultrasound,

review historical data and determine predictable level of emergency demand

and allocate emergency slots in the appointment schedule.

Liverpool, Dubbo, Sydney and Sydney Eye Hospitals


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Case study Pathology

Sydney Hospital identified waits for pathology results as

a major source of delay in their emergency department. A

process mapping session identified multiple issues and some

easy quick wins. Their key interventions were:

increased number of tests done on site rather than being

sent to another campus,

changes to hours of service,

changes to pathology collectors schedule to better

coordinate demand with service availability,

changes to local courier service,

increased communication between laboratory and ED staff.

They achieved a sustained reduction in time to pathology

results from a mean time of 116 minutes to 65 minutes.

3.1.27 Appropriate information on request formEducate JMOs and other staff on correct completion of request forms including

location of the patient and clinical notes. Have correct phone numbers for

clinicians point of contact for radiology rooms on display in ED and wards.

Liverpool and Albury Hospitals

3.1.28 Patients attending for tests

Where the patient has to attend a particular department for a test, ensure

there are sufficient portering/transport services to minimise delays and

waits. Redesign processes for calling for and transporting patients. Review

communications for these services and try using two-way radios or a computer

system for tracking patients movements around the hospital departments.

Albury, Dubbo, Wollongong and John Hunter Hospitals


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3.1.29 Stratified test ordering

The literature suggests that 20-30% of all pathology tests ordered areinappropriate. To increase appropriateness and cut down on unnecessary test

use, introduce a stratified ordering system in which certain tests need to be

approved by a registrar or senior clinician. Results in organisations using this

approach demonstrated reduction in inappropriate tests.

Radiology Traffic Light Order System (NSH) Radiology Request

Form for Stratified Ordering (Dubbo Hospital)

Pathology Traffic Light Protocol (Lyell McEwin Hospital, SA)

Case study

During the Patient Flow and Safety Collaborative, Albury

Hospital aimed to improve the flow of patients in the ED. At

a process mapping session, radiology diagnostic imaging was

identified as a major bottleneck. Audit of length of time taken

to complete various phases of the patient journey confirmed

delays were occurring at multiple steps. They implemented a

raft of interventions including: Designated triage number for x-ray,

Second pager implemented internally for trauma calls,

Wardsperson called by triage nurse or clerk,

ED initiated call in of second radiographer for prolonged

delays or significant backlog,

Back up wardsperson if ED wardsperson is busy,

PAC system implemented,

Multi-disciplinary team meetings between ED, Radiology

Department and Wardspersons Department.


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3.2 Emergency patient flow

3.2.1 Pre-bypass hospital early warning system

The hospital early warning system is a coordinated hospital-wide response

that occurs when a hospital is at high risk of going on ambulance bypass. For

this system to work a substantive process of engaging all clinical departments

in committing to enact the agreed protocols needs to occur.

The Austin and Repatriation Hospital, Victoria


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Case study hospital early warning system

(HEWS)The Austin Hospital was concerned that their ability to

respond and recover from stresses placed on the organisation,

exhibited by increased levels of access block, could

compromise emergency patient care. They recognised that

ambulance bypass is a significant hospital event and not just an

ED problem. They also thought, when the probability of bypass

in the next hour was high,

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