Aim / Title: Orthopaedic Length of Stay project DRG I08

1. Aim / Title: Orthopaedic Length of Stay project DRG I08 Presenter: Debbie Munro Hospital Name: Vulcan Key contact for this project ( name & details): Lesley RitchieImprovement ManagerMelbourne Health 9342 - 4569 The Health Roundtable New Zealand Using Benchmarking Data to Drive Improvement

2. Define TollgateOrthopaedic Length of Stay (DRG IO8) Project – September 2009 Exec Sponsor Di Gill Clinical Lead Andrew Bucknill Greenbelt: Lesley Ritchie Team Members Meinir Griffiths (7SW) Fiona Becker (5SE) Rhonda Beattie - Manning Ruth Harper Inese Tucker Eric Seal David Love Andrew Oppy Tom Treseder Audi Widjaja Belinda Cary / Debbie Munro

3. KEY PROBLEM Through involvement with the Health Round Table, it has been identified that DGR I08 'other hip and femur procedures' significantly exceeds the average for exemplar hospitals in the following areas: Average length of stay (ALOS) Day of surgery admission rate (DOSA) Percentage of patients discharged home Complication rate Improvement in these areas may increase access to services and patient through- put. Scope Statement Patient cohorts that fall within DRG I08 'other hip and femur procedures’ D C M I A 3

4. AIM OF THIS PROJECT Measure of Success Reduction in average length of stay from 9.91 days to 8 days for DRG IO8 (median length of stay will also be a key measure). Emergency readmission rate to remain stable currently an area of high performance for this DRG Alignment to ACHS Criteria 1.1.1 The assessment system ensures current & ongoing needs of the customer/patient are identified 2.1.1 The organisation’s continuous quality improvement system demonstrates its commitment to improving the outcomes of care and service delivery 4

5. Key Metrics – Baseline with Potential Benefit Median 8.0 days 5

6. Baseline data for Length of stay Range = 1 – 64 days Average skewed by a small number of exceptions. Further analysis needed. Median length of stay is 8.0 days 6

7. N=56 N=53 N=3 Baseline data for Length of stay Segmented Data – ORTM, Ortho & Trauma • Median LOS of 7 days for Orthopaedic steam. Patients who are managed solely by the orthopaedic unit • Median LOS of 9 days for patients who are streamed through ORTM. Patients within this group are managed through collaboration between the orthopaedic and medical units. • Median LOS for Trauma patients is 7 days

8. Baseline data for Length of stay Segmentation of Data - IO8A and IO8B • Median LOS of 9.5 days for IO8A • Median LOS of 5 days for IO8B

9. Procedure types within DRG IO8 76.3% of all procedures fall within the top 3 procedures as follows; Dynamic Hip Screw (DHS) Femoral Nail (insert or removal of) Open Reduction and Internal Fixation (ORIF) of Hip/Femur Other = 24 pts, all with different procedures

10. Complication Rate Q1 = 2 Median = 5 Q3 = 8 IQ Range = 6 n = 33 Q1 = 6.25 Median = 10 Q3 = 14 IQ Range = 7.75 n = 84 • Lower length of stay for patients who had no complication (No)

11. Next steps 11

12. Orthopaedic Length of Stay VOC Collection Customer Sample Comments Key Issue VOC Source Key CTQ Allied Health Fractured NOF patients can be a very complex group of patients as they often have lots of other co-morbidities which can lead to a longer length of stay, this needs to be considered Patient care and complexity impact length of stay Interview Average length of stay Allied Health Sometimes the ORTM patients don’t appear on our lists until day 2 or 3 so I don’t have the opportunity to intervene early Lag time to physio referral Interview Time to physio referral Allied Health Sometimes the orthopaedic team are hard to reach and they don’t give clear documentation in the history of pts weight bearing status or pager numbers, so you don’t know who to contact. Clear documentation of weight bearing status and unit contact details. Interview Time to physio intervention Nursing - Surgical best practice is to have these patients to theatre within 8 hrs but often this does not happen Lag time to theatre Interview time to theatre Nursing - Medical The orthopaedic unit is great at reviewing the patients post op. They come to see their patients first thing in the morning Post Op review Interview No of pts seen day 1 post op. Nursing - Medical Sometimes there is confusion over which unit the patient is under. Sometimes they are sent to 5SE without being accepted by the medical unit which causes delays in patient Management. This is particularly bad on weekends. Accurate streaming of patients & length of stay Interview No of pts stream to the correct ward. Average length of stay Nursing - Medical When Orthopaedic patients are on the medical ward they are sometimes not followed up well by the Orthopaedic unit pre- surgery and they seem to wait longer for theatre. This causes further deconditioning of these patients who often have multiple comorbitities Accurate streaming of patients. Lag time to theatre Interview No of pts stream to the correct ward. Time to Theatre Nursing - Medical Sometimes there are delays in having patient accepted by TRAC as they want additional tests that are not really required. Timely acceptance of patients by Trac Interview Average Length of Stay Anaesthetist There is a tendency now to operate on patients with significant co-morbidities. Elderly pts deteriorate quickly if they don’t receive surgery promptly but this is difficult to achieve as urgent ortho lists are always full. Access to theatre Interview Time to theatre Voice of Customer

13. Orthopaedic Length of Stay VOC Collection Customer Sample Comments Key Issue VOC Source Key CTQ Nursing - Surgical A lot of work was done previously were it was identified that most of the ORIF and NOF pts should be managed under the medical unit in partnership with orthopaedics because they were blocking orthopaedic surgery beds. This streaming should be done in ED but sometimes pts are not sent to the right areas and this can add time to their length of stay. Accurate streaming of patients & length of stay Interview No of pts stream to the correct ward. Average length of stay Nursing - Medical Sometimes theatre cases can be cancelled at the last minute, when the patient has already been fasting. Timely access to theatre Interview Delays to theatre by time, type Nursing - Theatre There are a number of factors that may cause the Orthopaedic unit to delay surgery. They are sometimes restricted by the availability of theatres, availability of specialised equipment, availability of other specialists or complexity of surgery. Timely access to theatre Interview Delays to theatre by time, type Nursing - Theatre There are sometimes delays getting patients to Theatre because the patient is not ready when we go to pick them up or the consent may not have been signed but there are times when the unit changes their mind and decides to do another patient first and leave the more complex cases for last. Timely access to theatre Interview Delays to theatre by time, type Executive This DRG has come up a number of times in the health round table data and needs to be addressed in 2009 Length of stay Interview Average Length of stay Patient When asked what do you think we do well, patient responded that we do everything well, staff are on the ball the whole time and very thorough. Level of care received Interview Patient satisfaction Patient Its good when staff are friendly as it is so boring in hospital Friendly interactions with staff Interview Patient Satisfaction Voice of Customer

14. Next Steps Measure Stage Define stage Project Charter Project Charter Key Metrics - Baseline Process Flow Value Stream Map SIPOC Diagram Baseline data Project Plan MSA Risks & Issues C&E Diagram) Lessons Learned Lessons Learned

15. LESSONS LEARNT Clarify scope and key measures in define stage Ensure engagement from key medical and nursing staff Be clear about what you are measuring and why, and ensure data is reliable Ensure statistical analysis is appropriate to the data i.e. confirm normality and identify exceptions 15