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My Job?

My Job?. South African Triage Scale and Acute and Emergency Case Load Management Policy Implementation Officer. Triage?. First come, first served “eye-ball” To the Letter (“inappropriate”) “Love thy Neighbour” Dr G Special. SATS used correctly. ↓Waiting times

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My Job?

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  1. My Job? South African Triage Scale and Acute and Emergency Case Load Management Policy Implementation Officer

  2. Triage? • First come, first served • “eye-ball” • To the Letter (“inappropriate”) • “Love thy Neighbour” • Dr G Special

  3. SATS used correctly • ↓Waiting times • ↓Emergency Centre Length of stay • ↑Patient flow • ↑Patient and staff satisfaction • ↓Mortality (2% to 0.7%)

  4. SATS Performance Indicator

  5. Time to Triage

  6. Triage (ambulance stretcher cases)

  7. Seen by Doctor • 0% Orange patients seen in under 10mins after SATS assigned • Orange and Yellow patients are seen by doctor on average 2 hours after arrival (about 50 minutes after triage) – this is in a system where Green patients are streamed elsewhere.

  8. Time waiting in EC • 71% of admissions spend over 8 hours in the EC (from arrival) • Average is 12,5 hours from arrival to ward bed • Average wait from time seen by specialist to time to ward is 7hours.

  9. Overcrowding If your hospital is >90% full OR Over 10% of the patients in the Emergency Centre have been waiting over 8hrs from arrival to admission THEN...

  10. INPATIENT MORTALITY IS INCREASED BY 30%! Mortality risk ratio is 1.1 for each hour spent waiting in the Emergency Centre Mortality risk ratio is 1.2 for each hour spent waiting for a doctor

  11. Overcrowding causes • Increased patient mortality • Ambulance diversion •• Increased inhospital lengths of stay • Patients not being placed on the appropriate ward •• Medical errors • Poor infection control • Poor hospital processes •• Financial losses to hospital and physician •• Medical negligence claims • Increased staff burnout and decreased morale

  12. “An overcrowded hospital should now be regarded as an unsafe hospital”

  13. Systems Improvement • No matter how few resources we have • there is always hidden capacity in the systems • Use our limited resources more effectively • Increase efficiencies, reduce duplication, reduce waste • Patients want: • the right treatment • without mistakes • without waiting • “Work smart not hard”

  14. Front Door Issues – Entry Portal GFJ: • 20% of CHC referrals are “inappropriate” • 40% GP referrals “inappropriate”

  15. EC Efficiency

  16. EC Efficiency

  17. EC Efficiency Nursing Staff • 44% of time is non-value added work • giving directions • pushing trolleys • answering phones • finding stock • ie Employ 10 nurses and you will get 5,6 nurses’ worth • ?Quality of the 56% nursing care done under pressurised and distracting conditions • Doctors only slightly more productive...

  18. Patient flow Who’s closing the hospital??

  19. Ward check • Ward 1: 0 Beds , 5 discharges pending • Ward 2: 4 Beds, 5 discharges pending • Ward 3: 5 Beds, 3 discharges pending • Ward 4: 3 Beds, 0 discharges pending

  20. Back Door Issues - Discharge planning • Patients admitted on Thursdays have longer lengths of stay than those admitted on Mondays • Patients often only leave beds at 17h00 on the day of discharge

  21. Discharge Process Discharge summary written and handed to nurse This often only happens at 12h00 Folder to pharmacy Transport arranged or 15h00... OPD appointments made Home-based care forms filled Patient waits in bed until medications or transport, whichever comes last

  22. With Discharge Planning Day before On the Day Discharge round first thing in the morning Transport confirmed Patient to discharge lounge as soon as transport confirmed • Contact transport (heads up) • OPD appointments • Home-based care forms • Intern to prepare discharge forms for next day

  23. With discharge planning, discharge rounds and discharge lounge Total length of stay shortened Every bed hour saved: • Reduces mortality and morbidity of patients awaiting beds • Reduces Cost to the Hospital

  24. ‘all improvement needs a change but not all change is an improvement’

  25. DMAIC • Define the Problem and its impact on the Organization • Measure the Current Performance • Analyze the Performance to identify Causes of this Performance • Improve the Problem by attacking its Causes • Control the Improved Process to Maintain the Gains.

  26. Finding ideas for change people providing the service patients guidelines (eg AECLMP and SATS policies!) change ideas/concepts (eg lean, 6-sigma) mapping the system identifying underlying problem (root cause analysis) novel ideas (creativity) eg brain storming best practice - sharing ideas What Change can we make that will result in an improvement?

  27. A little about Lean

  28. Types of waste Muri (overburden) – unreasonable work imposed because of poor organisation – pushing person or machine beyond natural limits. Improvement comes at the level of proactive planning.

  29. Types of waste Mura (uneveness): Problems inherent in system design or implementation. Improvement is in smoothing out the process

  30. Types of Waste • Muda (non-value added work): waste that becomes apparent once system implemented • Transportation: moving products that are not actually required to perform the processing • Inventory: all components, work-in-progress, finished product not being processed • Motion: people or equipment moving/walking more than is required to perform the process • Waiting: for the next step in the production • Overproduction: ahead of demand • Over processing due to poor tool or product design, creating activity • Defects (mistakes, re-work)

  31. Types of Waste Use of human resources: • Rationalisation • Creating thinking workers

  32. 5 WHY’s Why? Why? Why? Why? Why?

  33. 5S • Sort • Set in order/Straighten out • Shine • Standardise • Sustain

  34. VALUE STREAM MAPPING 10 min 6 min 12 min 2 min 1 Hour 30 min 2 hour 10 min 3 hours 24 min 6 hours 40 min

  35. VALUE STREAM MAPPING 3 hours 8 min 10 min 6 min 45 min 30 min 1 hour 24 min 3 hours 45 min

  36. PORTERS

  37. Ward3 to X-rays Ward 2 to Ward 3 X-ray EC to Ward2 EC to X-ray X-ray to EC Ward 4 Ward 1 Emergency Centre Ward 3 Ward 2 Porters’ Lodge

  38. Ward3 to X-rays Ward 2 to Ward 3 X-ray EC to Ward2 EC to X-ray X-ray to EC Ward 4 Ward 1 Emergency Centre Ward 3 Ward 2 Porters’ Lodge

  39. Getting ready to suture

  40. Some other processes impacting flow • Stock availability and placement • Pharmacy throughput • Laboratory turnaround time • Enquiries setup • Time to folder – place for bedside admission? • Statistics collection and acting on Escalation Policies

  41. Initiating Change Performance Valley of despair Time

  42. Rapid Cycle Change PLAN PLAN PLAN PLAN DO DO DO DO ACT ACT ACT ACT STUDY STUDY STUDY STUDY What are we trying to accomplish? What can we change that will result in an improvement? How will we know that a change is an improvement?

  43. Improving many parts of the system at once. PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN PLAN DO DO DO DO DO DO DO DO DO DO DO DO ACT ACT ACT ACT ACT ACT ACT ACT ACT ACT ACT ACT STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY STUDY Nursing duties Triage Wait for doctor Discharges

  44. End

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