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Michael Szwarcbord Flinders Medical Centre

Making Medical Journeys Work: Redesigning General Medicine Highest volume clinical service 15% of adult emergency admissions 13% of adult occupied bed days 300 admissions per month & growing Struggling with work-load Leadership ‘amenable to change’. Michael Szwarcbord Flinders Medical Centre

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Michael Szwarcbord Flinders Medical Centre

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  1. Making Medical Journeys Work:Redesigning General MedicineHighest volume clinical service15% of adult emergency admissions 13% of adult occupied bed days 300 admissions per month & growing Struggling with work-load Leadership ‘amenable to change’ Michael Szwarcbord Flinders Medical Centre Key contact Denise Bennett, 08 82046264 denise.bennett@fmc.sa.gov.au

  2. The General Medical Patient Journey: Flows prior to redesign Decision to refer to GM Pt allocated to a bed by Bed Manager On Take Jr Dr reviews pt & accepts or refuses Patient arrives in ED Pt t/f to ward (av. wait 12 hrs) Review by ED staff Medical & nursing care +/- allied health if referred Discharge ALOS 7 days Consultant review next day Problems with this system 1. Take system creates overburden & unevenness 2. General Medicine patients at the end of the specialty queue for a ward bed. 3. Safari ward rounds 4. Re-work to return patents to the right ward A typical day before redesign 10 patients admitted by medical team on take, 6 discharges on home ward, Ward admits - 2 specialty admissions, 1 ICCU patient, 3 new GM patients, = 7 outliers (70%) ICCU patient

  3. Redesign Aims for General Medicine • Reduce outliers • Create a manageable more even, safer workload for medical teams

  4. Key changes implemented P D A S P D A S P D A S P D A S P D A S P D A S P D A S P D A S P D A S

  5. Post-redesign Flow Short stay Long stay Aged Care Specialty Patient arrives in ED Review by ED staff Decision to admit to GM Inter- disciplinary assessment 4-24hrs Patient ‘pulled’ to AAU Short Stay Ward with dedicated team ALOS < 2 days Long stay Up to 25 patients ALOS 8 days GM / ICCU team ICCU

  6. Outcome 1More patients in the right place and improved flows Redesign Commenced

  7. Outcome 2 Safer, more equitable work-loads

  8. Outcome 3 Improved Flow: ED Waits

  9. Evaluation -1. Improve flow • No take • Improved queue management for General Medical patient flow • Dedicated outflow • First-in first out wherever possible • Addition of a new ‘value-added’ process step inter-disciplinary ‘assessment’ step early in the patient journey

  10. Evaluation-2. Organise flows according to value streams (processes of care) • Emergency Short stay • patient expected to stay less than 48 hrs • dedicated medical team • collocated with other emergency medical & surgical short stay patient • Emergency Long Stay • 2 dedicated teams on 2 X 21 bed dedicated wards • ICCU flows • dedicated medical team • pull system

  11. Evaluation – 3. Establish standard work Uniform ways of working despite changes in senior and junior medical staff • Not clinical practice, work routines. Example: Standard Long Stay Ward Round • Discharges before 12 midday increased from 15% to 25% Example: Separation Summaries • Separation summaries sent to GPs within 48 hrs increased from 30% to 70%

  12. Evaluation - 4. Maintain improvement work & keep improving • Development of people on the ground who understand the methodology and can apply it. • Continuous Improvement Forums • Junior Doctor lunch (2/52) • General Medicine Value Stream Continuous Improvement forum (monthly) • KPIs are presented and discussed (flow & quality) • Communicate standard work • Active redesign work is reported & discussed • Suggestions from staff

  13. No down side - Quality measures:mortality Redesign Commenced

  14. No down sideQuality measures: readmissions Redesign Commenced

  15. Redesigning Care Quarterly Report • Topic: AAU New Internal Flows: Intervention • Author / Date: Denise Bennett 26th March • Current Work Plan • Continue Intervention till the end of April 07. • Work Group continues to meet weekly to review flows & identify issues. • Each week a Problems of the Week is identified for staff to focus on. • I day week change support (funded by Redesigning Care) will continue till early April. • Lauri O’Brien (new RC CF) will become involved in this program of work, supported by DB Program Of Work: AAU Internal Flows – Trial February – April 07 The AAU commenced operation in February 05 & has had a major benefit on medical flows at FMC. Staff Feedback, demand data & tracking data indicated that AAU flows could be improved to streamline patient assessment by the 3 staff groups (medical, nursing, & allied health). A work group established the new flows based on this data & the new flows commenced in Feb. 07. Baseline data were collected on all major KPIs. Staff satisfaction for all staff groups was high except for consultant physicians. The intervention will be evaluated in early May 07. Gerrie Vandepeer is being funded one day per week by Redesigning Care in order to support the intervention on the ground & provide a mechanism for data collection. The program of work is facilitated by Denise Bennett. • Issues / Barriers • Slow to change some of the medical practices & trial may require initial evaluation then extension to bed down new flows. • Assessment Nurse expectations for number of assessments still not being met & this requires continued work. Contribution to FMC Lean Objectives – Quality / Flow / Cost & Intangibles • Intervention Goals • Improve teamwork between AAU clinicians • Standard work based on safe practice, optimal flow & minimal duplication. • Improved communication & documentation processes. • KPIs • Median time of T/F to AAU • Median time of T/F to ward from AAU • Median time of discharge or T/F to another hospital from AAU • Staff satisfaction • Number of nursing assessments each shift. • Time from MR10 to Nursing Assessment • Current State • Process Outcomes • New flows were implemented on 15th February & communicated to all staff groups. • The Admission to Discharge Planner has been revised in line with the new flow. • The Patient Journey Board has been revised to support the new flows. • Performance Outcomes • All flow KPIs indicate improvement from baseline, except for no. of nursing assessments. • Recommendations • Continue program in line with current program timelines as this objective is in line with overall hospital flow objectives. • Consider extension of trial if evaluation in early May indicates components of new flows require ongoing focus. Contact: denise.bennett@fmc.sa.gov.au

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