culture, strategy and how to embed timely quality care

Report
NEAT within the hospital
Culture, strategy and how to embed timely quality care
or
Don’t mention the war!
ACI/NSW Health/ECI Seminar, Sydney,
13th December 2013
A/Prof Harvey Newnham,
Clinical Program Director Emergency & Acute Medicine,
Director of General Medicine,
Alfred Health, Melbourne
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How are we doing?
Improved Much the same Worsened
No idea
1. Quality of patient care in your sphere of
influence in 2013 compared with 2011 is
……………..?
2. In what way do you feel the 4h NEAT
approach to date has contributed to quality of
care?
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Survey of Directors of
Victorian
General Medical Units
September 2013
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Certainly has led to increased focus on patient through put and we have implemented some practice change to improve this
Focus on KPI's to the detriment because we are treating a performance measure as an objective
The 4 h NEAT target has been a catalyst for some positive changes although there are balancing negative effects
Have noticed very little difference in reality
It has helped focus on what was previously very poor and unpatient centred performance.
Pressure on JMS to discharge patients and to transfer patients to ward regardless of
clinical management requirements
It has been challenging to maintain the high standard of patient care but feel we have achieved this.
Shorter ED length of stay and earlier contact with the treating team has lead to benefits
overall
There have been stress points with ED at times and some tensions that we have had to resolve
Pressure leads to deterioration in behaviours
General medicine is looking closer at internal structure and perhaps not filling gaps in other services as it was previously
We have been better accepted by ED people
The registrars feel more stressed and there has been some pressure put on them by ED staff which they have found difficult
to manage
Resources allocated to assist with achieving targets
We have had to operate within existing budget
It has helped focus on gaps in rostering
Consistent practice, excellent senior staff input, wonderful nurses and junior medical staff
with great nursing leadership
Very happy with care once they get in.
The Zen of
Healthcare
It’s not about what happens.
It’s about what you do with
what happens.
Modified from Aldous Huxley
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Working in healthcare:
What’s not to like?
The people:
Smart,
Experienced,
Committed,
Ultimately want to do the best job they can for our
patients
Very substantial Resource
High degree of public, political and
administrative Engagement
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Context of NEAT:
Essential problems in delivery of
care
For many patients we don’t know what to do.
When evidence exists it is often not applied.
Fidelity of execution.
Our health system is tweaking an historical model of care
rather than designing its own future
Solution: Design and create a comprehensive
system for delivering health care.
Richard Bohmer “Designing Care” 2009
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All just too hard
Don’t mention the war
(However will we win?)
It’s not about 4 hours – pebble in a pond
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It’s not about working harder
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E &TC cubicle occupancy May to August 2011, 2012, 2013
Which department would
you prefer to work in?
2009
2012
2011
2013
It is about excellence in patient care
Timely Quality Care (TQC)
Transforms the way we treat our patients to
ensure they all receive timely, quality care
consistent with their clinical needs
Is a whole of health service change that involves
everyone (clinicians, managers and support
staff)
Changes how we assess and treat our patients
from the moment they arrive to the time they
are discharged
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It is a new paradigm
‘It is no longer tenable that a good
practitioner can provide the best care
other than as part of an effective team
within a well organised health care
delivery system.’
Translated into medicalese:
We can enjoy what we do, use our skills to provide effective care,
have a manageable workload and maintain reasonable
remuneration, if we learn how to be part of an effective team.
Management speak:
We want everyone to work at the mid-upper level of their
competency.
We all need to
• work differently or
• be paid less or
• get off the bus.
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The Good News
The best innovations happen
within the tightest constraints
Paraphrased from Clayton
Christensen, in ‘the Innovator’s
Prescription’
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Our Timely Quality Care Journey
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Alfred Health




3 hospitals: The Alfred; Caulfield Hospital & Sandringham Hospital
Around 900 beds; 90,000 ED presentations, 92,000 inpatient events;
170,000 outpatient attendances.
Approximately 5000 equivalent-full-time staff made up by around
7000 people
State-wide services for trauma, burns, heart & lung transplants, HIV /
AIDS, hyperbaric service, cystic fibrosis, haemophilia, Melbourne
Sexual Health Centre

$900 million per annum

Strong General Medicine

Highest bed-day user
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The Journey starts:
In August and September 2010, four of us (H H N, P De V S, M J K,
A M S) undertook an investigative tour of 13 emergency hospitals in
the United States and the United Kingdom to observe innovative
approaches to patient flow pathways from the emergency department
(ED) to inpatient wards and consider their potential for use at Alfred
Health
Harvey H Newnham, Pieter De Villiers Smit, Martin J Keogh, Andrew M
Stripp, Peter Cameron
MJA 2012
p101
The Journey towards Timely Quality Care
E&TC and Acute/GenMed in same
program
Site visits US & UK 2010
Travelling roadshow by COO
E&TC Design sessions
In house conversations
Launch of daytime TQC Nov 2012
Individual unit developments –
Formation of Hospital at Night steering
committee late 2012
AMU model of care etc, E&TC modifications
Formation of Whole of Hospital TQC
Steering Group
Data, and more data
Site visits to Perth Hospitals
Importance of engaging HMOs
Draft principles established for whole of
hospital approach
Stakeholder input into principles
–Conversations about hospital at
night
–Draft principles established
–Stakeholder input
–Promulgation of hospital at night
plan
–Launch of hospital at night (ie 24h
TQC) Feb 2013
Ongoing monitoring by steering group
Sign off by HOUs of principles
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TQC – Craft group specific
approaches to
implementation
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Leadership Workshop
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Concerns must be voiced and taken
seriously
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GENERAL MEDICINE DESIGN
WORKSHOP
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Key Whole of Hospital Changes
Trust
 The Emergency physicians’ decision to admit
 The inpatient team to promptly provide appropriate
care
 The investigative/interventional services to deliver in
24 hours (treat in turn)
 Management to apply resources according to system
design/priorities based on accurate data
 Adjust rosters/work patterns to ensure staff are available
when required
 Match bed capacity to the time of highest demand and
ensure patient goes to the correct bed first time



admission beds, SAAU’s, MAAU's & Flex beds
Develop safe after hours/overnight teams
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Triage has become Streaming

3 minute assessment maximum

ATS allocated (? is it still relevant)

Patients streamed to either:



Resus & Trauma:
RITZ:
 Prioritise Cat 2 & AV to front of queue
 Everyone else treat-in-turn
Fast Track:
 Treat-in-turn
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Upfront Senior Decision making for all patients….
RITZ (Rapid Intervention & Treatment
Zone)
 Consultant led assessment team
 Determine interim management and
disposition plan
 “Treat in turn” principle instead of
“triage & wait”
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Safety is OK
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Dr Foster global health comparator
Alfred Health
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Bypass: Our Doors are Always Open
The Alfred
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NEAT 4h KPI July 2011–March 2013
Target 75%
The Alfred
NHPA website Sept 2013
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Patient Access as per NEAT
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Acute General Medicine Patient
Pathway
*Lead
Consultant
HOME
or
CH, SH, HITH,
private hospital
Ward 4GMU
Team A
Team B
4 Identical teams A-D
Consultant (8-12/1600*pm)
APT (8-1700)
BPT (8-2130)
2 x Interns (8-4 & 11-1930/2130)
Daily consultant ward round
Streaming
APT
Streaming
nurse
AAU
*Via call to streaming
APT registrar & nurse.
With interim orders
ESSU
Cubicles
RITZ
E & TC
As at 2nd December 2013
Patient
Ward 4AMU
Team C
Team D
DIRECT ADMIT
from community,
clinic or other hospital
via call to *lead
consultant
TQC GenMed % E&TC Admitted <4h
June-November 2013
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Staff Experience – 12 months on…….
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What NEAT is showing us
Before NEAT
Good Doctor + Experience + Resources = Best Care
Doctor: custodian of knowledge, skills and application of these to the
individual patient
Organisation: provider of resources
After NEAT
Health care delivery organisation manages….
Practitioners - typically in multidisciplinary teams
Knowledge base - decision support and practice-based evidence
Processes of care – reduced variation and delays, outcome orientated
to provide best healthcare outcomes at affordable cost
Adapted from Richard Bohmer “Designing Care” 2009
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10 Big Ideas
Future Hospital Commission 2013:
“the most important statement about the future of British medicine for a
generation”
“Hospitals must offer “seven-day care,
delivered where patients need it”.
It's time to build a new movement for
generalism, not specialism—”generalists
are the undervalued champions of
…acute hospital service”.
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Major Gaps
Practice-based evidence is in its infancy in our
system
Can’t implement change unless monitoring systems are good enough to
learn from mistakes and measure failure
Integration is essential
The divide between hospital and community care leaves us impotent
regarding demand management
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Where next?
PM’s & weekends
Treat-in-Turn expansion
Cardiology
Gastroenterology
Patient discharge pathway
Matching staff with workload (volume and
time)
New ward governance models
Standardisation of ward rounding
How many admitting units do we need?
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Conclusions
Don’t mention the war – it’s not about the 4 hour KPI!
It’s not about working harder • It is about leadership, teamwork, design, and reducing
variation
• Hospitals are full of smart people, we need to create the
environment/culture that allows them to achieve their
potential
It is about quality and excellence in care – quality saves time
and money
It is a journey that your staff have to travel with you
Let’s get the job done and move on to address the bigger
issues
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Acknowledgements
Martin Keogh – Services Director,
Emergency and Acute Medicine
Andrew Stripp – Chief Operating Officer
De Villiers Smit – Director Emergency
Services
Peter Hunter – Program Director of
Aged Care and Rehabilitation
Andrew Way – CEO
Bill Johnson – Program Director
Surgical Services
Amy McKimm – Redesign manager
Many, many others
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GenMed Team Staffing Dec 2013+
WEEKDAYS
CON
8am
A B C
APT
D
A B C
WEEKENDS
BPT
D
A B C
INTERN
D
A B C
D
CON
A B C
INTERN
BPT
D
A B C
D
12pm
1pm
5pm
7.30pm
9.30pm
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“Culture Eats Strategy for
Breakfast”
Pre TQC
Post TQC
You can’t remove triage
Don’t bring back triage
That’s ED’s problem
The hospital working more as a team
I was the wall
Thanks for the referral I’ll see them on the
ward
At night I see what’s on my list and just get
on with it
We have a night team and meet at 9 for
handover
Frequent unnecessary overnight calls to
on-call staff
The After Hours Clinical Lead can decide
What training overnight
Its great to get support, mentoring and
education after hours
I would never ask a registrar to do one of
my jobs
I’m not alone.
This is just about government targets
???? not so sure now
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Re-thinking E&TC Practices & Processes

Completely change triage


More timely care to reduce E&TC
occupancy



Upfront senior clinical decision making
“Treat in turn” instead of “triage and wait
New team structures


Move from triage to streaming model
Clarity of Roles & Responsibilities
E&TC to use their authority to admit

Reduce need for negotiation & delay
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Time based targets five
years on: The WA perspective
and other lessons.
 Dr Mark Monaghan
What has this been about?
 Enhancing access to care for acute patients and
making access to care a central component of
excellent clinical care.
 Replacing processes that are burdened with
waste and protectionism, and thereby reducing
morbidity, length of stay and mortality.
What has this been about?
 Creating a more effective system to cope with
increasing demand.
 Instilling the concept that hospital beds are a
valuable resource that we as clinicians have a
responsibility to utilise in the most efficient way
possible.
Key achievements – WA
Program
 Implementation of large scale, statewide change
program
 Establishment of redesign capacity across the
system
 Invested over $40M in solutions
 Leading the nation in emergency access reform
Where are we now?
 In terms of numbers and targets, the WA State
NEAT performance in high 70‘s, with our tertiary
site performance stalled or deteriorated slightly.
Where are we now?
 From a hospital clinician perspective it has
created an improved work environment that
persists despite challenges in maintaining
tertiary performance.
 The concept of the need to flow patients
efficiently has been embedded to a significant
degree. It is part of our language now.
A quick scan of the data
Presentation numbers compared to ED
hours of care
Access block and mortality
Beds saved for ED presentations at Tertiary
hospitals
What happened in 2012?
 Transition from project teams to hospital
executive ownership.
 Consequent lack of drive of solutions and
solution review.
 Significant ED demand.
 Ministerial focus on NEST.
So what did we do about this
performance trajectory?
 We attempted to rally managerial and clinician
engagement, however we were struggling to
know where to start.
 The Minister for Health commissioned an
external review –The Bell Review.
The Bell Review
 Daily accountability /core business
 Data
 Bed management structure/ outliers/ the
clinician’s role
 Consultant lead service-weekend performance
 Align multi-professional teams for timely
treatment and decision making
 ED discharge stream perfomance, decreased
patient moves within ED.
The Bell Review
 Capacity audit analysis. 25-30%, half of which is
under hospital control.
 Simplified points of access to specialties.
 Acute unit structure and staffing. “a safe haven”,
with focus on inclusion rather than exclusion
criteria.
 Appropriate IT solutions
The Bell Review
 Essentially, the take home message was that if
you want this to be successful, you have to get
serious and run it like a professional business
should run.
What has happened since
 Executive restructuring was already occurring in
several of our tertiary sites. This is occurring
across all tertiary sites now.
 This includes leadership training, greater time
allocation to divisional heads, JDF changes to
incorporate NEAT accountability (eg FSH).
What has happened since
 Bed management disassembling and increased
clinician involvement.
 Services to provide seven day structure –
endpoint being equivalent discharge rates to
weekdays
 Data/CapPlan utilisation for daily clinician bed
management.
 Some real accountability and ownership is being
seen at a hospital level.
Some general observations to
consider




ED versus Inpatient reform.
Flogging the discharge stream
The admission stream dilemma.
Direct admissions, inpatient occupancy and the
core role of the ED
 The future of NEAT
 The ministerial drive effect
Thanks

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