Culture, strategy and how to embed timely quality care or
ACI/NSW Health/ECI Seminar, Sydney
,
13 th December 2013
A/Prof Harvey Newnham,
Clinical Program Director Emergency & Acute Medicine,
Director of General Medicine,
Alfred Health, Melbourne
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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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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.

Modified from Aldous Huxley
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Working in healthcare:
S mart,
E xperienced,
C ommitted,
U ltimately want to do the best job they can for our patients
R
E
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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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(However will we win?)
not
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not
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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

is
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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is
‘ 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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Paraphrased from Clayton
Christensen, in ‘the Innovator’s
Prescription’
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Alfred Health
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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
In house conversations
Individual unit developments
–
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
Sign off by HOUs of principles
Travelling roadshow by COO
E&TC Design sessions
Launch of daytime TQC Nov 2012
Formation of Hospital at Night steering committee late 2012
– 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
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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
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The Emergency physicians’ decision to admit
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The inpatient team to promptly provide appropriate care
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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
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Fast Track:
 Treat-in-turn
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Upfront Senior Decision making for all patients….
RITZ (Rapid Intervention & Treatment
Zone)
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Consultant led assessment team
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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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Target 75%
NEAT 4h KPI July 2011–March 2013
The Alfred
NHPA website Sept 2013
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Patient Access as per NEAT
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Acute General Medicine Patient
Pathway
HOME or
CH, SH, HITH, private hospital
Streaming
APT
Streaming nurse Ward 4GMU
Team A
Team B
AAU
*Lead
Consultant
Ward 4AMU
Team C
Team D
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
*Via call to streaming
APT registrar & nurse.
With interim orders
DIRECT ADMIT from community, clinic or other hospital via call to *lead consultant
ESSU Cubicles
RITZ
E & TC
As at 2 nd December 2013
Patient

TQC GenMed % E&TC Admitted <4h
June-November 2013
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Staff Experience – 12 months on…….
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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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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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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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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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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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8am
CON
A B C D
WEEKDAYS
APT
A B C D
BPT INTERN
A B C D A B C D
WEEKENDS
CON
A B C D
BPT
A B C D
INTERN
12pm
1pm
5pm
7.30pm
9.30pm
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Pre TQC
You can’t remove triage
Post TQC
Don’t bring back triage
That’s ED’s problem The hospital working more as a team
I was the wall
At night I see what’s on my list and just get on with it
Thanks for the referral I’ll see them on the ward
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’m not alone. I would never ask a registrar to do one of my jobs
This is just about government targets ???? not so sure now
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Re-thinking E&TC Practices & Processes
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Completely change triage
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Move from triage to streaming model
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More timely care to reduce E&TC occupancy
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Upfront senior clinical decision making
“Treat in turn” instead of “triage and wait
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New team structures
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Clarity of Roles & Responsibilities
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E&TC to use their authority to admit
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Reduce need for negotiation & delay
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 Dr Mark Monaghan

 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.

 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.

 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

 In terms of numbers and targets, the WA State
NEAT performance in high 70‘s, with our tertiary site performance stalled or deteriorated slightly.

 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.

Presentation numbers compared to ED hours of care

Beds saved for ED presentations at Tertiary hospitals

 Transition from project teams to hospital executive ownership.
 Consequent lack of drive of solutions and solution review.
 Significant ED demand.
 Ministerial focus on NEST.

 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.

 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.

 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

 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.

 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).

 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.

 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