Transcript Slide 1

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
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•
•
•
•
↓Waiting times
↓Emergency Centre Length of stay
↑Patient flow
↑Patient and staff satisfaction
↓Mortality (2% to 0.7%)
SATS Performance Indicator
CTS priority
Target time to treat
Performance indicator
threshold
Red
Immediate
95%
Orange
10 minutes
80%
Yellow
60 minutes
75%
Green
240 minutes
70%
Time to Triage
Triage (ambulance stretcher cases)
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.
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.
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...
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
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
“An overcrowded
hospital should now
be regarded as an
unsafe hospital”
GFJ Total Closures/week
18
16
Ward 1
Move
14
12
10
8
6
4
2
0
Philippi
Drainage
Changes
Total
Closures/
week
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”
Front Door Issues – Entry Portal
GFJ:
• 20% of CHC referrals are “inappropriate”
• 40% GP referrals “inappropriate”
EC Efficiency
GFJ EC - Patient arrivals (weekdays)
14
12
Number of Patients
10
8
Mon
Tues
6
Wed
Thurs
4
Fri
2
0
Hour of Day
EC Efficiency
Patient arrival vs Nurses’ Schedule
------ Nurses’ schedule
Patient arrival per hour
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...
Patient flow
Who’s closing the
hospital??
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
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
Discharge Process
Discharge summary written and handed to nurse
Folder to pharmacy
Transport arranged
OPD appointments made
Home-based care forms filled
Patient waits in bed until medications or transport,
whichever comes last
This
often only
happens
at 12h00
or
15h00...
With Discharge Planning
Day before
• Contact transport (heads
up)
• OPD appointments
• Home-based care forms
• Intern to prepare discharge
forms for next day
On the Day
• Discharge round first thing
in the morning
• Transport confirmed
• Patient to discharge lounge
as soon as transport
confirmed
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
‘all improvement needs a change
but
not all change is an improvement’
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.
What Change can we make
that will result in an improvement?
Finding ideas for change
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•
•
•
•
•
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
A little about Lean
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.
Types of waste
Mura (uneveness): Problems inherent in system
design or implementation. Improvement is in
smoothing out the process
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)
Types of Waste
Use of human resources:
• Rationalisation
• Creating thinking workers
5 WHY’s
Why?
Why?
Why?
Why?
Why?
5S
• Sort
• Set in order/Straighten out
• Shine
• Standardise
• Sustain
VALUE STREAM MAPPING
10 min
1 Hour
6 min
30 min
24 min
12 min
2 hour
6 hours 40
min
2 min
10
min
3
hours
VALUE STREAM MAPPING
3
hours
8 min
45
min
10 min
30 min
6 min
1 hour
24 min
3 hours 45
min
PORTERS
X-ray
Ward3 to X-rays
Ward 2 to Ward 3
EC to Ward2
EC to X-ray
X-ray to EC
Emergency Centre
Ward 4
Ward 3
Porters’
Lodge
Ward 1
Ward 2
X-ray
Ward3 to X-rays
Ward 2 to Ward 3
EC to Ward2
EC to X-ray
X-ray to EC
Emergency Centre
Ward 4
Ward 3
Porters’
Lodge
Ward 1
Ward 2
Getting ready to suture
Some other processes impacting flow
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•
•
•
•
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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
Performance
Initiating Change
Valley of
despair
Time
Rapid Cycle Change
What are we trying to
accomplish?
PLAN
DO
ACT
What can we change that
will result in an
improvement?
STUDY
PLAN
DO
ACT
DO
ACT
PLAN
STUDY
PLAN
STUDY
DO
ACT
How will we know that a
change is an improvement?
STUDY
Improving many parts of the system at once.
PLA
N
PLA
N
DO
ACT
PLA
N
PLA
N
DO
ACT
STU
DY
Triage
STU
DY
PLA
N
DO
ACT
STU
DY
Nursing duties
STU
DY
PLA
N
DO
ACT
STU
DY
Wait for
doctor
STU
DY
DO
ACT
PLA
N
DO
ACT
PLA
N
DO
ACT
STU
DY
STU
DY
PLA
N
DO
ACT
DO
ACT
STU
DY
PLA
N
DO
STU
DY
DO
ACT
STU
DY
Discharges
STU
DY
PLA
N
ACT
PLA
N
DO
ACT
End