Change in the Acute Setting. Dr Veronica Devlin Lean Leader NHS Lanarkshire

Transcription

1 Change in the Acute Setting Dr Veronica Devlin Lean Leader NHS Lanarkshire 4 th International Conference, Society for Acute Medicine, Edinburgh 7-8 October 2010

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3 World class facilities World class staff World class systems?

4 Converting research to care Negative results Negative results Lack of numbers Inconsistent indexing 50% 18% Dickersin, % Koren, 1989 Submission variable 0.5 year Acceptance 17 years to apply 0.6 year 14% of Kumar, 1992 research Publication knowledge 17:14 35% 0.3 year Poyer, 1982 Balas, 1995 Poynard, 1985 Original research to patient care Bibliographic databases years Reviews, guidelines, textbook Patient Care 9.3 years Kumar, 1992 Antman, 1992 Expert opinion Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70

5 Traditional approach Randomised controlled trial, literature review Publish, debate National guideline or local protocols Laminate and put on noticeboard Education sessions Audit and feedback Focus on process Quality Improvement See the need for change Gather evidence locally Engage staff in the effort Small scale cycle of change Measure impact quickly, share performance Move on to next cycle of change Focus on process & people

6 "Now, here, you see, it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!".

7 What does lean add? Structure Focus Evidence Small scale change cycles Teamwork Metrics Sustainability Iterative process

8 The Cycle of Lean Work to perfection Define the value Implement pull Map the value stream Establish flow

9 Value In industry - it s value if the customer is willing to pay for it So activities that add no value are waste Necessary vs unnecessary waste In healthcare it s value if it adds something to the clinical picture, contains direct care etc Minimize Value Enabling VALUE Eliminate WASTE

10 The 8 wastes in healthcare Waiting: waiting in ED, patients waiting for discharge prescriptions, clinicians waiting for test results Inventories: full clinic waiting room, batching of lab samples for testing, stocks on wards, dictation waiting for typing Defects: Needle stick injury, missing patient information, wrong information communicated Excessive Processing: Multiple bed moves, re-testing, repeat assessments without clinical need Overproduction: Excessive reporting, Unnecessary tests, Irrelevant information sent out Movement: working across multiple sites, storage of consumables in disparate places Transportation: Moving patients to tests, patients having to attend different depts Under-utilisation: Physicians transporting patients, not fully using skill mix of staff

11 How does it work? Take a history Perform some observations Carry out an examination Decide on a treatment plan Initiate treatment Reassess the patient Monitor progress PREWORK ENGAGEMENT CoW, TVA VSM KAIZEN TRYSTORM ACTION PLANNING METRICS

12 The testbed Monklands District General Situated within Airdrie, North Lanarkshire 478 inpatient beds and 57 day beds Centralised renal unit Centralised services for inpatient ENT, Dermatology and Communicable Diseases Daily medical take - 36 Hairmyres Hospital Situated within East Kilbride, South Lanarkshire 353 acute inpatient beds and 52 day case places 20 continuing care beds 60 re-habilitation beds 60 psychiatric beds Cardiac Catheterisation Centre Centralised ophthalmology WoS Daily medical take - 25

13 Kaizen I ED and ERU Monklands Sep 09 Kaizen II - Wards Monklands Nov 09 Kaizen III - Care of the Elderly Hairmyres Feb 10 Kaizen IV - Medical Wards and AMU Hairmyres May 10 Kaizen V - ED and AMU Hairmyres Jun 10 Kaizen VI Surgical Flow Hairmyres September 10

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15 ERU Delays for junior medical assessment once arrived in ERU Knock-on effect leading to delays in consultant decision-making due to lack of information Issues with medicines reconciliation Environmental issues in ERU

16 KAIZEN Kaizen 1/2 GE facilitator 3 NHSL facilitators initially 40+ participants 4 workstreams 4 ½ days

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23 Emergency Receiving Unit Sub Workstreams Medicines Management Flow in Flow out 5S

24 CHANGE SUMMARY GP patients assessed in dedicated trolley bay Assessment completed before moving to ERU MINTS Majors nurse Altered working pattern for consultants Decide to Admit vs Admit to Decide ACE Unit set up in tandem Bed management changes 5S

25 resus reception See & treat LOORPLAN BEFORE KAIZEN Staff base Chaired area X-ray majors majors minors ERU

26 resus reception Acute Care of the Elderly LOORPLAN AFTER KAIZEN Staff base GP assessment X-ray majors majors minors Emergency Receiving Unit

27 ERU Length of Stay Length Of Stay ERU 1stJuly-17th Nov Pre-Lean intervention average Post-Lean intervention average

28 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 LOS Days Monklands LOS ERU July

29 GP Assessment Area admitted discharged th January-2nd March 17% discharged From assessment bay

30 medical admissions Monklands Monklands 08/09 Monklands 9/ AMRU KAIZEN SEPTEMBER % REDUCTION 2009/2010 FROM 2008/ April May June July August September October November December January February March

31 % From 10% pre kaizen to over 80% Post Kaizen % of Patients with ECS on admission Pre-Kaizen Kaizen week 22/10/ /11/ /11/ /11/ /11/ /12/ /01/ /01/ /01/ /01/ /02/2010 Date

32 % % of Patients with Accurate Medication Histories Documented by Medical Staff on Admission % of patients with accurate medication histories documented by medical staff on admission Pre-Kaizen (All patients) Kaizen week (GP referrals) 22/10/2009 (GP Referrals) 22/10/2009 (A&E patients) 05/11/2009 (GP referrals) 05/11/2009 (A&E patients) 12/11/2009 (GP referrals) 12/11/09 (A+E referrals) 19/11/09 (GP referrals) 19/11/09 (A+E referrals) 26/11/2009 (GP referrals) 26/11/09 (A+E referrals) 15/12/09 (GP referrals) 15/12/09 (A+E patients) 07/01/2010 (GP referrals) Date 07/01/2010 (A+E Referrals 14/01/10 (GP referrals) 14/01/2010 (A+E referrals) 22/01/2010 (GP referrals) 22/01/2010 (A+E)referrals 28/01/2010 (GP referrals) 28/01/2010 (A+E referrals) 04/02/10 (GP referrals) 04/02/10 (A+E referrals)

33 ERU STAFF HUB Problem Cluttered worktop space No floor space Untidy No designated area for nursing, medical & clerical staff Before Improvements Designated areas for all staff Quiet, uninterrupted area for medical staff Removed leaking air conditioning Next Steps After Maintenance schedule established Permanent signposting for reception and exit areas Install competent air conditioning

34 ERU CLEAN PREP AREA Before Improvements Clear, accessible worktops for drug preparation Clean visible space Storage fit for purpose Problem Cluttered worktop area Not suitable for drug preparation Out of date notices displayed Lack of ownership for maintenance of area After Next Steps Maintenance schedule established Prevent exposure to interruptions Obtain permanent facility to enclose area

35 ACE Rapid assessment and diagnosis Multidisciplinary team assessment Alternatives to admission Facilitated discharge or direct admission

36 The Trial Run - Elderly Pitstop

37 ACE Unit - PILOT PERIOD 8 working days 47 patients in total 14 discharged home 30% 26 admit direct to Care of the Elderly- 55% 15 admit ERU

38 ACE (Acute Care for the Elderly Unit) this unit is long overdue first class care I felt special great to avoid admissions ward 15% 55% 30% Home Direct to Specialty Admitted to Receiving Unit

39 9 th March 25 th June patients 77 discharged from ACE 191 admitted direct to CoE 2 admitted to another specialty 12 admitted to ERU as no CoE beds 1 inappropriate admission

40 ON AVERAGE 1 ADMISSION AVOIDED PER DAY 3 BEDS PER DAY IN ERU SAVED SAME DAY DISCHARGE PRE ACE < 4% POST ACE 26%

41 Hairmyres Kaizen Timetable CoE February 10 Medical Wards /AMRU May 10 AMRU/ED June 10

42 Staff Feedback CoE Kaizen Lean has made a huge difference to how we work Staff now more aware of patient flow and there has been great real changes all for the good Lean very hard work but the whole system has improved White board a big improvement Information now very visible for everyone to see SBAR handovers miss Information. Prefer verbal handover MDT with EDD & Admission date very good and keeps the team focused on discharge planning

43 Pre kaizen status Hairmyres Push system from ED All medical patients assessed in ED AMRU LoS 2.5 days Single rooms blocked No operational policy Lack of discharge planning Slow progress into CoE

44 Daily Dashboard Visual management Target driven Updated and reviewed daily Also for surgical and medical flow Monitors individual ward performance

45 Change Detail Clearly defined stroke pathway, pull direct from A&E, FAST & ROSIER training, protected stroke bed, organised ward initiative, shift changes to cater for visiting, 5S Key Performance Indicators Stroke Pathway Sustainability Monthly monitoring of KPI s, dedicated DECT phone, EDIS system installed for pull, FAST & Rosier training for A&E, AMRU & Ward staff, sharing success with staff & patients Mean LoS for Stroke Hairmyres Linear (Hairmyres) Pre Kaizen Post Kaizen Standard % Hairmyres Stroke Performance Improvements after 90 days Significant Improvement In 4 of 5 KPI s Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun Admitted to a stroke unit on day of admission Admitted to a stroke unit on day of admission or day after Swallow screened on day of admission CT on day of admission Asprin given on day of admission or day after

46 Medical Assessment Bay (MAB) 4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm (weekdays) Consistent staffing, bed availability Ambulance Service/ERC Criteria for access. JULY MAB ADMISSIONS VS D/C % of patients Discharged from MAB ADMIT DISCHARGE

47 Medical Assessment Bay (MAB) Key Performance Indicators MAB A&E (Medical Flow) Average Total Journey Time July 2010 MAB journey time 37 mins less than A&E Was 9% Now 18% admitted % Patients Admitted to Bed in <2hrs in <2hrs Pre-Kaizen Improvement Remainder mins Ave TTFA - July 2010 MAB A&E (Medical Flow) MAB TTFA 30 mins less than A&E % P a t i e nt s Admi t t e d a f t e r 2 10 mi ns % Patients Admitted after 210 mins From 48% to 33% Admitted between Pr e-kaizen Remainder 210 & 240 mins Post-Kaizen Remainder mins

48 Voice of Customer: MAB thank you all for the splendid A class care provided to me during my stay in MAB I was amazed at the dedication of all the staff in MAU and ward 2 keep up the good work! from start to finish this was a pleasant experience and I would like to pass on my thanks to the team who were equally caring and efficient. I was told this was a new pilot scheme that was not long started, well my congratulations, in my opinion it is very successful AGAIN MY THANKS TO THE TEAM OF WARD 2 ROOM 11. I have to say that the attention I received from the staff in ward 2 assessment bay was better than if I had paid for it

49 AMRU Length of Stay Change Detail Ward Pull, Bed meeting, Ward & Board Rounds, Single room identification, EDD, AMRU SOP, ward round start times, MAB, ward migration. Sustainability Feedback to stakeholders Continued data collection Reporting ownership Share successes/opportunities for improvement AMRU - Average Length of Stay by Week w/c 29 th March KAIZEN 1 KAIZEN 2 w/c 20 th July* *August data excluded to eliminate skewed data ALoS has consistently reduced since Kz1

50 AMRU Dashboard LENGTH OF STAY Key Performance Indicators NEW Patient moves Before noon am/pm Ward Round Start Times Ward Pull Parent Specialty Mix NEW Admissions vs. Discharges & Transfers Porter Response Times MAB Performance Surge Beds

51 Change Detail EDIS used to allocate beds in AMRU, SBAR Handover document, dashboard Key Performance Indicators Pull from AMRU % SCN Shift Spent on Phone Organising Patient Movement Sustainability SOP for Co-ordinator role in AMRU SOP/Training for how to allocate beds on EDIS Continuous improvement of SBAR handover document, improved communication routes between A&E & AMRU Post Kaizen Pre Kaizen Release up to 1hr45mins SCN time per busy shift

52 Change Detail AMRU Length of Stay Ward Pull, Bed meeting, Ward & Board Rounds, Single room identification, EDD, AMRU SOP, ward round start times, MAB, ward migration. Key Performance Indicators Sustainability Feedback to stakeholders Continued data collection Reporting ownership Share successes/opportunities for improvement AMRU - Average Length of Stay by Week w/c 29 th March KAIZEN 1 KAIZEN 2 w/c 20 th July* *August data excluded to eliminate skewed data ALoS has consistently reduced since Kz1

53 Change Detail AMRU Dashboard LENGTH OF STAY Key Performance Indicators NEW Patient moves Before noon am/pm Ward Round Start Times Ward Pull Parent Specialty Mix NEW Admissions vs. Discharges & Transfers Porter Response Times MAB Performance Surge Beds

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