Performance Improvement Bulletin

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1 SPECIAL DELIVERY UNIT/ NATIONAL TREATMENT PURCHASE FUND Issue No.1 08/12 Performance Improvement Bulletin Featured Work underway - Maximum Waiting Time Targets 2 Case Study No. 1 Galway & Roscommon University Hospitals Group 2 Case Study No. 2 Letterkenny General Hospital 3 Scheduled Care Endoscopy Performance Improvement programme 3 Case Study No. 3 St. Vincent s Hospital, Dublin successfully complete JAG accreditation 3 Case Study No. 4 Sligo Regional Hospital successfully complete JAG Accreditation 4 Case study No.5 Cork University Hospital Acute Medicine Programme 4 Emergency Department Trolley Waits 5 The Patient Treatment Register 5 Introduction Dr. Alan Smith was appointed to the role of Director of Performance Improvement for Scheduled Care in December 2011 and Lis Nixon was appointed as Director of Performance Improvement for Unscheduled Care in April The SDU and NTPF intend to embed support visits to hospitals as normal practice whereby they will meet with the Senior Executive Management Team(s) including the Medical Directors to discuss the implementation of performance improvement programmes as they evolve throughout the year. The aim of this bulletin is primarily to act as a platform to showcase examples of best practice relating to patient flow occurring in hospitals throughout Ireland. It will also provide an overview of some of the achievements of the SDU and NTPF Performance Improvement Programmes to date. It is the intention of this bulletin to concentrate on case studies in relation to scheduled and unscheduled care, in order for shared learning and networks of learning to occur. If you or your service has examples of best practice or case studies that you would like to share please contact Jennifer Hogan at: 1 Special Delivery Unit/National Treatment Purchase Fund - Performance Improvement Bulletin

2 Work underway - Maximum Waiting Time Targets Achievement of maximum waiting times for inpatient/day case surgery is a programme of work that is already well established. Three targets have been set by the Minister for Health in relation to waiting times for scheduled care; these targets must be met by 30 September All scheduled inpatient and day case adult patients should spend no more than 9 months on the waiting list from the time their name is put onto the hospital waiting list. 2. All scheduled inpatient and day case paediatric patients should spend no more than 20 weeks on the waiting list from the time their name is put onto the hospital waiting list. 3. All scheduled inpatient and day case routine GI endoscopy patients should spend no more than 13 weeks on the waiting list from the time their name is put onto the hospital waiting list. The primary aims of the performance improvement programmes will be to improve access for patients by supporting clinical teams in the delivery of quality assured elective care. For example, Table 1 demonstrates that when hospitals targeted the longest waiters, the maximum waiting times for patients who had been on the waiting list for more than 12 months, was reduced from 5% to less than 1% between July 2011 and July By the end of September 2012 the aim is to have a maximum waiting time target of 9 months. Table 1: Maximum Waiting Time Targets Impact on waiting time 50% Waiting Time 28% Time Bands 0-3 Months July Months 55% July % 6-9 Months 9-12 Months 6% 5% 12+ Months 5% 27% 12% Total waiting list by time bands <1% Case Study No. 1 Galway & Roscommon University Hospitals Group Galway University Hospital (GUH) and Merlin Park Hospital were the only hospitals in Ireland not to achieve the maximum waiting time target of 12 months by the end of However, as a result of clinical and administrative collaborative management and support across all of the hospitals in the group which includes Portiuncula Hospital, Ballinasloe and Roscommon County Hospital, the waiting list for inpatient and day case procedures is reducing each week. In January 2012 GUH had 9,901 patients potentially set to breach the 9 month target, as of July 12th that number has been reduced to 2,934 and GUH are on course to achieve the 9 month September target. As well as inter- hospital collaboration other measures including waiting list validation, improved reporting and focus, increasing theatre capacity and patient education and engagement were crucial in achieving the targets. Please contact Tony Canavan, Chief Operating Officer for further information at: 2 Special Delivery Unit/National Treatment Purchase Fund - Performance Improvement Bulletin

3 Case Study No. 2 Letterkenny General Hospital The Department of Orthopaedic Surgery in Letterkenny General Hospital has embraced the concept of an Enhanced Recovery Unit. The ERU was established in June 2011 and has enabled a 92% day-of- surgery admission for in-patient care. Protocols, which include the use of local anaesthetic infiltration, have been established that have allowed for up to 50% of hip and knee replacement patients to be mobilised on the same day as surgery. This has resulted in a significant reduction in the average length of stay to a median of two days and a mean of five days (down from a mean of 8.6). This has had substantial benefits in terms of patients throughput as reduced average length of stay leaves beds available for other patients, leading to fewer cancellations for non-clinical reasons. These developments have been enthusiastically adopted by all the staff and the positive reinforcement to patients and staff has resulted in measureable improvements in the experience patients have while undergoing a joint replacement at LGH. It is intended to roll out the benefits of the ERU to other surgical specialities such as gynaecology and general surgery. Please contact Dr. Paul O Connor, Clinical Director, for further information at Scheduled Care Endoscopy Performance Improvement programme The SDU Scheduled Care Endoscopy Performance Improvement Programme commenced in July The programme model will mirror that of the Clinical Programmes, bringing together under one governance and implementation model the activities that are currently underway within the HSE, the Royal College of Physicians of Ireland, the Royal College of Surgeons in Ireland, the Quality Assurance Programme in GI Endoscopy and the National Cancer Screening Service. Case Study No. 3 St. Vincent s Hospital, Dublin successfully complete JAG accreditation St. Vincent s Hospital, Dublin successfully completed the JAG accreditation process. Amongst other crucial success factors, the pathway to accreditation was achieved by separation of the waiting list into urgent, non-urgent and surveillance, the introduction of effective triage and a common waiting list, the monitoring of endoscopy start times, the allocation of a point value system for capacity planning and by maintaining patient flow from admission to discharge. Future plans include participation as a screening endoscopy unit as part of the national bowel cancer screening programme, an Advanced Nurse Practitioner training programme, a new endoscopic ultrasound service and the development of a combined regional waiting list. Please contact Tanya King, Assistant Director of Nursing, to find out how the pathway to accreditation was achieved at: or 3 Special Delivery Unit/National Treatment Purchase Fund - Performance Improvement Bulletin

4 Case Study No. 4 Sligo Regional Hospital successfully complete JAG Accreditation Sligo Regional Hospital recently undertook the JAG accreditation process. Some of the critical success factors for achieving accreditation include, active management of the waiting list, including consultant validation, the addition of a second endoscopy room, extra recovery space allowing two extra lists per week, and the backfilling of lists when consultants are taking leave. Essential to the success of completing JAG accreditation within such a short time frame (9 months) was the appointment of a project lead which ensured a project management approach was taken. Having buy in from the multi-disciplinary team and the Endoscopy Users Group combined with senior management support was also critical. Overall, the quality of the endoscopy service has improved in a measurable way. Please contact Karen Reynolds, Accreditation/Quality Co-ordinator, Sligo Regional Hospital, P: ext. 4210/2609 E: Case study No.5 Cork University Hospital Acute Medicine Programme The opening of the Medical Assessment and Short Stay Units in Cork University Hospital (CUH) has resulted in almost no medical patients waiting on trolleys in the Emergency Department, and a reduction by almost 3 days in the average length of stay from 9.13 in 2010 to 6.4 days in June This has resulted in savings of just over 20,000 bed days. Currently 47% of medical patients in CUH are discharged in less than 48 hours, compared to 35% in The success of this initiative required hospital wide support from the hospital executive management team, the wider physician group combined with active leadership and engagement from nursing and allied health professions. Adjustments were also made to the NCHD rosters and other critical success factors include: Initiation of leadership rounds which are performed Monday to Friday at 7.45am by the CEO and Director of Nursing, identifying areas in the ED experiencing obstruction to patient flow. This visible proactive leadership creates engagement with staff in the wider organisation and encourages participative leadership in creating solutions to the problems of patient flow. An additional 20 short stay beds were reconfigured and managed by the hospital physician group which generated a sense of ownership and focus on fast appropriate patient turnaround. The discharge planning teams activities were refocused on immediate intervention and rapid progress of the discharge process. The bed management team now starts earlier in the day and is more visible. The team engages in the early escalation of issues and provides frequent bed state analysis to the Director of Nursing, Chief Executive Officer and Clinical Director in order to activate early senior problem solving. The executive management team provides the consultants with the data pertaining to their own patients average length of stay for the purpose of benchmarking and creating accountability regarding bed usage The executive management board, and the Clinical Director together with the consultants now explore the various operational issues, and consultants are now held accountable for rostering, budgets etc. Simple initiatives have been introduced whereby patients no longer have to wait for a GP letter prior to discharge; the letter is now sent directly to the GP. For further information please contact either: Ms Ann Marie Keown, Programme Manager, National Acute Medicine Programme or Ms. Ber Baker Programme Manager CUH, 4 Special Delivery Unit/National Treatment Purchase Fund - Performance Improvement Bulletin

5 Emergency Department Trolley Waits The chart below shows a comparison between the number of patients, nationally waiting on a trolley between 2011 and 2012 to date. It is evident that the peak seen in February and April 2011 of over 400 patients waiting has not been repeated in 2012 and continues to decrease. National 30 Day Moving Average Trolley Count January 2011 vs August Jan 2 Feb 2 Mar 2 Apr 2 May 2 Jun 2 Jul 2 Aug 2 Sep 2 Oct 2 Nov 2 Dec Special Delivery Unit/National Treatment Purchase Fund - Performance Improvement Bulletin

6 The Patient Treatment Register Tables 2 and 3 represent a comparison of data from the Patient Treatment Register (the whole waiting list) between July 2011 and July The median waiting time for all surgical and medical patients has moved from 3 months in July 2011 to 2.7 months by July The key finding over this period is the 91% decrease in the >12 month waiters and the 51% decrease in the >9 month waiters. This trajectory is on course for the elimination of adult patient waits greater than 9 months. >9 Month Active Waiting List - July 2011 to July 2012 >12 Month Active Waiting List - July 2011 to July ,000 4,000 7, , ,000 5,000 4, ,000 2,500 2, , , ,000 1, , Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 6 Special Delivery Unit/National Treatment Purchase Fund - Performance Improvement Bulletin

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