Peterborough Regional Health Centre Update ED Process Improvement Program HSAA (2012/13) Central East Local Health Integration Network August 22, 2012 1
Overview of Presentation Focus on process improvement program (PIP) initiated in PRHC Emergency Department through Pay-For-Results, and will: Highlight & describe key improvement initiatives & outcomes Detail evidence & examples of progress; performance monitoring, measurement Next Steps HSAA Performance as @ June 30, 2012 2
Emergency Department Process Improvement Program 3
Background PRHC designated for Pay-for-Results Wave III (FY2010/11) and Wave IV (FY2011/12) Participated in the ED / ALC Wait Time Strategy Process Improvement Program (PIP) Implementation of ED PIP was PRHC s first exposure to LEAN thinking In 2010/11 PRHC utilized pay-for-results fixed funding to launch enterprise-wide LEAN solution for process improvement Awaiting approval for Pay-for-Results Wave V funding 4
Context Primary causes of ED overcrowding are: impaired flow of admitted patients from the ED to hospital inpatient units sub-optimal use of ED (diversion of CTAS 4 & 5, reduced readmissions, primary care for chronic disease management) PRHC s ED is regularly in a situation with no available stretchers within the ED for urgent and emergent patients. ED overcrowding is symptomatic of demand > capacity in hospitals and requires system-wide solutions. LEAN manufacturing principles can improve the flow of patients through the ED = greater patient satisfaction, reduction wait times, improved quality 5
ED Utilization Overall use of ED increased by 8.7% in past 2 years with a significant portion in CTAS 4 and 5. Almost 90% of patients are rostered in a FHT, 30,500 ED visits (approx. 40%) were for CTAS 4 & 5 6
Ambulance transfer times 14000 45 12000 39 40 11617 35 10000 8000 8994 10336 30 25 Ambulance Arrivals 6000 19 17 20 90th Percentile Transfer of Care Time (minutes) 4000 15 10 2000 5 0 Since 2009/10: 2009/10 2010/11 2011/12 0 Ambulance arrivals have increased nearly 30% Transfer of Care time (90pct) has decreased by 56%
Results 90 th Percentile ED LOS -Non-Admitted High-Acuity Patients Non-Admitted Complex Time (hrs) Target 14 Hours in ED 12 10 8 6 Patient LOS trending downward following PIP implementation 4 2 0 Q1 09/10 Q3 09/10 Q1 10/11 Q3 10/11 Q1 11/12 Q3 11/12 Q1 12/13 8
Results 90 th Percentile ED LOS -Non-Admitted High-Acuity Patients IMPROVEMENT INITIATIVE: Developed and Communicated Standard Work Established Blue Zone and developed internal wait area Standardized work for Nurses and Physicians Dedicated Physician assigned to Blue Zone Initiated a 5-bed virtual Clinical Decision Unit Standardized processes and tools such as Quick Tips Performance Management Daily Performance Huddles Kaizen event Lab and DI ED TAT; reduced CT TAT from 4.44 hrs. to 2.51 hrs. Off-Load Nurse Program 24/7 (funding announcement Aug 13, 2012) 9
Results 90 th Percentile ED LOS - Non-Admitted Low-Acuity patients Non-Admitted Minor Time (hrs) Target 7 6 5 Patient LOS trending downward following PIP implementation Hours in ED 4 3 2 1 0 Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10 Q1 10/11 Q2 10/11 Q3 10/11 Q4 10/11 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 12/13 10
Results 90 th Percentile ED LOS - Non-Admitted Low-Acuity patients IMPROVEMENT INITIATIVE: Green Zone Flow Relocated Green Zone for improved accessibility and developed internal wait room Trialed Super Track in Green Zone Ensure 2 triage nurses are at triage during peak periods Created re-assessment area for physician follow-up with patient Completed 6(S) standardized inventory, equipment stored in designated areas and created mobile suture and cast carts 11
Results 90 th Percentile Time to Physician Initial Assessment 6 Time to Physician Initial Assessment Target Hrs to see Physician 5 4 3 2 Time to initial physician assessment trending downward following PIP implementation 1 0 Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10 Q1 10/11 Q2 10/11 Q3 10/11 Q4 10/11 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 12/13 12
Results 90 th Percentile Time to Physician Initial Assessment IMPROVEMENT INITIATIVE: Reduce time to Physician Initial Assessment 2010/2011: Added new physician shift during peak demand (1200-1630 hrs Monday Friday) (later changed to add l physician shift Q Monday (8 hours) and added 2 hours physician time/day) Rezoned ED areas and optimized resources Redefined inclusion criteria for all ED patients in each zone Trialing new physician rotation in Blue Zone RATIONALE : Ensuring the most rapid possible contact with a physician satisfies desires of ED patients, improves safety & quality, promotes efficiency of care and shortens length of stay. MEASURING SUCCESS: 90th percentile time to Physician initial assessment < 3.3 hours (Pay-for-Results target) 13
Results 90 th Percentile ED LOS - Admitted Patients Admitted Time Target 70 60 Initiatives ongoing to address quarterly fluctuations (see next slides) Admitted time (hrs) 50 40 30 20 10 0 Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10 Q1 10/11 Q2 10/11 Q3 10/11 Q4 10/11 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 12/13 14
Results 90 th Percentile ED LOS - Admitted Patients IMPROVEMENT INITIATIVE: Reduce LOS and Diversion of Admissions in Emergency Multidisciplinary bullet rounds 2X/day in purple zone and once per day in yellow zone Home First philosophy: screening for High Risk for Discharge and identification of common clients CCAC in ER 12 hrs/day, 7 days per week EDD process begins in Emergency Tool created to identify patient contact for ride home on discharge 15
Medical Short Stay Unit Update Pilot project Date Admitted Discharge/Transfer Patient Days ALOS June 24-July 24 105 101 197 48 hours IMPROVEMENT INITIATIVE: Reduce LOS and Diversion of Admissions in Emergency Trialing an 8-bed Medical Short-Stay Unit with Hospitalist/NP model LOS < 48-72 hours 16 RATIONALE: Maximize ability to meet P4R targets by moving admitted patients to short-stay unit Maximize patient experience, safety and quality (ED and short-stay unit patients) Maximize total patients discharged from short-stay unit within 72 hours Minimize total patients transferred from short-stay unit to another unit Maximize conservable bed days opportunities
Key Outcome: Communication & Wayfinding WHAT WE HAVE DONE Volunteer desk in main waiting room Signs for self-screening for infection control Emergency flow process provided to every patient on arrival Colour-coded floor mapping/signs to assist patients and families in navigating within the department MEASURING PROGRESS: Patients and family members will be able to navigate the ED independently confirm with patient satisfaction questionnaires 17
Communication 18
Lessons Learned 1. Need to develop a clear and concise communication and sustainability plan 2. Solutions must be enterprise-wide and not just reside in the ED 3. Ensure synergies exist between the LEAN enterprise initiatives, Home First, GAIN, and make sure these dovetail - not compete 4. Ensure continuity and consistency exists with LEAN thinking throughout the organization 19
1 ED PIP Team The PIP team was recognized by the Health Centre with the Strong Regional Centre award, presented at the annual Celebrating Each Other event. 3 5 5
Next Steps Performance 1. Continue moving metrics towards P4R targets to increase patient and public satisfaction (access, service, quality) 2. Develop 1. Targeted LOS initiatives to improve flow and efficiency 2. Inpatient service by service rightsizing of bed capacity 3. Corporate surge plan (overcapacity protocol) 3. Support the development of regional networks to share best practices 21
Next Steps LEAN Improvements 1. Build organizational capacity to implement change through LEAN thinking 2. Kaizen event to optimize bed management plan 3. Develop sustainability plan for process improvement 4. Improve the work environment for staff through continuous learning 22
Next Steps Hospital/Primary Care Interfaces & Capacity Work with Family Health Teams to improve the patient care experience and quality care at the interface between the Health Centre and primary care providers - locally and across the broader region (e.g. ED diversion, reduce readmissions and strengthen chronic disease management) 23
Hospital Services Accountability Agreement Update 24
HSAA Results as @ Q1 (June 30, 2012) Accountability Many on or surpass target Overall on track ER Wait Times ongoing focus of resources & initiatives Knees & Cataracts expected to meet target Patient Safety & Health Outcomes Many on or surpass target HAIs a focus of LEAN initiatives majority on track (CLI (3 extended stay cases but none since May 3) and C. diff (sustain protection & screening improvements, move to antimicrobial stewardship)) CELHIN Specific Indicators Data submission on track for August 25
HSAA Results as @ Q1 (June 30, 2012) Volumes On Target Vascular, PCI & cancer bunker tracking well & on target Quality Based Procedures On Target Wait Times On Target Financial On Target 26
Questions? 27