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Breakout D3: How to Improve Flow of Patients Through
Medicine
Sunday May 15. 10:30 – 12:30
Carolyn Volker RN. ORN. MBA – Ass. Exec. Director – Patient Flow HMC
Dr. Anand Kartha MBBS MD MS – Head of Hospital Medicine
Dawoud Jamous RN. BSN.MSN -Director Nursing Bed Management
Seham Henidy RN. BSN MSN - Director Nursing Case Management
What Is the Challenge?
• HGH – 546 Beds
• 1500 Attendances in ED
• 70 – 80 Admissions per Day (15 – 20 Acute Medicine)
• Long Waits in ED >12 – 90 hrs.
• 60% Acute Care Beds occupied by Long Term Care
• Outliers in Surgical Wards
• Late Discharges & Few Discharges at Week End
• Readmission Rates Unknown
• No Clinical Space & Multidisciplinary Rounds
A M
orn
ing
Rou
nd
!
Current State of Flow
Ambulance
O ther
Ambulance
999
Other
Hospitals
ED
ED Short
Stay
O verseas
O utpatients
Home
ED Over Crowding
TEAM 1A
TEAM 1 B
TEAM 2B
TEAM 2A
TEAM 3A
TEAM 3B
TEAM 4A
TEAM 4B
TEAM 5A
TEAM 5B
RH
SNF
Other
Hospital
Home
Home Care
5N3 FM
40%
6S2 MM
5N1 FM
60%
6N3 MM
50%
MICU
3S2
STROKE
3S3 MM
38%
Delay to Decision Making
Repatriation
Paper Records
Poor Communicatio
n
40 % Beds
Hospital
Medicine
60% Acute Beds (LTC)
LTC Ventilator & Dialysis
Pts
Patients in Multiple Locations
Large Teams
Poor Consultant Availabilit
y
No Timely Follow Up
Service vs.
Education
Radiology Delays
No Clinical Space
Few Isolation Rooms
Few Private Rooms
Patient Refuse
to Leave
Patient factors
Ambulance
O ther
Ambulance
999
Other
Hospitals
ED
ED
Shor
t
Stay
O verseas
O utpatients
Home
TEAM 1A
TEAM 1 B
TEAM 2B
TEAM 2A
TEAM 3A
TEAM 3B
TEAM 4A
TEAM 4B
TEAM 5A
TEAM 5B
RH
SNF
Other
Hospitals
Home
Home Care
5N3 FM
40%
6S2 MM
5N1 FM
60%
6N3 MM
50%
MICU
3S2
STROKE
3S3 MM
38%
Repatriation
Patients in Multiple Locations
Large Teams
Poor Consultant Availabilit
y
Service vs.
Education
Few Isolation Rooms
Few Private Rooms
Patient Refuse
to Leave Patient
factors
Current State of HGH inpatient medicine
Radiology Delays
AMAU
Post discharge
clinic
Mobile Doctors
Weekend consultants
Evening consultant
Data Dashboard
Electronic Health Record
Lounge & offices
SNF transfers
Active Bed
Management
Team Case Manager
Patient Flow in Acute Medicine
Dr. Anand Kartha
Mr. D Jamous –
Director Nursing Bed Management
Ms. S Henidy
Jamous – Director Nursing Case
Management
Anand Kartha MD MS SFHM
Head of Hospital Medicine. Senior Consultant
Medicine. Assistant Professor of Clinical Medicine
Weill Cornell Medical College - Qatar
Opened 12 July 2015: 22 beds
Planned in two months
Ward
LOS <24 HRS
Triaging
Consultant accepts pt
to medicine
ED
Observation Unit
< 24 hrs
Bed available
Bed available
Flow of ED patients to AMAU
LOS 24-72 HRS
Y
N
N
Y
Y
Y
>72 HRS
Y
Y N
N
N
Post dc review
DC
MOP/ Mobile Docs
ED
DC
Y
N
ED
N
Bed crisis escalation policy
AMAU
What do we do differently in
AMAU?
Governance Clinical Leads:
• Sister Rosario
• Sister Rosemarie
Clinical Leads:
• Dr Syed
• Dr Zahid
7 days a week consultant-led MDT round
Board Rounds 4 times a day
24/7 Physician on-site
Standard Operating Procedures
Qatar Early Warning System/ RRT AMAU Manual
AMAU Coordinators
Pharmacist Counselling at Discharge
Post-discharge Assessment Room
Data Dashboard
Reducing discharge delays PDSA
Weekly Meeting
RESULTS
1705 ADMISSIONS IN 7 MONTHS
6N3 opened
6N1 opened
LOS = 2.7 days
MORTALITY
2 (0.15%)
30-DAY
READMISSION RATE
6.9%
TOTAL MEDICINE (AMAU + WARD)
ADMISSIONS DISCHARGES
WARD LOS
2015 MAY
Mean LOS (DAYS)
FROM ADMISSION ORDER TO DISCHARGE ORDER
5.3
ADMISSIONS PENDING IN ED
13.6
8.4 8.6
12.0 12.8
11.7 11.3
9.9
5.8
8.5
10.5 10.5 9.6 9.9
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
january august september october november december January/2016
PENDING ADMISSION IN ED
Conclusion
• AMAU is a designated medical inpatient area to
expedite treatment of patients anticipated to stay
less than 72 hours.
• Staffed by multidisciplinary teams 7 days a week.
• Different standard operating procedures
• Different culture
• Resulting in improvement in inpatient medicine
flow and quality of care.
RIGHT patient
RIGHT place
RIGHT time.
At FIRST time
Admissions
Inpatient
Care Disposition
MD Coverage
Bed Management
ICU/Step-down/OR/PACU/ Cath Lab
Nursing Units
Diagnostic Tests
Radiology tests
Environmental Services
34
Patient Through
put
Nursing/ physicia
n coverage
Supportive
services
Social and
security services
Case manager
Radiology
examination/
laboratory tests
ICU/ OR/ PACU/ AMAU/
CATH LAB
Emergency pathway
Elective Pathway
External Transfers
Arrival from abroad
Clin
ical
Be
d M
an
age
me
nt
Dis
char
ges
1. Review and study process
2. Identify the causes – bottle necks
3. Understand and manage variation
4. Redesign
5. Test the change
6. Maintain
Infrastructure
System People
Unavailable of extra OR
and PACU spaces
Environment
Inadequate spaces among
patients –congested areas
Poor knowledge about
other facilities
Increase the demand-
isolation cases in ED/
Seasonal flu.
Lack of knowledge of the impact of
bed crisis, Emergency crowded.
Lack of commitment
And Responsibility.
Unavailable of IT technology- No
bed management system
No clear policies/
procedures
Unavailable/ lack of beds in
other facilities.
Delay in Discharges/
Transfers from inpatient
No scheduling and
tracking system for the
elective demand
Increase patients waits in ED
No clear roles and
responsibilities
Short of manpower
Occupancy rate up to 95%, no
flow in the following day.
Increase the
demand of
single rooms
inpatients.
Achievements
People and Organization
Bed management
team-24/7 service
Clear roles and responsibilities
.
Clear lines of accountability
Reporting system-
escalation policies
Clinical engagement-
MDT Conferences
Capacity meetings
System-infrastru
cture
Understand the flow
Sufficient real time flow data
Benchmark data-KPI’s
Clear admission pathways
Maintain hospital bed
status
IT Technology.
Achievements
Hospital bed meetings/ huddles- IHI-RTDC
Manage Elective and Emergency Demand
Units huddle meeting-Nursing
Predicting & communicating tool
Matching capacity to demand-real time
2pm look back / Look forward
Timeliness of discharges.
Improved communication & cooperation
Action Focused
Awareness of Demand – Their Demand.
Use Pull rather than Push System
Escalation policies- Identify triggers
To patient safety and experience
To patient safety and experience
Create a central office to manage arrivals from
abroad-overseas
0
2
4
6
8
10
12
14
16
18
20
Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
4
10
5
8
6
2
67
12
1 12
01
0
2
0
2
Number of Arrival from abroad- Aug 2015 to April 2016
HGH
Otherfacilities
Transfers of patients to appropriate services
0
100
200
300
400
500
600
700
800
900
1000
509 500
527 474
615
499 494 501 560
Number of Transfers Aug 2015 to April 2016
Otherfacilities
DTA-Acute medicine
IHI
Huddles with
Wards
New Bed Management
4 Roles
AMAU
Emergency Wait DTA
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
54%
56%59% 56%
59% 58%52%
57%60%
% of Patient admitted within 4 hrs from ED Aug 2015 to April 2016
DTA
1. Develop a dedicated team.
2. Demand and capacity planning.
3. Variation management.
4. Demand escalation.
5. Standardization Practices.
6. Care coordination.
7. Governance.
8. Quality.
Case Management Department.
• Case Management is the engine for facilitating patient’s flow at HGH with a great clinical outcome.
Facilitating
Assessing
Planning
Advocacy for options and services to meet an individual’s and family’s comprehensive health needs
Active communication
Working collaboratively
with the Multidisciplinary
Team
VISION
Enhancing patient flow at HGH.
THROUGH
• Early patient discharge
• Efficient utilization of hospital beds
• Cost effectiveness
• Established in 2006
• 4 Departments and 10 Medical Teams across 30 units.
About Case Management
FISH BONE DIARAM Causes of Discharge Delays
Strategies to Improve Discharges
The Team
Discharge Lounge
40 45 60 59
97 96
22
58 68
106
209
317
020406080
100120140160180200220240260280300320340
JAN. FEB MAR. APRIL MAY JUNE JULY AUG. SEP. OCT NOV DEC
NU
MB
ER
OF
PA
TIE
NT
S
DISCHARGED PATIENTS THROUGH
DISCHARGED LOUNGE -2015
Open IV suite -------- Reduction in L.O.S
Electronic Patient list on Each Ward.
Daily Morning Huddle and Bed Capacity Meeting.
Opening of Bayt Al Dayfa
Vital Signs, Blood Sugar MONITORING,
IV Antibiotic administration by MDS
Discharges Through Medihostel
20
40 50
72
50 66 56
87 96
87
145
207
200
221
1
21
41
61
81
101
121
141
161
181
201
221
241
Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
NU
MB
ER
OF
PA
TIE
NT
S
MONTHS
Numbers Of Patients Admitted to Bayt Al Diyafah - 2015-2016
Case Management
take over
33
9
25
14 20
15 16
24
18 18
30
16
0
10
20
30
40
50
JAN. FEB MAR. APRIL MAY JUNE JULY AUG. SEP. OCT NOV DEC
NU
MB
ER
OF
PA
TIE
NT
S
PATIENTS TRANSFERED TO LONG TERM FACILITY-2015
6
11
2 3
0
5
2 3
3
1
4
0123456789
101112131415
JAN. FEB MAR. APRIL MAY JUNE JULY AUG. SEP. OCT NOV DEC
NU
MB
ER
OF
PA
TIE
NT
S
LONG TERM PATIENT REPATRIATED BACK TO THEIR HOME COUNTRIES-2015
Clinical Bed Management and scheduling system was developed.
Strategies to Improve Discharges
* Transforming Unit Base Case Manager to Team
Base Case Manager
* Physician led discharges for 7 days / week.
* Discharge planning policy was developed.
Strategies to Improve Discharges
* Moving discharges to the morning before peak
arrival times.
* long term care strategy – increase RH and ENAYA.
* Pre-discharge care such as health teaching,
referrals and take home medication should be done at least one day prior to actual discharge.
New Role in Medicine
• Comprehensive assessment.
• Daily Multidisciplinary Rounds.
• Proactive Discharge Planning.
• Develop an integrated system for a seamless flow of patients across the continuum of care.
• Effective use of Multidisciplinary Resources
• Coordination of medical equipment
• Education primarily about healthy lifestyle behavior and self-care.
• Throughput and safe transition of care.
Team Base Case Managers
Advantages of Team Based CM:
• Attendance @ daily ward round. • Enhances clinical experience . • Increase awareness. • Improved team communication. Increase
awareness of physician about CM Role. • Improved relationship with ward staff. • Early discharges
Home
IV Suite
Long Term
Facility
Alternate Out of
Hospital provision
Bayt Al Diyafah
Discharge Lounge
Mobile Physician
Skilled nursing Facility
Subacute
Unit (LTCU3
&4)
Rehabilitation Unit
Geriatric Unit
(LTCU1&2)
Repatriation
Thank You
Questions & Answers
Flow Simulation Exercise
1. 4 teams.
2. We will give you an example of a “bed crisis” day in
Hamad General Hospital.
3. You can discuss for 15 minutes
4. Your team will make top 3 recommendations on
what to do to resolve bed crisis
Scenario – 17th April 2016 – 09h00 AM
Specialty ED Pending Admissions
Elective Admissions
Predicted Discharges
Avg. Length Wait
ED Medicine 24 0 10 30 hrs.
ED Surgical 11 0 20 13 hrs.
ED Critical Care 7 2 4 12hrs.
ED Cardiology 10 0 8 15 hrs.
ED Others 9 0 5 12 hrs.
Elective Surgery
- 25 See above -
Total 61 27 47 -
Beds available now
HGH AWH HH TCH
0 3 0 4
Conclusions
• Presented Medicine but in
Reality Whole Hospital
• Team Work = Great Ideas • [email protected]