Download - Dr Augustus Kigotho - Gladstone Hospital - Patient Flow: Patients Hate Waiting. Eliminate It!
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GLADSTONE HOSPITAL
CHALLENGING PATIENT FLOW
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GLADSTONE HOSPITAL
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GLADSTONE REGION
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DEMOGRAPHICS
550km from Brisbane
100Km SE of Rockhampton
180km north of Bundaberg
Population 64000
3.2% Indigenous or Torres Strait Islander
10.3% born overseas
19.8% speak a language other than English at home
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Main hospital buildings built in the 1980s
Last Emergency Department redevelopment was in 1998 (17 yrs ago)
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SERVICES IN THE HOSPITAL
Emergency
Medicine
Surgery
Paediatrics
Obstetrics/Gynaecology
Palliative care
Physiotherapy
Mental health – NO PSYCHIATRIST – NO ADMISSIONS
Self managed renal dialysis service
3 chemotherapy chairs
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EMERGENCY DEPARTMENT
11 beds – 6 monitored
2 Resus bays
1 procedure room
7 consultation rooms
Can only use 3 at a time
X 2 video conference facilities
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30,000 PRESENTATION/YR
15-20% Adult Admission rate
20% Paediatric
16-20% Admission rate
Significant trauma challenges
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MY CHALLENGE
Appointed Director Nov 2014
2 Week intensive orientation
Took over Leadership.
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EMERGENCY DEPARTMENT NOW HAS
SPECIALIST LEADER
DOCTOR Augustus Kigotho, 58, has had somewhat of a
scenic tour from when he started his medical training in
Nairobi, Kenya, until he arrived in Gladstone two weeks
ago.
Dr Kigotho has taken up the role of head of Gladstone
Hospital's emergency department - the first time in
memory that the hospital has had a fully qualified
specialist in emergency medicine as the department's
head.
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1. IMMEDIATE CHALLENGE
NO DEPARTMENTAL HANDOVER
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2.STAFFING CHALLENGE
Highly locum dependent
Permanent staff – 1.5
Advanced emergency trainee – 1.0
GP on FACRRM training – 0.5
Rest – Locum staff
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3. NO DEPARTMENTAL LEADERSHIP
4. DAILY STAFF SHORTAGE OF 2-3 DOCTORS
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DATA UTILISATION
Intensive involvement of BADS unit ( Business Analysis Decision Support)
Regular meetings
Its not the data
Its what you do with the data!
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24 HOUR PRESENTATIONS:
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LOOKING AT THE DATA
STAFFING MODEL CHANGED
Activity driven roster
4 doctors in the morning
4 doctors in the afternoon
ED trainee top heavy as locums
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AGGRESSIVE RECRUITMENT DRIVE
Currently
2 permanent FACEM
2 permanent SMO – FACRRM
0.5 FACRRM
1 Advanced ED Trainee
1 NP
Recruitment of 3rd FACEM in process
Markedly reduced locum dependence
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CULTURAL CHANGE
MEETING TO DETERMINE WAY FORWARD
GOAL: Engage on Neat
Advantages vs disadvantages
Ensured full understanding
Sort commitment to the course
Triage re-education
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Nurse empowerment
Assured of full support from ED Director/NUM/Admin
Given power to follow up patient progress from MO
High emphasis on REVERSE TRIAGE
Documentation by doctors
Patient education by nurses
Nurse initiated investigations
Early involvement of lead SMO
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REVERSE TRIAGE
Education prior to discharge
Guarantee treatment complete
Information
Admission not required
Referrals complete
Transport arranged
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NURSING MODEL
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INCREASED LEADERSHIP PRESENCE AND
VISIBILITY
2 hourly ward round
ED Director/Num
EDDMS invited occasionally
This produced a DRAMATIC CHANGE
Nurses wanted to be on top
Doctors did not want excessive questions from nurses
Outcome: Rapid throughput through ED.
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STRUCTURAL CHANGE
Intensive patient centred CUBICLES:
Fully loaded trolley
IV Fluids
Drip stand
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3. BARRIER/BOTTLENECKS TO FLOW
Failure to appreciate NEAT importance by senior staff (Locums)
Nurses cannot receive ANY CALLS during ward hand over
Completion of 1st dose Abs in ED prior to transfer.
Resistance to change
Delayed documentation by medical staff, particularly Med Charts.
Limited access to radiology & pathology
Limited MH access
External consultations particularly neurosurgical/cardiology
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SOLUTIONS
Immediate staffing model change
Staff re-education / triage
Increased utilization of REVERSE TRIAGE
More ED trainees as locums
AGGRESSIVE RECRUITMENT DRIVE
Ward nurses can take ED handover ANYTIME
Initiation of push Abs and 1st. Dose completion in the wards.
Prolonged radiology availability upto 23:00hrs. CT 24hrs.
Pathology available until 18:00hrs Weekdays. Weekends till 18:00hrs!
MH available until 21:00hrs
Better utilization of NP
FAST TRACK is on track to start in August.
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ADMISSION PROCESS
Goal: Smoother admission process
1. DIRECT ADMISSION OF MEDICAL PATIENTS!!!
95% of all hospital diagnosis made by ED physician
ED physician gets the appropriate speciality disposition RIGHT 96% of the time
2. 30 min ward notification to pick up
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IMPROVED THROUGHPUT STRATEGY
Early SMO involvement
Determine optimal investigative strategy
Early discussion with other consultants for disposition.
Frequent computer rounds
Appropriate utilisation of SSU
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SSU
Opened within 1 month of arrival
High uptake and utilisation
Leading to improved NEAT Performance.
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TIME SEEN BY CATEGORY:
CAT 1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
sept oct nov dec Jan Feb Mar Apr May June July Aug
2013
2014
2015
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TIME SEEN BY CATEGORY:CAT 2
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TIME SEEN BY CATEGORY:
CAT 3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
sept oct nov dec Jan Feb Mar Apr May June July Aug
2013
2014
2015
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TIME SEEN BY CATEGORY:
CAT 4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
sept oct nov dec Jan Feb Mar Apr May June July Aug
2013
2014
2015
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TIME SEEN BY CATEGORY:CAT 5
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
sept oct nov dec Jan Feb Mar Apr May June July Aug
201320142015
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DID NOT WAIT
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ADMITTED NEAT TARGETS:
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DISCHARGED NEAT TARGETS:
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ONGOING STRATEGIES
Buy in
Set up specific goals – meet target
1. Ensure Executive support
2. Recruitment
3. Whole hospital involvement
4. Regular review of progress
5. Keep troops motivated – regular positive feedback
Reward champions
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LEADERSHIP
Performance leadership is key!!
Careful articulation of vision & mission
Know departmental dynamics
Identify
Change agents – Reward
Change resistant group
Cynics vs sceptics
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Summary
Data utilisation
Strategies
Cultural change
Leadership
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THANK YOU