dr karen murphy,sir charles gairdner & osborne park health care group - the ‘spice’ of life

SCGH Four Hour Rule Program

The SPICe of Life…

Dr Karen Murphy

A/Executive Director Medical Services

Sir Charles Gairdner & Osborne Park Health Care Group

Perth, Western Australia

July 2014

Sir Charles Gairdner Hospital

QEII Medical Centre - SCGH

Sir Charles Gairdner Osborne Park

Health Care Group

The problem ………In the Beginning

And then… The Four Hour Rule Program

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Process solutions – 5 key areas

Pat

ient

S

uppo

rtN

ursi

ngC

leric

alM

edic

al

Admissions

Stream

Discharge Stream

Patient to Emergency Decisions Unit

Patients should be transferred to EDU as

soon as it becomes clinically indicated. If no

plan identified at 3 hours post triage

(patients name on EDIS turns black), ED

Liaison Officer is responsible for informing

Senior Doctor

ED Senior Registrar

or Consultant

authorises a decision

to admit patient to

Emergency

Decisions Unit

ED Nursing Coordinator completes

details clinical & safety details on

booking slip & hands to ED Liaison

Officer

ED Medical Officer

documents plan in notes

(including DECT phone

number)

ED Liaison Officer

inputs information

into EDIS.

(patient is

transferred to SSU

location on EDIS)

OBS Coordinator sends OBS HSA to

collect patient. If unavailable organises

other HSA to transport. Upon collecting

patient HSA informs ACO or Resus

Coordinator

Emergency Decisions Unit

Admission Procedure

ED Clerk collects

booking slip,

admits to

TOPAS.

Completes

registration &

Financial

Election

HSA informs Obs

coordinator of patient

arrival

BOOKING SLIP

ED Medical Officer completes booking slip

and hands to Nursing Coordinator of Area

Or

CLINICAL HANDOVER

ED Medical Officer provides handover and

plan to Obs Coordinator (x6713) ONLY if

clinically indicated

EDU Pull

Obs Coordinator notices on EDIS that

patient is for EDU and pulls patient

across

Medical Team responsible

for patient from Triage

continues Medical

Management

ED Clerk informs

Obs Liaison

Officer of

admission details.

LO ensures

patient in correct

location on EDIS

Bed Realignment

Discharge ED Process - EDU

Ward Leadership Process

Four Hour Rule Program - Challenges

Not just about the Emergency Department

Front door to back door solutions

Engagement – some thought it would „go

away‟

Full implementation of solutions not

realised – poor compliance (& success)

Ownership & accountability


Results - context

ED presentations / Access Block


Performance against 4/24 target

2008 Jan 46% 2009 Jan

39%

2010 Jan 46%

2010 Aug 50%

2011 Jan 68%

2012 Jan 71%

2012 Aug 52%

2013 Jan 62%

0%

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100%

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2008 2009 2010 2011 2012 2013

Four Hour

Rule Program

commenced

Solution

implementation

commenced

Perfromance-

56% - Solution

Review &

Actions

Stokes Review Winter demand


NEAT in 2013… what was going wrong?

The FHRP resulted in performance

against 4 hour time frame by ~ 25%

Access block from 60% to 12%

Reached target in Oct 2011

Performance not sustained and declined in

2012

SCGH did not achieve target of 76%

NEAT in 2013…. Adding to the challenge

Change fatigue and effects on staff

engagement

Competing reform – NEAT vs NEST

Efficiency – ABM/ABF

Winter stress, high bed occupancy

Downstream care – inpatient, ambulatory,

community

Mental Health in ED

Re-igniting the flame… mid 2013

MfH – huge interest in NEAT

MfH – UK visit - Prof Derek Bell et al

invited to Perth

Team of auditors – clinical & statistical

analysts visited Perth July 2013

Reviewing Emergency Flow processes at 3

Tertiary sites in WA

Involving pre-visit departmental self-

assessment, professional workshop and

on-site visit / „Day of Care‟ audit.

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The Bell audit (1) - Aug 2013

Audit components:

1. Pre visit departmental self assessment

against „Adult Emergency Service

Standards for ACUTE admission‟ (UK)

2. Key Stakeholder Workshop

3. „Day of Care‟ survey & walkabout Audit task carried out on ALL patients in SCGH beds

at 0700 on Monday 5th August

Audit tool provided by UK team to review local

practice against adapted UK standards

Involving majority of wards, AAU, ED, Radiology,

Pathology, Pharmacy & Allied Health


The Bell Report

Preliminary results presented to

DG Health and Area Health

Service CEs 8th Aug 2013

Final Report to sites Sept 2013


Bell Recommendations for SCGH

1. Improve patient flow

2. Reduce complexity of internal ED systems

3. Reduce the complexity of the admission

interface between ED and AAU/SAU

4. Optimise the admission flow between ED and

specialist wards; and between AAU/SAU and

sub-specialty inpatient wards

5. Provide continuity of care

6. Optimise physical and staff capacity – Doing

today’s work today and making Monday’s

better


The Birth of SPICe!

Governance Governance Governance!

Strategic Patient Flow Implementation

Committee (SPICe)

Provide executive oversight of

organisational strategies aimed at

improving patient flow at SCGOPHCG

Broad, multidisciplinary & executive

representation

Meets weekly

ACE and SCG OPHCG ED attend


The SPICe Action Plan

Developed by SPICe – based on the Bell

recommendations

Dynamic document – forms basis of

agenda/minutes weekly

RAG status used to monitor achievement /

progress / barriers / risk

Action driven!


SPICe in action….. examples

1. Improving Patient Flow – front door to

back door and beyond

Consultant-led care - ensure daily consultant-

led care across all specialties

Discharge planning - Focus on the EDD –

whiteboards, patient room boards, health

record & TELL THE PATIENT! Monthly audits –

significant improvement with compliance across

all areas



1. Improving Patient Flow, cont‟d

Discharge Ward Utilisation – the „norm‟ rather

than the exception… recent improvement

Discharge „Rounding‟ – senior staff incl Exec on

the floor…

Review bed stock allocation to align with

demand – increase MAU capacity




RAT (Rapid Assessment Treatment) consultant

in ED to ensure early senior input

Admission of Emergency Patients Policy –

rights for ED drs




Daily NEAT Breach Report - identification of

contributing factors and actions to improve


3. Reduce the Complexity of Admission

interface between ED and AAU/SAU

Development of single admission proforma –

enhance continuity; reduce duplication



4. Optimise the admission flow between ED and

specialist wards

MHOA (Mental Health Observation Area) established

within SCGH to enable ED direct admission of

mental health patients. Managed/governed by

NMMHS - 4/24 performance & approp location for

patients

Alternate strategy for escort of MH patients –

deputising security staff (NMMHS-NMHS) - LOS

for MH pts on forms in ED



NEAT after Bell (1) …..

Significant improvements

ED KPIs

Pre 1000 discharges

Target (81%) met 13/51 days

(mid Oct – early Dec)


NEAT after Bell (1) ….

2008 Jan 46% 2009 Jan

39%

2010 Jan 46%

2010 Aug 50%

2011 Jan 68%

2012 Jan 71%

2012 Aug 52%

2013 Jan 62%

2013 Aug 62%

2013 Oct 77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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2008 2009 2010 2011 2012 2013

Four Hour

Rule Program

commenced

Solution

implementation

commenced Stokes Review

Aug 2013 -

Bell Audit

Sept 2013 -

Establish SPICe &

Action Plan


Keeping the SPICe going … change in

action..key factors

Leadership

Clear goals & expectations

Improved leadership of actions

Involvement of snr staff – audit / rounding

Accountability

Data data data

SPICe Action Plan – action driven (RAG

status)

Managing performance < expected


Keeping the SPICe going … change in

action..key factors

Communications / Involvement

Getting the message to everyone

Involving staff - all levels, all disciplines

Patient focus vs target focus

Looking for quick wins

Getting back to basics


Bell Audit (2) – March 2014

Follow-up audit – similar audit team led by

Prof Derek Bell

Same method as previous

Outcomes

Team acknowledged that much hard work

had taken place in the last few months

Staff expressed “ED a safer department

now”

Day of Care Survey 16% patients did not

meet criteria vs 27% (August)

Additional recommendations to build on

previous


NEAT after Bell (2) ….

2009 Jan 39%

2010 Jan 46%

2011 Jan 68%

2012 Jan 71%

2013 Jan 62%

2014 Jan 80%

2014 Apr 83%

0%

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40%

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2009 2010 2011 2012 2013 2014

Four Hour

Rule Program

commenced

Solution

implementation

commenced

Stokes Review

Bell Audit

Aug 2013

Sept 2013 -

Establish SPICe &

Action Plan

Bell

Review

Mar 2014

(Source: EDIS, HSIU Data Warehouse)


And now…..

Acknowledge the dynamic state

Focus on breaches within 4 – 4.30

Monitoring ward consultant led care

Monthly EDD audit & actions

Ward based Discharge Planning process

Bed meeting – revision and new model

Bed turnaround times – ward

Ability to „view‟ ED on MAU & SAU

SCG – OPH transfer / using capacity


NEAT % - current


Sustaining our achievements…

Support leadership

Maintain accountability – use data

Consistent, clear, frequent, RELEVANT messages


Dr Karen Murphy

[email protected]

Sustaining our achievements…

Embed the good – acknowledge reward

celebrate (at all levels / disciplines)

Manage the bad – performance

management, JDF, set expectations

Modify the ugly – continuous improvement


Dr Karen Murphy

A/Executive Director – SCG OP HCG

[email protected]

dr karen murphy,sir charles gairdner & osborne park health care group - the ‘spice’ of life

Health & Medicine

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