Jun

e 2

– 3

, 20

14

Dr. Phil Shin Chief of Medicine and

Medical Director, Critical Care &

Susan Woollard Program Director, Medicine, Critical Care and

Elder Care

Improving Patient Flow

North York General

• Community teaching hospital

• Affiliated with the University of Toronto

• Catchment area: 400,000 residents

Three Sites:

• General

• Branson

• Seniors’ Health Center

Beds:

• 413 acute care

• 200 long-term care

Volume:

• 110,000 Emergency Department visits annually

• 28,000 inpatient cases per year

• 5,800 births per year

%

Conservable

Days

90th ED LOS –

Admitted

Patients

% of Time

EAA 15 or

Fewer

25%

43%

89%

Our Improvement Story

2012 – 2015 Strategy

2nd Out of 74 Ontario Hospitals in ED Performance Funding Rank

Access to Care Executive Sponsor

Karyn Popovich & Dr. Donna McRitchie

Access to Care Committee

Chair: Karyn Popovich

Admin Janice Lepper

Access to Care Core Team

SI Leads: Maria Muia and Mary Lynne MacMaster

Project Manager: James Ibbott

Admin Jeanette Weetom & Audrey Oakley

A2C

Engagement

Groups

Change

Management

Consultants

Office of

Strategy

Management

Operations

Committee

Medical

Advisory

Committee

A2C Projects

Departmental /

Program Led

Improvements

Bed Transfer for Long Patient

Waits Expedite

Physician Service Expectations

Work with LHIN on Rehab / LTC

issues

Improve Ultra Sound TATs

Improve Cardio Resp. TATs

Do a Value Stream Analysis on UMS / BMS

Align Medicine Internists with Roles in UMS

Improve Inappropriate Admissions to

Hospitalist

CCAC Issues Log: RM&R, CM

Waiting, CCAC Policies

Site Visits to Southlake and

TEG. More benchmarking

Need IPAC Escalation Protocol

Portering Recommends

(George & UofT)

Work on Weekend Issues

NOW

Better Utilization of Stroke

Prevention / Clinic

Develop Cardia Care Pathway

(IPU) Improve Med-

Surg Clinic Capacity by

Appropriates Management

System for Wellsoft /

Teletrack Errors

Utilize NPs in ED

Managing Patient / Family

Expectations

Investigate why ALC is increasing

Improving Staffing: Problem

when going overcapacity

Escalation Protocol for

Surgery when cannot place

Protected Meeting Time

Standards

Patient Flow Navigators

Need a Cerner Flag for DI Consent

Standard Documentation / Planning for Long

Weekends

ALC Improvements

Escalation Protocol Phase

3

Isolation Room Capacity

Improvement

Conservable Days Working

Group

P&F Early Involvement in D/C Planning

Roles & Expectations in D/C Planning

Powerchart Enhancements D/C Planning

Sustainability in Access to

Care

Medical Imaging Service Delivery

Portering Service Delivery

P&FCC

Quality & Safety

Framework

Service Excellence

Model

Service Excellence

Connecting Care

Care Environments

Research & Innovation

LMS System

Education SI

Healthlinks

ED Renovations

Family Medicine Workflow

PowerScribe Upgrade to

PS360

cGTA and OnBase

HBAM & QBP

MH and Yellow Zone Process

Review

eCare

BDC Wait Time Improvement

Cardiac Clinic Outreach

Med-Surg Clinic Redesign

Senior Friendly Hospital

Branson CT Service

Consolidation

Access to Care

Governance Structure

2011/12 2012/13 2013/14 2014/15

Med-Surg Clinic

Short Stay

Beds

Escalation

Protocol

Daily Goal Rounds

Physician

Champions RM&R

Social Worker

Schedule

GIM Model

of Care

There’s No

Place Like

Home

Escalation

Protocol

(Phase 2)

Access to Care

Celebration &

Recognition

Teletracking

Upgrade

Discharge

Management

Planning Event

Leadership

Walkabouts for

Daily Goal

Rounds

Increase

Private

Rooms

Project Planned for

2014-15

ALC Improvements

Escalation Protocol

(Phase 3)

Sustainability for A2C

Patient & Family Early

Involvement in

Discharge Planning

Transportation Service

Improvements

MI Service

Improvements for ED

Access to Care

Project Timeline

• Trigger based on

patients waiting in ED,

ICU and elsewhere

• Unassigned are the

patients waiting in ED

that have not been

assigned to a bed

• ED and CTAS

information used to

show volume and

acuity

• Status comes out 5

times a day

Escalation Protocol

What are the Benefits

Escalation Protocol:

Transfer patient waiting to an

unbudgeted bed immediately

Patient transferred to inpatient unit

Other patients waiting benefit

from having access to care

on inpatient unit faster

Obtain clinical services sooner

Availability of resources in

Emergency / ICU

Better patient outcomes, safety and patient

experience

2011/12 2012/13 2013/14 2014/15

Med-Surg Clinic

Short Stay

Beds

Escalation

Protocol

Daily Goal Rounds

Physician

Champions RM&R

Social Worker

Schedule

GIM Model

of Care

There’s No

Place Like

Home

Escalation

Protocol

(Phase 2)

Access to Care

Celebration &

Recognition

Teletracking

Upgrade

Discharge

Management

Planning Event

Leadership

Walkabouts for

Daily Goal

Rounds

Increase

Private

Rooms

Project Planned for

2014-15

ALC Improvements

Escalation Protocol

(Phase 3)

Sustainability for A2C

Patient & Family Early

Involvement in

Discharge Planning

Transportation Service

Improvements

MI Service

Improvements for ED

Access to Care

Project Timeline

Daily Goal Round Agenda:

• Patient name/Diagnosis/MRP

• Expected Date of Discharge (EDD)

• Daily Goals - i.e., facilitate diagnostic tests, interventions, clinical assessments, etc.

• Outstanding Issues/Barriers – i.e. any outstanding items from Diagnostic Imaging, Lab results, referrals, consults, family meetings, social work, physiotherapy/occupational therapy, etc.

What’s Different? • Everyday • Before 10am • Frontline nurses

present patients

The Goal: To drive collaboration between members of our multidisciplinary team to facilitate a safe and effective discharge plan for patients, and their families and caregivers. Frequency: Every week day before 10:00am for 30-45 minutes

Daily Goal Rounds

The Goal: to collaborate with the multidisciplinary team to facilitate a safe and effective discharge plan. At bullet rounds the appropriate traffic light disposition will be determined.

Allotted Time: 30mins

Be precise

Utilize time well

Look at the big picture

Lean thinking!

Expedite discharges

Team approach

Agenda:

1) Patient name/Diagnosis/MRP

2) EDD (expected discharge date)

3) Daily Goals - i.e. facilitate diagnostic tests,

interventions, clinical assessments etc.

4) Outstanding issues/barriers – i.e. any

outstanding items from Diagnostic Imaging, Lab

results, referrals, consults, family meetings,

social work, PT/OT, etc.

Daily Goal Rounds

Daily Goal Rounds:

Impact to Staff

“Critical thinking of nurses has been enhanced, more proactive. Nurses now come with a discharge plan and are asking at Rounds “what the plan is””

“Helps to have Unit Coordinator to delegate and be more involve as a coach. It is now off the UC and more on Nurses”

“More confidence, better information from nursing,

nurses know their patients better i.e. lab results. Lots of great feedback”

“Nurses are more

accountable and physician seek out the primary nurse more than before.”

“Students enjoy the process and participate”

2011/12 2012/13 2013/14 2014/15

Med-Surg Clinic

Short Stay

Beds

Escalation

Protocol

Daily Goal Rounds

Physician

Champions RM&R

Social Worker

Schedule

GIM Model

of Care

There’s No

Place Like

Home

Escalation

Protocol

(Phase 2)

Access to Care

Celebration &

Recognition

Teletracking

Upgrade

Discharge

Management

Planning Event

Leadership

Walkabouts for

Daily Goal

Rounds

Increase

Private

Rooms

Project Planned for

2014-15

ALC Improvements

Escalation Protocol

(Phase 3)

Sustainability for A2C

Patient & Family Early

Involvement in

Discharge Planning

Transportation Service

Improvements

MI Service

Improvements for ED

Access to Care

Project Timeline

GIM/Physician Model of Care Result:

Medical School Cardiology

Respirology

Gastro-enterology

Internal Medicine

Oncology

Geriatrics

Infectious Diseases

Specialists in General Internal Medicine or General Internists Are expert diagnosticians: they are considered medical detectives Are leaders in medical education, particularly clinical examination

Specialize in the management of patients with multi-system or undifferentiated disease Sort out illnesses and balance their management

Endocrinology Rheumatology

Hematology Allergy and Immunology

What is a Specialist in

GENERAL INTERNAL MEDICINE

Critical Success Factors

Critical Care Process

(Intensivist - Led Model)

Rapid Referral Clinic

Medical Consult Service

ED Consultation

Inpatient Most Responsible

Physician

GIM Model of Care

Research Question

• Does the implementation of a general internal medicine

model of care in a community teaching hospital have a

measurable impact on the quality of patient care?

Physician Engagement Score 85% The provincial 75th

percentile was 66.1%

Staff Engagement Score 66.6% The provincial 75th percentile

was 66.1%

Critical Success Factors

Culture and Innovation

The Journey Continues

Thank You!