Transformational change across Tasmania Lauri O’Brien Principal Redesign Consultant HSI Tas.

Commonwealth-funded program for the better health of Tasmanians ­ HEALTH SERVICES INNOVATION TASMANIA (HSI Ta Department of Health (DoH) Tasmanian Health Assistance Package Innovation in Clinical Services – Clinical Redesign WORKING TOGETHER TO IMPROVE HEALTHCARE

Secondary level service Context North West Regional 160 beds and King Island Launceston General 260 beds Population 125,000 Mersey 100 beds Secondary level service Total population 125,000 Royal Hobart 460 beds Population 250,000 WORKING TOGETHER TO IMPROVE HEALTHCARE

Bed demand and capacity Specialist Outpatient Clinics The first steps Key Priority Areas selected by Health Partners Consortium/Commonwealth ­ Emergency Access Elective Surgery Bed demand and capacity Specialist Outpatient Clinics Mental Health WORKING TOGETHER TO IMPROVE HEALTHCARE

Building capability in the system Clinical Redesign 3 THOs State-wide and Local initiatives and outcomes Undergraduate Programs Nursing Medicine Paramedics Pharmacy Postgraduate Programs Professional honours in CR Working with People Leadership WORKING TOGETHER TO IMPROVE HEALTHCARE

WORKING TOGETHER TO IMPROVE HEALTHCARE

DoH Funding Body Health Partners Consortium HSI Tas ­ DoH Funding Body KEY: Funding / Accountability Clinical Redesign support, mentoring, education and data support Advisory Collaboration Health Partners Consortium HSI Tas Clinical Redesign Office (Executive Sponsor THO-N CEO) Clinical Redesign Office (Executive Sponsor THO-NW CEO) Clinical Redesign Office (Executive Sponsor THO-S CEO) Clinical Redesign Work Groups (multiple) Clinical Redesign Work Groups (multiple) Clinical Redesign Work Groups (multiple) WORKING TOGETHER TO IMPROVE HEALTHCARE

Macro diagnostics across the state ED presentation profile LOS by speciality % admitted by specialty NEAT % Admitted and discharge stream Ward admission profile by day of the week and hour of the day Ward discharge profile by day of week and time of day Discharges before 1000 Occupancy across the week Arrival mode, walk in/ambulance Tracked 15 time points in the Emergency patient journey for three days in the four acute hospitals Discharge audit performed seven days a week twice a day in the four acute hospitals WORKING TOGETHER TO IMPROVE HEALTHCARE

Timeline ranged from 6 – 11 hrs across the four hospitals Back of house issue Some results Timeline ranged from 6 – 11 hrs across the four hospitals WORKING TOGETHER TO IMPROVE HEALTHCARE

Bed audit % of beds not required for an acute condition ranged from 25 % to 43% across the state WORKING TOGETHER TO IMPROVE HEALTHCARE

Course set up Scoping Diagnostics Solutions Implementation Sustain Defining problem statement / introduction to A3 tool Scoping / root cause analysis / 5 whys Project management basics / risk and issue management / governance and reporting Communication Stakeholder engagement and mapping Theories and frameworks (six sigma, theory of constraints, LEAN) Ethics approval / literature reviews Change management Waste Big picture mapping Data collection and process mapping Staff and patient interviews / what does the customer value? Data analysing Diagnostic plan and report Diagnostic report back Confirm problem statement – what does data say? Issues prioritisation / setting SMART goals and objectives Push vs pull 5S / visual management controls Standard work Load levelling / rapid improvement / first-in first-out Queuing theory Human factors / human error Site visit – LEAN in Pharmacy RHH / implementation plan and report Sharing project learnings and experiences Executive reporting Sustainability Post implementation evaluation Writing for publication Reflections / where to from here WORKING TOGETHER TO IMPROVE HEALTHCARE

Diagnostic phase: State wide focus on Bed demand and capacity Emergency access Short stay Flow roles Fast track Team based care Triage Tracking Staff and patient surveys 1: 1 interviews What drives you crazy? NEAT Data Bed Demand and Capacity (Patient flow) Admissions policy Escalation plans Footprints ( beds required per specialty) Audit on referral patterns to internal teams and length taken to be seen Analysis on beds required 80%, 90%, & 95% of the time Staff and patient surveys WORKING TOGETHER TO IMPROVE HEALTHCARE

Who is accepting me? WORKING TOGETHER TO IMPROVE HEALTHCARE

Diagnostic phase: State wide focus on Hips and Knees arthroplasty Theatre productivity and planning Surgical Redesign Macro diagnostics Chief Psychiatrists Office Forensics + Drugs and Alcohol Adults (inpatient and Community) Child & Adolescents Older Person Five units at a time using Rapid Improvement event method WORKING TOGETHER TO IMPROVE HEALTHCARE

Medical Patient Journey Diagnostic Report

Medical Patient Journey Themes across the state Culture Lack of standardisation Fragmented communication and team work Lack of transparency and visibility Communication and Information Flow Culture and Mindset Ownership of the Patient Journey Teamwork Variability and Unclear Processes WORKING TOGETHER TO IMPROVE HEALTHCARE

Executive Summary many medical patients spend time in outlier wards The Case for Change - Sources of variation in LOS, and possible bed savings Source of variation in LOS Potential savings (bed days per year)* Number of potential free beds Patients on outlier wards 2410 6.6 Admitting team/consultant 1789 4.9 Mode of separation 1753 4.8 Time of day of admission 2020 4.5 Day of week of admission 1226 3.4 Access block (patients spending more than 8 hours in ED after admission) 767 2.1 Post-take discharges by day of week 215 0.6 After adjustment for other factors, LOS for these outlier patients is on average 48% longer. many medical patients spend time in outlier wards *These potential savings are not additive, because removing one source of variation is likely to affect others Version D.0

Medical patient LOS (length of stay) histogram Graphs depict medical patients stay by bed days – of note are the number of one and two day stays, and the peaks to 4 days, 10 days and 20 days. Medical patient length of stay by groupings - under 6 days is the highest representation at 36.8% followed by 7-13 days at 29.6%. For 21+ bed days, 3.4% of patients account for 20.3% of bed occupancy. Medical patient LOS (length of stay) histogram Two days One day Admissions Bed days LOS N % 0-6 days 3630 73.6% 10203 36.8% 7-13 days 908 18.4% 8214 29.6% 14-20 days 227 4.6% 3685 13.3% 21+ 169 3.4% 5614 20.3% Total 4934 100.0% 27716 Source: BIU Separations and BIU Emergency Attendance tables from KPI menus . Period : 1 Oct 2012 –30 Sep 2014 (2 years)   Clinical Redesign Program – North West Rethinking healthcare service delivery 18

Inflow, Admissions and Transfers LOS versus day of admission If this distribution of LOS for patients admitted on each day of the week was the same as for patients admitted on Mondays, this would save an average of 3.4 beds. NB. Zero is the set number (i.e. Thursday admissions). Those below the line have a shorter LOS when compared to Thursday’s rate of admissions. Conversely, those days above the line have a higher LOS than Thursday admissions. Version D.0

Capacity Building WORKING TOGETHER TO IMPROVE HEALTHCARE

WORKING TOGETHER TO IMPROVE HEALTHCARE

Solutions Design Workshop……. Challenges Solutions Design Workshop……. Next steps Solution design for medical Patient journey Diagnostic phase for other streams… Multiple IT systems across the state Access to the source of truth Small population Three Health regions: merging to one on the 1st July WORKING TOGETHER TO IMPROVE HEALTHCARE

Thankyou WORKING TOGETHER TO IMPROVE HEALTHCARE