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

2. 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

3. 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
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4. 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
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5. 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
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6. WORKING TOGETHER TO IMPROVE HEALTHCARE

7. 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)
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8. 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
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9. 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
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10. Bed audit
% of beds not required for an acute condition ranged from 25 % to 43% across the state
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11. 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

12. 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
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13. Who is accepting me?
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14. 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
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15. Medical Patient Journey
Diagnostic Report

16. 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
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17. 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

18. 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 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

19. 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

20. Capacity Building
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21. WORKING TOGETHER TO IMPROVE HEALTHCARE

22. 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
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23. Thankyou
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