1. Prof. David Ben-Tovim Southern Adelaide Local Health Network & Flinders University

2. 2 Principle 2: Value stream. CASE STUDY

3. 3 Arrival by ambulance Arrival by car/bus/ on foot Seen by triage nurse at triage desk Category 1 or trauma Resus PSA helps paramedics put pt onto barouche Category 2 st into ed Category 3+ to lie down or sit-up waiting Triage cubilces Waiting room Clerical area for documenting and starting medical record Paramedic provides clerical staff with info for record A side cubicles B side cubicles Paed ED X-ray waiting room EECU Recovery A-side coordinator manages pt flows- moves pts in according to triage category, waiting time, informal assessment of severity, and dr work flow Drs supposed to assess pts in Ed cubicles. Patients seen according to dr seniority, severity of illness, informal assessments and work flow. Decision to admit after more or less negotiation and assessment, then admit to ward when bed available Discharged home/transfer another hospital Fast track to existing fast- track service- chest pain, ICCU, CCMU, labour/deliv ‘ O l o g y a n d g e n m e d. s u r g d r s a n d n u r s e s A side coordinator manages nursing organisation B- side coordinator manages nursing organisation Drs allocated to pts, nurses allocated to cublcles ED map

4. 4 Amb Self Triage Desk Registration & given own paperwork Waiting room B-side of ED, B side team A side cubicles and team Resus Likely to be discharged Likely to be admitted See in order of arrival

5. Garrett Hardin- The tragedy of the Commons Science, 1968,: 162; 1243-1248

6. [ Adam Smith] contributed to a dominant tendency of thought that has ever since interfered with positive action based on rational analysis, namely, the tendency to assume that decisions reached individually will, in fact, be the best decisions for an entire society…

11. Elinor Ostrom-Governing the Commons: the evolution of Institutions for Collective Action- Cambridge Univ Press, 1990 Nobel Prize winner- Economics 2009. The Tragedy of the Commons is not inevitable- it is the outcome of the unmanaged Commons

16. P D A S 1 2 3 4 5 Diagnostic Phase ScopeEmbedSustainImprove Assess Impact Intervention Phase P D A S P D A S P D A S P D A S Lean principles Problem Real Problem