MacroNEAT at a Tertiary

Paediatric Hospital

Therese Oates & Nicky Close

Project Managers

Take home message 2012

conference

• Executive Engagement

• Medical Buy in

Process Changes

• Optimising Demand and Capacity Predictive Tool from our data unit

• Hospital Report changes to reflect Dashboard

• Implementation of iphone technology to improve communication and patient flow.

• Establish business rules

• Consistency of practice in ALL areas

• EDIS access and visibility

• Greater emphasis on Key Performance Indicators and Accountability

• Review of our elective medical admission process

Changes Continued

• Changes to patient flow meetings venue and time to incorporate combined

nursing and medical streams as part of flow initiative.

• Neat admission targets highlighted daily to nursing and medical teams.

• Weekly emails to key stakeholders. We pulled all KPI data and sent it relevant Key stakeholders.

• LOS > National benchmark most top 10 drg’s

• Discharge data per ward before 1100 <20% disseminated to key stake holders

• Admission facilitation % visible to public

Royal Children’s Hospital Brisbane

Demographics

• 114 funded inpatient beds

• Capacity to flex to 128 over census

• 17 single room

• 5 post transplant rooms

• 3 bed burns unit

• Service provided PICU/HDU, Haemodialysis, Oncology, Burns, Ortho, Surgical, ENT, Plastics, Gen Med, Gastroenterology, Endocrine, Immunology, Neurology, Neurosurgery, Rehabilitation, Mental Health, Liver transplants, Respiratory Medicine, Limb Reconstruction, Cerebral Palsy services, Dental and Ophthalmology.

NEAT Performance

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Project team engaged

Despite what the data projected the RCH was committed to process

improvement, service proficiency, improved patient access and the

patient experience.

We wanted to expand and take control of our Patient and Family Journey

with a vision toward QCH - due to open doors late 2014

Executive Engagement

• New Executive Director Medical Services:- Dr John Wakefield

• New Executive Director Nursing Services:- Shelley Nowlan

• Project Sponsor:- Nursing Director Critical care and Surgical Services:- Karyn Ehren

• Project Medical Consultant:- Dr Alan Sive

• DEM Process Improvement:- Dr Natalie Deuble

• Patient Flow Consultant:- Dr Lynne McKinlay

“Efforts to reduce variations in

admissions depend on the

discharge process”

Insert Photo of Handover room

Bed

OccupancyAdmits Admits

Outlies

Number

of Long Discharge

Activity

tomorrow

0800 7am 11am

1:1 1:2

Patients

from other

specialities

Stay

Patients

> 14 days

Date

(HBCIS) Impact on

Service

provision

To be completed & brought to 0800 bed meeting

Nursing

Hours

per

Patient

Day

Patients no

longer requiring

tertiary care:

Potential

transfers other

hospitals and or

HITH

Identifiable Risks

/Issues: Clinical

Safety, Discharges ,

Staffing

requirements, skill

mix etc.

Expected

D/C's am

and pm

Specials

No. staff

Ward template

Introducing a checklist for discharging patients

Discharge planning starts on admission

Task Timing Who Y

Identify day and time of discharge On admission and modify daily Primary team

Complete discharge script As soon as meds known Resident

Notify consulting teams of discharge time As soon as known Resident

Complete transport forms On admission Resident

Parent education and written action plans From admission Reg and Nurse

Organise hospital in the home 48 hours before discharge Reg and Nusrse

Discharge Letter Start on Admission, complete within 24 hours of

discharge

Resident

Multidisciplinary discharge meeting 72 hours before discharge Reg/Res

Equipment requirements 24 hours before discharge Nurse

Contact referring/accepting hospital 48 hours before discharge Reg/Cons

Nurse

Identify and record criteria-based nurse discharge details As soon as possible after admission Reg/Cons

Follow-up/ OPD appointments 24 hours before discharge

DEM board

Interim Care Plans

Key Challenge

• Competition for single rooms.

• VRE

• MRSA

• Neutropoenia

• BMT and Liver transplants – immunosuppressed

• Infectious cohort:- RSV,Para 1,2,3, Adeno, Flu A, B. Meningococcal, Meningitis, Chicken Pox, HMPV, Gastroenteritis, Swine Flu, Scabies, Hand foot and Mouth……………...

• Special needs for families

• Family Centred care.

• YOU NAME IT KIDS GET IT!

The Myth: - We are special !

• No we are not:- However, as one of 2 Tertiary Paediatric Referral Hospitals

in Queensland, we do aim to provide the best quality service for the children

who attend our service

• 17 million in budget cuts to CHS with 85 positions lost.

• NEAT is nothing new! Its about optimising

• Our current processes to achieve max efficiency

The NEAT project

2012 –Admitted NEAT PERFORMANCE

What the data also told us..

• NEAT per hour of day tracked over 12 months – 0100 best time to get

inpatient bed

• Indicating late discharge trend combined with higher volumes of arrivals to

ED in the late evening

ED

ED

Inpatient

Bed Process

A patient perspective

Hour 1

Hour 2

Hour 3

Hour 4

Discharge

SOLUTIONS

29

WIT

HIN

TH

E F

IRS

T H

OU

R

MOVING INTO HOUR 2

1. Patient

presents to

triage

2. Identify

suitability

for Rapid

Assessment

& Treatment

(Green Zone

Streaming)

4. AO

undertakes

bedside

registration

6. Early Disposition

identified

5. RAT initiated

3. AO escorts

patient to

allocated

treatment

space

Hour 1

Hour 2

Hour 3

Hour 4

Discharge

31

SOLUTIONS Early Senior Decision

Making

Inpatient consultation

requested checklist /

communication script

Interim Management

Care Plan

Improved Data Capture

Hour 1

Hour 2

Hour 3

Hour 4

Discharge

Hour 1

Hour 2

Hour 3

Hour 4

Discharge

35

Outstanding Issues

• Back transfer of patients to referring satellite paediatric facility.

• Impact of infective patients on bed availability

• Booking and triage processes for elective medical patients

• Criteria led discharge in nominated DRGs

• Reward and Recognition process.

37

“ A continuous Treasure Hunt to add value

A continuous Bounty Hunt to eliminate anything

that doesn’t add value”

Mayer & Jensen 2009, Hardwiring flow

Flow is….