Five innovations to improve length of stay management and whole system patient flow

Introduction This guide is for Health Services aiming to improve their inpatient processes and care delivery. The five innovations are based around developing a shared understanding of capacity and demand, empowering all staff to manage patient’s length of stay, using simple improvement tools and care bundle techniques and promoting leadership through executive involvement and organisational escalation plans. Use this guide as the starting point to develop an improvement plan. Click on the tabs to progress through the five improvements. Additional resources to support the innovations are available in the Patient Flow Change Package. For further information on the Patient Flow Collaborative, please visit www.health.vic.gov.au/patientflow

Variation patterns - large variation in admission patterns One Understanding data Understanding data Variation patterns - large variation in admission patterns Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans Range between the process limits is 19-95 Average is 57

Variation patterns - large variation in discharge patterns One Understanding data Understanding data Variation patterns - large variation in discharge patterns Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans Range between the process limits is 5-107 Average is 56

Discharges vary more than Admissions One Understanding data Understanding data Variation patterns – mismatch between discharge (capacity) and admission (demand) patterns. Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans Discharges vary more than Admissions

Reducing length of stay One Understanding data Understanding data Reducing length of stay Two Empowering staff Provide care in another environment linking to community, e.g. HARP Three Tally charts and action plans Take half day off clinically unnecessary LOS and it has dramatic impact through reduction in waits, delays, unnecessary queues, better decision making and communication. Four Inpatient care bundles Five Escalation plans Note: Average LoS = 7.24 days

Variation in admissions and discharges - Specialist Medical Ward One Understanding data Understanding data Variation in admissions and discharges - Specialist Medical Ward Two Empowering staff Three Tally charts and action plans Match admission demand to capacity created through timely discharge Four Inpatient care bundles Five Escalation plans

One Understanding data Understanding data Variation in Admissions and Discharges - Specialist Surgical Ward (2003-04) Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

One Understanding data Understanding data Smoothing flow – Can we predict our emergency demands? Two Empowering staff Predicting emergency admissions demand and create capacity to meet daily needs. Admission via ED Day range Mean Cardiology 3 5 4 Medicine 8 10 9 Surgery 7 Neuroscience 2 6 Total beds needed for ED admits in 24 hrs 20 31 25 Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Empowering staff Leading management of patient flow by assertive, One Understanding data Empowering staff Two Empowering staff Leading management of patient flow by assertive, cooperation with care providers To effectively manage patient’s length of stay, front line staff need assertive and cooperative communication styles, especially during times of low staffing, and increasing demand a clearly communicated knowledge of policy and organisational goals to improve whole system patient flow. A simple communication style model can remind staff of the best communication methods. Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Empowering staff Checking assertiveness One Understanding data Empowering staff Checking assertiveness The following questions can help to assess assertiveness©: Do you express your thoughts, feelings, and beliefs in a direct and honest way? When you differ with someone you respect, are you able to speak up and share your own viewpoint? Do you usually have confidence in your own judgment? Are you able to refuse unreasonable requests made by friends or co-workers? Do you ask for assistance when you need it? If someone else has a better solution, do you accept it easily? Do you readily accept positive criticism and suggestions? Do you try to work for a solution that, as far as possible, benefits all parties? Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans © Organizational Development and Training, Department of Human Resources, Tufts University, Somerville, MA

Empowering staff Barriers to assertiveness One Understanding data Empowering staff Barriers to assertiveness Barriers to assertiveness can prevent solutions or actions progressing patient care. These barriers include: steep authority gradient steep experience gradient rank lack of confidence fear of reprisal personal agenda ambiguous policy or lack of enforcement lack of clarity about patient –centred organisational goals and vision. Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Empowering staff Graded assertiveness One Understanding data Empowering staff Graded assertiveness A simple method to assist solving issues with patient’s length of stay can be used; this is called ‘graded assertiveness’. Graded assertiveness is a process of advocating and justifying a position until patient care is assured. Graded assertiveness should be used if the initial enquiry/request is unsuccessful in resolving the problem in an appropriate way. Graded assertiveness is a process of progression through four levels of assertiveness: Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles 1. Probe I need to know what is happening 2. Alert What is happening is preventing effective length of stay 3. Challenge The patient is not going to get timely care and treatment 4. Emergency This needs referral to a higher authority, as it is causing unnecessary delays for the patient Five Escalation plans

One Understanding data Empowering staff By moving through the four stages of graded assertiveness, a resolution should be found for effective length of stay management. Ultimately the patient should receive the right care, at the right time, with the right clinician with the right equipment/resources. Two Empowering staff Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Empowering staff Tally charts and actions plans One Understanding data Empowering staff Two Empowering staff Variation in length of stay Simple delay tally charts and action sheets for delays have produced significant improvements to patients’ care plans, reducing the length of stay. Tally charts can be updated each day identifying if there are any delays in the patient’s length of stay. Action sheets stating the delay category and action can be prepared by the Ward/unit nursing staff, thus promoting ownership of patient’s clinical care. Each delay category must have a pre-defined guided intervention. Example templates are set out on the following two pages to make additional copies. Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Delay Tally Sheets Patient ID Delay (refer to Action Plan categories) Action taken

Delay Action Plan Delay category Action to be taken

One Understanding data Inpatient care bundle Two Empowering staff Care bundles are an improvement tool which makes sure a clinical process delivers the elements of care needed to optimise patient outcomes. The care bundle approach encourages clinical teams to agree on the elements of clinical interventions and manage unwarranted variation in care delivery. Once the care bundle is agreed, measurement can be applied to promote and manage consistent high standards of care. A simple care bundle has been developed to assist with optimising inpatient stays. This care bundle can be converted to any clinical area and the measurement tool applied. Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

One Understanding data Inpatient care bundle Two Empowering staff Elements for a length of stay care bundle should include: - Discharge medication - Follow up arrangements – e.g. OPD etc. - Day/time of discharge communicated to patient/carer - Letter to General Practitioner - Transport plan The following simple codes can be used to audit whether the care bundle element has been completed: 0 – not complied 1 - complied 2 - not required. The Care Bundle Graph tool incorporates these five elements and collects and automatically graphs audit data, on compliance with the care bundle approach. An electronic version is located on the accompanying CD or available from the patient flow website. Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Escalation and contingency plans One Understanding data Escalation and contingency plans Two Empowering staff Simple escalation plans for inpatient management which are action orientated and easy for all staff to follow can produce significant benefits during bed block and by pass. Actions must be proactive and have policy driven trigger points. Essential to this approach is focussed, single minded leadership to resolve access issues. Accountability to the CEO is assumed to underpin and drive the escalation plans. Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Escalation and contingency plans One Understanding data Escalation and contingency plans Two Empowering staff Short term actions that can be incorporated into escalation policies: Review all inpatients by the patient’s clinical team Executive grand round of all patients. This team should include Executive General Manager, Senior Clinical Lead and Senior Nurse Lead Tracking of all inpatient delays should be enforced on all wards Predicting Emergency Department admissions over the next 24 – 48 hours to plan bed requirements Increase Emergency Department staff for expediting treatment of low acquity patients Arrange one hourly Bed Manager and Lead Executive meeting Identify single point of accountability e.g. General Manager to stop other duties and focus on issue at hand reporting directly the the CEO Agree and review tasks every 2 hours until situation reversed. Three Tally charts and action plans Four Inpatient care bundles Five Escalation plans

Acknowledgements Jenny Bartlett Chief Clinical Advisor, Office of the Chief Clinical Advisor Lee Martin Manager, Clinical Innovation Agency Director, Patient Flow Collaborative Marcus Kennedy Clinical Lead, Patient Flow Collaborative Patient Flow Collaborative Team Rochelle Condon, Improvement Lead Ruth Smith, Improvement Lead Fiona Dickson, Improvement Lead John Walker, Communications and Logistics Lead Prue Beams, Data Consultant

Contacts Support to implement these system wide initiatives is available via the Patient Flow Collaborative team who can be contact via: Clinical Innovation Agency Email: cia@dhs.vic.gov.au Phone: 9616 7022 Patient Flow Collaborative Team Lee Martin 9616 7859 Manager, Clinical Innovation Patient Flow Collaborative Director Rochelle Condon 9616 9026 Improvement Lead Ruth Smith 9616 9025 Improvement Lead Fiona Dickson 9616 9030 Improvement Lead Prue Beams 9616 7742 Data Consultant John Walker 9616 9037 Communications and Logistics Lead