1. My Job? South African Triage Scale and Acute and Emergency Case Load Management Policy Implementation Officer

2. Triage? First come, first served “eye-ball” To the Letter (“inappropriate”) “Love thy Neighbour” Dr G Special

4. SATS used correctly ↓Waiting times ↓Emergency Centre Length of stay ↑Patient flow ↑Patient and staff satisfaction ↓Mortality (2% to 0.7%)

5. SATS Performance Indicator CTS priorityTarget time to treat Performance indicator threshold RedImmediate95% Orange10 minutes80% Yellow60 minutes75% Green240 minutes70%

6. Time to Triage

7. Triage (ambulance stretcher cases)

8. Seen by Doctor 0% Orange patients seen in under 10mins after SATS assigned Orange and Yellow patients are seen by doctor on average 2 hours after arrival (about 50 minutes after triage) – this is in a system where Green patients are streamed elsewhere.

9. Time waiting in EC 71% of admissions spend over 8 hours in the EC (from arrival) Average is 12,5 hours from arrival to ward bed Average wait from time seen by specialist to time to ward is 7hours.

10. Overcrowding If your hospital is >90% full OR Over 10% of the patients in the Emergency Centre have been waiting over 8hrs from arrival to admission THEN...

11. INPATIENT MORTALITY IS INCREASED BY 30%! Mortality risk ratio is 1.1 for each hour spent waiting in the Emergency Centre Mortality risk ratio is 1.2 for each hour spent waiting for a doctor

12. Overcrowding causes Increased patient mortality Ambulance diversion • Increased inhospital lengths of stay Patients not being placed on the appropriate ward • Medical errors Poor infection control Poor hospital processes • Financial losses to hospital and physician • Medical negligence claims Increased staff burnout and decreased morale

13. “An overcrowded hospital should now be regarded as an unsafe hospital”

16. No matter how few resources we have there is always hidden capacity in the systems Use our limited resources more effectively Increase efficiencies, reduce duplication, reduce waste Patients want: the right treatment without mistakes without waiting “Work smart not hard” Systems Improvement

17. Front Door Issues – Entry Portal GFJ: 20% of CHC referrals are “inappropriate” 40% GP referrals “inappropriate”

18. EC Efficiency

20. Nursing Staff 44% of time is non-value added work – giving directions – pushing trolleys – answering phones – finding stock ie Employ 10 nurses and you will get 5,6 nurses’ worth ?Quality of the 56% nursing care done under pressurised and distracting conditions Doctors only slightly more productive...

21. Patient flow Who’s closing the hospital??

22. Ward check Ward 1: 0 Beds, 5 discharges pending Ward 2: 4 Beds, 5 discharges pending Ward 3: 5 Beds, 3 discharges pending Ward 4: 3 Beds, 0 discharges pending

23. Back Door Issues - Discharge planning Patients admitted on Thursdays have longer lengths of stay than those admitted on Mondays Patients often only leave beds at 17h00 on the day of discharge

24. Discharge Process Discharge summary written and handed to nurse Folder to pharmacy Transport arranged OPD appointments made Home-based care forms filled Patient waits in bed until medications or transport, whichever comes last This often only happens at 12h00 or 15h00...

25. With Discharge Planning Day before Contact transport (heads up) OPD appointments Home-based care forms Intern to prepare discharge forms for next day On the Day Discharge round first thing in the morning Transport confirmed Patient to discharge lounge as soon as transport confirmed

26. With discharge planning, discharge rounds and discharge lounge Total length of stay shortened Every bed hour saved: Reduces mortality and morbidity of patients awaiting beds Reduces Cost to the Hospital

27. ‘all improvement needs a change but not all change is an improvement’

28. DMAIC D efine the Problem and its impact on the Organization M easure the Current Performance A nalyze the Performance to identify Causes of this Performance I mprove the Problem by attacking its Causes C ontrol the Improved Process to Maintain the Gains.

30. Finding ideas for change people providing the service patients guidelines (eg AECLMP and SATS policies!) change ideas/concepts (eg lean, 6-sigma) mapping the system identifying underlying problem (root cause analysis) novel ideas (creativity) eg brain storming best practice - sharing ideas What Change can we make that will result in an improvement?

31. A little about Lean

32. Types of waste Muri (overburden) – unreasonable work imposed because of poor organisation – pushing person or machine beyond natural limits. Improvement comes at the level of proactive planning.

33. Types of waste Mura (uneveness): Problems inherent in system design or implementation. Improvement is in smoothing out the process

34. Types of Waste Muda (non-value added work): waste that becomes apparent once system implemented – Transportation: moving products that are not actually required to perform the processing – Inventory: all components, work-in-progress, finished product not being processed – Motion: people or equipment moving/walking more than is required to perform the process – Waiting: for the next step in the production – Overproduction: ahead of demand – Over processing due to poor tool or product design, creating activity – Defects (mistakes, re-work)

35. Types of Waste Use of human resources: Rationalisation Creating thinking workers

36. 5 WHY’s Why?

37. 5S Sort Set in order/Straighten out Shine Standardise Sustain

38. VALUE STREAM MAPPING 10 min 30 min1 Hour 6 min 2 hour 12 min 10 min 2 min 3 hours 24 min 6 hours 40 min

39. VALUE STREAM MAPPING 8 min 30 min 45 min 10 min 1 hour 6 min 3 hours 24 min 3 hours 45 min

40. PORTERS

41. Porters’ Lodge X-ray Ward 4Ward 1 Ward 2Ward 3 Emergency Centre Ward3 to X-rays EC to Ward2 X-ray to EC Ward 2 to Ward 3 EC to X-ray

42. Porters’ Lodge X-ray Ward 4Ward 1 Ward 2Ward 3 Emergency Centre Ward3 to X-rays EC to Ward2 X-ray to EC Ward 2 to Ward 3 EC to X-ray

43. Getting ready to suture

46. Some other processes impacting flow Stock availability and placement Pharmacy throughput Laboratory turnaround time Enquiries setup Time to folder – place for bedside admission? Statistics collection and acting on Escalation Policies

47. Initiating Change Valley of despair Performance Time

48. Rapid Cycle Change What can we change that will result in an improvement? PLAN DO STUDY ACT How will we know that a change is an improvement? What are we trying to accomplish? PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT

49. Improving many parts of the system at once. PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT Wait for doctor Discharges Triage Nursing duties PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT PLA N DO STU DY ACT

50. End