Thinking Out of the Box Ambulatory Service in

Hospital Authority

Dr. Woon-Leung NG

Department of Medicine & Geriatrics

United Christian Hospital

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Thinking Out of the Boxo

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Thinking Out of the Blue

NOT

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2006

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Conventional • Ask for more IP beds

• Ask for more manpower

• Ask for more resources

• Ask colleagues to work harder

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Conventional • Ask for more IP beds

• Ask for more manpower

• Ask for more resources

• Ask colleagues to work harder

Counter-intuitive • Cut IP beds

• Convert to Ambulatory

• Cut wastages

• Challenge colleagues to work smarter

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Reforms

• Reduce In-patient Beds

• Redesign an ambulatory care centre (UACC)

• Recruit a dedicated ambulatory care team

• Reconfigure our service model

• Reducing Avoidable Hospitalization

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Prevent Avoidable Hospitalization

eeResults

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A&E Admissions (MED 1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals

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Average no. of IP beds per day (MED 1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals

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IP bed occupancy rate (%) MED (1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals

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Total IP bed days occupied - MED (1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals

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Graph 1 – AE Adm Graph 2 – IP Beds

Graph 3 – Occupancy Rate Graph 4 – Total IP Bed Days

"A statistic should tell a story." -- Margaret Thatcher

Think Substitution

Think Ambulatory 1st

Think “Back”

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Think Substitution

Think Ambulatory 1st

Think “Back”

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Think Substitution - IP Bed is not the only Option

• IP bed is expensive

• IP bed cannot be expanded indefinitely

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Day Medical Care Ambulatory Care in Internal Medicine

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Nurse-Led Service •Drug infusion / injection

•Transfusion / Chemo Rx

•Catheter Care

•Special dynamic tests

• Insulin tolerance test

• Autonomic function test

Medical Procedures Endoscopies

Bone marrow

Lumbar Puncture

Biopsies

Abdominal &

Pleural tap / Bx

(USG-guided)

Day Cardiac Procedures •Cardiac cath / Change of pacemaker

•Pre-procedure education and consent

Rheumatology •Biologic Rx

•Joint Injections

•Musculoskeletal

Ultrasound

Medical Consultation

For Complex Care •Supported Discharge

•Drug titration

•Conjoint programme with AED

Multi-disciplinary Service •TIA clinic

•Cognitive clinic

•Autologous BMT workup

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IN OUT

Ambulatory Care

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Alternatives

Life or organ threatening illness

Access to Specialist Services

Ambulatory Care To Reduce

Avoidable Hospitalization

Fast-tracked Ambulatory Procedures

Early Discharge

Prolonged

IP Rx AED Admission For Mx of

Wax and Wane Medical Conditions

Ambulatory

& Community

Intervention

to prevent

Admissions In-Patient

Procedures

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Think Substitution – Alternative Pathways

• Create timely and organized service to address patient needs

• Standardized and Protocol-Driven

• Tailored to individuals

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“I just remove everything that isn’t part of the Statue.”

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Hospitality

HK$ 4,680

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Hospitality

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Workup of a Lung Mass

Workup of a Lung Mass

Traditional IP Pathway

• Admitted to MED through AED

• Initial Workup in ward, review results,

• Consult Respiratory team

• Further arrangement for workup

Workup of a Lung Mass

Traditional IP Pathway

• Admitted to MED through AED

• Initial Workup in ward, review results

• Consult Respiratory team

• Further arrangement for workup

Ambulatory Pathway

• Arranged to be directly assessed by Respiratory team specialist at Ambulatory Care Centre

• Preliminary workup initiated at AED

• One-stop counseling, workup, ± procedure

Think Substitution – Bottleneck

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• Eliminate everything that is not value-added to patient care or that can be replaced

• Hotel Service

• Waiting (in hospital)

• Non-value added processes that consume the time and expertise of professional staff (Bottleneck)

“I just remove everything that isn’t part of the Statue.”

Think Substitution – Elimination

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Think Substitution

Think Ambulatory 1st

Think “Back”

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International Experience

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http://www.institute.nhs.uk/ambulatory_emergency_care/public_view_of_ambulatory_emergency_care/ambulatory_emergency_care_homepage.html

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Think Ambulatory 1st

• Every emergency admissions would be considered as having ambulatory care potential unless there was clear evidence to the contrary

• For those where existing services cannot adequately provide the ambulatory alternative, there can be further exploration

Think Substitution

Think Ambulatory 1st

Think “Back”

Gallerie dell'Accademia, Florence

Prevent Avoidable Hospitalization

Purpose

Policy

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Position & Priority

Michael Porter

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Protocols

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Patient Journey

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Passion

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Collaborations • Rapid access to Diagnostics: Imaging, Pathology

• Other supporting services: nursing, allied health, community healthcare support, transport

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Curriculum

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Career Pathway

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Critical Mass

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Community Acceptance

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Corporate Direction

Think “Back”

So we fix our eyes not on what is seen, but on what is unseen, since what is seen is temporary, but what is unseen is eternal.

2 Corinthians 4:18 , Bible

Deal with issues at the back