undertaking the macroneat project within a paediatric tertiary hospital
DESCRIPTION
Nicole Close, Nurse Manager Patient Flow, Therese Oates, Clinical Nurse Consultant Project officer MACRONEAT, Royal Children's Hospital Brisbane delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow conference 2013 in Melbourne. For more information on the annual event, please visit the conference website: http://bit.ly/1f3Pp03TRANSCRIPT
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MacroNEAT at a Tertiary
Paediatric Hospital
Therese Oates & Nicky Close
Project Managers
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Take home message 2012
conference
• Executive Engagement
• Medical Buy in
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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
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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
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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.
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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
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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
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“Efforts to reduce variations in
admissions depend on the
discharge process”
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Insert Photo of Handover room
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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
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Introducing a checklist for discharging patients
Discharge planning starts on admission
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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
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DEM board
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Interim Care Plans
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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!
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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
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The NEAT project
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2012 –Admitted NEAT PERFORMANCE
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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
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ED
ED
Inpatient
Bed Process
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A patient perspective
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Hour 1
Hour 2
Hour 3
Hour 4
Discharge
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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
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Hour 1
Hour 2
Hour 3
Hour 4
Discharge
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31
SOLUTIONS Early Senior Decision
Making
Inpatient consultation
requested checklist /
communication script
Interim Management
Care Plan
Improved Data Capture
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Hour 1
Hour 2
Hour 3
Hour 4
Discharge
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Hour 1
Hour 2
Hour 3
Hour 4
Discharge
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35
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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.
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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….