Cre­at­ing a new way of work­ing — and a bet­ter place for patients and staff

Back­ground

Improv­ing the health­care expe­ri­ence often goes hand in hand with improv­ing the qual­i­ty of care. Health­care providers that pri­ori­tise patient-centred care are more like­ly to have effec­tive com­mu­ni­ca­tion, coor­di­nat­ed care, and com­pre­hen­sive sup­port ser­vices. These fac­tors can enhance the accu­ra­cy of diag­noses, increase adher­ence to treat­ment plans, and reduce med­ical errors.

By improv­ing the health­care expe­ri­ence, these health­care providers can enhance patient sat­is­fac­tion, improve the qual­i­ty of care, increase patient engage­ment, boost their rep­u­ta­tion, achieve cost sav­ings, and ful­fil their eth­i­cal responsibilities.

Our client is a health­care provider found­ed in the late 1800s. Since then, they have grown to serve a 17-county region across three states. With almost 3000 employ­ees, they are fed­er­al­ly des­ig­nat­ed as a Region­al Trau­ma Cen­tre. They employ over 200 physi­cians and mid-level prac­ti­tion­ers and admit over 10,000 patients annually.

Analy­sis

The client was just a year away from mov­ing into new­ly con­struct­ed, state-of-the-art oper­at­ing rooms (OR). They knew that their sys­tems and process­es could be improved — and under­stood that they would be mov­ing prob­lems and bad habits into their new space if they didn’t do it now.

Addi­tion­al­ly, their emer­gency depart­ment (ED) was also near­ing capac­i­ty giv­en their grow­ing aver­age length of stay (ALOS). ED man­age­ment was in favour of includ­ing cost­ly addi­tions to accom­mo­date more patients.

From our analy­sis, we dis­cov­ered a few areas of concern:

1. While ‘block sched­ul­ing’ (gen­er­al­ly a hold on sev­er­al hours or ORs by a depart­ment) is “owned” by the client, they did lit­tle to man­age its efficacy.
2. Their cur­rent ORs were sched­uled for use (‘Sched­ule Fill’) for only 40% of the avail­able time.
3. Sched­ule Fill is about 18% when design capac­i­ty is considered
4. Lack of active super­vi­sion of the pro­fes­sion­al staff.
5. ED room turnover time is length­en­ing cycle times and caus­ing capac­i­ty issues.
6. Lack of an effec­tive sys­tem in ED to process incom­ing patients.
7. Avail­able infor­ma­tion is weak and not aligned with the pace of work.
8. Lead­er­ship unable to use data to dri­ve improvement.

Based on the out­come of our analy­sis, it was agreed that a need for rel­e­vant, time­ly data and KPIs were need­ed to dri­ve the change process. It was also agreed that changes in ED ALOS and OR util­i­sa­tion would need to be made.

Project Approach

We began the trans­for­ma­tion project by set­ting up two Man­age­ment Action Teams (MATs) — one for the ED ALOS reduc­tion, and one for the OR util­i­sa­tion capac­i­ty improve­ment. Both would report direct­ly to the exec­u­tive steer­ing com­mit­tee com­prised of the CEO, CFO, CNO, VP Sup­port Ser­vices, and CMO.

The 32-week project began by drilling down into the key process­es and behav­iours that would need to be altered. The ED ALOS team focused on reduc­ing the time before a patient saw a doc­tor and the time decid­ing if a patient should be admit­ted to the main hos­pi­tal as an in-patient. The OR team pri­mar­i­ly focused on pre-admission test­ing, incom­plete charts, first case start delays, sched­ule fill, turnover time, and sur­geon block/OR utilisation.

Project Imple­men­ta­tion

Changes by the ED ALOS team pro­duced an ALOS decrease from 177 to below 155 min­utes. This was accom­plished by includ­ing a Charge Nurse round­ing tool, with dai­ly report­ing on any patients with a length of stay (LoS) over 2 hours, and by chang­ing to a care team mod­el instead of indi­vid­ual MDs and nurses.

Our tri­als showed a sig­nif­i­cant decrease in ALOS was pos­si­ble by sta­tion­ing an MD in the Triage depart­ment once the ‘deci­sion to admit’ time was reduced. To accom­plish this, a LoS MAT was cre­at­ed to improve the abil­i­ty of mov­ing patients though the sys­tem in a more con­trolled manner.

In the OR, changes began with remov­ing and adjust­ing blocks from groups who habit­u­al­ly under­utilised them. We then focused on improv­ing ‘first case on time starts’ and reduc­ing room turnover times. As the effi­cien­cies came through and addi­tion­al OR vol­ume did not mate­ri­al­ize, we began to reduce on-call OR staff to match the num­ber of procedures.

“We tried sev­er­al years ago to take back sur­geon blocks. What is dif­fer­ent this time is that it is data-driven and has includ­ed the sur­geons in the process.”

CNO

Many changes in rou­tine behav­iour and cul­ture took hold, includ­ing a focus on com­ple­tion of patient doc­u­men­ta­tion and charts before surgery, anaes­the­sia tak­ing an active role in the next day’s OR sched­ul­ing, and a twice-daily hospital-wide ‘bed hud­dle’ led by the ED. This hud­dle afford­ed all par­tic­i­pants the oppor­tu­ni­ty to dis­cuss ALOS and patient flow through­out the entire hospital.

Key Results