Introducing the RITZ - Department of Health
Introducing the RITZ - Department of Health
Introducing the RITZ - Department of Health
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<strong>Introducing</strong> <strong>the</strong> <strong>RITZ</strong><br />
Improving access for Non-Admitted patients at The Nor<strong>the</strong>rn Hospital<br />
Oliver Furness<br />
Program Leader<br />
Redesigning Care<br />
Dr Helen E. Stergiou<br />
Director<br />
Emergency <strong>Department</strong><br />
<strong>Health</strong> Innovation Conference - 24 February 2010
Acknowledging our Team Approach<br />
• Redesigning <strong>the</strong> Non-admitted Patient Journey<br />
Working Group<br />
Key drivers<br />
• Jenelle Linton, Project Officer<br />
• Roslyn Martin, ED Nurse Practitioner<br />
• Dr Herman Chiu, Clinical Lead / Emergency Physician
• Setting <strong>the</strong> scene<br />
– The Nor<strong>the</strong>rn Hospital Emergency <strong>Department</strong> (ED)<br />
– Redesigning Care and <strong>the</strong> non-admitted patient<br />
• What we did<br />
– Diagnostics<br />
– Solution design<br />
• Outcomes<br />
– Key indicator results<br />
• What we learnt<br />
– Wise advice
What is <strong>the</strong> <strong>RITZ</strong> ?
It is not a new strategy to move<br />
Emergency Patients to 5-star hotels<br />
The <strong>RITZ</strong>…
It’s a new treatment space<br />
at The Nor<strong>the</strong>rn Hospital<br />
The Rapid Intervention and Treatment Zone<br />
Non-admitted patients<br />
Prompt access<br />
High Quality Care
Setting <strong>the</strong> scene<br />
• The Nor<strong>the</strong>rn Hospital ED<br />
– 66,200 presentations in 2008 = average 181 per day<br />
– Strong performance: Bypass / LOS < 24hrs / Time to treat (CAT 1/2/3)<br />
– Opportunities for Improvement: LOS
What we did…<br />
• Redesigning Care at Nor<strong>the</strong>rn <strong>Health</strong><br />
• Lean thinking approach<br />
• Examine our processes from <strong>the</strong> patients’ perspective<br />
• Identify, analyse and eliminate waste (duplication, delays, inefficiencies)<br />
• Ensure optimal process flow<br />
• Structured approach focused on diagnosing <strong>the</strong> problem<br />
Start Up<br />
Diagnostics<br />
Solution Design<br />
Implementation<br />
Transition /Evaluation<br />
Majority <strong>of</strong> project time<br />
- Understand current process<br />
- Identify issues and root causes<br />
- Process mapping<br />
- Staff/patient observation<br />
- Hospital activity data analysis<br />
- Only developing solutions once root cause identified
Redesigning <strong>the</strong> non-admitted emergency patient journey<br />
• Pt Observation example…
Diagnostic Stage Outcomes<br />
• Clear link between <strong>the</strong> ‘time patients wait to be seen’ and<br />
‘total time in ED’ (LOS).<br />
• Analysis identified a number <strong>of</strong> key causes to delays in<br />
initial assessment:<br />
– Lack <strong>of</strong> available space (cubicles) to assess patients<br />
– Staff wasting time searching for equipment, supplies, paperwork<br />
– Variability in how patients are allocated to Medical Staff<br />
– Delays in <strong>the</strong> process <strong>of</strong> ordering and reviewing Radiology tests<br />
– Clerical role interruptions and lack <strong>of</strong> role clarity.
Solution Development<br />
• Process:<br />
– A small dedicated team <strong>of</strong> ED staff developed solutions to <strong>the</strong>se issues<br />
– Goal was to ensure rapid intervention and treatment <strong>of</strong> specific pt<br />
cohort by medical and nursing staff<br />
– Solution logic:<br />
Reduce wait time<br />
for registration<br />
Reduce wait time<br />
for initial assessment<br />
& test ordering<br />
Reduced ED LOS
Solution Design – Key components<br />
• New model <strong>of</strong> care<br />
– Clinical Streaming<br />
– At Triage patients meeting inclusion criteria sent directly to <strong>RITZ</strong><br />
• New clerk role (relocated from registration)<br />
– Patients registered in <strong>the</strong> <strong>RITZ</strong><br />
• Medical and nursing staff allocated to <strong>RITZ</strong><br />
– Clinical Seniority<br />
• New Radiology ordering process<br />
– Simple investigation requests sent via fax
Solution Design – Key components<br />
• Redesigned environment<br />
– Revised equipment & supplies storage<br />
Before – <strong>RITZ</strong> Office work station<br />
Before – <strong>RITZ</strong> Storage / Work station<br />
11
Solution Design – Key components<br />
After – <strong>RITZ</strong> Storage / Workstation<br />
After – <strong>RITZ</strong> Office workstation
Outcomes
85.00%<br />
80.00%<br />
75.00%<br />
70.00%<br />
65.00%<br />
60.00%<br />
55.00%<br />
50.00%<br />
ED LOS < 4hr<br />
27/04 - 3/05/09<br />
4/05 - 10/05/09<br />
11/05 - 17/05/09<br />
18/05 - 24/05/09<br />
25/05 - 31/05/09<br />
1/06 - 7/06/09<br />
8/06 - 14/06/09<br />
15/06 - 21/06/09<br />
22/06 - 28/06/09<br />
29/06 - 5/07/09<br />
6/07 - 12/07/09<br />
13/07 - 19/07/09<br />
27/07 - 2/08/09<br />
20/07 - 26/07/09<br />
3/08 - 9/08/09<br />
10/08 - 16/08/09<br />
17/08 - 23/08/09<br />
24/08 - 30/08/09<br />
31/08 - 6/09/09<br />
7/09 - 13/09/09<br />
14/09 - 20/09/09<br />
21/09 - 27/09/09<br />
28/09 - 4/10/09<br />
5/10 - 11/10/09<br />
12/10 - 18/10/09<br />
19/10 - 25/10/09<br />
26/10 - 1/11/09<br />
2/11 - 8/11/09<br />
9/11 - 15/11/09<br />
16/11 - 22/11/09<br />
23/11 - 29/11/09<br />
30/11 - 6/12/09<br />
07/12-13/12/09<br />
14/12 - 20/12/09<br />
21/12 - 27/12/09<br />
28/12 - 3/01/10<br />
4/1 - 10/1/10<br />
11/1 - 17/1/10<br />
18/1/10 - 24/1/10<br />
25/1/10 - 31/1/10<br />
01/02/10 - 07/02/10<br />
<strong>RITZ</strong> established<br />
New process and new limits for<br />
‘usual standard practice’<br />
TARGET = 80%<br />
Weekly Control Chart<br />
(20/04/09 – 07/02/10)<br />
Median ED LOS < 4hrs<br />
Old process = 64.6% (20/04 - 20/07)<br />
New process = 69.4% (21/07/09 – 07/02/10)<br />
Sustained Improvement <strong>of</strong> 5%
100.00%<br />
95.00%<br />
90.00%<br />
85.00%<br />
80.00%<br />
75.00%<br />
70.00%<br />
65.00%<br />
<strong>RITZ</strong> LOS < 4hr<br />
20/07 - 26/07/09<br />
27/07 - 2/08/09<br />
3/08 - 9/08/09<br />
10/08 - 16/08/09<br />
17/08 - 23/08/09<br />
24/08 - 30/08/09<br />
31/08 - 6/09/09<br />
7/09 - 13/09/09<br />
14/09 - 20/09/09<br />
21/09 - 27/09/09<br />
28/09 - 4/10/09<br />
5/10 - 11/10/09<br />
12/10 - 18/10/09<br />
19/10 - 25/10/09<br />
26/10 - 1/11/09<br />
2/11 - 8/11/09<br />
9/11 - 15/11/09<br />
16/11 - 22/11/09<br />
23/11 - 29/11/09<br />
30/11 - 6/12/09<br />
07/12-13/12/09<br />
14/12 - 20/12/09<br />
21/12 - 27/12/09<br />
28/12 - 3/01/10<br />
4/1 - 10/1/10<br />
11/1 - 17/1/10<br />
18/1/10 - 24/1/10<br />
25/1/10 - 31/1/10<br />
01/02/10 - 07/02/10<br />
TARGET = 80%<br />
Weekly Control Chart<br />
(20/07/09 – 07/02/10)<br />
Median <strong>RITZ</strong> LOS < 4hrs = 83.6%
10.00%<br />
9.00%<br />
8.00%<br />
7.00%<br />
6.00%<br />
5.00%<br />
4.00%<br />
3.00%<br />
Failed to Waits<br />
Median Failed to Waits<br />
Old process (pre 21 Jul) = 6.5%<br />
New process (post 21 Jul) = 5.87%<br />
TARGET = 5%<br />
27/04 - 3/05/09<br />
11/05 - 17/05/09<br />
25/05 - 31/05/09<br />
8/06 - 14/06/09<br />
22/06 - 28/06/09<br />
6/07 - 12/07/09<br />
20/07 - 26/07/09<br />
3/08 - 9/08/09<br />
17/08 - 23/08/09<br />
31/08 - 6/09/09<br />
14/09 - 20/09/09<br />
28/09 - 4/10/09<br />
12/10 - 18/10/09<br />
26/10 - 1/11/09<br />
9/11 - 15/11/09<br />
23/11 - 29/11/09<br />
07/12-13/12/09<br />
21/12 - 27/12/09<br />
4/1 - 10/1/10<br />
18/1 - 24/1/10<br />
01/02 - 07/02/10<br />
<strong>RITZ</strong> established<br />
Weekly Control Chart<br />
(20/07/09 – 07/02/10)
Things we learnt…<br />
• Clinical leadership drives change<br />
• Access to clinically relevant data is crucial to engage clinicians<br />
– Establish a need for change (e.g. Failed to Waits)<br />
• Constantly communicate<br />
– Frontline staff need to know what’s happening and why<br />
– Sustain interest/engagement<br />
• Limited availability <strong>of</strong> clinical staff<br />
– Creativity with meetings<br />
• Environment has a major impact on staff and patients<br />
• Sustainability is driven by local ownership<br />
– Frontline staff must be involved:<br />
• identifying and validating issues<br />
• developing <strong>the</strong> solutions<br />
• Fundamentals are imperative<br />
– Staffing / Seniority<br />
• ongoing performance management
Want to know more?<br />
Oliver Furness<br />
Dr Helen E. Stergiou<br />
Program Leader<br />
Director<br />
Redesigning Care<br />
Emergency <strong>Department</strong><br />
(03) 8405 2066 (03) 8405 8013<br />
oliver.furness@nh.org.au<br />
helen.stergiou@nh.org.au