Pieter E. Buwalda, Manager Hospital Operations Programs, Nij Smellinghe Hospital in Drachten (The Netherlands) & Gijs Andrea, Consultant, implementor, trainer at House of TOC, Education Implementation Management Consultancy (The Netherlands) @ TOCICO International Public Sector Effectiveness Conference 2013 Vilnius - How to improve the quality of healthcare services using managerial tools. - How to improve the quality of care AND decrease the workload on nurses and doctors with the same amount of patients treated. - How to decrease occupation of beds? - How to decrease length of stay? More information - http://pse.lt

1. “Quality of Care.… on time!”
Vilnius, Lithuania
oktober 2013
Pieter Buwalda, Hospital Nij Smellinghe, The Netherlands
Gijs Andrea, International House of TOC, The Netherlands

2. Agenda
 Introduction
 Problem Analysis: Bottlenecks in Care delivery proces
 Design of Solution
 Experiences
 Questions

3. Who are we?
Pieter Buwalda, Hospital Nij Smellinghe
Manager Hospital Operations Program
CPIM, MSc BA, TOC Health
15 years experience in Health
Improve, redesign, development of
processes
Gijs Andrea, International House of TOC
Consultant, Implementor, Trainer
MSc TOC Healthcare Management
25 years experience in Health
Train people & improve processes

4. The Hospital
•
•
•
•
•
General Hospital, North East of the country
283 beds clinical capacity
82.000 first consultations, 27.600 inpatients
25 specialties
Merging with hospital Dokkum

5. Quality Desires / Requirements
 Better quality of care by consciously planning
 Admission of patients on wards with most expertise
 LOS not longer or shorter than medically required

6. Operational Desires/Requirements
 Reducing non-medical delay in ALOS (13,7%)
 Less refusals for admission
 Less unnecessary waiting for diagnosis or discharge
 Current / more production → less costs
 More efficient execution of necessary organizational
tasks → more time for care tasks

7. Prerequisites for Intervention
 No efforts into bureaucratic analysis
 Practical and goal oriented tool
 User friendly for every participant in the care process
 Aimed at continuous improvement

8. What’s the problem (group session)?
 Logistical issues of care often not regarded
 Transfer moments MD/nurse are extending LOS
 Often delay by other disciplines
 Sometimes unable to admit patients on “home” specialty ward
 LOS extending policies
 Frequent scarce bedcapacity
 Beds are blocked in order to create “protective capacity”.

9. Problems: Cause and Effect
Extremely high
Extremely high
stress levels among
stress levels among
staff
staff
Nurses spend a lot
Nurses spend a lot
of time on searching
of time on searching
and checking
and checking
Nurses have to
Nurses have to
deliver care on other
deliver care on other
than ‘home’ ward
than ‘home’ ward
Sometimes patients
Sometimes patients
are admitted on the
are admitted on the
wrong ward
wrong ward
Sometimes there are
Sometimes there are
no beds available
no beds available
Sometimes
Sometimes
patients stay too
patients stay too
long
long
Patients sometimes are
Patients sometimes are
discharged too early
discharged too early
Patients
Patients
experience long
experience long
waiting times
waiting times
Sometimes there
Sometimes there
are admission
are admission
stops
stops

10. Looking for Evidence (1)
A1
Beds
36
A2
A3
B2
B3
Total
38
33
38
36
181
Admissions1 458
526
481
606
679
2750
Days1
4242
4121
3173
4755
3746
20037
ALOS1
9,3
7,8
6,6
7,8
5,5
7,3
Capacity
4320
4560
3960
4560
4320
21720
Occupation
98%
90%
80%
104% 87%
92%
Median
7
5
4
6
4
5
Days/Med
1105
778
657
966
880
4602
Days > med
74%
82%
79%
80%
77%
77%
Transitions
290
100
30
260
80
760
1
jan-apr 2010 HIS data Nij Smellinghe

11. Looking for Evidence (2)
SPREAD LENGTH OF STAY
180
ALL WARDS.
160
600
140
500
400
120
300
A1
100
200
A2
A3
100
B2
80
B3
0
S
I
T
A
P
F
O
R
E
B
M
U
N
1
4
7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55
60
40
20
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
NUMBER OF DAYS
35
37
39
41
43
45
47
49
51
53
55
57

12. Rootcauses of Non-Medical delay
 Work in Process (WIP)
 High Occupancy rates
 Multitasking
 Performing too many tasks
 Priorities
 Not available
 Incorrect, unreliable

13. Criteria for a Solution
 Decrease ALOS
 Eliminate Guests
 Eliminate Admission stops
 Decrease waiting times & lists
 Decrease workload, pressure & stress
 Increase production and/or Decrease costs

14. Expected effect on ALOS

15. Elements of Solution (1)
Reduce non-medical waiting times by:
1. State your Goal: Estimated Date of Discharge (EDD)
2. Collect and update Discharge Related Tasks (DRT)
3. Daily: Prioritise each DRT and register reasons for Delay

16. EDD – DRT - Priorities
2. Define tasks
3. Apply priorities
1. State the Goal
DRT
(Buffer Management)
EDD

17. Apply Priorities

18. Elements of Solution (2)
Reduce non-medical waiting times by:
1. State your Goal: Estimated Date of Discharge (EDD)
2. Collect and update Discharge Related Tasks (DRT)
3. Daily: Prioritise each DRT and register reasons for Delay
4. Weekly: monitor production, LOS, Top 20 delayed patients,
displaced patients
5. Monthly: production, LOS, most relevant reason for delay
6. Quarterly: production, LOS, top 3 delayreasons (hospital level)

19. Managing the Operation (1)
1. Production + LOS
=> What to do now?

20. Managing the Operation (2)
2. Top 20 Delays
=> Need help?

21. Managing the Operation (3)
3. Reasons for Delay
=> Start a project

22. ALOS 2012 week 1 – 40 (start)
7,53 mean of all patients
ALOS 2013 week 1 - 40
6,43 mean of all patients
Reduction:
15% mean diff. (downward trendline!!!)

23. ALOS 2011 week 1 – 40 (start year) 7,02 mean of all patients
ALOS 2012 week 1 – 40
6,33 mean of all patients
ALOS 2013 week 1 - 40
5,06 mean of all patients
Reduction:
28 % mean diff. (downward trendline!!!)

25. Results
 Decrease ALOS
 Eliminate Guests
 Eliminate Admission stops
 Decrease waiting times & lists
 Decrease workload, pressure & stress
 Increase production and/or Decrease costs???

26. Critical Success Factors
 Non-Agressive Aim (synthesis):
 reduction of LOS → effect of improved quality of care
 approaching medical LOS
 Connect primary HIS with TOC software (data entry)
 Focused Operational Meetings on the Ward (daily / weekly)
 Implement in ‘the system as a whole’
 Search for integration in existing “systems”
 Patientlist (on paper / tablet)

27. Quotes we like
“I just have to admit...
Focus on your goal increases both
timeliness of care and of discharge.
I can always admit my patients now!”
Medical Docter

28. More information
Pieter Buwalda
Hospital Nij Smellinghe, Drachten, The Netherlands
P.Buwalda@Nijsmellinghe.nl
Gijs Andrea
International House of TOC
G.Andrea@houseoftoc.com