Alberta Health Services

1. Taming of the Queue
March 29, 2012
Improving provincial waiting time for
Hip & Knee Arthroplasty through reduction in LOS
Jane Squire Howden
Co-Chair, Provincial Hip & Knee Working Group
Bone & Joint Strategic Clinical Network
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2. What have we done?
Developed a quality improvement approach
that is being used to ensure evidence based care
continuum implemented in 12 arthroplasty
sites across Alberta to reduce wait times and
Improve Quality
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3. Spread the Integrated Care Path across Alberta
Target improvements in:
√ Efficiency: Length of stay
√ Accessibility: Waiting times
√ Safety: Adverse events; surgical safety checklist
√ Appropriateness: Patient mobilization; antibiotics
√ Acceptability: Patient satisfaction
√ Effectiveness: Pain control; on-time first case
setup
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4. Measurable Progress June 2010 – May 2011
• Quarter over quarter improvement in LOS
oFrom 6.4 days (F08/09) to 5.1 days (F10/11 Q4)
• Reductions in both acute care LOS and transfer LOS
• 8000 actual bed days have been saved combined
with an increased volume of 901 cases province wide
• Projected bed days saved for F11/12 – 11500
• Improvements in accessibility, acceptability, safety,
• Effectiveness, efficiency & appropriateness
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5. OLD: Patient Navigation Path
Service 179
Physician A Service 1
Service 311 Primary Care Group Physician W
Agency F Agency Y
For Profit Rehab. Public Rehab
Service 467 Service 222
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6. Hip and Knee Care – History
• Alberta Health Services and Alberta Bone, Joint Health
Institute and Alberta Orthopedic Surgeons developed an
evidence-based Hip and Knee Replacement Continuum
• Pilot project to test the continuum was 2005 – 2006
• Edmonton, Calgary, and Red Deer implemented the
continuum
• Continuum implementation spread to all sites that are
doing Hip and Knee Replacements
• Provincial Hip and Knee Working Group provide
leadership
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7. NEW: Integrated Hip & Knee Care Path
Multi-faceted Systematic Evidence-based
Increased Community Care
Community Care
Hospital Care
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8. Goal
• Fully implement the Integrated Care Path
• To improve waiting time for Hip & Knee
Arthroplasty
• Improvement in Length of Stay across
province
• To improve Quality and Safety indicators in
each site
• Eliminate waste & reinvest savings
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9. Measure Performance
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10. A step toward sustainability
eliminate waste and reinvest to improve
16000
bed days
$12 000 000
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11. Spread the Integrated Hip and Knee Care
Path Across Alberta
Balanced Scorecard
Monitors Improvement
B A S E L I N E
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12. It’s all about the “How”
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13. Process
• The use of a collaborative model to:
o engage 12 hip and knee arthroplasty front line teams
Alberta-wide
o develop and implement a quality improvement
scorecard & plans to achieve a targeted goal
o support evaluation and ongoing monitoring of
improvement indicators
• Team leads report progress monthly to the Provincial Hip
and Knee Working Group
• Face to face meetings 2 x’s per year with all team
members province-wide
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14. Providers are the secret to sustainability
Engage and support providers as they are the solution
What front line providers know:
ohow ‘it really works and doesn’t work’ - they treat the
people
owhat is practical ‘on the ground’
The front line providers are: RN’s Surgeons, Anesthetist,
Internal Medicine, Occupational Therapy, Physical Therapy,
anyone that works directly with the patient.
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15. Providers are the secret to sustainability
Engage and support providers as they are the solution
What front line providers may not think about:
oProviders’ individual decisions actually drive total
access, quality and cost of ‘the system’
oThere is a ‘continuum of care’ that is connected.
oWhat happens in one part affects all parts up and
downstream
oTeams are essential – within and across the continuum
oTeams working with data can drive major improvements
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16. Using Measurement in Quality Improvement
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17. First steps to managing Wait times
The Bone & Joint Clinical Network worked with ABJHI to develop 5
year strategic plan to address wait times & achieve 14 week waiting
time targets.
• Determined one set of Wait Times Rules - what is being measuring
and how will it be measured starting with Family Doctor referral
• Transparency – all arthroplasty surgeons in the province provided
ABJHI with waiting time data so that “true demand” could be
captured
• Waiting list clean up – methods to achieve this consistently across
province
• Modelling to manage pent up demand (backlog), then steady state
requirements to meet demand across province.
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18. Keys to Success
• Use of bottom-up approach more successful vs.
top-down approach
• Multidisciplinary team participation & buy in.
• All team members have the same “authority” in
decision making
• Evidence based decision making
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19. Keys to Success
• Front-line staff determined improvement
strategies to meet the target
• Look across the continuum of care
• A small change can have a big impact
• Data is the basis for all decisions.
• This is not a research project, the data does
not have to be perfect to be usable.
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20. Keys to Success
• Regular meetings that require teams to report on
activity.
• No judgment, support the teams to achieve
goals through sharing successes and ideas to
resolve challenges.
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21. Efficiency Results
 Length of Stay
Average length of stay based on administrative data
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22. Appropriateness Results
 Mobilization Day 0
“Mobilization Day 0” - patient weight-bearing at bedside with assistance and use of aids on day of surgery.
Mobilization Day 0 not tracked for 3 of 11 sites
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23. Accessibility Results
 Wait time from Referral to Surgery (T0 – T2)
500
450
400
350 Current
300
Baseline
Days
250
200
150
100
50
0
Alberta 1 2 3 4 5 6 7 8 9 10 11
Sites
T0-T1 Wait Times data collected from surgeon office or central intake clinic data sets
T1-T2 Wait Times data from administrative data sources
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24. 5-Year Plan to Reduce Waits
60
Edmonton
South
50
90% Wait Time (Weeks)
40 North
Central
30
Calgary
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14 Weeks from
10 Decision to Surgery
0
Baseline F2011/12 F2012/13 F2013/14 F2014/15 F2015/16
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25. Measurable Progress
• From June 2010 to October 2011 11,384 acute care bed days
were saved, equating to over $8.5 million dollars to be
reinvested
• In 2011/12, nearly 1300 additional arthroplasty cases where
completed to assist in reducing wait times. 80% of patients are
now meeting the wait time target compared to 65% in 2010/11.
• Final goal of 90% of patients having their surgery completed in
14 weeks by 2015/16 is on track.
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26. Thank you!
Jane Squire Howden
jsquire@edmontonmsk.ca
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