Toolkit for bed managers

IMPROVING PATIENT ACCESS
TO ACUTE CARE SERVICES
A practical toolkit for use in public hospitals
Developed by the Clinical Excellence Commission

Clinical Excellence Commission

Dear reader,
As you are no doubt aware, the flow of patients through an acute hospital
depends upon a complex set of relationships between many departments,
services and people. Achieving improvements in the way patients move
through such a complex system requires a coordinated approach to admission,
treatment and discharge of patients based on core principles of system
engineering. It requires hospitals to untangle the complexity of their existing
processes so they can understand where the key bottlenecks exist within their
clinical units. It also requires a fundamental commitment to providing safe,
effective, efficient and timely care where services are designed first and
foremost according to patient needs.
Successfully improving flow across an organisation requires an extraordinary
level of commitment to a complex and exhaustive change process. It also
requires acknowledgement that there may, at times, be a requirement to tackle
issues that have previously been “sacred cows” within your organisation. For
these problems to be solved, leaders in your organisation must be committed
to this change process in very practical ways. Appropriate time and resources
should be allocated to ensure the improvement process is successful. A realistic
assessment of the number of individuals and teams needing dedicated time
away from their usual clinical duties to commit to the change process should be
made, and steps taken to ensure that they have the capacity to do so.
This Toolkit is designed to be an aid to you and your organisation should
you choose to embark upon the journey to improve patient access to acute
services. The Toolkit is a compilation of strategies and ideas from multiple
sources including:
The NSW Institute for Clinical Excellence Patient Flow and
Safety Collaborative
NSW Health documents and projects
Access projects within New South Wales Public Hospitals
Weekend Discharge project
Effective Discharge Planning Framework
Emergency Department Access projects including the Rapid Emergency
Access Team (REAT) and Emergency Medical Unit (EMU) projects
Improving Patient Access to Acute Care Services

Operating Theatre project
Best practice sites identified during consultation with Area Health Services (AHS)
Other local, national and international experts, literature and projects
reporting success in improving patient flow.
Particular acknowledgement is made of the contribution of leaders of the
modernisation process within the UK National Health Service (Helen Bevan,
Kate Silvester, Richard Lendon, Ben Gowland, Karen Castille and many others)
to much of the thinking contained in the Toolkit. Similarly, the Australian
members of the Access Improvement Taskforce listed at the end of this

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document have all contributed greatly to ensuring that locally applicable
solutions are contained within this document.
The Toolkit is aimed at hospitals providing acute adult medical and surgical
care, although many of the principles may be applicable in obstetric, paediatric
and mental health services. The Toolkit does not specifically address flow issues
for these streams of patients.
The level of evidence for many of the interventions described in the Toolkit
is Level II, Level III or Level IV. The interventions described however, have
been shown to produce results at least at a local level. The Toolkit does not
claim to be a comprehensive list of effective strategies and interventions.
Rather it seeks to describe an approach that your organisation could adopt as
it starts to redesign its patient care processes, and to describe some practical
interventions that have been found to be useful in organisations elsewhere.
If an intervention isn’t included this does not mean that it is ineffective or
that its use is not recommended. Similarly, interventions that have worked
elsewhere may not be suitable, or may need to be adapted, for your institution.
Careful analysis of your local data needs to form the basis upon which you
determine which interventions are most appropriate to implement locally. This
preliminary analysis of local data is discussed in Section 2.2 - Review data to
understand hospital activity and performance.
We believe that the principles contained in this Toolkit can be applied to
small-scale (local clinical unit level) to large-scale (whole hospital) redesign
programs. The complexity and resource requirements may differ according
to the size of the project, but the fundamentals — of removing barriers to
efficient patient flow through providing care based on the needs and experience
of patients as they travel through the organisation — will remain the same
regardless of the project size. We hope that you will find this Toolkit useful as
you embark upon redesigning how patients interact with your health service.
Lastly, I would like to acknowledge the work of the team at the Clinical
Excellence Commission that have put this toolkit together. Louise Kershaw,
Director of the Patient Flow and Safety Collaborative, has assembled a vast
array of interventions that have been shown to improve patient access to
acute services and was a key driver in the writing of this toolkit. Together,
Louise, Lorraine McEvilly and Celia Mahoney have worked tirelessly to manage

the Patient Flow and Safety Collaborative and to produce the final toolkit. My
deepest thanks go to these extraordinary individuals.
Best wishes and good luck,

Dr. Rohan Hammett
Director
Healthcare Improvement Projects
NSW Clinical Excellence Commission
March 2005
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Contents
HOW TO USE THIS TOOLKIT 6
1. INTRODUCTION 7
2. PLANNING THE IMPROVEMENT WORK 11
2.1 Identify and define the problem 12
2.2 Review data to understand hospital activity and performance 12
2.3 Engage clinicians and convene the redesign team 14
2.3.1 Leadership 14
2.3.2 Team members 15
2.4 Diagnostic Work 16
2.4.1 Understanding the current systems and processes 16
2.4.2 Tools for understanding processes 17
2.5 Determine your aim 19
2.6 Designing and implementing changes 20
2.6.1 Identify interventions to implement 20
2.6.2 Practical ideas for effecting change 21
2.6.3 Implementation plan 22
2.7 Analyse the Results 23
2.7.1 Methods of measurement 23
2.8 Communicating the change 24
2.8.1 Key factors for successfully managing change 25
Case study - Western Sydney AHS -
Neck of Femur Patient Flow Group 26
Checklist prior to starting your improving access project 34
3. INTERVENTIONS 35
3.1 General strategies 36
3.1.1 Shared work plans, practices and schedules
within multi-disciplinary teams 36
3.1.2 Develop multi-disciplinary evidence based pathways 37
3.1.3 Relative performance table 37
3.1.4 Convene a redesign team 38
3.1.5 Improve communication systems 38
3.1.6 Referral to specialist services 39
3.1.7 Service level agreements 39

3.1.8 Managing capacity to respond to need for services 39
3.1.9 Minimise variation in capacity to provide care 40
3.1.10 Change to 7 day a week services 40
3.1.11 Buffer beds 40
3.1.12 Smoothing variation in elective activity 41
3.1.13 Develop advanced nursing roles 41
3.1.14 Up-skilling peripheral hospitals for complex patient needs 42
3.1.15 Align staff specialist/consultants work to maximise efficiency 42
3.1.16 Bed management system 43
3.1.17 Centralised bed authority/bed co-ordinator 43
3.1.18 Regular multi-disciplinary bed meetings 45
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3.1.19 Teleconference bed updates 45
3.1.20 Clinical prioritisation of patients 45
3.1.21 Reconfigure beds to reduce outliers 46
3.1.22 Over Census Policy 46
3.1.23 Guidelines and protocols for test ordering 47
3.1.24 Review permissions to order tests 48
3.1.25 Prioritise tests for Emergency Department
or patients waiting for discharge 48
3.1.26 Allocated time for emergency cases 48
3.1.27 Appropriate information on request form 49
3.1.28 Patients attending for tests 49
3.1.29 Stratified test ordering 50
3.2 Emergency patient flow 51
3.2.1 Pre-bypass hospital early warning system 51
3.2.2 Streaming techniques 53
3.2.3 Alternate admission processes 53
3.2.4 Develop alternate services to prevent ED presentation 54
3.2.5 Advanced nursing and allied health practitioner roles 54
3.2.6 Fast Track 54
3.2.7 See and Treat 55
3.2.8 Lean thinking 56
3.2.9 Clinical pathways around presenting problems not diagnoses 57
3.2.10 ED access to day surgical list bookings 57
3.2.11 Communications clerk 58
3.2.12 Emergency medicine unit 58
3.2.13 Flag and case manage frequent attendees 58
3.3 Improving Flow of Emergency Surgical Patients 59
3.3.1 Clinical guidelines or pathways 59
3.3.2 Team briefing and debriefing sessions 60
3.3.3 Emergency department physician admission rites 60
3.3.4 Review existing demand for emergency operating theatre time 61
3.3.5 Prioritisation protocol 61
3.3.6 Prioritisation team 61
3.3.7 Pre-operative placement of patients waiting for OT 61
3.4 Medical strategies 62
3.4.1 Medical assessment and planning unit 62

3.4.2 Day only admission ward for ED patients 62
3.4.3 Flag and case manage frequent medical admitted patients 62
3.4.4 Trial at home program 63
3.4.5 Improve appropriateness of admission 63
3.4.6 Safety risk assessment 63
3.5 Improving communication 64
3.5.1 Improving communication with GPs and community nursing 64
3.5.2 Generic transfer/discharge to hospital form for
all residential aged care facilities (nursing homes) 65
3.5.3 Link ‘discharge from ward time’ with ‘admission
from Emergency Department’ time 65
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3.5.4 Scheduled transfers 65
3.6 Improving discharge processes 66
3.6.1 Discharge risk assessment form 66
3.6.2 Admission and discharge plan 67
3.6.3 Criteria driven discharge 67
3.6.4 Nurse activated discharge 67
3.6.5 Monday morning audit 68
3.6.6 Weekend discharge pharmacy 68
3.6.7 Multi-disciplinary Discharge Meetings 69
3.6.8 Informing patients and carers about their discharge 70
3.6.9 Discharge checklist 70
3.6.10 Estimated day of discharge 71
3.6.11 Estimated length of stay table 71
3.6.12 Compare the estimated date of discharge
to the actual date of discharge 72
3.7 Aged care 73
3.7.1 Aged care assessment team (ACAT) 73
3.7.2 Transitional care beds 73
3.7.3 Community transitional care beds 73
3.7.4 ComPacks service model 74
3.7.5 Purchase transitional care beds 74
3.7.6 Direct emergency admission protocol 74
3.7.7 “Dependant care” stream of patients managed
by specialist nurse practitioner 74
3.7.8 Walking assistance program 75
3.8 Elective Patient Flow 75
3.8.1 Quarantined elective surgical beds 75
3.8.2 Criteria driven discharge 75
3.8.3 Surgical pathways and estimated day of discharge (EDD) 76
3.8.4 Increase day of surgery admission rates and
manage performance outliers better 76
3.8.5 Audit all theatre delays or cancellations 76
3.8.6 Surgical peri-operative liaison nurses 76
3.8.7 Medihotels 77

3.8.8 Flexible staffing 77
3.8.9 Align leave of multi-disciplinary surgical teams 77
3.8.10 Clinical teams operating pooled referrals 77
3.8.11 Clinical pathways 77
3.8.12 Improve completion of consent forms 78
3.8.13 Marking operating site 78
3.8.14 Improve compliance with fasting requirements 78
3.8.15 Predict surgical case length accurately 78
GLOSSARY OF TERMS 79
ACKNOWLEDGEMENTS 80
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How to use this Toolkit
The Improving Patient Access Toolkit is divided into the following sections:
Introduction to patient flow
Planning the improvement work
Diagnosing flow problems in your organisation
Key elements of an access improvement project
Interventions/change ideas
The Toolkit has been designed with the intention that you should adopt a
systematic approach to improving patient flow across your organisation. To do
this, you should start at the beginning of the Toolkit and work your way through
the different stages of designing and implementing a successful redesign
program. However, should you simply want change ideas and strategies to
implement, you should go directly to the interventions section where there are
detailed descriptions of many specific changes you can test.
Throughout the document you will find the following icons that will guide
you to useful resources.

Key to icons:

Tool available on CD Rom

Hospitals where interventions are in place

Resource available on the internet

Bookmark link within document

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1. Introduction
Introduction to the principles
of managing patient flow
During the course of a single treatment journey a patient will interact with
dozens of clinicians and clinical and non-clinical services that have the potential
to impact on their care. There are multiple steps and handovers that need to
occur smoothly for the patient to receive optimal care in as timely a manner as
possible. At key points in a hospital where many patients are interacting with a
single service (e.g. in the emergency, radiology, and pathology departments or
in the operating theatres) there is great potential for delays in the treatment of
one patient to result in flow-on of delays to other patients and to other services
throughout the hospital. Like a pebble causing ripples on a pond, relatively
small delays in the treatment of one or two individuals may have significant
ramifications for flow of patients across the whole organisation.
It is vital that hospitals have an understanding of the key groups of patients
they treat, and the type of care required to produce optimally efficient
management of flow of these patients. Interestingly, in most acute hospitals
patients fall into one of three categories:
Category 1 - short stay patients with an average
length of stay (ALOS) of less than 48 hours
Category 2 – multi-day patients with an ALOS of less than 10 days
Category 3 – patients with an ALOS greater than 10 days.
It is useful, in planning service delivery, to think of how services can be
arranged to optimise flow for these three groups of patients. As can be seen in
Figure 1, the majority of patients fit into category 2 (ALOS <10 days). For these
patients even a small reduction in length of stay will produce significant bed

capacity within an organisation. For example, if discharge planning processes
were improved, or delays in diagnostic tests eliminated, resulting in an
improvement in ALOS of 0.5 days, dozens of beds would be made available.
For patients in category 1 (ALOS <48 hours), strategies to provide
alternatives to acute hospital admission are likely to be most effective. For
example hospital-in-the-home services that can provide intravenous antibiotics
for cellulitis, or additional support services for elderly patients following a
fall, or provision of care for nursing home patients directly in their residential
facility, may all prevent admission for these patients.

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For category 3 patients (ALOS > 10 days) strategies focussed on
prevention of adverse events, improved liaison with community care
providers and case management may all help prevent the extreme lengths of
stay often seen in these patients.
In general, the types of services required to ensure optimal flow for each
category of patient will be similar almost regardless of the specific clinical
condition that has brought them into hospital. For example most category 1
patients require some simple diagnostic tests, short-term intravenous therapy
of some sort and some nursing care or monitoring for a short period of time.
If services are redesigned appropriately, much of this care could be provided
in facilities other than the acute hospital e.g. ambulatory care units, nursing
homes, general practice, or the patient’s home.
Similarly, the patients in category 2 will require diagnostic services, medical and
nursing management and planning to provide appropriate support post-discharge.
Much of this care can be planned before admission for elective patients, or very
early during their admission for emergency patients. The key constraint areas of
the hospital (e.g. radiology, pathology, operating theatres, intensive care) can
plan how many of these patients will require their services based on historical or
prospective data to minimise delays to their treatment. This will enable a matching
of capacity and demand that will improve the efficient flow of these patients and
prevent delays that increase length of stay and result in flow-on effects across the
whole organisation.

Figure 1

Length of stay | Medical Patients
250

200
Category 1 | prevent admission

150
Category 2 | take a day off clinically unnecessary

ALoS and it has a dramatic effect
100
Category 3 | these patients may have more
complex support needs
50

0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay (days) | Average LoS = 7.24 days
Source | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals

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The importance of managing variation
Many of the delays that plague patients attempting to access acute services
are not due to inadequate resources, but rather the result of the variation with
which these resources are utilised. For example, many hospitals have extensive
waiting lists for outpatient clinic appointments. When an analysis is undertaken
of the number of clinic appointment times available, it is often the case that the
current clinical capacity actually matches the demand for the service, except
that every time there is a public holiday or a conference, the outpatient clinic is
cancelled and as a result a waiting list is produced. If clinics were rescheduled
rather than cancelled this would not occur.
Similarly, the variation in the number of patients a hospital admits for
elective surgery may in itself be contributing to waiting lists, access block
and surgical cancellations. The graph shown in figure 2 below is taken from a
hospital that on average admitted 49.7 patients every day. In the top part of
the graph you can see that the number of patients admitted varied between
24 and 78 on any single day. To ensure it could provide enough beds for all
patients on 99.9% of days, this hospital required 78 beds to be kept open for
elective admissions. In the bottom part of the graph the same average number
of patients were admitted (49.7) but, by reducing the variation in the number
of patients admitted (38-70 cf 24-78), the number of beds required to ensure
availability for 99.9% of patients was reduced to 68.

Figure 2

Total Admissions | April-November
80
78 beds
70 required each
60 day to give
50
99.9% chance
of admission
40
Admissions
30
Average = 49.7
20 UPL = 78.1

Standardised Admissions | April-November
80

70 68 beds
60
required each
day to give
50
99.9% chance
40 of admission
Admissions
30
Average = 49.7
20 UPL = 67.9

Daily bed requirement reduced from 78 to 68
Source | Kate Silvester / Richard Lendon / Improvement Partnership for Hospitals 9

Thus if we manage the variation in the way we provide our services, we will
find greater capacity to deliver services in an efficient manner. Interestingly,
in most hospitals elective activity varies far greater than emergency activity
on a daily basis. Similarly, there is often far more variability in the number
of patients discharged than the number of patients admitted. Both of these
processes (number of elective patients admitted and number of patients
discharged) can be managed by the organisation itself. Understanding the
management of variation in service delivery is crucial to smoothing the flow of
patients through acute hospitals.
Gaining a greater understanding of the way in which patients move into,
through and out of the organisation and the bottlenecks that are hindering
efficient movement will assist in understanding which changes should be
made to gain improvement. To do this effectively an organisation will need to
examine its own data to identify patterns in activity that need to be redesigned.
The resources below contain more detailed descriptions of the information
contained in this introduction and can be referred to in order to gain a greater
understanding of the key principles of managing patient flow. The Toolkit may
then be utilised to redesign the way a patient travels through the system.

Improving patient flow

www.steyn.org.uk/

Queuing theory (NHS website)
Patient flows, waiting and managerial learning paper (NHS)
www.cognitus.co.uk/healthcare.html#1

NHS Flow Management Wizard
www.natpact.nhs.uk/demand_management/wizards/big_wizard/
index.php?page=/demand_management/wizards/big_wizard/Step_
4/Basic_Queuing_Theory.php

Foundations of demand and capacity (NHS presentation)

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2. Planning the
improvement work
Successful implementation of changes will depend on effective
project management throughout the period of the project.

Project steps
Identify and
define the
problem
review data to understand
activity and performance

engage clinicians and
convene the redesign team

complete baseline
diagnostic work

determine the aim

identify interventions to trial

design and implement
the changes

analyse the results

build in accountability to
help sustain changes

communicate
the changes
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2.1 Identify and define the problem
Before commencing work, it is useful to try to sum up the problem you wish
to improve in one sentence e.g. reduce or eliminate access block, improve
discharge processes for medical patients, or decrease delays in transferring
patients between hospitals. Identify the problem from the patients’ perspective
and use terms that describe their experience. This will help clarify the core
objective of the work you are about to undertake and prevent your project
from suffering from a diffuse, poorly directed lack of purpose.
The amount of work and degree of change required will vary depending on
the scope of the project. Significant improvements to patient access to acute
services may be produced by implementing change at local departmental level,
service, ward or across an entire hospital.

2.2 Review data to understand
hospital activity and performance
It is vital that characteristics of patient populations and their flow through
the system are understood. The following is a general list of data that will help
in understanding patient flow in the organisation and may be obtained from
the Patient Access System (PAS), Disease Index (DI), Emergency Department
Information System (EDIS) or the Health Information Exchange (HIE). Only
extract the data needed to help understand that part of the system of interest.
Use the data to highlight problems or to prove the changes implemented are
making a significant improvement.
1 Numbers of access block patients by day at 12 MD, 4 pm and 8 pm. This
will identify within-day variation in demand for services that will assist
with planning staffing needs throughout your organisation.
2 Number of beds used daily by ED status (admitted and discharged from
ED, admitted through ED, not admitted through ED) at peak times (12 MD

and 4 pm). This will assist in identifying the bed requirements for each
clinical department to deal with their emergency patient load. It should be
utilised in conjunction with an analysis of elective admissions by clinical
department to plan appropriate bed allocation.

12

3 Count the number of beds required to cover a given proportion of days
(e.g. 95% of days). This will help you to understand the size of the
improvement required to eliminate access block in your organisation.
4 Number of access block patients for each day of week. This will identify
the between-day variation in demand for services to assist with planning
schedules for clinical activity and staffing.
5 Percentage of overnight access block patients who reach a ward bed
before midday. This will help identify any problems related to turnover of
available beds.
6 Distribution of specialties for access block patients (% bed use by
Consultant Medical Officer specialty). This will help identify departments
in which redesign processes might be most useful, or in which there may
be a need for additional resources to improve flow.
7 Percentage bed base by Consultant Medical Officer specialty (Emergency
and non-emergency bed distributions). This will enable a current appraisal
of bed utilisation and management of bed allocation on a data-based
rather than historical basis.
8 Outliers by Consultant Medical Officer specialty and ward — bed days used.
This will identify the degree of disorganisation of current bed management
practices and provide a focus to case management models to improve
length of stay for these patients.
9 Emergency overnight medical discharge rate by day of week (% weekend
discharge). This will characterise variation in discharge practices across
days of the week. It should be done for a 12-month period. Note the peaks
in discharge prior to public holidays. Readmission rates after these public
holidays usually do not change despite the high discharge rates suggesting
that these patients really were ready for discharge. You can check these
readmission rates in your own organisation.
10 Elective overnight admission rate by day of week. This will show the
variation in elective services in your organisation. If this variability can be
minimised it will, of itself, create extra bed capacity in your organisation.

11 Analysis of length of stay against benchmark by Consultant Medical Officer.
This will help identify variation in clinical practices that may be contributing
to delays for patients. These can be addressed by the clinical unit manager.

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For access to or assistance with extracting the above data, contact the hospital
case mix manager (or person who collates data for reporting to the health
department). They will have access to the data and the skills and knowledge
to extract this data or will be able to suggest other sources of assistance.
Alternatively your executive sponsor will be useful in securing the services of
an appropriately skilled person to do this.

Access Blocked Patient Analysis 2002-2003 (NSH)

Hospital Flow Measurement Guide (IHI)
www.qualityhealthcare.org/IHI/Topics/Flow/PatientFlow/
EmergingContent/HospitalFlowMeasurementGuide.htm

2.3 Engage clinicians and
convene the redesign team

2.3.1 Leadership
Effective leadership is crucial to maintaining a focus on improving the
patient experience. The team should include:
someone with the skills, energy and enthusiasm to lead the project,
strong medical and nursing leadership at all organisational levels,
clinician managers who are effective champions for the project. They have
an important role in spreading improvements to other departments and may
be required to performance manage individual variance,
individual clinician leaders who participate and use their influence to
support change amongst their colleagues,

leaders with a clear vision of the project who can sell this vision to others.

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2.3.2 Team members
When bringing together a project group or a redesign team ensure
there is a mix of administration, medicine, nursing and allied health
representation relevant to the project’s aims. Enthusiasm and interest in
the project are essential qualities to look for in team members. They should
also have an operational role in the processes to be changed. Many sites
that have successfully improved patient flows have also actively involved
consumers in the work of their teams, in a manner appropriate to the
context of the organisation.
Team members also need to take the following roles:

2.3.2.1 Executive sponsor
Previous experience has demonstrated that effective sponsorship at an
executive level is crucial to successful implementation of organisational
change. Executive sponsors need to be at Area Health Service level or
executive level in a facility i.e. Director of Clinical Services or Hospital
Executive Director and be:
someone with enough influence in the organisation to oversee the change,
someone prepared to set aside time for the project.

2.3.2.2 Clinical leaders
Most projects require a nursing lead and a medical lead. They should be
someone who:
understands the processes of care,
is able to provide technical expertise in order to produce solutions that are
technically proper, ethically sound and effective,
can provide effective leadership,
is an opinion leader who can influence his/her peers to produce

improvement in existing systems of care delivery.

15

2.3.2.3 Project co-ordinator
Someone who:
understands not only the details of the system, but also the various effects
of making change(s) in the system,
has the necessary skills, including computer literacy, project management
and high-level organisational skills,
ideally has some experience in change management, process mapping and
Clinical Practice Improvement (CPI) techniques.

2.4 Diagnostic Work

2.4.1 Understanding the current
systems and processes
Identify what the main streams of activity are within the service where
you are seeking improvements e.g. elective day of surgery admission
stream, emergency medical admit and discharge from ED, elective medical
procedure admissions.
Identify what the key processes and issues are within those streams, using a
variety of means that collect patient and staff perspectives of the problem.
Use interviews, focus groups, patient journeys and process mapping.
Review:
current or recent projects, their aims and outcomes to date,
current policies and procedure manuals,
currently available data.
Measurement for Improvement, Improvement Leaders’
Guide (NHS)

www.modern.nhs.uk/improvementguides/
measurement/

16

2.4.2 Tools for understanding processes

2.4.2.1 Process mapping
The flow of patients through hospital, whether as emergency admission,
ED presentation, outpatient or for an elective procedure, involves multiple
processes, many of which may be repeated approximately the same way for
every patient. Even very complex procedures may be standardised, based on
sound scientific practice. This can help to reduce variation and inefficiency
caused by poor communication and redundant complexity. Process mapping is
a technique to identify inefficiencies; redundant steps in clinical workflow;
bottlenecks or blockage points where time or resources are wasted.
Improving Patient Flows - Guide to Process Mapping
(Institute for Clinical Excellence)
Improvement Leaders Guide to Process Mapping, Analysis and
Redesign 2002 (NHS)
Easy Guide to Clinical Practice Improvement 2002 (NSW Health)

2.4.2.2 Patient journey
Tracking a patient’s journey through the healthcare system is a simple way
to understand where problems lie and how the service looks through the eyes of
a patient. Any member of staff can do this by shadowing a patient through the
system and keeping a time log of activities. Alternatively, ask a patient or their
carer to write a diary of their experience. The patient journey may be used to
verify findings of the process mapping exercise and will allow identification of
any waits and delays in real time.

Patient Journey Tools (Institute for Clinical Excellence)

17

2.4.2.3 Understanding major bottlenecks
For those bottlenecks identified in the process mapping, you should audit
the reasons for patients waiting and measure the waiting times involved. For
example you could record the time from request for diagnostics to the time
results are reviewed by the referring team.

result review
decision request
available report

The time in between each of these steps can be useful to highlight what
works well, what is causing problems, and opportunities for improvement.
Other tools such as Fishbone (Ishekawa or Cause and Effect) Diagrams and
Pareto charts may be useful to determine what the underlying causes of the
problem are. Refer to the NSW Health Clinicians Toolkit.

Clinicians Toolkit (NSW Health)

2.4.2.4 Patient flow audits
Greater than 14 day audit — do a walk around of all patients with a length of
stay greater than 14 days. Ask if they are sick, are they waiting for something,
why have they not been able to go home?

Discharge Delay Data Collection Worksheet
(Western Sydney Health)

Monday audit — review all patients who are discharged on Monday. Ask the
following questions. Were they medically stable on Saturday or Sunday? Why
weren’t they discharged earlier? e.g. lack of services, waiting for a test,

waiting for review by medical officers.

Discharge Audit Tool (RNS Hospital)

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2.5 Determine your aim
Develop a statement about the aim of your project. An aim is used to keep
the team focused on what it is trying to achieve and provide a measure for the
project’s success.
Based on your diagnostic data, determine aims that include:
the percentage improvement you will work towards achieving,
the time within which you will achieve the aim.
Example: To have less than 10% of 75 year old patients experiencing four hour
access block within six months.
It is important to note a few key points about these aims:
1 Use the diagnostic work to find what is important to the different
stakeholder groups involved. Engage the team with something that matters
to each of them.
2 Once the issues the team wish to address are clear, set aims at hospital
and departmental level that act as levers to engage change at ward and
individual clinician level.
3 Make the aims SMART i.e. specific, measurable, achievable, results
orientated and time scheduled.
The aims should describe:
what is expected to happen,
the system to be improved,
the setting or sub-population of patients,
goals.

Develop Your Aims from your Diagnostics Presentation

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2.6 Designing and implementing changes

2.6.1 Identify interventions to implement
Once problems and issues have been identified and prioritised a decision
needs to be made regarding what changes you will implement to achieve the
aim. Go to Section 3 of the Toolkit which has a range of ideas, suggestions and
changes implemented in other organisations. Read through the interventions
listed in the appropriate section and download any references or tools. At
a redesign team meeting agree on a list of interventions you wish to trial
or implement, based on the results of your diagnostic work. It is important
to focus on interventions relevant to those significant problems identified
during your diagnostic analysis. Look for the common sense solutions before
introducing radical change. Many of these will emerge during process mapping
and redesign activity.
In some cases, a decision to implement a particular strategy may be made
straight away. This is appropriate where there is a high level of confidence
from the diagnostic work and evidence from other organisations where it is in
place, that it will effect an improvement. However other interventions will
need to be trialled, adapted to local context and evaluated for effectiveness
before a decision to implement is made. Clinical Practice Improvement (CPI)
methodology is a useful tool for trialing interventions.

Easy Guide to Clinical Practice Improvement Methodology
(NSW Health)
PDSA Worksheet (Institute for Clinical Excellence)

20

2.6.2 Practical ideas for effecting change
Create a culture where change is encouraged and people are willing to try
something new.
Use cases that actually happened in your hospital to demonstrate process
and system problems affecting patient outcomes to foster organisational and
individual will to change.
Publicise the findings of the diagnostic work to highlight problem areas and
engage clinical staff and management.
Use success stories to create an expectation that change can occur.
Establish a process in your hospital or department to keep up to date with
the current best practice.
Use incentives, e.g. wards with high morning discharge rates given priority
for receiving extra staff.
Acknowledge and celebrate success when it is achieved.
This should help to create a culture where things change/improve constantly so
that a state of change/improvement becomes the stable state.

Improvement Leaders Guide -
Managing the Human Dimension of Change (NHS)
www.modern.nhs.uk/improvementguides/human

Organisational Change, a Review for Healthcare Managers,
Professionals and Researchers (NHS)
www.sdo.lshtm.ac.uk/pdf/changemanagement_review.pdf

Making Informed Decisions on Change (NHS)
www.sdo.lshtm.ac.uk/pdf/changemanagement_booklet.pdf

Quality collaboratives: Lessons from research
(The Nordic School of Public Health)

Improvement Leaders Guide - Spread and Sustainability, 2002
(NHS)

21

2.6.3 Implementation plan
Once you have a list of interventions you plan to trial, create an
implementation plan including a breakdown of the interventions into lists of
tasks you need to complete in order to implement the intervention. Brainstorm
potential barriers and plan to proactively manage these. Many of the barriers
to change that will be encountered relate to poor communication. Give all
appropriate people the opportunity to be involved. The implementation plan
should be specific with individuals accountable for completion of work by a
specific date. The following example is an excerpt from an implementation
plan that describes a few of the actions that may be required to implement
nurse initiated X-rays.

Figure 3
Example | Implementation plan
Planned step Action Identified Strategies Individual
required barriers to overcome responsible
barriers and by when
Introduce Write a Radiology Joint working Training
nurse protocol apprehension group to programme
initiated detailing re service develop the in draft by Dr
X-ray indications getting protocol and Sarah Jones
for nurse overwhelmed guidelines for 04/04/04
initiated when RN can
X-ray initiate
Develop Nurses Training by Joint working
a form not having radiology and group chaired
specifically confidence emergency by and
for this to make the departments supported by
purpose decision due for nurses Peter Brown.
to lack of to ensure First meeting
information they feel 06/05/04
skilled and
supported

in decision
making.
Work with Doctors Involve the
radiology concern over ED doctors in
department the quality of the protocol
to develop the service development
agreed
guidelines
Set up
monitoring
systems
22

2.7 Analyse the results
The team should determine how to measure the progress of their work and
develop a strategy to achieve this. Avoid the temptation to spend so much time
collecting or pursuing “perfect” data that the improvement work doesn’t get
started. Measurement plays the following important roles.
Key measures are required to assess progress on your aim.
Specific measures can be used to learn more about the problems that exist
within the system.
Balancing measures are needed to assess whether the system as a whole is
being improved.
Data from the system (including from patients and staff) can be used to
focus improvement and refine changes.

2.7.1 Methods of measurement
Different methods may be used to gain measures, both qualitative and
quantitative, to provide the information described above.
Clinical measures of patients’ health
Documentation of behaviour
Questionnaires
Interviews
Assessments
Summary of databases
Chart audits
Observations

23

Once process mapping is complete it usually highlights areas requiring further
information gathering or audit. This will help the team to fully understand the
nature and size of the problem to be addressed and prioritise the area to work on.

Measurement Strategy Worksheet

Measurement Presentation - Helen Ganley (NSH)

Weekend Discharge Audit Report (RNS Hospital)

SPC for Beginners - Powerpoint Presentation (NHS)
www.modern.nhs.uk/InnovationandKnowledge
Group/7338/SPC_for_beginners_web.ppt

Patient Perceived Needs Survey (NICS)

2.8 Communicating the change
For these projects to work smoothly there needs to be good communication
with individuals, departments, patients, providers, management and clinicians.
As interventions are implemented, display information about the changes
that have been made and the results achieved in a clear graphical format. Show
performance against targets.
Every individual in the healthcare team including nurses, doctors, allied
health professionals, administrators, managers, secretaries, cleaners, food
services and porters, play a significant part in the patient’s journey. They will
all offer a different and valuable perspective. Remember, if people know what

is going on and are actively involved, they will have greater ownership of the
problem and the solutions.
Identify data and measures that have “shock” value and use them to gain
acknowledgement of the problem and engagement of staff in the need for
change. Identify all those who have some role to play in the care processes that
you aim to change and be open and share information with them.

24

2.8.1 Key factors for successfully managing change
Evidence suggests that the following factors all significantly improve the
chances of a project making an effective and sustainable impact.
An organisational will and commitment to change the system to, first and
foremost, meet the needs of the patients.
Visible commitment from executive and senior management.
Local ownership of solutions to the problems encountered by local clinical
and management teams.
Resources committed to the redesign process, including personnel
experienced in change management to facilitate this locally.
A core multi-disciplinary team who drive change, facilitated and supported
by a project coordinator.
Medical, nursing and allied health engagement, leadership, and participation
in the team.
Investigation and data analysis of existing issues and problems utilising
tools such as extensive process mapping and redesign of inefficient
processes of care.
Rapid implementation of strategies that have been shown to be effective in
improving flow in similar hospitals.


25

Case study - Western Sydney AHS -
Neck of Femur Patient Flow Group:
Contact Details: Maria Lingam maria_lingham@wsahs.nsw.gov.au
Rosio Cordova rosio_cordova@wsahs.nsw.gov.au

Team Members
Cathie Whitehurst Executive Representative

Celine Hill Team Leader, Trauma Program Manager

Rosio Cordova Facilitator, Quality Manager

Maria Lingam Clinical Nurse Consultant (Orthopaedics)

Narelle Allen Clinical Nurse Educator (Orthopaedics)

Gail Hook NUM, D4A (Orthopaedics ward)

Robert Dowsett Director ED Westmead

Gayle McInerney Director ED Auburn

Geoff Shead Surgery Stream representative

Randolph Gray Orthopaedic Registrar

Elizabeth Stafidas Surgical Support Services representative

Peter Landau Staff Specialist, Geriatric Medicine

Sue Voss Anaesthetics Consultant

Linda Gutierrez Trauma Data Manager

Dr John Fox Director, Orthopaedics Unit, Westmead Hospital

Dr Roger Brighton Director, Orthopaedics Unit, Blacktown Hospital

The Aim
According to evidence-based best practice, patients with fracture of the
neck of femur (NOF) should have early surgery (within 24 to 36 hours) once a
medical assessment has been made.
The aim of the project was to increase by 25% the current rate of patients
with NOF fractures (those patients who were identified clinically fit and not
requiring extensive diagnostic tests) having an operation within 24 hours by
January 2004.
26

Background
Analysis of data previous to project commencement (Jan 02 to Jun 03)
identified that only 42% of patients with neck of femur fracture were
reaching theatre within 24 hours.
Furthermore, an audit on patients who didn’t go to theatre within 24 hours
demonstrated 30% didn’t do so because they were unfit and/or required extensive
diagnostic tests such as bone scan and Magnetic Resonance Imaging (MRI).
Based on the analysis, it was evident that we were able to improve
access to theatre for those patients who were delayed for other reasons
than identified above.

Project Development
A multi-disciplinary team was formed with representatives of key
stakeholders including cross campus representation to facilitate transfer of
knowledge and expertise. A number of tools were used to determine the nature
and extent of the problem and to identify how change could be achieved within
the resources available.
A brainstorming exercise took place in order to identify the current patient
journey (Figure 7 - page 32). This identified the following issues:
Patients with NOF fracture were in most cases referred for geriatric review
before seeing the Orthopaedic registrar: especially in cases where there is
pain but X-ray is normal and patient is able to walk.
Geriatric review only occurs during working hours. Patients presenting after
hours have to wait until next day.
Orthopaedic review only occurs until 9pm, if a call is made after that
time then the patient will wait in ED until the next day to be seen by the
Orthopaedic registrar.
The Anaesthetist can request further medical review, delaying operating
time (which can take an extra day).

Patients from district hospitals usually wait longer due to the lack of bed
and/or incomplete documentation.
Customer expectations were collected anecdotally. Expectations from the
following customers and service partners were noted:
Patients wanted to receive prompt and adequate treatment and staff
expressed their will to provide patients with efficient services.

27

A cause effect analysis (Figure 4) assisted the team in identifying the priority
areas requiring attention. The team decided to focus on issues surrounding
accessibility and assessment. The issues surrounding patients’ fitness and co-
morbidities was something the team was unable to influence. There was a
similar issue with insufficient operating theatre times, as this required the
provision of major financial resources.

Figure 4
Assessment Accessibility

No specialised Booking times
nursing review in ED
Disorganised booking times

Geriatrician review vs
Orthopaedic review Orthopaedic review vs
Anaesthetist review
Incomplete patient
documentation No beds available
upon transfer

NOF patients
waiting more
Patient requires Theatre availablity than 24 hours
MRI or Bonescan for operation
Family refuses operation Lack of OT time
Patient is
medically unfit NOF not considered for
emergency theatre
Patient
Operating
theatre

Action
The following interventions were implemented in order to simplify the
current patient flow process (Figure 5). Timeframes, responsibilities and
performance measures were assigned to various members of the team. Key
strategies focused on redesigning the current process.

28

Figure 5
Issues Intervention implemented
Patients referred Once ED Registrar reviews tests and admission is
for geriatric review identified, then the ED Registrar calls the Orthopaedic
before seeing the Registrar as well as informing the Geriatric Registrar.
Orthopaedic Registrar.

Geriatric review In absence of the Geriatric Registrar, the Medical Registrar
only occurs during can review the patient after hours or weekends.
working hours.

Orthopaedic review only ED Registrar is able to organise transfer of patients to
occurs until 9pm, if a the Orthopaedics Ward upon confirmation of fracture.
call is made after that
time then the patient
will wait in ED until the
next day to be seen.

The Anaesthetist can Anaesthetist review occurs at the beginning of the diagnostic
request further medical process rather than at the end, upon admission to the ward.
review, delaying
operating time.

Patients from district Checklist is used upon transfer of NOF patients from district
hospitals wait longer for hospitals to ensure documentation is complete. This reduces
operation due to the lack delays to theatre due to incomplete documentation.
of bed and/or incomplete District hospital patients are returned to the hospital
documentation. of origin after operation for post-operation treatment.
This reduces long waits in ED due to the lack of bed, as
this has been quarantined in the hospital of origin.

Disorganised Orthopaedic Registrar will book theatre when diagnosis is
booking times. confirmed either before 9pm or between 7am-7.30am as this
would help in organising lists and prioritising theatre patients.

No specialised nursing The Clinical Nurse Consultant (Orthopaedics) is called upon
review in ED. patient’s ED admission to start the care management process
rather than waiting until the patient is admitted to the ward,
i.e. this assists early identification of what the patient requires
in terms of protection of skin integrity, rehabilitation etc.
Education sessions were conducted at various shifts in ED to
raise awareness among staff.
Data collection. The current data collection form was modified to allow capture
of information on reasons why the patient is delayed in going to
theatre within 24 hours.
29

Results
Data was collected pre and post project implementation. A comparison
of the data showed that an average of 70% of patients with neck of femur
fracture reached theatre within 24 hours during the seven months of project
implementation compared to 42% before the project (refer to Figure 6).
Overall, the rate of NOF fracture patients going to theatre within 24 hours
increased by 28%.
A further positive outcome of the project was that it crossed departmental
boundaries in order to achieve what is best for the patient.

Figure 6
Pre-project mean 42% NOF Project

100% UCL = 100%

Mean = 70.1%
Rate

50%

LCL = 24.4%

0

Jan 02 - Jun 03 Jul 03 - Jan 04

30

Holding the gains
There are a number of strategies in place to sustain improvements post
project such as:
Continued data collection process for the NOF information to review ongoing
performance indicators and provide performance report to management.
Monthly monitoring of performance and presentation of findings to
management meetings of Orthopaedics, Anaesthetics, Geriatrics as well as
ward staff.
Orientation of Orthopaedic and Geriatric Registrars on the NOF Program and
management guidelines.
Continue active communication between the fractured neck of femur team
and the Orthopaedic Registrars to deal with any new reasons for delays.
Establish communication between the ASET team CNC and the Orthopaedics
CNC to identify NOF patients early in Emergency.
Continue early medical review/Geriatric Registrar.
Organise fractured neck of femur case conferences twice weekly to monitor
appropriateness of the current patient journey.


31

Figure 7

NOF Fracture Patient Flow (pre-project)

Patient
presents Time recorded & triage
to ED-Triage category provided

Patient is
admitted MRN is produced

JRMO Time is recorded prospectively In ED X-ray order is put
medical Tests include X-ray & blood in X-ray box & pick up
assessment pathology tests by X-ray staff

Test results Geriatrician
reviewed in informed or Med.
ED by Senior reg called after
ED Doctor hours

Special Medical
Geriatric Is geriatric Yes Fracture of
Yes review Yes tests for hip management
Admission admission hip?
required? needed? required? pain ordered

No No Time Ortho
registrar is called
Patient sent Seen by to be recorded by
Yes
home the Ortho Geriatric registrar
registrar
Seen by Time to be recorded
the Ortho by Ortho registrar
registrar and
Patient No Time of diagnosis
Op theatre booked at time follows as
requires per 1 & mode to be
Some # missed. admission to of diagnosis before 9pm or
recorded
Patients may Ortho ward? booked at 7am next day
be recalled
Yes

Is bed Yes Is fracture Yes Fit for Yes OT Yes Rejected by Yes Ward
available? confirmed? OT? available? anaesthetist? (medical
assessment)

Booking time
Patient may recorded in
be admitted Op theatre,
to Ortho No No No No No operating time
ward during including start
the night if Wait in ED Ward Ward Ward Patient has & finish times
X-ray shows (special (medical (OT rebook operation
fracture tests) management) daily)

32

Figure 8

NOF Fracture Patient Flow (post-project)
Patient presents Time recorded & triage category provided
to ED-Triage MRN is produced

Nurse suspects
NOF fracture

ED Nurse orders
an X-ray

ED Nurse calls CNC to review patient’s needs
on Ortho CNC skin integrity, rehabilitation etc

ED Registrar review
patient & order blood
tests & ECG

Confirmation of
NOF fracture

Patient admitted
ED Registrar to to D4A
call the NOF team Obvious Yes
(Ortho Registrar and fracture?
Geriatric Registrar)
Book theatre at
the same time

Is patient fit Yes Patient goes
to theatre? to theatre

No
Anaesthetists No
agree with
NOF team?
Yes
Further investigation,
other teams review
are requested Improving Patient Access to Acute Care Services

33

Checklist
prior to starting your
improving access project

Organisational commitment secured

Principles of change understood

Diagnostic work

Scope of project defined

Engagement of stakeholders

Convene project team

Project aim agreed with team

Defined project plan

Potential interventions identified

Measurement strategy in place

PDSA cycles planned

34

3. Interventions
An intervention is a change, idea or strategy that is designed to improve
outcomes for patients, staff and the organisation. These interventions are
tried and tested ideas and may produce dramatic improvements in patient
flow in an organisation where they have not previously existed. However, these
“fixes” may not produce long-term sustained improvement unless a structured,
organisation-wide redesign process occurs. It is likely that long-term gains will
only be sustained by adapting an organisational approach to matching service
capacity and demand and smoothing variation in activity as outlined in the
general interventions below.
The interventions are divided into three sections:
General strategies
Emergency patient flow
Elective patient flow

The layout for each intervention is as follows:
Intervention title - a short description of the intervention and key elements of
implementation.

Tools to assist with implementing the intervention are contained
in the attached CD. A tool is anything that is of practical use in
implementing the change. This may be a checklist, Powerpoint
presentation or file.

A hospital or organisation where the intervention is in place
- not a comprehensive list as these interventions are often in
place in many sites.

Resources – These are links to websites or reference
documents that contains more detail on the intervention or
any reported results.

Bookmark link within document.

35

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