Turn-Key Solutions
Yet another unfair advantage
Our approach, working collaboratively with all stakeholders, is to train and coach staff in the required skills to provide them with the capabilities to safely experiment on, and improve, their own actual work processes employing lean techniques. Whereby staff share a common language and understanding to utilise the appropriate lean tool and techniques to suit their own situation and to solve their particular problem.
Always taking into account current work being undertaken in an organisation and before embarking on any Future State re-design activities, we firstly need to establish a rigour and stability within the organisation which will in itself drastically improve Length of Stay, Time of day discharges, DToC reduction and ED performance metrics. We achieve this through ‘scientific operational management’ and by employing our proven, 'oven ready' and hugely successful processes namely:
· Assigning Process Owners
· Employing the Visual Hospital
· Employing Levelled Discharge Targets
· Employing Plan for Every Patient in ED
· Employing Plan for Every Patient on the Wards
· Employing Plan for Every Delay
Process owners
A process does not work unless it has an owner, and the speed at which a process change is implemented depends upon the amount of time that the process owner can devote to it.
We carry out a ‘Diary Exercise’ with many Healthcare execs, senior managers and line managers. It is totally normal when conducting these exercises to find that the genuine demands placed on these individuals can be in excess of 24 hours a day.
The Diary Exercise enables, through de-selection and re-assigning of work, the freeing up of the process owner’s time to actually own the process that they have been assigned.
The Visual Hospital
The Visual Hospital process works by visualising patient demand for discharge and acting upon this demand. Whilst most organisations can now provide patient ‘demand to get in’ from their Emergency Department or via GP referral our observation is that they never really know their patient ‘demand to get out’, the demand for discharge. It simply cannot be seen.
Most organisations now freely admit that patient demand to get in is actually very predictable. Likewise, we can confirm that demand to get out is equally predictable by the day and by specialty.
It is absolutely normal that, at any given time between 25% and 35% of beds on wards are occupied by patients who are medically fit enough for a safe discharge or transfer to their next planned destination, but they are still occupying a bed, often the wrong bed.
Organisations employing the Visual Hospital in conjunction with ‘levelled discharges’ can expect to benefit from an average length of stay reduction in the region of 25%.
Levelled Discharges
Hospitals around the world crave for discharges earlier in the day, as opposed to a large batch later in the day, the ‘early bird’ or the ‘golden patient’ yet fail to do so in a sustainable manner.
However, ask any member of staff in ED and they will tell you that when admitting patients all they need are small numbers of available beds ‘drip fed’ evenly throughout the day.
Levelled discharge targets when fully understood, and adhered to, provide just that along with just a few very unambiguous actions that need to be completed every 2 hours to achieve this. They enable circa 30% of total daily discharges by 11:00 and 50% by 13:00. Additionally they also provide the opportunity to design robust and formal escalation processes when failing to meet these targets.
Plan for Every Patient in ED
Despite the fact that patients‟ transit time in ED is extended due to a lack of available beds, ED departments can fail spectacularly even if beds are available.
There are usually up to ten generic steps that a patient undergoes whilst attending ED. Therefore, if a Majors Department (for example) consists of twelve bays and they are all full, that equates to some 120 activities that staff have to hold in their heads and attempt to remember them all.
Plan for Every Patient in ED sets agreed visual time fences for each of these activities and highlights any which have not been completed on time.
Plan for Every Patient (PfEP) in ED not only acts as a management tool to ensure adherence to plan however, It also provides a powerful data collection vehicle for capturing, evidencing and removing the recurring issues that prevent adherence to plan, that ultimately extend the patients’ Transit Time.
Plan for Every Patient on the wards
Plan for Every Patient (PfEP) on the wards embodies the PDCA cycle. It is a simple, yet extremely effective visual operational management tool whereby immediately upon a patient being admitted to the ward a complete plan is drawn up, visually, for the patient, from admission until they are planned to be medically fit enough for a safe discharge or transfer.
This represents the ‘P’ (Plan) in the PDCA cycle, the delivery, review and updating of this plan then completes the cycle. This is repeated for every patient enabling staff to practice and really learn this scientific method.
The ward manager, at a given time of day, invites the nurses responsible for each bay to attend and report whether each individual patient actually received that, which they were planned to receive, the previous day and if not (variance to plan) agree how to catch back, to get back on plan (the Check & Adjust in the PDCA cycle). The ward manager also reiterates today’s plan for each individual patient (the Do in the PDCA cycle).
Again, PfEP on the wards not only acts as a management tool to ensure adherence to plan however, it also provides a powerful data collection vehicle for capturing, evidencing and removing the recurring issues that prevent adherence to plan, that ultimately extend the patients’ LoS.
It is entirely normal during the first month of implementation for planning accuracy (the Patient receiving exactly what was planned for them ‘On Time and In Full’) to rise from 40% to 85% and can contribute towards an additional LoS reduction (above and beyond the VH reductions) in excess of 10% on that ward.
Plan for Every Delay
The Visual Hospital reveals many more delayed discharges (ie medically fit enough for a safe discharge or transfer to their next planned destination but are still in an acute bed) than an organization realizes that they have, or indeed report upon. Working with Hospital Staff and Partner organisations, Plan for Every Delay (PfED) sets agreed visual time fences for the usual complex pathways (eg Nursing Home without Capacity) and highlights any which have not been completed on time.
Again, PfED not only acts as a management tool to ensure adherence to plan however, it also provides a powerful data collection vehicle for capturing, evidencing and removing the recurring issues that prevent adherence to plan, that ultimately extend the patients’ Length of Stay post being declared medically fit.
Depending on the number of delays exposed by the Visual Hospital it may be appropriate to assign a small expert task force, working with partner organizations/services to work with PfED (centrally and visually) to reduce the delays to a manageable number that can then transition onto the ward’s Plan for Every Patient.