New Zealand Chapter Meeting #2 October 2010

1. New Zealand Chapter Meeting #2 October 2010 HRT1017B - Long-Stay Patient Workshop The long-stay patient issue and experience of Australasian Hospitals

2. The long-stay patient issue and experience of Australasian Hospitals No Who owns the long stay Patient? Who is concerned about the long stay patient? 2

3. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

4. What is a Long Stay Patient ? This is a long stay patient’s medical record A long stay patient is an outlier A long stay patient is one where the LOS is considerably greater that the LOS that one would normally expect A current working definition of a long stay patient is one where the LOS=>21 days

5. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

6. All DRG Family I03 episodes for six months Sorted by days of stay Flagged at 21 days or more as “Long Stay” Case Studies Case 1 : Hip Replacement St Elsewhere – 6 months episodes

7. The Standard chart – focuses attention on average patient The Outliers Are seldom considered

8. The Bed Day Usage chart – shows that long-stay patients are important The Outliers • 21 days or more : 5% of episodes • 29% of total bed days

9. Long Stay Patients are lost in the system Our metrics focus on discharged patients, not those still in the hospital Long Stay patients (the LOS=>21 days) are less than 3% of the total They affect the average length of stay by 25%, but this is less than a day when the “normal” LOS is over five days Who is concerned about the long stay patient?

10. 1,900 Episodes 1730 Episodes 5,350 Episodes 24,100 Episodes Case 2 Hospital Alpha, Multi day 2007- 2008 Episodes Length of Stay Bed Days The Long Stay Patient Issue / Opportunity 72,500 Bed Days 21 to 350 Days 14 to < 21 Days 29,500 Bed Days 7 to < 14 Days 52,000 Bed Days Less than 7 Days 66,000 Bed Days 33,080 Episodes 220,000 Bed Days

11. The Long Stay Patient Issue / Opportunity So What ? This is equivalent to 198 beds for a year 72,500 bed days / 365 days =198 beds Or this is equivalent to 6144 patients for a year 72,500 bed days ∕ 11.8 day (LOS) =6144 episodes / patients Any way one looks at this ,these figures are non-trivial

12. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

13. Total HRT bed day trends 2004-2010

14. Total HRT Long Stay Bed Day Trends 2004-2010 FOR THOSE PATIENTS WHERE L.O.S.> 21 DAYS

15. In the year 2009-2010 2.2% of Patients used 32.1% of bed days

16. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

17. Answer 1 -The Impact on the Patient Case study From the Stranded Patient Support Unit -Point of view

18. Answer 1-The Impact on the Patient Case study - continued Who is concerned about the long stay patient?

19. Q. Why is the Long Stay Patient important ? Answer 2 . Because it is “The canary in the coal mine” • The long stay patient serves as a sentinel for • Patient Risk Issues • Capacity Issues • Management Issues • Financial Issues The Long stay patient serves as a marker for whole of hospital performance

20. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

21. What do we currently know about Long Stay?. . . • Long Stay is a big issue and not high on anyone's radar. • One hears a lot about Bed Blockers, but little about causes of long stay • The Data is poor • Because it has not been looked at previously • Statistical Discharges are a nightmare . The number of long stay patients can be understated by 50% • There is no case record • Scope can be vague • Normalisation is a large problem. Problems and issues become accepted • Consequently a patient can be in for 500+ days. • Long Stay not age or sex dependent

22. What do we currently know about Long Stay?. . . • A large number of problems appear to be facility specific • - organisation problems – e.g. theatre access • - clinical problems – e.g. adverse events, poor management of delirium • Omission appears to be as large a problem as commission • Patients can become stranded • Causes not picked up in Medical Records • The best predictor of length of stay appears to be the current length of stay • Hospitals are dangerous places Who is concerned about the long stay patient?

23. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

24. How do we improve the situation? How does one reduce these outliers ? Management Plan : Recognition of problem Leadership Agree scope and implement a professional programme Ownership of problem Support for owner Diagnosis : Identify &understand what causes Long Stay at a specific facility : Prevention:Remove the identified problems (Rocks). Identify potential high risk patients at an early stage. Identify long stay patients and manage where appropriate Rescue Identify Patients at risk and rescue where appropriate

25. The Management Plan… • Recognition of problem • Senior management and clinical staff must understand that the Long Stay patient is a major issue . • The issue is the same magnitude as emergency patients, elective patients etc • The issue must be quantified on a daily basis • There needs to be concern for these patients • Leadership • Visible Leadership is essential • Long Stay is no different to Patient Safety, Emergency ,Elective • Visible leadership makes a large impact on the issue and in many ways is an easy intervention

26. My Preference 107Z The Management Plan… • Agree scope and implement a professional programme • The scope of the task needs to be agreed at the commencement of the project • Scope can vary from • An Area Health District • to • A DRG or group of DRGs • Given the magnitude of the issue ,the strong recommendation is to start with as wide a scope as possible • To achieve success a professional programme must be undertaken

27. 2010 SAFER Patient Care Collaborative Program :Reducing harm from hospitalisation OR Long Stay Patients Implement a professional programme -Example Period : March-December 2010 Diagnosis : March- June 2010 Intervention : June –October 2010 Hospitals Canterbury (NZ) Hawkes Bay (NZ) Lakes (NZ) Waikato (NZ) Townsville (Qld) Sir Charles Gairdner (WA) Wide Scope Narrow Scope + 2 projects in NSW and SA

28. Implement a professional programme -Example • February: Establish team, agree scope and baseline • February+???? Establish daily valid reporting • March: Programme Director visits individual hospitals • March to June: Diagnosis • May: 2 Day workshop –Melbourne • March to Deember: Teleconferences • June to December Prevention and Rescue • October 2 Day workshop – Melbourne

29. The Management Plan… • Ownership of problem • Accountability for Long Stay patients must reside at the 2nd organisational level for the facility e.g. Director of Clinical Services • Everyone owns the problem • Support for Owner • The owner of the problem must be supported • Visible senior management leadership and support • Senior Clinical Support • Data analysis expertise • At least one senior nurse ,full time and back filled

30. Diagnosis, Diagnosis, Diagnosis Identifying the causes of long stay • History • Understand the base line situation (Long Stay Patients 2008/2009 ) • Real Time Correct Data • Identify Long Stay Patients on a daily basis • Detailed investigation and review of new Long Stay patients • Causes not symptoms • Determine and understand the causes of Long Stay • Review and profile at least 40 new long stay patients and record the causes • There are common issues and site specific issues NOTE: 1.Diagnosis first ,Intervention second 2. How did the patient get there?  Why is the patient here today?

31. Diagnosis, Diagnosis, Diagnosis Some identified problems • Lack of visibility • Not a priority • Waiting, Waiting, Waiting • PICC • CT • Cath Lab • OT • Rehabilitation Assessment • Clinical Decision (House Surgeon, Registrar ,Consultant) • Complications from adverse events • Infections • Lack of clear management plan • Lack of clear discharge plan • Referrals not followed up or actioned • Poor to nil discharge planning • Discharge meetings do not include medical staff • Unclear entry criteria for facilities and programs patients referred to • New Staff

32. Prevention Identify the problems and remove them • The Major Problems • The lack of awareness of the long stay patient problem • Leadership • Inability to measure LOS daily • The length of time patients are in the hospital • The best predictor of length of stay appears to be the current length of stay • Hospitals are dangerous places

33. Prevention…2 Remove the identified problems • Waiting, Waiting, Waiting • PICC • CT • Cath Lab • OT • Rehabilitation Assessment • Clinical Decision (House Surgeon, Registrar ,Consultant) • Complications from adverse events • Infections • Lack of clear management plan • Lack of clear discharge plan • Referrals not followed up or actioned • Poor to nil discharge planning • Discharge meetings do not include medical staff • Unclear entry criteria for facilities and programs patients referred to • New Staff

34. Prevention…3 Remove an identified problem – Example

35. Prevention…4 Understand the identified problems in detail and remove HOW? There are a number of lean techniques that can be of assistance e.g. Problem Solving Value Stream Mapping Waste Audits Michael Blatchford will take you through these techniques this afternoon

36. Prevention …5 Identify those patients at high risk, early and manage • Patient admitted / transferred and nothing occurs for 7-14 days • Patient over 80 and major surgery • Patient lives in supported accommodation and has a major event • Patient has a significant adverse event • No clear clinical management plan • No clear discharge plan

37. Rescue Identify long stay patients and manage where appropriate Identify stranded and long stay patients via the monitoring system and review • Rescue stranded patients • Actively manage all stranded patients • Develop and implement an agreed rescue process • Clear management plan and accountabilities • Clear discharge plan and accountabilities • Monitor and follow up

38. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

39. The Opportunity Few patients result in many bed days, therefore manage the few, to achieve significant benefits The Benefits • Significantly improved patient care • Significantly improved patient experience • Reduced ALOS and bed requirements • Improved bed availability, if surplus beds remain open • Significant financial savings, if surplus beds are closed

40. Q. Who is concerned about the long stay patient? A. Everyone should be THANK YOU & QUESTIONS ?

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