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Aim / Title: Orthopaedic Length of Stay project DRG I08. Presenter: Debbie Munro Hospital Name: Vulcan Key contact for this project ( name & details): Lesley Ritchie Improvement Manager Melbourne Health 9342 - 4569. The Health Roundtable. New Zealand.

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aim title orthopaedic length of stay project drg i08

Aim / Title: Orthopaedic Length of Stay project DRG I08

Presenter: Debbie Munro

Hospital Name: Vulcan

Key contact for this project ( name & details): Lesley RitchieImprovement ManagerMelbourne Health 9342 - 4569

The Health Roundtable

New Zealand

Using Benchmarking Data to Drive Improvement

define tollgate orthopaedic length of stay drg io8 project september 2009

Define TollgateOrthopaedic Length of Stay (DRG IO8) Project – September 2009

Exec Sponsor

Di Gill

Clinical Lead

Andrew Bucknill

Greenbelt:

Lesley Ritchie

Team Members

Meinir Griffiths (7SW)

Fiona Becker (5SE)

Rhonda Beattie - Manning

Ruth Harper

Inese Tucker

Eric Seal

David Love

Andrew Oppy

Tom Treseder

Audi Widjaja

Belinda Cary / Debbie Munro

key problem
KEY PROBLEM

Through involvement with the Health Round Table, it has been identified that

DGR I08 'other hip and femur procedures' significantly exceeds the average for

exemplar hospitals in the following areas:

Average length of stay (ALOS)

Day of surgery admission rate (DOSA)

Percentage of patients discharged home

Complication rate

Improvement in these areas may increase access to services and patient through-

put.

Scope Statement

Patient cohorts that fall within DRG I08 'other hip and femur procedures’

D

C

M

I

A

3

aim of this project
AIM OF THIS PROJECT

Measure of Success

Reduction in average length of stay from 9.91 days to 8 days for DRG IO8

(median length of stay will also be a key measure).

Emergency readmission rate to remain stable

currently an area of high performance for this DRG

Alignment to ACHS Criteria

1.1.1 The assessment system ensures current & ongoing needs of the

customer/patient are identified

2.1.1 The organisation’s continuous quality improvement system

demonstrates its commitment to improving the outcomes of care and

service delivery

4

baseline data for length of stay
Baseline data for Length of stay

Range = 1 – 64 days

Average skewed by a small number of exceptions.

Further analysis needed.

Median length of stay is 8.0 days

6

baseline data for length of stay1

N=56

N=53

N=3

Baseline data for Length of stay

Segmented Data – ORTM, Ortho & Trauma

  • Median LOS of 7 days for Orthopaedic steam. Patients who are managed solely by the orthopaedic unit
  • Median LOS of 9 days for patients who are streamed through ORTM. Patients within this group are managed through collaboration between the orthopaedic and medical units.
  • Median LOS for Trauma patients is 7 days
baseline data for length of stay2
Baseline data for Length of stay

Segmentation of Data - IO8A and IO8B

  • Median LOS of 9.5 days for IO8A
  • Median LOS of 5 days for IO8B
procedure types within drg io8
Procedure types within DRG IO8

76.3% of all procedures fall within the top 3 procedures as follows;

Dynamic Hip Screw (DHS)

Femoral Nail (insert or removal of)

Open Reduction and Internal Fixation (ORIF) of Hip/Femur

Other = 24 pts, all with different procedures

complication rate
Complication Rate

Q1 = 2

Median = 5 Q3 = 8 IQ Range = 6 n = 33

Q1 = 6.25

Median = 10

Q3 = 14 IQ Range = 7.75

n = 84

  • Lower length of stay for patients who had no complication (No)
voice of customer

Orthopaedic Length of Stay

VOC Collection

Customer

Sample Comments

Key Issue

VOC Source

Key CTQ

Allied Health

Fractured NOF patients can be a very complex group of

patients as they often have lots of other co-morbidities which

can lead to a longer length of stay, this needs to be

considered

Patient care and

complexity impact

length of stay

Interview

Average length of

stay

Allied Health

Sometimes the ORTM patients don’t appear on our lists until

day 2 or 3 so I don’t have the opportunity to intervene early

Lag time to physio

referral

Interview

Time to physio

referral

Allied Health

Sometimes the orthopaedic team are hard to reach and they

don’t give clear documentation in the history of pts weight

bearing status or pager numbers, so you don’t know who to

contact.

Clear documentation

of weight bearing

status and unit contact

details.

Interview

Time to physio

intervention

Nursing - Surgical

best practice is to have these patients to theatre within 8 hrs

but often this does not happen

Lag time to theatre

Interview

time to theatre

Nursing - Medical

The orthopaedic unit is great at reviewing the patients post

op. They come to see their patients first thing in the morning

Post Op review

Interview

No of pts seen day 1

post op.

Nursing - Medical

Sometimes there is confusion over which unit the patient is

under. Sometimes they are sent to 5SE without being

accepted by the medical unit which causes delays in patient

Management. This is particularly bad on weekends.

Accurate streaming of

patients & length of

stay

Interview

No of pts stream to

the correct ward.

Average length of

stay

Nursing - Medical

When Orthopaedic patients are on the medical ward they are

sometimes not followed up well by the Orthopaedic unit pre-

surgery and they seem to wait longer for theatre. This causes

further deconditioning of these patients who often have

multiple comorbitities

Accurate streaming of

patients.

Lag time to theatre

Interview

No of pts stream to

the correct ward.

Time to Theatre

Nursing - Medical

Sometimes there are delays in having patient accepted by

TRAC as they want additional tests that are not really

required.

Timely acceptance of

patients by Trac

Interview

Average Length of

Stay

Anaesthetist

There is a tendency now to operate on patients with

significant co-morbidities. Elderly pts deteriorate quickly if

they don’t receive surgery promptly but this is difficult to

achieve as urgent ortho lists are always full.

Access to theatre

Interview

Time to theatre

Voice of Customer
voice of customer1

Orthopaedic Length of Stay

VOC Collection

Customer

Sample Comments

Key Issue

VOC Source

Key CTQ

Nursing - Surgical

A lot of work was done previously were it was identified that

most of the ORIF and NOF pts should be managed under the

medical unit in partnership with orthopaedics because they

were blocking orthopaedic surgery beds. This streaming

should be done in ED but sometimes pts are not sent to the

right areas and this can add time to their length of stay.

Accurate streaming of

patients & length of

stay

Interview

No of pts stream to

the correct ward.

Average length of

stay

Nursing - Medical

Sometimes theatre cases can be cancelled at the last minute,

when the patient has already been fasting.

Timely access to

theatre

Interview

Delays to theatre by

time, type

Nursing - Theatre

There are a number of factors that may cause the Orthopaedic

unit to delay surgery. They are sometimes restricted by the

availability of theatres, availability of specialised equipment,

availability of other specialists or complexity of surgery.

Timely access to

theatre

Interview

Delays to theatre by

time, type

Nursing - Theatre

There are sometimes delays getting patients to Theatre

because the patient is not ready when we go to pick them up

or the consent may not have been signed but there are times

when the unit changes their mind and decides to do another

patient first and leave the more complex cases for last.

Timely access to

theatre

Interview

Delays to theatre by

time, type

Executive

This DRG has come up a number of times in the health round

table data and needs to be addressed in 2009

Length of stay

Interview

Average Length of

stay

Patient

When asked what do you think we do well, patient responded

that we do everything well, staff are on the ball the whole time

and very thorough.

Level of care received

Interview

Patient satisfaction

Patient

Its good when staff are friendly as it is so boring in hospital

Friendly interactions

with staff

Interview

Patient Satisfaction

Voice of Customer
next steps1
Next Steps

Measure Stage

Define stage

Project Charter

Project Charter

Key Metrics - Baseline

Process Flow

Value Stream Map

SIPOC Diagram

Baseline data

Project Plan

MSA

Risks & Issues

C&E Diagram)

Lessons Learned

Lessons Learned

lessons learnt
LESSONS LEARNT

Clarify scope and key measures in define stage

Ensure engagement from key medical and nursing staff

Be clear about what you are measuring and why, and ensure data is reliable

Ensure statistical analysis is appropriate to the data i.e. confirm normality and identify exceptions

15