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NEAT within the hospital Culture, strategy and how to embed timely quality care or Don ’ t mention the war! ACI/NSW Health/ECI Seminar, Sydney , 13 th December 2013. A/Prof Harvey Newnham, Clinical Program Director Emergency & Acute Medicine, Director of General Medicine,
NEAT within the hospitalCulture, strategy and how to embed timely quality careorDon’t mention the war!ACI/NSW Health/ECI Seminar, Sydney, 13th December 2013
A/Prof Harvey Newnham,
Clinical Program Director Emergency & Acute Medicine,
Director of General Medicine,
Alfred Health, Melbourne
Much the same
1. Quality of patient care in your sphere of influence in 2013 compared with 2011 is ……………..?
2. In what way do you feel the 4h NEAT approach to date has contributed to quality of care?
Certainly has led to increased focus on patient through put and we have implemented some practice change to improve this
Focus on KPI's to the detriment because we are treating a performance measure as an objective
The 4 h NEAT target has been a catalyst for some positive changes although there are balancing negative effects
Have noticed very little difference in reality
It has helped focus on what was previously very poor and unpatient centred performance.
Pressure on JMS to discharge patients and to transfer patients to ward regardless of clinical management requirements
It has been challenging to maintain the high standard of patient care but feel we have achieved this.
Shorter ED length of stay and earlier contact with the treating team has lead to benefits overall
There have been stress points with ED at times and some tensions that we have had to resolve
Pressure leads to deterioration in behaviours
General medicine is looking closer at internal structure and perhaps not filling gaps in other services as it was previously
We have been better accepted by ED people
The registrars feel more stressed and there has been some pressure put on them by ED staff which they have found difficult to manage
Resources allocated to assist with achieving targets
We have had to operate within existing budget
It has helped focus on gaps in rostering
Consistent practice, excellent senior staff input, wonderful nurses and junior medical staff with great nursing leadership
Very happy with care once they get in.
For many patients we don’t know what to do.
When evidence exists it is often not applied.
Fidelity of execution.
Our health system is tweaking an historical model of care rather than designing its own future
Solution: Design and create a comprehensive system for delivering health care.
Richard Bohmer “Designing Care” 2009
Itis about excellence in patient care
Transforms the way we treat our patients to ensure they all receive timely, quality care consistent with their clinical needs
Is a whole of health service change that involves everyone (clinicians, managers and support staff)
Changes how we assess and treat our patients from the moment they arrive to the time they are discharged
Paraphrased from Clayton Christensen, in ‘the Innovator’s Prescription’
In August and September 2010, four of us (H H N, P De V S, M J K, A M S) undertook an investigative tour of 13 emergency hospitals in the United States and the United Kingdom to observe innovative approaches to patient flow pathways from the emergency department (ED) to inpatient wards and consider their potential for use at Alfred Health
Harvey H Newnham, Pieter De Villiers Smit, Martin J Keogh, Andrew M Stripp, Peter Cameron MJA 2012 p101
Site visits US & UK 2010
In house conversations
Individual unit developments –
AMU model of care etc, E&TC modifications
Formation of Whole of Hospital TQC Steering Group
Data, and more data
Site visits to Perth Hospitals
Importance of engaging HMOs
Draft principles established for whole of hospital approach
Stakeholder input into principles
Sign off by HOUs of principles
Travelling roadshow by COO
E&TC Design sessions
Launch of daytime TQC Nov 2012
Formation of Hospital at Night steering committee late 2012
Conversations about hospital at night
Draft principles established
Promulgation of hospital at night plan
Launch of hospital at night (ie 24h TQC) Feb 2013
Ongoing monitoring by steering groupThe Journey towards Timely Quality Care
RITZ (Rapid Intervention & Treatment Zone)
NHPA website Sept 2013
from community, clinic or other hospital
via call to *lead consultant
CH, SH, HITH,
4 Identical teams A-D
2 x Interns (8-4 & 11-1930/2130)
Daily consultant ward round
*Via call to streaming
APT registrar & nurse.
With interim orders
E & TC
As at 2nd December 2013
Good Doctor + Experience + Resources = Best Care
Doctor: custodian of knowledge, skills and application of these to the individual patient
Organisation: provider of resources
Health care delivery organisation manages….
Practitioners - typically in multidisciplinary teams
Knowledge base - decision support and practice-basedevidence
Processes of care – reduced variation and delays, outcome orientated
to provide best healthcare outcomes at affordable cost
Adapted from Richard Bohmer “Designing Care” 2009
“Hospitals must offer “seven-day care, delivered where patients need it”.
It's time to build a new movement for generalism, not specialism—”generalists are the undervalued champions of …acute hospital service”.
Practice-based evidence is in its infancy in our system
Can’t implement change unless monitoring systems are good enough to learn from mistakes and measure failure
Integration is essential
The divide between hospital and community care leaves us impotent regarding demand management
PM’s & weekends
Patient discharge pathway
Matching staff with workload (volume and time)
New ward governance models
Standardisation of ward rounding
How many admitting units do we need?
Dr Mark Monaghan
Transition from project teams to hospital executive ownership.
Consequent lack of drive of solutions and solution review.
Significant ED demand.
Ministerial focus on NEST.
We attempted to rally managerial and clinician engagement, however we were struggling to know where to start.
The Minister for Health commissioned an external review –The Bell Review.
Capacity audit analysis. 25-30%, half of which is under hospital control.
Simplified points of access to specialties.
Acute unit structure and staffing. “a safe haven”, with focus on inclusion rather than exclusion criteria.
Appropriate IT solutions