Introducing the RITZ - Department of Health

Introducing the RITZ
Improving access for Non-Admitted patients at The Northern Hospital
Oliver Furness
Program Leader
Redesigning Care
Dr Helen E. Stergiou
Director
Emergency Department
Health Innovation Conference - 24 February 2010

Acknowledging our Team Approach
• Redesigning the Non-admitted Patient Journey
Working Group
Key drivers
• Jenelle Linton, Project Officer
• Roslyn Martin, ED Nurse Practitioner
• Dr Herman Chiu, Clinical Lead / Emergency Physician

• Setting the scene
– The Northern Hospital Emergency Department (ED)
– Redesigning Care and the non-admitted patient
• What we did
– Diagnostics
– Solution design
• Outcomes
– Key indicator results
• What we learnt
– Wise advice

What is the RITZ ?

It is not a new strategy to move
Emergency Patients to 5-star hotels
The RITZ…

It’s a new treatment space
at The Northern Hospital
The Rapid Intervention and Treatment Zone
Non-admitted patients
Prompt access
High Quality Care

Setting the scene
• The Northern Hospital ED
– 66,200 presentations in 2008 = average 181 per day
– Strong performance: Bypass / LOS < 24hrs / Time to treat (CAT 1/2/3)
– Opportunities for Improvement: LOS

What we did…
• Redesigning Care at Northern Health
• Lean thinking approach
• Examine our processes from the patients’ perspective
• Identify, analyse and eliminate waste (duplication, delays, inefficiencies)
• Ensure optimal process flow
• Structured approach focused on diagnosing the problem
Start Up
Diagnostics
Solution Design
Implementation
Transition /Evaluation
Majority of project time
- Understand current process
- Identify issues and root causes
- Process mapping
- Staff/patient observation
- Hospital activity data analysis
- Only developing solutions once root cause identified

Redesigning the non-admitted emergency patient journey
• Pt Observation example…

Diagnostic Stage Outcomes
• Clear link between the ‘time patients wait to be seen’ and
‘total time in ED’ (LOS).
• Analysis identified a number of key causes to delays in
initial assessment:
– Lack of available space (cubicles) to assess patients
– Staff wasting time searching for equipment, supplies, paperwork
– Variability in how patients are allocated to Medical Staff
– Delays in the process of ordering and reviewing Radiology tests
– Clerical role interruptions and lack of role clarity.

Solution Development
• Process:
– A small dedicated team of ED staff developed solutions to these issues
– Goal was to ensure rapid intervention and treatment of specific pt
cohort by medical and nursing staff
– Solution logic:
Reduce wait time
for registration
Reduce wait time
for initial assessment
& test ordering
Reduced ED LOS

Solution Design – Key components
• New model of care
– Clinical Streaming
– At Triage patients meeting inclusion criteria sent directly to RITZ
• New clerk role (relocated from registration)
– Patients registered in the RITZ
• Medical and nursing staff allocated to RITZ
– Clinical Seniority
• New Radiology ordering process
– Simple investigation requests sent via fax

Solution Design – Key components
• Redesigned environment
– Revised equipment & supplies storage
Before – RITZ Office work station
Before – RITZ Storage / Work station
11

Solution Design – Key components
After – RITZ Storage / Workstation
After – RITZ Office workstation

Outcomes

85.00%
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
ED LOS < 4hr
27/04 - 3/05/09
4/05 - 10/05/09
11/05 - 17/05/09
18/05 - 24/05/09
25/05 - 31/05/09
1/06 - 7/06/09
8/06 - 14/06/09
15/06 - 21/06/09
22/06 - 28/06/09
29/06 - 5/07/09
6/07 - 12/07/09
13/07 - 19/07/09
27/07 - 2/08/09
20/07 - 26/07/09
3/08 - 9/08/09
10/08 - 16/08/09
17/08 - 23/08/09
24/08 - 30/08/09
31/08 - 6/09/09
7/09 - 13/09/09
14/09 - 20/09/09
21/09 - 27/09/09
28/09 - 4/10/09
5/10 - 11/10/09
12/10 - 18/10/09
19/10 - 25/10/09
26/10 - 1/11/09
2/11 - 8/11/09
9/11 - 15/11/09
16/11 - 22/11/09
23/11 - 29/11/09
30/11 - 6/12/09
07/12-13/12/09
14/12 - 20/12/09
21/12 - 27/12/09
28/12 - 3/01/10
4/1 - 10/1/10
11/1 - 17/1/10
18/1/10 - 24/1/10
25/1/10 - 31/1/10
01/02/10 - 07/02/10
RITZ established
New process and new limits for
‘usual standard practice’
TARGET = 80%
Weekly Control Chart
(20/04/09 – 07/02/10)
Median ED LOS < 4hrs
Old process = 64.6% (20/04 - 20/07)
New process = 69.4% (21/07/09 – 07/02/10)
Sustained Improvement of 5%

100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
70.00%
65.00%
RITZ LOS < 4hr
20/07 - 26/07/09
27/07 - 2/08/09
3/08 - 9/08/09
10/08 - 16/08/09
17/08 - 23/08/09
24/08 - 30/08/09
31/08 - 6/09/09
7/09 - 13/09/09
14/09 - 20/09/09
21/09 - 27/09/09
28/09 - 4/10/09
5/10 - 11/10/09
12/10 - 18/10/09
19/10 - 25/10/09
26/10 - 1/11/09
2/11 - 8/11/09
9/11 - 15/11/09
16/11 - 22/11/09
23/11 - 29/11/09
30/11 - 6/12/09
07/12-13/12/09
14/12 - 20/12/09
21/12 - 27/12/09
28/12 - 3/01/10
4/1 - 10/1/10
11/1 - 17/1/10
18/1/10 - 24/1/10
25/1/10 - 31/1/10
01/02/10 - 07/02/10
TARGET = 80%
Weekly Control Chart
(20/07/09 – 07/02/10)
Median RITZ LOS < 4hrs = 83.6%

10.00%
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
Failed to Waits
Median Failed to Waits
Old process (pre 21 Jul) = 6.5%
New process (post 21 Jul) = 5.87%
TARGET = 5%
27/04 - 3/05/09
11/05 - 17/05/09
25/05 - 31/05/09
8/06 - 14/06/09
22/06 - 28/06/09
6/07 - 12/07/09
20/07 - 26/07/09
3/08 - 9/08/09
17/08 - 23/08/09
31/08 - 6/09/09
14/09 - 20/09/09
28/09 - 4/10/09
12/10 - 18/10/09
26/10 - 1/11/09
9/11 - 15/11/09
23/11 - 29/11/09
07/12-13/12/09
21/12 - 27/12/09
4/1 - 10/1/10
18/1 - 24/1/10
01/02 - 07/02/10
RITZ established
Weekly Control Chart
(20/07/09 – 07/02/10)

Things we learnt…
• Clinical leadership drives change
• Access to clinically relevant data is crucial to engage clinicians
– Establish a need for change (e.g. Failed to Waits)
• Constantly communicate
– Frontline staff need to know what’s happening and why
– Sustain interest/engagement
• Limited availability of clinical staff
– Creativity with meetings
• Environment has a major impact on staff and patients
• Sustainability is driven by local ownership
– Frontline staff must be involved:
• identifying and validating issues
• developing the solutions
• Fundamentals are imperative
– Staffing / Seniority
• ongoing performance management

Want to know more?
Oliver Furness
Dr Helen E. Stergiou
Program Leader
Director
Redesigning Care
Emergency Department
(03) 8405 2066 (03) 8405 8013
oliver.furness@nh.org.au
helen.stergiou@nh.org.au