North Shore Hospital report - New Zealand Doctor

Opinion 07HDC21742The Whole Patient Journey ParadigmThis model encourages us to take the whole patient journey perspective, from referral todischarge. A number of different patient journeys will need to be considered, based onpresenting problem, whether referred by general practitioner, age, local patterns of practice,and so on.The pathways are examined (diagnostics) to identify which parts of the pathway areunnecessary and where in the pathway are the tightest ―bottlenecks‖ to patients accessing therequired next phase of care. Parts of the General Medical admission pathway at North ShoreHospital have been described above and wastage, duplication and unnecessary bottlenecks arereadily apparent.Solutions then have two focuses: to eliminate unnecessary steps (referred to as ―leanthinking‖) and to prioritise solutions which fix the narrowest ―bottlenecks‖ first. Fixingobstructions to patient care, when there are bigger obstructions in the same pathway, will notimprove patient movement and instead will disillusion and frustrate. So, from this model, twofurther principles fall:3. Unnecessary steps in the patient journey should be identified and eliminated.4. The narrowest bottlenecks in the patient journey should be fixed first.The Models of Care ParadigmA variety of models of acute care have been proposed and trialled and some have had success.The common features of these models are that they take the patient‘s perspective (what isgood for the patient is good for the model), they continue the whole patient journey (thereforewhole system) paradigm, and they emphasise ―lean thinking‖ and working on the narrowestbottlenecks first. The additional contribution they make is the emphasis on ―value added‖tasks, and how best to achieve them. To explain this it is worth describing the ―Models ofCare‖ paradigm as being the ―itinerary‖ of the ―whole patient journey‖. In other words: wheredoes the patient go, what happens there, and who does it? Patients have some ―value added‖things happen to them on their journey, such as resuscitation, diagnosis, or definitive care.They also have a number of things happen which do not add value, such as waiting, repeatedassessments and ―storage‖ in lieu of an appropriate place to go, and elimination of these stepsis in keeping with the concept of ―lean thinking‖. To do the ―value added tasks‖ well it isappropriate to have a place resourced to do that task, with staff trained for, and focused onthat task. Putting a number of different patients, with different required ―value added tasks‖,with multiple staff with different objectives, in a single clinical space (for example, an ED)results in inefficiency, confusion and frustration.I imagine that at times in parts of North Shore Hospital ECC there were patients beingassessed by Emergency Medicine staff, others being assessed by General Medical staff, othersbeing assessed by other specialty staff, others receiving treatment, others being seen on award round, others being monitored, others waiting for a bed, others waiting for tests, otherswaiting to be discharged, and so on. The mixed and confused function, with multiple differentpatients, multiple different staff, and multiple different tasks all in the one space, makes forerrors and inefficiencies.EDs should have governance structures which allow authority over the ―department‖, so thatprocesses can be modified to minimise these inefficiencies. The Clinical Director ofEmergency Medicine at North Shore Hospital (the specialty, not the department) did not havesuch authority and it appears had limited capacity to influence how other specialties used thedepartment. It is likely that this governance structure contributed to a persistence ofinefficiencies. Indeed, the Clinical Director of Emergency Medicine position has been vacantApril 2009 125