Tobi Wilson is the Chief Operating Officer at the Royal Melbourne Hospital. In the lead-up to the Hospital Bed Management & Patient Flow conference he spoke to us about improving patient flow through real time information, the importance of finding the right system and putting in place appropriate accountability structures.
IIR Healthcare: In the past, ambulance ramping time throughout Victoria has been a cause for public concern. Strategies to reduce ramping time need to be tailored to the specific hospital. How does the RMH deal with this?
Tobi Wilson: It is correct that each hospital needs examine its own circumstances to understand what strategies may help to improve ambulance transfer times. In saying that, there are some common principles; that it is not just an ED problem and requires a whole of hospital or even whole of system response; that our existing processes that lead to delays are not working and we need to look at things differently; and that additional resources are not always the solution.
At the RMH we have implemented strategies to improve ambulance transfer times as part of our overall improvement project for the Emergency Pathway. For us the big change was to implement appropriate escalations and enforce accountability around that. We made it very clear who is responsible for what. The answer to the issue obviously cannot be an ED response alone. The whole hospital needs to be involved. The problem is always to do this in real time. Our strategy has included a changed model of care in the Emergency Department with a focus on timely assessment and appropriate disposition for all patients, automated escalations around ambulance delays involving ED, bed management and operations as well as accountability for performance. For me accountability and governance were really the driving factors for managing the change with good results.
IIR Healthcare: You mentioned a focus on timely patient assessments. Can you give an example of how your new approach has led to an improvement?
Tobi Wilson: We have a measure in Victoria around the percentage of patients that are triaged within a certain amount of time and in August we were sitting around 65% of patients assessed within their recommended time. We now sit above 80% and that has been predominantly due to the changed model. There is definitely a focus on trying to assess the patient sooner and assess them with a senior clinician so that we can get decisions made sooner. We can then put plans in place to manage that patient appropriately.
IIR Healthcare: What other key factors are inhibiting patient flow in the modern hospital?
Tobi Wilson: For all the effort that we make around improving patient flow, I do believe that we do not spend enough energy ensuring that we have appropriate governance and accountability structures in place. Real time information assists us in understanding our demands and placing appropriate accountability with respective team members.
Like most hospitals we have agreed on timeframes for steps to be undertaken, for example time to bed request, response time for inpatient units, etc. Again, like most hospitals, before we had real time information this was very difficult to enforce, and almost always done in retrospect. Real time patient flow gives us the ability to understand where our barriers are and implement appropriate escalations to address these.
IIR Healthcare: What approaches has the RMH taken to tackle these issues?
Tobi Wilson: Implementing a patient flow system has opened up a lot more opportunities for us. Knowing how many beds you have available and upcoming, where each patient is in their journey, and what the barriers significantly improves our ability to manage flow. We are only part of the way along this journey, but we are already getting better traction than we have had in the past as it is more difficult not to comply.
IIR Healthcare: How difficult was it to implement real time information?
Tobi Wilson: We went out to tender for a patient flow system. We didn’t think that any of the systems that we had seen had everything we wanted. It is really important when you are looking at patient flow that you do understand both demand and supply. All the systems that we had seen were lacking in the demand side. We couldn’t see well enough what was coming in on a ward-by-ward basis, but also into the entire hospital. Going out to tender let us specify exactly what we wanted from a product and we were able to engage with a vendor who was happy to commit to delivering that. We still don’t think we have the perfect product, but we are a lot further down the path than we were before we went to tender.
The way we implemented the product was I think quite clever because we were very much focussed on what the frontline users were seeing and how they were going to use the tool. In the backend we are then using all the gathered information to manage our beds and patient flow. The front end-users think it is a great tool for what they need to do clinically and how to manage their ward, but we now also have the information we need in the backend. This enabled us to start changing the conversation we are having with people because we can see what really is happening on the different wards rather than what we are told is happening.
IIR Healthcare: Did the implementation require a lot of training?
Tobi Wilson: No, it didn’t require a lot of training. It is actually a very simple system. It covers a number of clinical areas. We use it for all our handovers as well as for a lot of our referrals. There were some bits and pieces that the frontline users had to learn, but the backend really integrates with some existing tools that we have built in house. The new system actually automates the systems whereas before they were reliant on manual data entry. This always led to inaccuracies and a lack of timeliness. By automating everything it actually allowed us to have proper conversations about what was happening at any given moment in time.
IIR Healthcare: In which areas do you still see room for improvement?
Tobi Wilson: I think we are at about 40% there of what the product will eventually be able to deliver. We know what the next 20% is. There is a bit of work that we haven’t got quite right yet. We are collaborating with the vendor to fix this at the moment. The improvements evolve around better managing what we call our add-ons or transfers from other hospitals. We will also start paging our inpatient units about certain events and there will be a few other automated notifications that will follow over the next few months.
In terms of the last 40% we still haven’t quite figured out what to do yet, but I think we are quite lucky to have a tool that is flexible and have a vendor who is responsive and able to help us as we come up with new ideas.
IIR Healthcare: In your opinion, how advanced is the healthcare sector when it comes to implementing real time information?
Tobi Wilson: I think the RMH is probably a bit ahead compared to where other hospitals are. Since we have implemented the system we have had more than a dozen visits from other hospitals to have a look and see what we are doing. There is a lot of interest in this space, but compared to other industries we are in the infancy of making use of real time information. Hospitals are so rich in data, but they lack in information that is actually useful. I think we really need to look on how we can use this data and make better decisions.
IIR Healthcare: What role do people and culture play in achieving greater efficiency?
Tobi Wilson: At the end of the day, it is all about the people and the culture of the organisation. We are very clear about the reasons we have for improving the Emergency Pathways, namely that we need to more our patients most in need to the most appropriate place to be looked after by the right team at the right time. This is something we can all agree on and it is the basis for everything we do.
IIR Healthcare: You will be presenting and chairing part of the 2014 Hospital Bed Management & Patient Flow conference. Are there any presentations that you are particularly looking forward to?
Tobi Wilson: I am really interested in hearing from Fiona Webster about the work that has been done at Austin Health with the CSIRO as I am always interested how we can better incorporate modelling in to how we operationally manage our demand. Similarly the improvement in performance that Monash has had in ambulance transfer times has been significant. I look forward to hearing Prof George Braitberg describe how this has been achieved.