Volume 188 · Issue 6 · Letters

Redesigning the processes underlying clinical care in Australia can unleash its potential

Paddy A Phillips DPhil, FRACP, FACP · Clifford F Hughes AO, FRACS, FACC, FCSANZ

Health services across Australia are being challenged by rising demand caused by ageing populations, the high prevalence of chronic diseases and increasing patient expectations.1 Our public health services show many symptoms of strain, with growing queues and longer waiting times for access to care in emergency departments and for elective surgery. Here, we describe the emergence of a new and effective response to this situation. The global perspectiveThroughout the 1990s, health service models employed both in Australia and overseas had predicted a decline in demand for inpatient beds and an increase in demand for day-only beds and outpatient procedures in public hospitals,2 resulting in reductions in bed availability. However, in more recent years, the actual trend has been towards higher demand for inpatient beds. The number of older patients using inpatient hospital beds has increased to the extent that they now use about 50% of all inpatient bed-days (Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication). In addition, the complex, chronic nature of many of the illnesses of older patients means that they stay in hospital longer (Tony Dunn, personal communication), increasing pressure on the availability of inpatient beds. Occupancy rates are over 95% in many hospital wards,3 placing pressure on bed access for elective surgery, resulting in regular postponement of elective surgery and lengthening surgery waiting lists. This is particularly the case in winter months when demand for inpatient beds is at its highest (Tony Dunn, personal communication). As well as delays in access to care, the challenges in ensuring safety and quality across the whole health care system are substantial. Worldwide, study after study has demonstrated that events compromising patient safety occur in around one in five to one in 10 of all hospital admissions.4,5 This compares poorly with contemporary industrial quality standards of 3.6 errors per million parts produced.6 The universally high incidence of events that compromise patient safety means that they cannot simply be attributable to individual failings or to the funding and structural characteristics of the health systems involved. NSW Health and Flinders Medical Centre (FMC) in South Australia, the locations in which the redesign work that is the subject of this supplement is occurring, are not alone in facing these challenges. The same problems have been identified in other health services in Australia,7 and overseas (eg, the United Kingdom, Ireland, the United States8-10). In the UK, the government has led a major program of reform to improve patient access to health services and to reduce adverse events. In 2001, it established the Modernisation Agency which developed approaches to redesigning health care delivery. Some of these approaches have been used in the programs developed by NSW Health and FMC. The Institute of Healthcare Improvement in the US10 promotes similar approaches to redesigning patient journeys in hospitals across the country. The situation in New South WalesNSW Health is the largest health service in Australia. It comprises eight Area Health Services (AHSs) across the state. In the 2004–05 financial year, it serviced a population of 6.9 million with an annual expense budget of over $11 billion, and with a full-time equivalent staff of about 93 000. In that same period, the service recorded 1.4 million public hospital admissions and two million visits to public hospital emergency departments (EDs).3 The public health system in New South Wales was showing clear signs of strain (Box 1). Before the introduction of the Clinical Services Redesign Program in NSW in 2005,11 congestion in hospital EDs had been growing, with resultant delays and difficulties for patients in accessing care. Many patients each day were being kept waiting on stretchers outside the ED for over an hour.12 Triage times for patients in the Australasian Triage Scale categories 3 and 4 are the best indicators of the efficiency of EDs, as patients in these triage categories account for the bulk of emergency presentations at EDs. The targets for these two categories had not been met before clinical process redesign initiatives in NSW public hospitals.12 In the years 2002–2005, ED patients who needed to be admitted to hospital experienced access block of 40%–50%, and reaching 60% in some hospitals — NSW Health’s target was less than 20%. An access block of 50% on an average winter afternoon in NSW public hospitals means that about 400 people are being kept waiting in EDs for admission. Patients were often admitted to inappropriate wards (ie, they were “outliers”, who are empirically observed to have a longer length of stay), which exacerbated access block in other parts of the hospital (Box 2). Patients in need of elective surgery procedures were often waiting longer than 12 months (10 000 patients in 2004), while those with cases classified as urgent by their surgeons were waiting longer than 30 days (4000 patients in 2004). Underlying all this has been the relentless pressure resulting from an ageing population. The proportion of people aged 65 years and older in NSW will increase from 13.6% to about 20% between 2006 and 2026,13 and demand for health services will increase accordingly. Although people aged 70 years and over represent only 9.7% of the population, they account for 41.6% of all public hospital use (Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication). In conjunction with the ageing of the population, there will be future increases in the number of people with chronic diseases such as diabetes. For instance, the proportion of Australians with diabetes is expected to more than treble between 2000 and 2051.14 The situation at Flinders Medical CentreFMC is a 500-bed teaching general hospital in the southern suburbs of Adelaide. It provides the whole range of acute services required by a population of about 300 000 people. Smaller community hospitals and the private health care system also service that population. Within this de-facto consortium of care providers, the primary role played by FMC is the provision of time-urgent, complex care. Over 70% of patients who require an overnight stay are admitted as emergency cases, and over 40% of patients presenting at FMC’s ED are subsequently admitted.15 Before the launch of the Redesigning Care program in 2003,16 FMC was showing similar signs of strain and stress to those described above. However, the congestion within its ED was so severe that there was increasing evidence of a major problem with the provision of safe care within that department and elsewhere in the hospital. This provided a particularly powerful impetus for developing an improvement program. There are many repercussions for staff in a health system under this kind of strain. They struggle to maintain morale; they have high workloads; they often feel that they have limited or no control over their working conditions, and they lack the ability to make decisions. Root causes of these problemsThe growing demand for health care outlined above is external to health services, and is therefore beyond their control. Concentrating solely on the difficulty of external forces can simply induce a sense of helplessness that is unwarranted. Within health services, there are substantial opportunities to improve the safety, quality and accessibility of the care provided. Box 3 illustrates a typical patient journey through a hospital and shows the kinds of problems and disconnections between the components of care that interfere with the provision of an effective, well coordinated patient journey through the health system. Typical examples of the problems and disconnections follow. Poor communication, with care delivered in clinical “silos”, and miscommunication and adverse events usually occurring at the interfaces of these silos. Decisionmakers are often not able to be contacted as needed; for example, decision making for surgical patients in ED can often be delayed because surgical staff are busy in theatre. Poor alignment of activities; for example, delivery of a meal, a physiotherapist visit and an investigation all happening simultaneously. Imperfect alignment of laboratory and imaging services with patient requirements, and lack of a robust prioritised approach to laboratory workload to optimise overall hospital patient flow. Poor interface between specialist teams and ED staff. Staff not being rostered according to the requirements of patients. A typical example is the “9 to 5” rostering which still dominates for various staff in service areas such as ED, even when patient arrivals and the business of the ED peak in late afternoon to early evening. This mismatch of patient demand and staff supply results in minimal staff having to deal with maximal activity. This causes further frustration for staff, worsening of patient queues and increases the risk of adverse events. ED staff needing to “shop around” for an inpatient team to take responsibility for a patient (often older) who is difficult to “sell”. Lack of a common understanding by both staff and patients of the expected patient pathway and date of discharge, which inhibits better planning of preparatory work before discharge. Particularly problematic is the poor compliance with documenting an estimated date of discharge. This is compounded by senior nurses and registrars not being empowered to discharge patients. Processes for smooth discharge, such as preparation of discharge prescriptions, are often not well planned. For example, a junior doctor is called at late notice to write prescriptions for a patient ready for departure, but the doctor is busy with other tasks and does not complete the prescriptions until after the pharmacy has closed, thus resulting in a delay in the patient’s departure. Decision making in wards tends to happen only “9 to 5” Monday to Friday. Suboptimal processes for accessing services delivered in the community. Only certain professions, rather than the multi-skilled team, are authorised to perform the tasks required to “move the patient along”. All of these factors result in unnecessary delays in discharging patients from acute facilities into the community, causing a damming of patient flow “downstream” that exacerbates the “upstream” congestion in the ED. Traditional response to these problemsA common strategy for relieving the pressure on the health system generally focuses on creating new infrastructure (eg, more staff and more beds). However, this approach only provides temporary relief, and is unaffordable in the long term. Providing more beds will not remedy the disconnections described above, which have been exposed in the analysis of the patient journey during clinical redesign. Designing a process that ensures the essential steps in this journey come together like clockwork, and are simple for staff to follow, results in a significant increase in capacity in health systems. The “more beds” approach locks in the traditional service delivery models, which are often not appropriate given the changing nature of the population and its health problems. For example, inpatient care is often less appropriate for older people than well delivered community-based care. Optimal patient experiences are not solely dependent on bed availability. In NSW, the redesign program was introduced together with additional bed capacity as well as strong performance management to ensure improved outcomes, and this combination has worked well. At FMC there was no capacity added, but major improvements were still seen. Clinical process redesignA fresh view of the changing nature of the demand for health care services is clearly required. There needs to be a rethink of the best models of providing care to meet that demand, and to ensure that care is safe, effective, well coordinated and easy to deliver. Clinical process redesign is the approach used across the whole health system in NSW (through the Clinical Services Redesign Program, with implementation of its pilot solutions commencing in August 2004) and at FMC (through the Redesigning Care program, commencing in November 2003), resulting in major improvements to patient access and safety. OutcomesThe application of clinical process redesign in NSW Health and at FMC has greatly improved the delivery of care in the face of significantly increased demand. In NSW, emergency admission performance (Box 4) and the number of patients waiting more than 12 months for surgery (Box 5) have greatly improved, while death rates in EDs have fallen (Box 6). At FMC, there have been similar improvements in access to emergency care (Box 7). ConclusionThis supplement on clinical process redesign is being published to promote the effectiveness of this approach. The application of process redesign is continuing in NSW and at FMC because the task is not yet finished. However, we believe there is sufficient evidence that large-scale changes can be made in areas of service delivery that have been resistant to improvement for some time. In our view, continuous improvement through redesign has to be fundamental to the way we do business from now on. If management engage and work together with frontline staff, taking ownership of their processes and work environments, they can improve the way the system works for patients, as well as for staff. They can create well coordinated, efficient patient journeys, and make it easy for staff to provide safe and effective clinical care. The efficiencies they introduce and the adverse events they prevent will release funds for further investment in health care. New capacity will be needed over time, but it should be introduced to meet the needs of new models of care. In our experience, the most difficult phase of redesign is not identifying issues or designing new solutions; it is implementing those solutions and embedding the redesigned model into core business processes. It is not simply a matter of finding a new way, but of making that new way “the way we do things around here”. Subsequent articles in this supplement outline the methods of clinical process redesign, its application to both unplanned and planned arrivals at NSW hospitals, the use of an approach known as “lean thinking” in the redesign process at FMC,15 and important aspects of implementing and sustaining change in health care. 1 A patient’s story Edna was a reasonably active 78-year-old woman with diabetes, vascular disease and congestive cardiac failure. She presented to a large teaching hospital emergency department (ED) with confusion and mild fever that was eventually diagnosed as urinary tract sepsis. It took over 18 hours for her condition to be assessed and treatment commenced in the ED, and for an inpatient team to accept responsibility for her care. During Edna’s time in the busy ED she had to stay on a bed in a corridor and was difficult to manage because she was confused and kept trying to get out of bed. During her time in hospital Edna’s diabetes became uncontrolled, and she developed a pressure ulcer. She ended up staying in hospital for over 6 weeks. We believe Edna is indicative of the type of patients who are increasingly becoming the core work of our EDs and hospitals. Her story is typical of the delays and the adverse events which arise from the poorly designed systems which underpin the delivery of clinical care. 2 Overcrowding stemming from the emergency department In a typical teaching hospital in New South Wales, average occupancy rates were 98% before redesign began. Patients requiring admission from the emergency department were frequently sent to the next available bed despite it not being “owned” by the appropriate specialty team. On average, 30% of the patients in the surgery ward had non-surgical complaints (ie, were “outliers”) and not only acted as a barrier to the admission of elective surgical patients, but, as outliers, had a 36-hour longer stay than if they had been in the appropriate ward. 3 Problems and disconnections identified along a patient journey ED = emergency department. * Patients admitted to an available bed in a ward that is not the designated ward for their condition. 4 Emergency admission performance* in New South Wales hospitals, 1995–2007 ED = emergency department. CSRP = Clinical Services Redesign Program. * Percentage of patients admitted through the ED who egress from the ED within 8 hours. 5 Number of patients waiting > 365 days for surgery in New South Wales hospitals, January 2005 to June 2007 6 Number of deaths per 10 000 attendances in New South Wales public hospital emergency departments, July 1999 to June 2007 CSRP = Clinical Services Redesign Program. 7 Patients who presented, and those who did not wait for treatment at Flinders Medical Centre emergency department, January 2001 to April 2007

Tony J O’Connell MB BS, FANZCA, FJFICM · David I Ben-Tovim PhD, MRCPsych, FRANZCP · Brian C McCaughan FRACS · Michael G Szwarcbord BSc, BSocAdmin, FAIM · Katherine M McGrath FRCPA, RCPA, MRACMA

Clinical process redesign is the application of process redesign and change management to health care. Importantly, clinical process redesign starts with the patient-eye view. Modern hospitals and health services are organisationally complex entities,1 employing several thousand staff working in professional, functional and geographic groups. Each group has an internal, usually hierarchical, structure, and orientates its work by the views held within its dominant professional or organisational membership. Groups cherish their autonomy, so that medical or surgical divisions view the world from their medical or surgical perspective. Patients, however, move horizontally across hospitals (Box 1). Their journeys take them from unit to unit, receiving care from different groups as they go. The patient is the only person who sees the whole journey. Staff only see the component for which they are responsible, and no single staff member oversees all the steps in a patient’s journey. The result is that poor coordination of the patient journey is common. The traditional approach to solving the problems of health care is to ask each department within a health service to address the problems in their area. However, this cannot solve problems which result from poor overall design of clinical processes and disconnections between the stages of the patient journey that cross multiple departments. Clinical process redesign is concerned with improving patient journeys by making them simpler and better coordinated. It does not have an impact on the actual clinical care provided at the different stations along the way. Clinical process redesign — what’s different?Process mappingIn clinical process redesign, problems are analysed from the perspective of the patient’s journey. This is defined as the end-to-end sequence of all the steps required to provide clinical care for a patient. Because the entire journey is considered, attention is paid to support groups and clinical groups that might otherwise be overlooked. To understand all of the processes involved, the journey must be mapped in detail. Mapping makes all the steps that make up the journey visible to everyone involved. It engages staff in understanding the journey end-to-end, and in owning any problems that emerge. Mapping can be done in different ways — by the team together documenting the patient journey step by step, or by a series of interviews and “tag-alongs”, where a staff member travels with a patient and documents his or her journey. In either case, the steps of the journey are made visible, and this visibility drives the redesign process. Mapping the patient journey needs careful planning and facilitation to prevent the “blame game” (ie, each group blaming other groups for the problems within the journey).2 The first rule of a mapping session is that it must record what the process is, not what people think it should be. Subsequently, the views of individuals need to be confirmed with data in order to distinguish between rhetoric and fact. Mapping reveals poor coordination between the steps in patient journeys, and where additional steps have been added over years in an effort to make a dysfunctional system work. Mapping demonstrates problems in patient journeys in a way that cannot be disputed, and focuses the group on solving the root causes. It enables groups who work side by side to appreciate the contribution each makes to the whole journey rather than blaming each other when difficulties occur. Finally, when it becomes clear how complex and cumbersome many journeys have become, mapping generates “permission to change” from all involved — this is a vital ingredient in clinical process redesign. The mapping process and redesign process should be short. The NSW Health method (the Clinical Services Redesign Program) allows, on average, 12–16 weeks for the whole process of mapping, solution development and implementation planning. Involving staffA crucial feature of the mapping process is to bring together all the key groups and individuals who are critical to improving the clinical processes. Frontline clerical staff, porter and cleaning staff, junior nursing and medical staff are as important in this as senior consultants and nurse managers. Mapping sessions must occur at times and places that make it easy for clinicians to attend. Personal approaches by senior management and presentations to state-level leadership groups such as clinical networks or councils are important to achieve full and active participation of influential clinical leaders. It may be necessary to fund “back-fill” replacements for staff or to pay visiting medical officers, general practitioners or patients to ensure their attendance. When necessary, senior management must send the message that change is inevitable: “The process will proceed with or without you. This is your chance to make it work for yourself, your colleagues and patients.” It is important to highlight the importance of clinician input while demonstrating that the redesign work will not be held hostage to individual preferences or resistance. Managers need to preset the parameters for solutions and participate in the process to ensure that solutions are practical and affordable. When clinicians and other staff do engage, the redesign solutions must be implemented to reinforce the benefits of participation and overcome latent cynicism about the possibility of effective change. Involving patientsPatients who make the journeys are the only ones who can identify the problems from their perspective. The experiences of patients and carers need to be captured in the mapping stage, and patients and carers must also participate in solution design. This can be through combined staff–patient working parties, or by having separate consumer working parties. In more recent projects in New South Wales, each redesign team has been asked to interview 10 patients and carers about their experiences and analyse their stories for themes reflecting the eight dimensions identified by the Picker Institute.3 The redesign teams then use this information to design their solutions, and remeasure the patient and carer experiences at a later date to ensure there have been sustained improvements. Questioning the status quoRedesigning the cumbersome and frustrating processes underpinning clinical care that are revealed by mapping requires a robust debate about a number of issues, including: why a particular step occurs; what can be changed; what steps really add value and have an impact on patient outcomes; and what steps do not add value and can be eliminated. We need to question in whose interest the current system is organised. Processes are often organised around traditional staff roles or to compensate for equipment inadequacy, rather than to serve patients’ needs. In the example in Box 2, the step of paging the equipment officer did not add value and was easily changed. While allowing nurses to order an x-ray in a case of suspected fracture will reduce patient delays, it will provoke debate, and will only be supported if the patient perspective takes priority over entrenched practices. These kinds of debates are an essential part of the education of staff as to why the changes should be made. The best criterion to diffuse disagreement is “if this was your mother, what would you want to happen?”. The patient journey perspectiveThe mapping process also facilitates moving the focus from the part of the patient’s body that is affected, or the professions involved in the patient’s care to that of the horizontal journey, and allows new groupings related to the process or journey to emerge. “Patient-care families” are groups of patients whose journeys share many of the same process steps, even though the specifics of their clinical care may differ. The article in this supplement from Flinders Medical Centre (FMC) (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”) describes an approach to clinical process redesign that is centred on patient-care families and the development of streams of care (or value streams) for designated patient-care families.4 Redesign may challenge conventional wisdom. For some years, Australian emergency departments (EDs) have used the Australasian Triage Scale5 to prioritise the order in which patients are seen so that patients are attended to in triage order, rather than the order of presentation. Clearly, this makes sense in relation to critically ill patients. However, it leads to patients in lower triage categories having extended waits. At the FMC ED, staff allocate a triage category to all patients, identifying the relatively small number of patients with time-critical threats to life and limb who take priority. All other patients are seen in order of arrival, no matter what their allocated triage category. They are divided into those who are likely to go home directly from the ED, and those likely to be admitted, with each group being seen by a different team of doctors and nurses. This approach has improved access to care and reduced overall waiting times in the ED without compromising the care of the critically ill.6 The move away from the strict use of the triage scale is quite confronting to many staff, and sustaining such changes requires committed leadership and ongoing monitoring. Applying the clinical process redesign methodNSW Health — the Clinical Services Redesign ProgramNSW Health piloted clinical process redesign in one hospital (John Hunter in Newcastle) in 2002, and implemented it in 10 Sydney hospitals (Westmead, Nepean, Prince of Wales, Liverpool, St George, Canterbury, Royal North Shore, Gosford, Campbelltown and Wollongong in the financial year 2004–05). After significant success at most sites, the NSW Government funded a 3-year, statewide program. At its peak, the Clinical Services Redesign Program (CSRP) included 75 separate redesign projects in 60 hospitals (Box 3). More details of redesign projects in 23 hospitals and their outcomes are to be found in the appendix to this supplement. A program office was established in NSW Health to manage the CSRP. In addition, four senior managers were appointed within NSW Health to liaise regularly with Area Health Services (AHSs), in which program offices were also established to coordinate programs at the local level and liaise centrally. The CSRP relied on the involvement of frontline staff to participate in projects, and funding was available to release staff to the redesign program full-time. AHSs were set ambitious targets for performance and a regular monitoring system was established for reporting all results across the state, including monthly meetings between chief executives and the health department to discuss performance. Impact was maximised by linking AHS performance to additional funding for beds and elective surgery. A panel of national consulting firms (Accenture, KPMG, PricewaterhouseCoopers and PA Consulting) was retained to provide expert advice to AHSs on undertaking process re-engineering and to facilitate redesign working parties. The firms also assisted in coaching local hospital managers to give them the skills necessary to implement the solutions. They brought a range of business process redesign and re-engineering methods to the CSRP, including “lean thinking”, “six sigma” and the “theory of constraints”.7-9 Staff appreciated the neutrality of external facilitators who were often able to overcome territorial behaviours. Knowledge management was a key part of the program. It was facilitated by regular meetings of senior executives and clinicians, and by workshops on tackling common problems. The program office presented redesigned models of care in easy-to-grasp formats and regularly broadcast and celebrated successes in redesign. The new models of care were accompanied by implementation toolkits available on the Australian Resource Centre for Healthcare Innovations website.10 In addition, the Human Services Network, developed by the NSW Government,11 was used for establishing communities of common interest. The NSW Minister for Health and the Director-General of Health regularly visited sites to review progress and maintain senior executive focus on the outcomes of redesign. Clinician leadership was highly visible through various state-level priority taskforces. Flinders Medical Centre — the Redesigning Care programThe FMC Redesigning Care program is described in more detail in a subsequent article in this supplement (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”).4 It was initiated after an aggregated root-cause analysis of a series of disturbing patient events indicated a major breakdown in the capacity to provide safe care in the ED and elsewhere in the hospital. This prompted the search for an effective improvement strategy. Lean thinking, with its emphasis on methods for looking at end-to-end processes, the creation of flow, the value of patient time and staff expertise, and the recognition that activities which did not add value to patient outcomes were potentially wasteful,7 approved a good fit with the underlying values of the organisation. A small team of clinicians and senior managers learned about lean thinking by linking with local and international experts through Lean Enterprise Australia12 and the global Lean Enterprise network, and by contact with staff from the School of Management at the University of South Australia. A program governance group involving senior clinicians and managers, which reported to the FMC hospital management executive, ensured that the Redesigning Care program worked across the whole hospital and was viewed as a major program. ImplementationBox 4 outlines the stages involved in redesign programs. It reflects the generic approach arrived at independently by NSW Health’s CSRP and the FMC Redesigning Care program, although specifics vary between settings. Initially, the set-up phase involves deciding issues such as the overall scope of the project, the make-up of the redesign team, and the choice of performance indicators. In the diagnostic phase, the mapping of the patient journey identifies the disconnections and facilitates a diagnosis of the problem being tackled, with impressions being confirmed by direct observation and data when relevant. That phase will usually point to a variety of solutions which have the potential to improve flow, increase safety and improve the quality of the processes. Once the redesign solutions are agreed (and this can involve decisions about “hard” territorial issues, such as reallocation of beds between units), they need to be implemented. It is this step of the process that is, by general agreement, the most difficult. If the solutions are novel, they will require considerable skill in implementation, combining project management skills with managing the human dimension of change in a complex hospital structure (see Box 4). This demands a new skillset for health managers who have previously operated in a “command and control” atmosphere. Redesign programs rely on energetic management. The implementers may need coaching in change management and project management techniques, and added support for their increased workload. Managers and staff involved in process redesign also require high-quality, real-time information. Data identifying the nature and extent of problems and evidence of improvements provide the strongest tool with which to engage clinicians in the change process. ConclusionProviding high quality, efficient health care cannot be accomplished without the time and effort required to bring staff together to examine the process of care delivery. The staff need to see the patient journey as a whole. Training and communication with staff about how to undertake clinical process redesign are investments that will ensure the continuing development of improved processes that work for patients and staff alike. 1 Hospital organisation and the patient journey* * Patients move horizontally through a sectional and hierarchical organisation. 2 Mapping a process in the emergency department (ED) In one mapping session in an ED it became clear that an equipment officer had been appointed to distribute patient equipment, including crutches. That officer had to be paged by the nurses before crutches could be dispensed. However, the officer was rarely available immediately. Thus, there was usually a delay, after which the crutches were given out by the ED nurses. It was a simple and effective change to allow ED nurses to dispense crutches directly. 3 Scope of the Clinical Services Redesign Program in New South Wales Location: All NSW Area Health Services (metropolitan, regional, rural) plus statewide projects, including the NSW Ambulance Service Funding: Total over 3 years: $70 million Focus issues: Emergency departments, surgery, patient flow, mental health, cardiology, discharge planning, diagnostics, aged care, chronic care, management support Number of projects: 75 Number of hospitals: 60 Time investment: Over 1200 weeks of full-time project activity, including external expertise 4 The phases of clinical process redesign Program management and communication and change management are an essential and ongoing part of clinical redesign.

David I Ben-Tovim PhD, MRCPsych, FANZCP · Melissa L Dougherty BA(Psych)(Hons) · Tony J O’Connell MB BS, FRANZCA, FJFICM · Katherine M McGrath FRCPA, RCPA, MRACMA

Australian public hospital emergency departments (EDs) have recently been experiencing an overwhelming growth in demand for unplanned care: in New South Wales ED attendances are up 6.5% (Tony Dunn Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication). The most obvious sign of this is a queue of patients on ambulance trolleys, waiting for a bed in the ED. The challenges facing Australian EDs have been described previously in this Journal, and include lack of access to inpatient beds, workforce deficiencies,1 safety issues,2 increased mortality,3,4 and inefficiencies that compound each other. The volume of demand for beds for patients being admitted from the ED often also resulted in a destructive impact on elective surgery.5 We have carried out system-wide redesign in over 60 NSW hospitals (through the Clinical Services Redesign Program) and at Flinders Medical Centre in South Australia (through the Redesigning Care Program) to tackle these issues. The diagnostic phase of our redesign work confirms these previously reported observations, and includes other findings, such as: ambulatory patients were complaining that little information is given about reasons for their long waits or how much longer they will have to wait; patients’ uncertainty and frustration is often expressed by anger and aggression toward staff, or by not waiting to be seen by a doctor; patients in an ED who needed to be admitted to hospital sometimes waited days before being transferred to a ward; patients were often not admitted to their specialist team’s home ward; staff in busy EDs often felt under siege, and there was a mind-set among hospital management and ED staff that if the ED is very busy, the best response is to reduce patient demand by not accepting ambulances, rather than to improve internal hospital processes; when one hospital is busy, so are most hospitals in the vicinity; the overall pattern of presentations to EDs is surprisingly predictable when analysed by season, day of week or hour of day (eg, hospitals are most often congested on Monday afternoons as occupancy peaks because of the combination of elective arrivals, ongoing emergency arrivals and the delayed departure of inpatients because the rate of discharge at weekends is reduced); and congestion in ED is contributed to by inefficient flow of patients through the entire hospital, as well as inefficiencies within the ED. Clearly, an annual growth in hospital ED demand across Australia of about 5%–8% per year (Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication) cannot be accommodated by ambulance diversion. Previous explanations for the challenges in EDs have focused on a lack of inpatient beds and workforce deficiencies. While these clearly contribute, our redesign work has identified numerous correctable issues which, when addressed, permit substantial improvements in performance with modest increases in bed capacity and workforce. Examples include such mundane issues as the mismatch of staff rosters to patient attendances and the predictable adverse impact of junior medical staff term rotations. Time-consuming processes within emergency departmentsIncreasingly, patients in EDs are older6 and frail, with multiple problems that take many hours to assess. Such patients can be hard to place with medical teams, which have become increasingly specialised around single-organ diseases. Teams may not feel confident outside their subspecialty and may be reluctant to accept the patient. Another large patient group is people with chest pain, who are managed under treatment protocols that require them to wait many hours for tests to exclude a cardiac cause. Patients of all kinds are often assessed first by junior medical staff, who then present the problem to registrars and then to ED specialists. Thus, decisions about treatment can be delayed for hours. Once assessed by ED staff, patients often need further assessment by specialty teams who may be unable to attend immediately because of other commitments. Patients also wait in the ED for test results while diagnostic departments process samples from all parts of the hospital, and patients from the ED are not necessarily given priority. Problems in the wardsOur diagnostic work during the redesign of patient flow through hospitals confirms that congestion in ED is exacerbated by systematic failure to manage the processes and rate-limiting steps involved in patient progress through the hospital. Typical examples include: the often haphazard nature of discharge planning; the dependence on visits by medical staff for decisions, despite the routine nature of most patient journeys; the lack of a shared understanding among staff, patients and carers of the likely patient trajectory; and the compounding impact on the incidence of adverse events and increased length of stay if patients aren’t nursed in their “home ward”. Clinical redesign solutions: a whole-of-ED management systemOur experience is that redesigning patient journeys makes it possible to improve flow for all three major patient groups presenting at EDs — those who don’t require admission, those requiring only a short admission, and those requiring a longer admission. Preventing unnecessary hospitalisationA large number of patients who have historically stayed in hospital for only 1–2 days have conditions such as cellulitis, deep vein thrombosis and community-acquired pneumonia that are amenable to safe management in the community using “hospital in the home” models.7 Home-based care can also be preferable for older people, who often become confused and debilitated in hospital. Other advantages of community-based care include the reduced risk of hospital-acquired complications, and that such care can replace the final portion of an otherwise longer hospital stay. Smoothing the load before arrival at hospitalLoad levelling between EDs can be significantly improved by introducing ambulance case-distribution algorithms to minimise clustering of ambulances at any one ED. This removes the concept of bypass, replacing it with the concept of each hospital accepting the expected load from its community and having plans in place to handle surges in demand. When specialty service availability is also factored into the distribution algorithm, this load levelling ensures that patients are taken to a hospital that will provide the necessary services in a timely manner. This approach requires regional planning. We believe its introduction as part of system-wide redesign in metropolitan NSW has been a significant contributor to reduced ambulance response time despite rising demand. Implementing solutions for patients who do not need admission: streamingIn NSW in the 2005–06 financial year, 40% of patients admitted to public hospitals came through EDs (Tony Dunn Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication), and these patients are demanding on ED staff time. However, the number of patients attending EDs is over 2 million per annum in NSW, and 77% are not admitted (Box 1). Redesigning pathways for this large group is potentially very beneficial, as moving them quickly through the ED can reduce congestion and frustration and improve the safety of care. A number of care models have been used in NSW to achieve this effect, such as “fast track zones”, advanced practice nurses, and rapid assessment teams. Fast track zones stream patients with conditions of lower urgency or complexity, especially those who are ambulatory, into a separate zone of the ED where they are attended by a separate group of ED staff. Having experienced staff in this zone permits rapid decision making and faster handling. Medical staff can be supplemented in this model by nurse practitioners and experienced physiotherapists (used at Liverpool Hospital for minor musculoskeletal conditions), who are able to efficiently and independently manage a large subset of these patients and achieve high patient satisfaction.8 Protocol-based nurse-initiated ordering soon after patient arrival has reduced time to analgesia and decision making. Rapid assessment teams permit assessment, diagnosis and simple treatments to begin soon after the patient arrives. At John Hunter Hospital, ED patients are directed into one of three streams: high acuity/high complexity; low acuity/high complexity; or fast track (low acuity/low complexity). The groups are allocated to separate teams. There have been improvements in access block and triage time and a reduction in ED length of stay for both admitted and discharged patients. At Flinders Medical Centre, patients who present to the ED have been streamed into two broad categories — those most likely to go home and those most likely to need admission. These groups are treated within two separate areas of the ED by distinct staff. Except for patients with time-critical presenting problems, patients are seen in their order of arrival rather than by triage category. This simple approach has resulted in improved access for both groups of patients and has reduced the rate of adverse events. Implementing solutions for patients requiring short admissions (less than 48 hours)Many patients require only a relatively short inpatient period of monitoring once their initial assessment and treatment has been completed. Ten per cent of ED attendances in NSW result in a hospital stay of less than 48 hours (Box 1). A number of hospitals have established wards where short-stay patients are managed together, grouped by their likely duration of stay or other characteristics. This can improve the quality of the patient experience and reduce time spent in hospital. Very short-stay units, such as 12–24-hour wards adjacent to EDs and managed by ED physicians (emergency medical units or short stay observation units) are now common. Wards with stays up to 48 hours managed by inpatient services have also been established. At the Flinders Medical Centre, a short-stay ward for patients whose predicted length of stay is less than 72 hours cares for both medical and surgical patients in the same ward. That one ward now manages around a quarter of all adult overnight, emergency admissions. Short-stay wards work well when care is straightforward, protocols for common conditions are well developed, and nurses are empowered to advance patients to the next step in their treatment pathways once agreed criteria are met. The most important feature of these wards is the mindset for patients, their carers and staff that the patient will stay only the designated time period. This drives the development of good systems to standardise and coordinate care pathways and avoid delays so that patients can be transferred to the next stage of their journey in a predictable process. Short-stay wards can be better places than the ED for patients who need a prolonged period of investigation, assessment or monitoring before the decision is made as to whether they need to be transferred to a specialist team. Implementing solutions for patients requiring longer admissionsThe challenge for hospitals in managing patients who stay more than 48 hours is to guarantee processes that support smooth flow through the hospital from presentation to discharge, with minimal waste of time and effort. In NSW, 13% of ED attendances result in hospital stays longer than 48 hours (Box 1). The following clinical process redesign solutions have been found to enable a faster, safer, more efficient patient journey through the hospital. Solutions relating to the EDElectronic ambulance arrivals boards, linked to ambulance control rooms, can alert ED staff to imminent arrivals and to pending surges in demand. Use of non-clinical staff, a better staff skill mix and clearer allocation of roles according to skills can allow tasks to be performed by the appropriate category of staff, thus freeing more highly trained staff for tasks that only they can undertake. Identifying a manager who is responsible for overseeing patient flows in the ED and redistributing workloads or activating escalation plans at peak periods. For a complex system such as an ED to function well in the face of high and fluctuating levels of demand, staff need a clear chain of command. Solutions relating to the wardsProcesses in the wards that “pull” patients who need admission out of the ED to the wards, rather than waiting until there is an overflow in the ED causing a “spill” or “push” of patients from the ED to the wards. This requires cooperation between nurse unit managers to facilitate transfer of patients. Regular review and modification of bed allocations to minimise “outlier” patients (those in a ward that is not the designated ward for their condition). This is an essential step, although often contentious, as number of beds is seen to equate to the status of a unit. It benefits clinicians by reducing time spent travelling between wards, and ensures skilled teams who are familiar with the patient’s disease manage the patient. The benefits to patients include a better journey and higher quality care with reduced errors and fewer delays. A daily morning ward meeting, led by the nurse manager, where medical, nursing and allied health staff meet for a short focused discussion of each patient. The patient’s journey is reviewed to determine what needs to happen next, and who will do what, by when. This ensures better coordination, and that clear work plans are made for the day, thus reducing the number of frustrating telephone calls to gather and share information. Information technology solutions such as a hospital electronic bed board have also been found to be effective. They provide bed managers and nurse unit managers with a clear picture of pending emergency and elective demand, and of available capacity. We have introduced electronic bed boards in over 100 hospitals in NSW. Universal discharge planning, with all patients having an estimated date of discharge from the time of admission. This allows better preparation for discharge, ensuring all referrals have been prepared, medications are ready, and carers are prepared to receive the patient at home. Solutions relating to the whole hospitalAdmission rules to guarantee that all patients (especially those who have complex, multiple problems) are rapidly allocated a specialist. Clear rules about how ED staff will communicate with in-patient teams (including accountability for decisions about patients) and commitment from inpatient teams to rapidly attend the ED as needed. Direct admission to the appropriate specialty ward for patients with chronic disease who are well known to the hospital. This avoids patients having to wait and repeat their complex medical history and ensures they are treated by the team who know them. Access to accurate, current data for clinical staff and hospital managers to interpret patient flows through the hospital. Real-time analysis of performance and the ability to establish the root causes of patient flow blockages are crucial. Having a patient flow unit reporting to an accountable senior manager is an important component of a well managed system. More efficient communication between teams through the use of mobile phones and other new technologies, thereby delivering the right care to patients in a timely manner. This improves patient flow and also reduces staff frustration. ResultsOverall statewide performance on emergency access key performance indicators (KPIs) has “turned around” since the implementation of the Clinical Services Redesign Program commenced in NSW in August 2004. Performance for the three most challenging KPIs, emergency admission performance (percentage of patients admitted through the ED who egress from the ED within 8 hours), triage 3 performance (percentage of patients in triage category 3 whose treatment is commenced within 30 minutes of arrival), and off-stretcher time (percentage of patients moved off an ambulance stretcher into an ED bed within 30 minutes of arrival) had been progressively deteriorating before the implementation of solutions arising from redesign in August 2004. Since the Clinical Services Redesign Program was implemented, performance has been improving, as shown in Box 2, Box 3, and Box 4. These results are not just a one-day snapshot; they reflect millions of ED attendances throughout NSW, rising to over 1.8 million attendances in the final year represented in each graph. Importantly, they highlight how NSW performance in all three parameters was previously progressively deteriorating until redesign commenced. The performance of a sample of 19 NSW hospitals (including the 10 with the busiest EDs) that underwent redesign of emergency patient flow is detailed in Box 5, showing that even in the face of rising demand (of between 5% and 27%), performance improved or was maintained in 52 of 57 instances for the three KPIs presented. ConclusionIn the face of rising demand, redesign of clinical processes in hospital wards as well as within EDs is essential for improving patients’ access to emergency care. By setting hospital bed capacity at an appropriate level, raising the awareness of and accountability for performance indicators, and redesigning the processes that underpin clinical care and the patient’s journey, we have found that poor performance can be turned around across an entire state and this improvement can be sustained. 1 Disposition of patients from New South Wales emergency departments Data covers 1.7 million NSW public emergency department attendances in the 2005–06 financial year. Source: Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, December 2007. 2 Emergency admission performance* in New South Wales hospitals, 1995–2007 ED = emergency department. CSRP = Clinical Services Redesign Program. * Percentage of patients admitted through the ED who egress from the ED within 8 hours. 3 Triage 3 performance* for New South Wales hospitals, 1995–2007 CSRP: Clinical Services Redesign Program. * Percentage of patients in triage category 3 whose treatment is commenced within 30 minutes of arrival. 4 Off-stretcher times* for New South Wales hospitals, 2002–2007 CSRP: Clinical Services Redesign Program. * Percentage of patients moved off an ambulance stretcher into an emergency department bed within 30 minutes of arrival. 5 Emergency performance indicators in 19 New South Wales hospitals for the financial years 2004–05 to 2006–07 Demand increases (%) Outcomes (percentage point change*) Hospital ED attendances Admissions through the ED EAP Triage 3 Triage 4 St George ↑ 18% ↑ 16% ↑ 16 ↑ 23 ↑ 19 St Vincent’s ↑ 26% ↑ 29% ↑ 11 ↓ 3 ↑ 4 Prince of Wales ↑ 18% ↑ 25% ↑ 13 ↑ 17 ↑ 13 Sutherland ↑ 20% ↑ 28% ↑ 22 ↓ 2 ↑ 10 Wollongong ↑ 18% ↑ 16% ↑ 20 ↑ 24 ↑ 16 Royal North Shore ↑ 18% ↑ 18% ↑ 5 ↑ 3 ↑ 5 Bankstown ↑ 27% ↑ 13% ↑ 34 ↑ 8 ↑ 16 Concord ↑ 19% ↑ 6% ↑ 24 ↑ 4 ↑ 9 Campbelltown ↑ 27% ↑ 6% ↑ 2 ↑ 14 ↑ 12 Liverpool ↑ 22% ↑ 45% ↑ 10 ↑ 21 ↑ 16 Royal Prince Alfred ↑ 20% ↑ 34% ↑ 12 ↑ 14 ↑ 8 Tweed ↑ 5% ↑ 43% ↓ 12 ↑ 5 Steady The Children’s Hospital at Westmead ↑ 22% ↑ 16% ↑ 9 ↑ 21 ↑ 23 Blacktown ↑ 18% ↑ 11% ↑ 18 Steady ↑ 5 Newcastle Calvary Mater ↑ 16% ↑ 20% Steady ↑ 4 ↑ 4 John Hunter† ↑ 12% ↑ 18% ↑ 21 ↑ 30 ↑ 32 Gosford ↑ 9% ↑ 6% Steady ↑ 7 Steady Westmead ↑ 24% ↑ 23% ↑ 11 ↑ 31 ↑ 28 Nepean ↑ 22% ↑ 21% ↑ 12 ↓ 3 ↑ 4 ED = emergency department. EAP = emergency admission performance (% of admissions through ED who egress from the ED within 8 h). Triage 3 is the percentage of patients in triage category 3 whose treatment is commenced within 30 minutes of arrival. Triage 4 is the percentage of patients in triage category 4 whose treatment is commenced within 60 minutes of arrival. * Percentage point change (eg, improvement from 63% to 75% is ↑ 12). † John Hunter outcomes data cover the period commencing in 2002, as redesign commenced earlier in this hospital. Source: Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, December 2007.

Tony J O’Connell MB BS, FANZCA, FJFICM · Jane E Bassham RN, BN · Rod O Bishop BSc(Med), MPH(Hons), FACEM · Christopher W Clarke PhD, LLM, FRACP · Carolyn J Hullick BMed, DipPaed, FACEM · Diane L King MB BS, FACEM · Carmel L Peek RN, BHA · Raj Verma BSc, GradDipBus · David I Ben-Tovim PhD, MRCPsych, FRANZCP · Katherine M McGrath FRCPA, RCPA, MRACMA

Lack of focus on the need to balance the hospital resources required for both emergency and planned demands often leads to emergency patients taking precedence in being admitted, and the resultant cancellation of planned admissions. This had been the situation in the New South Wales health system for many years. The interminable increase in the waiting list size is the inevitable consequence. Over the past few decades, advances in technology in both surgery and anaesthesia have facilitated shorter lengths of stay in hospital for patients undergoing planned procedures. Many patients require only a few hours in hospital, or a stay of less than 24 hours. Much of the growth in demand for surgery could be accommodated by more use of day-only or extended day-only models of care. The previous article in this supplement (→ Clinical process redesign for unplanned arrivals in hospitals) discussed redesign solutions for unplanned arrivals at hospitals.1 Here, we will consider the application of the Clinical Services Redesign Program to planned arrivals in NSW hospitals. Diagnosing the problems with planned arrivalsA number of factors contributing to the problems resulting from planned arrivals have been elucidated in the diagnostic phase of the redesign method. They are discussed in the following sections. Pattern of planned arrival flowsAs the previous article in this supplement (→ Clinical process redesign for unplanned arrivals in hospitals) shows, unplanned hospital demand is predictable over time, and the degree of randomness or variability is relatively small.1 On the other hand, analysis of the planned hospital demand over time commonly shows large variability in the patient flows on a daily basis. Planned arrivals are largely scheduled to suit clinician preference rather than being spread evenly across the full working week. The result is a high planned patient load early in the week and a lighter load at the end of the week. Unfortunately, the unplanned demand also peaks at the beginning of the week because of a reduced discharge rate at weekends. Smoothing out the variability in the scheduling of planned arrivals will reduce this potential source of capacity stress in hospitals and will improve the overall ability of the hospital to deal with the natural variability of arrivals.2,3 Managing planned arrivalsNSW hospitals have lacked a purposeful approach to managing the demand for planned surgical procedures. An essential component of managing any system is information about internal and external influences to make it possible to track and predict changes in demand. To date, good management information (eg, waiting list profiles, theatre session utilisation lists) has not been readily available to managers or staff. Waiting list control and managementCategorising patients on the waiting list requires more precision than has previously been used. The categories used are: Category 1 (admission desirable within 30 days); Category 2 (admission desirable within 90 days); and Category 3 (admission desirable within 365 days). Placing large numbers of patients in Category 1 (considered “urgent”) places considerable stress on the system to schedule their surgery within 30 days; this inevitably increases waiting times for patients not in the urgent category. Patients are prioritised on a waiting list in order of urgency, but they frequently have their surgery performed in a more random order based on clinicians’ preferences related to their operating theatre (OT) lists. This queue jumping leads to longer waiting times for many patients. In NSW, the number of patients waiting more than 12 months for planned surgery had continued to increase between 1995 and 2004, reaching an unacceptable level of 10 551 patients in January, 2005. Operating theatre and procedure room utilisationEfficient preadmission and OT processes are necessary to avoid cancellation of planned procedural or operative interventions. Cancellation rates resulting from bed unavailability, patients being medically unfit or not arriving, and emergency surgery load were 10%–15% in some facilities. The resultant financial cost to the system of a fully staffed and equipped OT remaining idle is considerable, and patients and their families bear a significant social and financial burden (Box 1). Applying clinical services redesign to the planned patient journeyThere are multiple steps in the redesign of the journey for a patient being admitted for a planned procedure. The main components for the redesign of the planned patient journey, whether for a short stay or a more prolonged admission, are shown in Box 2. This simple schema covers the patient journey from referral through to discharge. The redesigned planned patient journeyThe main components of the planned patient journey, once redesigned, will facilitate the management of an efficient, cost-effective, safe and high-quality service. Integrating the components requires that management take responsibility for the whole patient journey, avoiding multiple managers and multiple interfaces. The components of the patient journey are described below. Planned surgeryAn essential component in managing planned arrival demand is ensuring that the capacity of the system, including beds, staff, equipment, and OT sessions are matched with the demand. Inhouse software programs have now been developed to provide managers with the ability to estimate future planned and unplanned demand based on trended demand data for the state and for individual hospitals. An additional inhouse software program monitors the waiting list and forewarns managers about patients nearing their maximum waiting time at facility level, and ensures that patients on the waiting list have a planned admission date. Waiting list managementWaiting list management should ensure that all patients have their procedures in an appropriately prioritised and timely manner. In NSW, major changes were made to waiting list processes as part of the Clinical Services Redesign Program, and resulted in the 2006 publication of NSW Health’s Waiting times and elective patient management policy.4 In addition to this policy, specific guidelines for prioritisation of urgent conditions have been developed, and only patients with these diagnoses are automatically placed in Category 1 by booking-office staff.5 An opt-out system is in place and altered priority categorisation can be organised through the Area Director of Surgery, who is a surgeon. The Area Director makes the final decision, usually after consultation with the clinician concerned. A patient is not placed on the waiting list if his or her surgeon does not have sufficient OT time available to do the surgery within the required timeframe. Instead, discussions are held with the surgeon to determine how additional OT time could be made available, or the patient is referred to a surgeon who can perform the surgery within the timeframe. Implementation of this policy ensures that the patient is admitted in the shortest time within their priority category and prevents queue jumping. Preadmission processesThe Pre-Procedure Preparation Toolkit (PPPT)6 is an essential determinant for success and defines the processes to prepare the patient medically, socially and administratively. In the Clinical Services Redesign Program, it was recognised that patients should not be required to visit the facility for anaesthetic assessment unless absolutely necessary. Thus, a triage system has been adopted which uses a standardised patient health questionnaire — this is an internationally accepted practice. The preadmission process is also used to assess patients’ postdischarge needs and to ensure that appropriate plans and resources are in place when patients are ready for discharge after their procedures (eg, home-based rehabilitation following hip replacement surgery, home help, etc). Bed management for planned proceduresThe number of beds needed for planned procedures is relatively small if the advances in technology that reduce the length of inpatient stay are applied effectively. One way of ensuring that planned demand requirements are met is to use admission configurations more suited to the planned arrivals than the unplanned arrivals. The extended day-only (EDO) model mandates a stay of less than 24 hours with patients being managed according to agreed protocols. Under the EDO model, patients are less likely to have their procedures cancelled and discharge is predetermined by a specific protocol.7 In NSW, the identification of diagnosis-related groups (DRGs) suitable for the EDO model, together with policy support, has led to a significant increase in these designated DRGs going through as EDO admissions in line with the expectations of reaching the 80% target. Theatre utilisationIt is well recognised that efficiency in managing planned procedures relies heavily on OT efficiency. Cancellation rates increase as OT efficiency decreases, with resulting costs to the system and to patients and their families. Late starts and overruns are acknowledged to contribute significantly to a lower level of OT efficiency. Since the Clinical Services Redesign Program was implemented, theatre staff have been working with surgeons to improve the accuracy of theatre lists so that the number of cases listed is appropriate for the time available (Box 3). Moving appropriate procedures (eg, endoscopy, flexible cystoscopy) out of the operating suites reduces competition with major surgical procedures for a limited number of sessions. Where possible, patients undergoing these procedures should continue to recover in the OT recovery suite for efficient use of resources. Postprocedure processesThe emphasis on protocol-based management of patients throughout their journey provides significant benefits to both patients and staff in terms of certainty of purpose and the perception of a well organised experience. Discharge planning and protocol-based patient management are part of the PPPT, and are essential components of the EDO model of care. Support servicesInformation technology is required in the OT environment to provide the necessary data for information management. Planning of sterilising services, transport services and radiological services, to name a few, also need to be integrated into OT scheduling. The management of OTs has been hampered by the variable quality of data management systems, thus making review of OT utilisation difficult. The electronic medical record scheduling system currently being rolled out across NSW will improve the quality of OT scheduling, and the improved information technology support will assist in more automated and integrated data collection. Results from redesign of planned arrivalsThe initial results from the clinical process redesign of planned arrivals are impressive. Within a relatively short time there has been a significant increase in more timely patient access to treatment. It is anticipated that the redesign processes will continue to improve the delivery of services for planned arrivals. The results of the redesign are summarised below. The total waiting list has been reduced from 68 451 in January 2005 to 56 640 in June 2007. A 97% reduction in the numbers of patients in the Category 1 (admission desirable within 30 days) whose surgery was overdue, from 5308 in January 2005 to 135 in June 2007 (Box 4). This improvement was sustained through the winter period. A 99% reduction in the number of patients who have waited more than 365 days for surgery, from 10 551 in January 2005 to 84 in June 2007 (Box 5). Between January 2005 and June 2007, average waiting times for patients on the waiting list in categories 1, 2 and 3 decreased: Category 1, 70 days to 12 days; Category 2, 141 days to 72 days; and Category 3, 226 days to 122 days. ConclusionsApplying clinical redesign methods to the planned patient journey has successfully allowed management to recognise the blocks and inefficiencies, and to facilitate the development of solutions for improvement. The redesign solutions require committed clinician support and strong managers to ensure their implementation, and a robust performance management system for sustainability. With these in place, the improvements are unquestionably impressive, not only in terms of efficiency, safety and quality gains but also for enhancing patients’ experiences. 1 Gains from improving efficiency of operating theatre use In one Area Health Service, it was determined that the total operating theatre (OT) time unused or poorly used because of late starts, delays and overruns was approximately 11 600 hours across all their facilities. It was estimated that if this waste was decreased by 10%, there would be sufficient sessional OT capacity to halve that Area’s waiting list without increased staffing or resources. 2 Schema of the main components for the redesign of the planned patient journey 3 Simple solution to improve operating theatre efficiency Sydney South West Area Health Service (AHS) successfully improved efficiency by planning an increase of one procedure per operating theatre in every second session. Across the hospitals in that AHS, this would increase the number of procedures by 7000 per annum without changing the number of sessions or the amount of staffing. Coupled with better defined processes concerning surgery start time, they also successfully reduced overruns. 4 Numbers of Category 1 patients* waiting > 30 days for surgery in New South Wales hospitals, January 2005 to June 2007 * Admission desirable within 30 days. 5 Numbers of patients waiting > 365 days for surgery in New South Wales hospitals, January 2005 to June 2007

Donald G MacLellan BSc, MD, MBA, FRACS · Patrick C Cregan FRACS · Brian C McCaughan FRACS · Tony J O’Connell MB BS, FRANZCA, FJFICM · Katherine M McGrath FRCPA, RCPA, MRACMA

In November 2003, the Flinders Medical Centre (FMC), a 500-bed teaching general hospital in the southern suburbs of Adelaide, initiated a program of clinical process redesign across the entire hospital. Redesigning Care, as the program is known, is based explicitly on applying an approach called “lean thinking”,1 which was developed in the manufacturing sector, to health care. The FMC provides the whole range of secondary and tertiary services required by its community, but its main focus is on providing time-urgent, complex care. The extensive nature of the Redesigning Care program, and its focus on a specific improvement method, may be of interest to those outside our centre. Redesigning Care can be considered in three broad phases: “getting the knowledge”, “stabilising high-volume flows”, and “standardising and sustaining”. Phase 1: Getting the knowledgeIn 2003, the emergency department (ED) at FMC saw around 45 000 patients, 40% of whom were admitted to hospital. In that same year, the number of patients seen per day peaked at around 140 once or twice per week during the winter period. At this time, congestion in the ED had become so severe that the recovery area of the operating theatre suite had been taken over as an extension of the ED. There was bitter conflict between staff, key senior clinicians were prepared to leave, the “blame game” was pervasive, and surgical and medical programs were proving hard to sustain. An aggregated root-cause analysis of a series of deaths in the ED and elsewhere in the hospital made it clear that, despite having implemented a range of strategies to relieve congestion,2 the capacity to provide safe care was under threat. As clinicians and senior managers, we were united in acknowledging that we needed to do something, but we did not yet know what or how. We were fortunate to obtain a key piece of advice from a member of the then United Kingdom National Health Service Modernisation Agency,3 who advised that sustainable change requires as much care in developing an improvement team, as in the improvement interventions themselves. Consequently, the Redesigning Care team — comprising three experienced clinicians designated as clinical facilitators, and a part-time director who was also a member of the hospital executive — was formed. GovernanceThe hospital management executive is the authorising body for all redesign activities at FMC. The Redesigning Care program itself is managed by a reference group of the most senior hospital executives, plus the redesign team. Clinical leaders from the major clinical divisions take leadership roles in their own areas, and each major work program involves an executive sponsor from outside the relevant operational division. Why “lean thinking”?Lean thinking1 is an approach to the redesign of complex processes derived from methods developed in the manufacturing sector. Successful modern manufacturers, such as the Toyota Motor Corporation, are concerned with the timely, safe manufacture of a diverse range of cars or other goods, in large volume and at high quality. We also faced the challenges of volume, timeliness, diversity, and safety and quality, and after an early success with applying lean thinking, we elected to use it as the basis for our whole program of clinical process redesign. While lean thinking remains at the heart of the Redesigning Care program, over time we have borrowed from many other manufacturing philosophies. Getting the technical knowledgeAs an improvement team, we needed to “get the technical knowledge” for redesign. Team members read the existing texts on lean thinking,1 and the team and hospital senior managers spent 2 days with a lean thinking expert from Lean Enterprise Australia. We also received generous support from the staff of the School of Management at the University of South Australia, where the team plus senior managers also participated in a Diploma in Lean Manufacturing. Through these contacts, we all came to appreciate the complexity of other service and manufacturing industries, and the seriousness with which quality control is approached outside health care. Knowledge of lean thinking principles and practices helped us develop a new way of looking at our work, moving away from a craft-group skill base (eg, medical care, nursing) or a body system orientation (eg, cardiovascular, respiratory) towards a process view where the care is seen as the outcome of a sequential series of steps through a sectional and hierarchically organised institution or service (see illustration in "Patient journeys: the process of clinical redesign").4 Lean thinking principles need to be adapted to the specifics of health care,5 but adaptation is necessary for every setting in which lean thinking is applied, and the basics of process improvement are as appropriate for health care as they are for other service and manufacturing industries (Box 1). From the outset, we realised that the Redesigning Care program was a change management process. Putting lean thinking into a broader change management context provided us with our overall redesign method (Box 2). The Redesigning Care facilitators have developed substantial knowledge about process redesign. They begin a program of work by working with the senior staff involved to determine the scope of that piece of work: what is being “made” (is it a clinical service, a document, a report, or what?); where the process begins and ends; who uses what is being made overall, and at each step; and what do these “customers” value? There are two kinds of customers for a process at FMC: the patients for whom the care is provided, and the staff member or staff group next in line in the care process. The facilitators then bring multidisciplinary groups of frontline staff together to diagnose process problems using mapping and staff “tag-alongs”, documenting actual practice (→ Patient journeys: the process of clinical redesign).4 Those same groups identify opportunities for redesign and make the necessary changes by means of a series of plan-do-study-act cycles6 (Box 2), each of which is evaluated according to relevant measures identified in the diagnostic phase. The key measurement issue is: how can we tell if what we have done has made things any better? As far as possible, the processes and outcomes measured need to be important to both the patients cared for by the institution and the practitioners. Separate measures may be required to capture these different concerns. Progress can be made quickly in some programs of work. The initial change to the flows within our ED were planned and executed within weeks. Other programs, such as the redesign of the flows of medical inpatients admitted as emergency cases, take concerted efforts over long periods. Complex areas of work are visited and revisited in a process of continuous improvement. The facilitators also work on developing widespread understanding of lean thinking principles and practices. They communicate them in a variety of ways, including lean thinking education days for large numbers of staff, open staff meetings, newsletters and an intranet site. Phase 2: Stabilising-high volume flowsAt the outset of the Redesigning Care program, we tried to improve the flow of patients presenting as emergency cases. We undertook a series of mapping sessions, looking at the hospital services in the greatest difficulty — the ED and adult medical and surgical inpatient services. By improving the flow of patients through these services, we aimed to improve safety, reduce congestion, and restore the integrity of our surgical program. The mappings brought together large numbers of staff from each service who plotted out the end-to-end journeys taken by typical patients. “Short” and “long” patient-care familiesPatient-care families are groups of patients with a number of processing steps in common. A key lean thinking strategy is to look at the processing steps of patient-care families from end to end, to improve the sequencing of the processes involved. In lean thinking, those sequences of steps that add value or materially improve the care for patient-care families are called value streams. The mapping revealed both problems and similarities across services. Time and again, clinicians differentiated groups of patients whose care was relatively straightforward and likely to be completed in a limited number of processing steps, from patients with more complex problems who will require more processing steps. We started to recognise that “short” and “long” constitute a basic method for identifying patient-care families and their end-to-end value streams. Short patient-care familiesShort patient-care families are those whose care involves a limited number of processing steps, most of which will be undertaken by clerical and nursing staff. This is not to downplay the skills of clinicians, but the clerical and nursing elements in the journeys of short patient-care families are not only numerically the most frequent, but are also surprisingly similar, even when the clinical specifics differ widely. Short care requires concentrated and focused effort to complete all the necessary processing steps related to admission, assessment, treatment and discharge in a timely manner. Our experience is that this is best managed by enabling nursing and clerical staff to focus on that type of work without trying to juggle the continuing demands of patients requiring longer care. Early interventions at FMC streamed all ED patients into either a short-care (likely to be discharged) stream, or a longer-care (likely to be admitted) stream.7 This was followed by the development of a short-stay (less than 72 hours) medical/surgical emergency inpatient ward within the body of the hospital.8 Patients continue to be discharged in a timely manner from that ward no matter how congested the rest of the hospital becomes, thus aiding patient flows. Indeed, at times, up to a quarter of all adult inpatient emergency admissions are managed through this one ward of 26 beds. Long patient-care familiesHospitals such as FMC need to be able to provide for the care needs of patients with severe, complex or multidimensional problems. Rather than trying to improve the specific treatment protocols for these long patient-care families, we began with programs of work on two common elements of long processing: medical “take” and bed management. Medical take refers to the process whereby medical teams are rostered to take all emergency admissions of designated types over a “take” period, with a new team taking over at the end of the take period, be it 24 hours, 48 hours or longer. The take team then continues the care of patients who are not referred onward to specific specialty groups. Dismantling “take”, and “pull” rather than “push” bed managementAn important goal of the long patient-care family teams was to minimise the time patients spend as outliers in wards other than the home ward of the treatment team. A multiyear, multigroup program balancing workloads and bed capacities between highly specialist and generalist medical teams set the scene for a major practice change — dismantling the existing medical take system (in which hospital teams are rostered to take what may be large numbers of unplanned arrivals and process those patients). In a busy hospital, take is a source of substantial day-by-day variability in the number of patients cared for by each team. The new system involves patients either being allocated directly to a highly specialised unit, or, if a period of further clinical “sorting” is required over and above that undertaken in the ED, patients are referred to an acute medical assessment unit for the first 12 hours of their care. From there, medical emergency patients in long patient-care families are assigned to home teams at a consultant-led team meeting every morning, where allocations are balanced so as to keep numbers relatively even between teams. These changes have gone hand-in-hand with a change to the bed management system. The change involved moving away from a central bed manager “pushing” patients into any available bed to instead functioning as a facilitator to help wards develop a structured process to “pull”. Thus, ward staff pull or find those patients from settings such as the acute medical assessment unit, the ED and high-dependency areas who best fit their ward care profiles, and move them expeditiously into their wards. The overall outcomes for the amount of time patients spent as “ward outliers” is shown in Box 3. Other interventionsA lengthy program rebalancing surgical waiting list structures, together with improved access to a small number of overnight-stay beds, enabled our surgical elective program to be restored to near full function. This strategy was aided by the enthusiastic uptake of clinical practice improvement initiatives throughout the surgical services, and this enthusiasm then spreading within the hospital. Detailed programs of redesign in important support areas such as pharmacy and central sterile supply were also undertaken during this period. Phase 3: Standardising and sustainingWith a well conducted diagnostic phase and frontline participation, new ways to improve clinical processes readily emerge. Sustaining changes and making them “the way that is done around here” is a continual challenge. The key to this task seems to be creating standardised processes. This has always been challenging in health care where autonomy is held dear, but lean thinking is concerned with standardising processing sequences, not with changing the conduct of care itself. Once the best, most efficient and most effective way of undertaking a process has been developed and agreed on, it should become “standard work”.1 This standard work is developed and continually improved by the people who do the work. Examples from two different areas illustrate this process. 5S Hospitals, as workplaces, are often disorganised. People spend long periods of time just looking for things. Workplace organisation is a key feature of many lean thinking practices. It is reified under the rubric 5S (Sort, Set in order, Shine, Standardise and Sustain),9 which designates a set sequence of actions. When redesigning the provision of discharge medication, it became clear how much time rotating and relieving staff spent in the ward medication storage areas just looking for medications. In response to this, a standardised medication storage and labelling process was developed by a multidisciplinary team. Teams of nurses from each ward then reviewed their medication cupboards, implemented the standard format and agreed how and by whom the improvement would be maintained. The process then became a standard part of daily ward work. Rotating and relieving staff in particular appreciate the time saved when moving from ward to ward. Many different 5S programs are being implemented across FMC, from the ED to the operating theatres. The resulting easier working conditions are valued by all concerned. Ward rounds and discharge summariesWard rounds are the key decision-making process in the medical day. A program of work has been undertaken to standardise the structure of ward rounds, especially those relevant to the care of patients with complex medical problems. The original aim was to improve the timing of decisions relating to discharge. This involved mapping out the daily processes for clinical teams, then obtaining agreement on new sequences. The new sequences involve protected time for junior staff to process and review potentially dischargeable patients before the arrival of the consultant for the morning round, allowing the round to start with the potentially dischargeable patients. A further period of protected time for the junior medical staff later in the day allows administrative processes to be completed. Serendipitously, it was found that this dramatically improved the capacity to complete discharge summaries in a timely manner, and a major program of work was developed around this opportunity. Standardising aspects of the way junior and senior medical staff organise their day across the hospital has increased the percentage of patients with complex medical problems whose discharge summaries were completed within 24 hours of discharge from around 40% to over 80%. Our goal is to raise this to at least 90% of discharge summaries by the end of this calendar year. OutcomesWhen the Redesigning Care program began in November 2003, the ED was struggling to cope with 140 patients arriving each day. The ED now routinely sees between 180 and 210 patients per day (an increase in demand of up to 50%) and manages them within the same physical space and with similar staff–patient ratios as previously. We have not had to resort to using the recovery area for overflow, and Box 4 and Box 5 show that overall processing outcomes have generally improved despite the increased numbers of arrivals. The small decrease in the percentage of patients in triage category 2 whose meaningful treatment was commenced within 10 minutes represents additional delays of 1 or 2 minutes, and has not been accompanied by any change in clinical outcomes.7 The number of patients leaving the ED without waiting to be treated declined sharply after the introduction of new processing sequences and improvements in aligning staff with those sequences, and has stayed low (Box 6). This is a concrete demonstration of patient satisfaction with the services provided. There have been other benefits. Staffing has stabilised within the ED and across nursing services throughout the hospital. Towards the end of the financial year 2005–06, the hospital reported only six nursing vacancies across a service with almost 2000 staff. Reassuringly, the number and types of serious adverse events throughout the hospital have declined strikingly since the beginning of the Redesigning Care program. In the financial year before the program began, the hospital made 91 notifications of serious medicolegal adverse events to its insurers. In the past financial year, the whole region, of which the hospital is the largest service, generated only 19 such referrals. This is despite the average overall numbers of emergency admissions increasing from 1200 per month at the onset of Redesigning Care, to over 1600 per month at present. (In Box 7, the increase in separations relates to the adult medical and surgical activity.) Length of stay for medical patients admitted as emergency cases has fallen by about a day since the Redesigning Care program began, saving around 15 000 bed-days to date. Reassuringly, rates of unplanned readmissions to hospital have remained stable despite increased activity and decreased length of stay (Box 7). The FMC has seen a substantial growth in demand for care in recent years, and continued growth will mean that the imperative to improve will remain, and indeed increase. 1 Process redesign with the use of lean thinking The basics of process improvement through lean thinking include: being clear about what it is that you “make” at the step or stages in which you are involved identifying who your customers are — who uses what you make, and what they value identifying activity families or patient-care families and their value streams improving flow identifying and reducing waste moving from “push” to “pull” processes acknowledging that process improvement must be continuous 2 Redesigning care — a virtuous circle * Testing a change by planning it, trying it, observing the results, and acting on what is discovered. 3 Percentage of medical and surgical inpatient bed-hours during which beds are occupied by “ward outliers”,* Flinders Medical Centre, 2003–2007 * Patients admitted to an available bed in a ward that is not the designated ward for their condition. 4 Time spent in the emergency department for all patients, discharged patients and admitted patients, Flinders Medical Centre, 2002–2006 Financial year Mean overall time (h) All patients Discharged patients Admitted patients 2002–03 5.4 3.7 8.3 2003–04 5.3 3.5 8.2 2004–05 4.9 3.4 7.3 2005–06 4.8 3.4 7.0 5 Percentages of all emergency department patients whose treatment was commenced in compliance with protocols for their triage categories, Flinders Medical Centre, 2002–2006 Triage categories Financial year 1 2 3 4 5 2002–03 100% 75% 63% 59% 74% 2003–04 100% 70% 58% 66% 89% 2004–05 100% 68% 59% 72% 93% 2005–06 100% 69% 63% 74% 90% 6 Patients who presented to and those who did not wait for treatment at Flinders Medical Centre emergency department, January 2001 to April 2007 7 Percentage of all acute separations that were unplanned readmissions,* Flinders Medical Centre, 2001–2007 * Emergency readmission within 28 days of discharge within same major diagnostic category.

David I Ben-Tovim PhD, MRCPsych, FRANZCP · Jane E Bassham RN, BN · Denise M Bennett RM, BN, MBA · Melissa L Dougherty BA(Psych)(Hons) · Margaret A Martin RN, BN, MHSS · Susan J O’Neill RN, BN, MNSc · Jackie L Sincock RN, BN, GradCertHSM · Michael G Szwarcbord BSc, BSocAdmin, FAIM

The preceding papers in this supplement have described the stress in public hospital health care, the methods and application of clinical process redesign, and the substantial improvements achieved through redesign for both patients and staff. Here, we outline the key criteria for successful use of this clinical process redesign in both implementing and sustaining improvement. NSW Health and Flinders Medical Centre (FMC) in South Australia have been undertaking clinical process redesign projects since August 2004 and November 2003, respectively. In response to local needs and conditions, there have been variations in the way these redesign projects have been carried out. The common principles for successful implementation and sustainability that have emerged from our experience are listed below. They are supported by evidence from overseas programs undertaking similar reforms, particularly the National Health Service in the United Kingdom1 and the Institute for Healthcare Improvement in the United States.2 Leadership by the chief executive and senior managementVisible involvement of the chief executive and senior management is essential.3 Senior management needs to set the standards for service delivery and drive the change process. This requires management to engage and challenge staff with “stretch goals” (ambitious goals that stimulate staff beyond their current achievements), set the parameters for acceptable solutions, ensure strategies are implemented within set timeframes and budgets, monitor performance, and reward success. Staff members need to see that the program is a priority for their chief executive officer. To succeed in the face of obstacles and setbacks, resistance, or failure of certain elements of the project, senior managers need to be resilient and keep the momentum going. The experience at FMC (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”)4 has highlighted the significant benefits of having the executive team at hospital level directly involved in the redesign. FMC found it valuable to have senior clinicians and executives involved in tracking patient journeys and in clinical work. This has helped take redesign from being a project to being part of what staff do every day. In New South Wales, regular visits to clinical redesign sites by the NSW Director-General of Health and the NSW Minister for Health have been found to be a powerful motivator for staff, as these visits indicate that clinical process redesign is a high priority. Engaging clinical leadersClinical process redesign is not about changing clinical practice, but it does change the system of care delivery. Thus, clinical leadership is critical to success. A very important factor in engaging clinicians is for management to commit in advance to implementing the solutions designed by staff. Trust is gained when staff see their solutions being implemented; not implementing the solutions identified by staff, we feel, can lead to further cynicism. To commit to implementation, management must set the criteria for solution development in advance, and state what resources are available. If an expensive solution is proposed, staff need to understand that they will be required to justify the expense and ensure there are not less costly ways of achieving the desired result. Solutions that lie within current resources should be implemented immediately, and changed if they are not effective. Ensuring that increased safety is an outcome of redesign is attractive to clinicians, as is making the essential steps in a patient journey work more efficiently for staff. Clinicians have a vested interest in simplifying frustrating clinical processes and in eliminating waste. Involving clinicians in analysing the problems and developing the solutions should be done in a manner that meets their needs as busy professionals with limited free time — for example, short meetings at times when most are available. Multidisciplinary team solution designRedesign is best owned and managed by a workgroup comprising people who actually do the work, supported by those with redesign expertise. The workgroup must be given the time and the resources to gather and analyse the data, develop interventions, then plan the implementation and monitor its impact. ImplementationImplementation of the solutions is the hardest part of the process, and managers need to be given the necessary change management skills. There are professional courses available for managers on how to introduce change, and external consultants can give advice and coaching on this subject. Focus on the patient journeyA core focus of the clinical redesign process is the patient journey for groups of patients with similar service delivery needs. These groupings are broader than disease-based classifications. They are defined by grouping together patients with similar journeys, such as patients who visit the emergency department and then return home, frail older patients with multiple comorbid conditions, or relatively fit patients in hospital for day-only procedures. Understanding patient demand and standardising patient journeys will assist in simplifying the redesign process, so that the steps in a journey are readily known and understood by staff and able to be easily communicated to patients. Standard processes (a “lean thinking” concept5) are robust in design, less prone to error and are easy to teach to new staff. They should become second nature to staff and be easily integrated into information technology systems. Patients and carers as part of the teamPatients and carers must be involved in both defining and solving problems. In our projects, many innovative solutions have come from patients with no health care expertise. The patient journey should be designed to meet patient and carer needs, and the quality of the journey must be an outcome measure. We need better measures of the patient experience to include in the evaluation of redesign projects. DataSolutions need to be evidence-based. The process of redesign involves seeking stakeholder views on the problems and their causes, and then testing their opinions against available data. This helps resolve the problem of having multiple individual opinions or conflicting opinions as to the cause of a problem and its possible solution. The use of evidence also ensures that the selected solutions have a higher probability of being successful. This process builds trust with staff and confidence in management, and ensures time is not wasted trying inappropriate solutions. Rigorous monitoring of redesigned processes against set targets is essential to confirm that the intervention is achieving its goals. The data need to be simple, clearly visible to all stakeholders and available in real time so that problems can be analysed and corrected. Monthly data available 2–3 weeks after the end of the month are simply of no use. Clinical process redesign requires real-time information on a daily, weekly and monthly basis. Sometimes it is even required on an hourly or continuous basis. While some of the necessary data can be collected on paper or in simple databases, the redesign process has highlighted the need for much better data management systems. Ultimately, we have learnt that information technology systems that deliver relevant information to frontline managers are essential for achieving high-quality, efficient patient journeys (Box 1). Targets and timeframesThe desired outcomes for the patient journey need to be “stretch targets” — that is, ones that seem difficult to achieve. We have found this is essential to stimulate real innovation, as it challenges participants to think “outside the square”. Fear of failure is a major obstacle in this process, but we have found the excitement and pride staff feel when they realise what can be achieved with current resources is a powerful motivator in sustaining the program. Achievement inspires even further innovation and truly amazing results can be seen. It is very rewarding to observe a real sense of pride among health care staff who have improved the quality of their service. Managing the process — internal versus external managementAs outlined in other articles in this supplement, both NSW Health (→ Patient journeys: the process of clinical redesign)6 and FMC (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”)4 created a central group to manage their overall redesign programs. In NSW, this involved many hospitals across the state, whereas FMC is a single medical centre. In both places, there was recognition that the redesign process was a method that had been widely and successfully applied in other industries5 and there was a need to learn from or directly involve experts in redesign. FMC staff attended an external course to learn the redesign principles, whereas NSW Health engaged external consultants. The NSW statewide project delivered a significant return on this investment for NSW Health by reducing length of stay for patients. In both cases, strong program management, both centrally and at the level of individual projects, was essential. In NSW, the use of external facilitators (→ Patient journeys: the process of clinical redesign)6 was a powerful tool in breaking down the “silo” mentality and facilitating multidisciplinary teamwork. Their expertise in change management and in establishing data charts was exceptionally helpful in driving change. It was also essential to get the process up and running in multiple sites, where management and clinicians were often uncertain as to the benefits of the program. Organisational readinessWhen is an organisation ready for redesign? In our view, if there are acknowledged problems with access, flow, safety, waste or patient outcomes, it is time to act. It is easier to act and change mindsets through demonstrating that things can be improved than through waiting until there is general agreement that redesign could work. Health professionals have many opinions, all deeply and passionately held, and the impossibility of reconciling these views without evidence to the contrary is one of the biggest barriers to reform in health care. We have found that the key to organisational readiness is leaders who believe that things have to change. Selection of projectsIn our experience, it is best to start the redesign process with a problem that obviously needs to be fixed (eg, access block or ambulance diversion). Quick wins on high-profile problems engage staff and breed success. Improvements of the patient journey for high-volume patient groups, such as emergency medical cases, will also reap benefits, because improving efficiency in this group releases more capacity back into the system than improvements for lower-volume patient groups. Complete patient journeys are often complex, and can rarely be redesigned in one stroke. It will normally take a number of projects over time to comprehensively remodel a major patient journey. However, substantial improvements can be achieved with a well executed initial project, and this will build support for further improvements. Some projects are simple and straightforward (eg, standardising the layout of ward storage areas to remove the need for staff to learn the locations of essential equipment in each ward). Other projects are more complex and may involve more than one hospital. Each will require a different approach to engaging staff and implementing changes, and will need different timeframes. Local versus system-wide reformThe type of clinical process redesign methods we have described in this supplement work best at local hospital or unit level. A different approach is required to simultaneously run redesign projects across a number of hospitals. Nevertheless, our experience has shown that it is possible to do this with careful planning and well coordinated central program management. This has been demonstrated by the experience in NSW Health, by the Department of Health in the UK1 and in the “100 000 Lives” campaign of the US Institute for Healthcare Improvement.2 Knowledge sharing between teams was essential. It was achieved through workshops, online communities of interest and through the database of the Australian Resource Centre for Healthcare Innovations.7 Persistence and flexibilityIt does not matter which improvement method or model (lean thinking,5 six sigma,8 or theory of constraints9) is used in the redesign process, as long as it is applied with rigour and persistence. We have found that there needs to be constancy of purpose by all those involved in clinical process redesign. It is important to recognise that the redesign projects are not controlled trials, but are more akin to action research10 in that they are not designed to be perfect or dictated by strict protocols, but rather to be iterative and flexible as the need arises. In fact, it is crucial to their success that they are modifiable in response to data, as well as to staff and patient feedback. The plan-do-study-act11 method (testing a change by planning it, trying it, observing the results, and acting on what is discovered) is ideal for a flexible improvement model and allows reflective learning from one intervention to feed into the next. SustainabilitySustainability involves an ongoing improvement process. It should be a process of continuous review and improvement of health service delivery to meet a set of agreed standards. It needs to be embedded to become part of normal business for a health care organisation, not a series of one-off projects or crisis-driven reform programs. Sustainability, in our experience, is the most challenging phase of clinical process redesign. It is best depicted as a staircase, which demonstrates the notion that redesign is, by nature, continuous (Box 2). With this in mind, how should we approach sustainability? Our view is that it should be thought about as a dynamic process containing three main elements — standard work, maintenance and continuous improvement (Box 3). Standard workStandard work occurs at the end of successful implementation. The new processes (standard work) must be documented, and various roles defined and made explicit, especially with new or temporary staff. An important part of standard work is removing variation in the way a process is done. The performance of individuals and the team must then be monitored to ensure procedures are being performed as expected (Box 4). MaintenanceMaintenance of the improved standard work is an important element of sustainability. A process owner needs to be assigned to each redesigned patient journey. This person is required to “care” about and review the redesign work on a regular basis. Performance on relevant targets and key performance indicators must be regularly measured and tracked. The process owner will need to spend time in the workplace to observe how things are being done and identify opportunities for further improvements. Maintenance is essential within health care because of the dynamic nature of the workforce. The turnover of trainee staff is extremely high, and this can result in a breakdown in standard work. Maintenance of redesign work ensures that the improved practices become embedded, despite the changing nature of the clinical teams. Continuous improvementGrowing demand and technological change requires us to constantly improve to maintain standards. A regular forum where performance and process issues are discussed with stakeholders from across the patient journey is an ideal mechanism to promote ongoing improvement. The output of these forums should provide the next opportunity to redesign and improve the journey (Box 5). ConclusionClinical process redesign holds much potential. It has already demonstrated that it is a powerful tool for improving the systems that underpin health care service delivery. It has provided benefits for patients and staff by enhancing access and patient flow, and increasing safety, as well as improving the experience and health outcomes for patients. 1 Immediate access to performance information Web-based technology has been shown to be highly effective in providing real-time information (including process control charts for triage times and access block) to key managers in Sydney West Area Health Service in New South Wales. Managers have found that the additional cost of providing the data required is a small price to pay for the resulting major improvements in the quality of services. 2 The “staircase” of sustainability 3 The cycle of sustainability 4 Example of the standard work element of sustainability in process redesign at Flinders Medical Centre At Flinders Medical Centre, a standard process has been developed for writing discharge summaries, and this is used as a basis for intern orientation. It is displayed visually at each computer in the doctors’ offices and is included in the clinical handbook for each clinical division. 5 Example of the continuous improvement element of sustainability in process redesign at Flinders Medical Centre Within general medicine at Flinders Medical Centre, the junior doctors, consultants, department head and the redesign team meet every 2 weeks over lunch to review performance in regard to the redesign work, and to identify problems and improvement opportunities. This meeting is also an ideal mechanism for identifying, on a regular basis, the internal system problems that this group of clinicians face every day.

Katherine M McGrath FRCPA, RCPA, MRACMA · Denise M Bennett RM, BN, MBA · David I Ben-Tovim PhD, MRCPsych, FRANZCP · Steven C Boyages PhD, FRACP, FAFPHM · Nigel J Lyons BMed, MHA · Tony J O’Connell MB BS, FANZCA, FJFICM

Demand, as reflected in emergency department attendances, rose in all hospitals (range, 5%–27%) and surgical activity rose 2% across NSW over this period, yet performance on emergency and elective access indicators improved or was steady in 85 of the 95 possible instances for the four outcomes presented. Patient volume increases Outcomes Hospital ED attendances Admissions through ED Projects EAP* Triage 3* Triage 4* Long-wait elective surgery list† St George ↑ 18% ↑ 16% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution ↑ 16 ↑ 23 ↑ 19 475 to 0 St Vincent’s ↑ 26% ↑ 29% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution ↑ 11 ↓ 3 ↑ 4 195 to 0 Prince of Wales ↑ 18% ↑ 25% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution ↑ 13 ↑ 17 ↑ 13 303 to 0 Sutherland ↑ 20% ↑ 28% • Emergency patient flow; • Discharge planning; • Acute coronary care syndrome; • Ambulance case distribution ↑ 22 ↓ 2 ↑ 10 Data unavailable Wollongong ↑ 18% ↑ 16% • Emergency patient flow; • Discharge planning; • Acute coronary care syndrome ↑ 20 ↑ 24 ↑ 16 15 to 3 Royal North Shore ↑ 18% ↑ 18% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 5 ↑ 3 ↑ 5 70 to 11 Bankstown ↑ 27% ↑ 13% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Ambulance case distribution; • Redesign of booked surgery ↑ 34 ↑ 8 ↑ 16 264 to 0 Concord ↑ 19% ↑ 6% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 24 ↑ 4 ↑ 9 175 to 0 Campbelltown ↑ 27% ↑ 6% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↓ 2 ↑ 14 ↑ 12 332 to 0 Liverpool ↑ 22% ↑ 45% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 10 ↑ 21 ↑ 16 219 to 0 Royal Prince Alfred ↑ 20% ↑ 34% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 12 ↑ 14 ↑ 8 79 to 0 Lismore ↑ 13% ↑ 13% • Emergency patient flow; • Discharge planning ↓ 2 ↑ 13 ↑ 17 149 to 0 Port Macquarie ↑ 21% ↑ 2% • Emergency patient flow; • Discharge planning ↑ 5 ↓ 3 ↓ 2 227 to 0 Tweed ↑ 5% ↑ 43% • Emergency patient flow; • Discharge planning ↓ 12 ↑ 5 Steady 63 to 5 The Children’s Hospital at Westmead ↑ 22% ↑ 16% • Emergency patient flow; • Discharge planning; • Redesign of booked surgery ↑ 9 ↑ 21 ↑ 23 25 to 0 Blacktown ↑ 18% ↑ 11% • Emergency patient flow; • Discharge planning; • Ambulance case distribution; • Redesign of booked surgery ↑ 18 Steady ↑ 5 25 to 4 Newcastle Calvary Mater ↑ 16% ↑ 20% • Emergency patient flow; • Discharge planning Steady ↑ 4 ↑ 4 Steady at 0 John Hunter‡ ↑ 12% ↑ 18% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 21 ↑ 30 ↑ 32 15 to 0 Belmont ↑ 11% ↑ 16% • Emergency patient flow; • Discharge planning; • Redesign of booked surgery ↑ 11 ↑ 5 ↑ 8 Steady at 0 Dubbo ↑ 8% ↑ 3% • Emergency patient flow; • Discharge planning; • Redesign of booked surgery ↓ 4 ↑ 3 ↓ 5 Steady at 0 Gosford ↑ 9% ↑ 6% • Emergency patient flow; • Discharge planning; • Acute coronary care syndrome Steady ↑ 7 Steady 367 to 39 Westmead ↑ 24% ↑ 23% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 11 ↑ 31 ↑ 28 23 to 0 Nepean ↑ 22% ↑ 21% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 12 ↓ 3 ↑ 4 537 to 0 ED = emergency department. EAP = emergency admission performance (% of admissions through ED who egress from the ED within 8 h). Triage 3 = triage 3 performance (% of patients in triage category 3 whose treatment is commenced within 30 minutes of arrival). Triage 4 = triage 4 performance (% of patients in triage category 4 whose treatment is commenced within 60 minutes of arrival. * Percentage point change (eg, improvement from 63% to 75% is ↑12). † Change in the number of patients who have waited more than 365 days for surgery. ‡ John Hunter outcomes data cover the period commencing in 2002, as redesign commenced earlier in this hospital. Source: Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, December 2007.

Glossary Action research: research undertaken by teams that is flexible and iterative; the aim is to problem-solve in order to improve the way processes are performed and services are delivered. Clinical process redesign: a health care improvement method that involves the redesign of the processes and services underpinning clinical care to make them safer and more efficient for patients and more satisfying for staff. Clinical silos: clinical specialties, subspecialties or geographical locations within which care is provided without regard to other components of the overall patient journey through a medical facility. Continuous improvement: continuous and incremental improvements to clinical processes achieved by removing unnecessary activities and variations, so that each state is the starting point for the next step on the journey towards the ideal state. Diagnostic phase: the phase of clinical process redesign that involves mapping the patient journey, identifying and prioritising the problems and validating the findings with relevant data. Implementation: the application or realisation of clinical process redesign on a patient journey. Lean thinking: a method that focuses on service provision in the most efficient manner by improving flow and eliminating waste from processes. Maintenance: actions undertaken to keep a redesigned process operating. Outliers: patients admitted to an available bed in a ward that is not the designated ward for their condition, because of congestion in the wards and the emergency department. Patient-care family: a functional group of patients who share a large proportion of clinical process steps regardless of their illnesses. Patient journey: the primary perspective in clinical process redesign; all the sequential steps in providing a patient’s clinical care; it includes the movement of a patient (from emergency department to ward or x-ray department) and the movement of a sample or document relating to the patient (eg, blood specimen, medical record, etc). Plan-do-study-act cycle: a quality improvement method consisting of the four continuous steps, plan, do, study and act, aiming to test a change by planning it, trying it, observing the results, and acting on what is discovered (also known as the Deming cycle or Plan-do-check-act cycle). Process mapping: documenting the patient journey, not as the ideal, but as it is, and involves confirming it with data. Process owner: a staff member is assigned to maintain and review a redesigned patient journey on a regular basis. “Pull” bed management: ward staff following a structured approach to identify patients in the emergency department who best fit their ward profile and then “pulling” those patients from the emergency department to their ward, rather than having to take any patient just because the ward has a bed available. “Push” bed management: wards taking patients from an overflowing emergency department just because there are beds available. Root-cause analysis: analysis of the original cause for variability or waste in a process. Segmentation: grouping patients into patient-care families (which have a common set of care processes) and treating each family separately. Six sigma: a systematic method for improving the operational performance of an organisation by eliminating variability and waste (“sigma” stands for standard deviation from the mean in a normal distribution). Standard work: the standard way of undertaking a sequence of care after the best, most efficient and most effective way of undertaking a care process in the patient journey has been established and agreed. Stretch goal or target: an ambitious goal or target that stimulates the team or institution to achieve far beyond their current capability. Sustainability: actions undertaken to maintain a redesigned process. “Take” system: a roster system involving hospital teams being rostered to take what may be large numbers of unplanned arrivals and process those patients. Theory of constraints: a method for identifying and overcoming key bottlenecks and constraints which inhibit an organisation achieving its goal. Value stream: the sequence of steps that add value to patient care within a patient-care family.