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Redesign Achievements 2009/10

Contents Redesign

3 What is Redesign? The story since 2005

Surgery Redesign Predictable Surgery Program Emergency Surgery Program Surgery Futures Program

3 4

6 6 8 8

Cardiology Redesign Chest Pain Evaluation Areas State Cardiac Reperfusion Strategy

9 9 9

Acute Care Redesign


Medical Assessment Units Safe Clinical Handover

Emergency Redesign Fast Track Zones Emergency Short Stay Units

Out of Hospital Redesign Hospital in the Home Advance Care Planning ComPacks

Patient Flow Redesign Patient Flow Systems Predictive Planning Tool

Patient and Carer Redesign NSW Annual Patient Survey Experience-Based Co-design Program Studer Pilot and Customer Feedback System

10 11

12 12 13

14 15 16 17

18 18 18

19 19 20 20

Performance Management Redesign



22 2

What is Redesign? In 2005 NSW Health received funding to implement a state-wide clinical process improvement program known as Clinical Services Redesign. “Redesign” provides a way for health staff to improve access to care and improve patient experiences. Investment in Redesign is now being directed towards implementation and sustainability of the program. Redesign follows a robust framework for improving clinical processes. Frontline staff use this methodology to identify issues across the patient journey, design solutions and then implement the best solutions. Using the Redesign Methodology ensures problems analysed before solutions are developed by utilising data analysis, project and change management techniques which delivers long term sustainable changes. Redesign is part of the strategy to transform the NSW health system. Redesign has set out to achieve this by focusing on: • Process improvement: - we’re changing the way we do things to improve processes and deliver better patient journeys • Performance Management: - increased managerial focus on targets and performance The Redesign process improvement methodology has been proven to work in NSW Health. Over 116 Redesign projects have been completed in 8 areas that were creating the most stress on the health system. These 8 areas include; Surgery, Cardiology, Acute Care, Emergency, Aged & Chronic Care, Patient Flow, Mental Health and Performance Management. Redesign projects have resulted in new ways of delivering better care for patients and carers. Eighteen best practice models of care have been captured and promoted. New tools have been developed including; ambulance arrivals board, bed board, WAND, risk assessment tools. New approaches to delivering care have also been designed including; fast track zones, medical assessment units, patient flow units, hospital avoidance initiatives.

Redesign Methodology Project Initiation & Start up


Solution Design

Implementat ion

Implementat ion Monitoring

Evaluation / Sustainability


The story since 2005 Why we needed to change People are living longer, by 2050 26% of the population is projected to be 65yrs + and only 15% of the population being 0-14yrsâ‚ . Not only are we living longer but technological advances have aided us to live healthier for longer, such as pre hospital thrombolysis, pre hospital assessment for primary angioplasty, drug therapies and surgical advances.

Further impacting on our health are our diet and lifestyle choices . It is well known that high saturated fat and high sugar diets, smoking, recreational drug use, binge drinking, lack of exercise are pre cursors for chronic disease. In Australia 70% of the burden of illness and injury is attributable to chronic diseaseâ‚‚. Current models of hospital based care do not adequately cater for the needs of older people or people with chronic diseases. An external report in 2007 (Hardes Report) projected that growth in demand would require additional beds equivalent to a small hospital each year. 6,000,000 5,000,000

Emergency Department attendances in Australia are increasing

4,000,000 3,000,000 2,000,000 1,000,000 0









Figure 1: AIHW, Australian Hospital Statistics: ED Attendances by year 2001-02 to 2008-09

2,600,000 2,500,000 2,400,000 2,300,000 2,200,000 2,100,000 2,000,000 1,900,000 1,800,000 1,700,000

Emergency Department presentations in NSW are also increasing

ED Attendances

Projected ED Attendances

Figure 2: NSW Health Annual Report: Total ED Attendances by Year 2000-01 to 2008-09 & *NSW Health Predictions: 2009/10 to 2010/11

A long period of no real growth was seen in people attending emergency departments in NSW. This was followed by a 21% increase from 2005. This is projected to be a 24% increase by 2011. 4

Hospital admissions in Australia are increasing

5,000,000 4,500,000 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08





Figure 3: AIHW, Australian Hospital Statistics: Hospital Admissions by year 2001-02 to 2008-09 1,700,000 1,650,000 1,600,000 1,550,000 1,500,000 1,450,000 1,400,000 1,350,000 1,300,000 1,250,000 1,200,000

Hospital admissions in NSW are the highest volumes ever recorded and the strain on our health system is continually increasing

Acute Inpatient separations

Projected Inpatient Separations

Figure 4: NSW Health Annual Report: Total Admitted Patient Episodes by Year 2000-01 to 2008-09 & *NSW Health Predictions: 2009/10 to 2010/11

To address changes in demand on acute services, models of care were developed that divert patients away from the acute setting and serve to reduce what would otherwise be higher demands for acute hospital services. The models of care have been developed to produce safe, quality care for patients that reduce delays, eliminate waste and decrease patient waiting times.

NSW Health is providing Better Journeys and Smarter Care Person in Community

Intervene Early to keep @ home

Emergency Department

Inpatient Care

Minimise ED LOS


Minimise inpatient LOS/ Promote function

Person in the Community

Prevent readmission/ sustain care


Surgery Redesign Predictable Surgery Program NSW aims to provide surgery to all patients within the national benchmark according to clinically based priority categories. The predictable surgery program, which has been operating since July 2005 provides oversight to ensure that the people of NSW have predictable and timely access to appropriate surgical services. The Australian Institute of Health and Welfare (AIHW) (2008) National Health Data Dictionary no. 14, National Benchmarks indicates the urgency with which the patient requires elective hospital care/surgery. The current code values are: • Category 1 —admission within 30 days desirable for a condition that has the potential to deteriorate quickly to the point that it may become an emergency • Category 2 —admission within 90 days desirable for a condition causing some pain, dysfunction or disability but which is not likely to deteriorate quickly or become an emergency • Category 3 —admission at some time in the future acceptable for a condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency. 2000

The Predictable Surgery Program has maintained category 1 overdue patients, at minimal numbers

1500 1000 500





















Cat 1

Figure 5: NSW HIE Database: Category 1 Overdues. Patients waiting >30 days for Surgery. July 2004 to July 2010




















7000 6000 5000 4000 3000 2000 1000 0

The Predictable Surgery Program has cleared the back log of category 2 overdue patients, those who are waiting greater than 90 days for surgery

Cat 2

Figure 6: NSW HIE Database: Category 2 Overdues. Patients waiting >30 days for Surgery. July 2004 to July 2010


12000 10000 8000 6000 4000 2000 Apr-10

















The Predictable Surgery Program has cleared the back log of category 3 long wait patients, those who are waiting greater than 12 months for surgery

Cat 3

Figure 7: NSW Health Information Exchange (HIE) Database: Category 3 (Long Waits), Patients waiting >12months for Surgery. Jan 2004 to July 2010

The number of surgical ready for care long wait patients (waiting more than 365 days) in January 2005 was 9,940. As at the end of June 2010 there has been a significant decrease in the number of surgical ready for care long wait patients to 1,063. This is an 89% reduction since the commencement of the Predictable Surgery Program. The predictable surgery program has resulted in improved efficiencies, increased staff satisfaction and timely access to planned surgery for patients . Pre-procedure patient preparation, is also part of the predictable surgery program and maximises the efficient coordination and integration of surgical resources. All patients undergoing elective surgery require a preadmission review, although not all patients require a face-to-face assessment. This is outlined in the NSW Department of Health (2007) Pre-Procedure Preparation Toolkit available at: Pre-procedure preparation results in decreased cancellations, patient conditions will be optimised for the procedure, non duplication of tests, organisation of post procedure support services, education of patients on what is expected post operatively, answering of patient questions and improved and timely access to allied health interventions. Between 2004/05 to 2009/10 the government has invested $300.5 million to increase elective surgery, this means that more surgery is being performed and more patients are having their operations at the right time. In the 2010/11 budget an additional $85.5 million is being invested in elective surgery. For further information on the Predictable Surgery Program please follow the link to the ARCHI website:


Emergency Surgery Program The Emergency Surgery program has been in place since 2009. It separates emergency surgery (unplanned surgery) from elective (planned surgery) to ensure timely access for patients.

The Emergency Surgery Guidelines were released in June 2009 by the Surgical Services Taskforce in conjunction with the NSW Department of Health (also endorsed by the Royal Australasian College of Surgeons-RACS). These guidelines will ultimately provide the people of NSW with timely access for emergency surgery, reductions in elective surgery cancellations and improved patient safety and outcomes. It is predicted that call backs and overtime for staff will be reduced as more emergency surgery will be done in daylight hours instead of after hours, this will also improve staff satisfaction and morale.

Find the Emergency Surgery Guidelines at: /GL2009_009.pdf Further information on the Emergency Surgery Program is available at: at:


Surgery Futures Program The Surgery Futures program commenced in March 2010 in consultation with the Surgical Services Taskforce, metropolitan Area Health Services, key clinical and professional colleges and associations and the private hospital and day procedure centre industry associations. The Surgery Futures program aims to describe how surgical services will be delivered over the next 5 to 10 years in the greater Sydney area. Specialist surgeons and managers will be able to capitalise on emerging surgical advances, make effective use of available resources and produce the best outcomes for patients. There is a growing need to plan surgery for the future as: • The demand for surgery is increasing, and the profile of that demand is evolving • Our workforce is changing; part time work, nursing shortage, specialisation • Most states in Australia have, or are in the process of developing, service capability for specific hospital services • Networks continue to develop nationally and internationally, one of their aims is to ensure patients are streamed to the most appropriate facility in a timely manner • There is wide dispersion of surgical services across Sydney Planning surgery for the future takes into account developments in surgical services across 4 main areas: 1. Workforce, Education and Training : building a sustainable workforce, training and simulation, supportive workforce roles and sub-specialisation 2. Changes in Surgical Practice: Streaming planned &emergency surgery, endoluminal, minimally invasive surgery and private sector surgery 3. Impact of Technology on Surgery Advances: Imaging advances, increasing use of stents, robotic & other advanced modalities and nano and other biotechnology 4. Other influences on Surgical Services: Pharmacological advances, anaesthetic innovations, and integrated service models

Further information on the Surgery Futures Program is available at:


Cardiology Redesign The most common reason for presentation to an Emergency Department (ED) by ambulance is due to chest pain. To ensure the residents of NSW have timely and equitable access to cardiac care and ensure these patients are being directed to the best people to care for them, several strategies have been implemented. Over the period September 2006 to the present Chest Pain Evaluation Areas have been implemented across NSW to improve processes for managing patients presenting to hospital with chest pain. These include best practice chest pain protocols, 7 days a week exercise stress testing, and cardiac assessment nurses .These strategies streamline care for cardiac patients. To ensure cardiac patients not only have timely and equitable access to cardiac care, we also want to ensure they have this care delivered as safely as possible. A Chest Pain Patient Journey working party has been formed to standardised the Chest Pain Pathway for all hospitals across NSW. This commenced in October 2009 and is expected to be released in November 2010. The State Cardiac Reperfusion Strategy commenced in NSW in March 2010 to provide patients suspected of having a heart attack to have their ECG sent from the ambulance to a cardiologist or the ED. 7 of the 10 nominated sites are currently transmitting on the new digital system. The cardiologist or the ED confirms if the patient is having a heart attack . If so, they are sent directly to the cardiac catheter lab (and by-pass the ED) where they will receive an intervention to open up the blocked arteries and minimise damage to the heart muscle caused by the heart attack. Heart attack patients that are cared for in this way have a decreased length of stay, fewer hospitalisation days, reduced clinical events (particularly cardiogenic shock) that prolong hospitalisation days and has been proven to reduce death, heart attacks, stroke or repeat treatment for a heart attack₃,₄ . Between March to August 2010 81 patients have been cared for in this way. 25 20

An increasing number of heart attack patients are bypassing the ED for immediate treatment in the cardiac catheter lab

15 10

5 0 March Concord

April RPA

May June Liverpool

July Nepean

Aug Total POW SVH

Figure 8: State Cardiac Reperfusion Strategy, number of ECG transmissions per month from Ambulance to Cardiologist/ED


Acute Care & Medicine Redesign Medical Assessment Units (MAUs) MAUs provide an alternative to treatment in emergency departments for people of all ages with complex and chronic conditions.

Patient flow is improved through rapid assessment, faster diagnosis and earlier treatment by senior clinicians. Patients are expedited through the ED to a multidisciplinary team who are specialists in caring for patients with complex and chronic conditions. Patients spend less time in the hospital system and are provided with a safe supported recovery at home (reflected in the low readmission rates). Across NSW, 28 MAUs have been established since January 2008 with 2 more to be opened over 2010/11. In 2008/09 29,049 patients went through a MAU and in 2009/10 41,615 patients went through a MAU, this is a massive 70% increase. 20 18 16 14 12 10 8 6 4 2 0

Average Total hrs of MAU patients in ED


60 40 20 0


ALOS MAU patients transferred to ward (days)


ALOS in MAU (hours)


Figure 9: NSW Health Information Exchange (HIE) Database: Average Total hours of MAU patients in ED. Jul 2008 to June 2010



Figure 10: NSW HIE Database: Average Length of Stay (ALOS) in the MAU. Jul 2008 to June 2010 30%


Readmission rate of MAU separations

20% 15%







Figure 11: NSW HIE Database: Average Length of Stay (ALOS) of MAU patients transferred to a ward (days). Jul 2008 to June 2010

Figure 12: NSW HIE Database. Readmission rates within 28days of MAU separations. Jul 2008 to May2010


Safe Clinical Handover NSW Health has been working in conjunction with the Acute Care Taskforce (ACT) to develop and implement standard key principals for Safe Clinical Handover. Safe Clinical Handover implementation is part of Stage One of the governments response (Caring Together: The Action Plan for NSW₅) to the Special Commission of Inquiry into Acute Services in NSW Public Hospitals (2008). It was seen that inadequate communication in the clinical setting contribute to adverse events in patient care. All NSW Health Area Health Services, including the Children's Hospital Network, Justice Health and the Ambulance Service of NSW are presently implementing Safe Clinical Handover. Some results to date include: • Implementation of bedside nursing and midwifery handover, where needed • Eradication of taped handover from all health services. • Increasing involvement of Medical teams in clinical handover The second stage of the Safe Clinical Handover program is on the clinical handover at all shift changes (weekdays and weekends) for Junior Medical Officers (JMOs). JMOs are the least experienced members of the medical workforce, and frequently move between wards, facilities and Area Health Services. Inexperience and variable or absent processes relating to clinical handover have been shown to present significant risks for patient care. The objectives of this program are to ensure that handover happens with consistency and quality, at all shift changes which will ensure clarity of responsibility and accountability for all clinicians. The JMO shift to shift Safe Clinical Handover program promotes 3 key elements: • a communication framework (ISBAR) • senior leadership • key principles for locally appropriate shift to shift handover. The 3 key elements are currently being tested at 6 sites with a plan for state-wide implementation in January 2011. The third stage of the Safe Clinical Handover program will be to ensure clinical handover occurs consistently between hospitals and General Practice and vice versa. The objective is to ensure a consistent transfer of clinically prioritised information and to ensure it is meaningful and appropriate for the patients’ continuity of care. Further information on Safe Clinical Handover, including the implementation toolkit, monthly newsletter updates, examples of local innovations and access to process redesign eLearning is available at: Implementation toolkit

Supportive templates

Monthly newsletter updates

The Clinical Handover Standard Key Principles Policy is available at: 12

Emergency Redesign Patients presenting to Emergency Departments (EDs) are separated into 5 different triage categories with recommended maximum patient waiting times for treatment for each category 6. The EDs have experienced a 21% increase in demand since 2005. To cope with this increase in demand numerous models of care have been introduced in order to minimise the waiting time for patients in ED, whist maintaining a safe and effective standard of care.

Patients presenting in all Triage Categories have increased by 21% since 2005

900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Triage 1 Triage 2 2004/05 2005/06

Triage 3 2006/07

Triage 4 2007/08

Triage 5 2008/09

Figure 13: NSW Health Information Exchange (HIE) system extraction on the 19th February 2010, No. ED patients by year (2004/05 to 2008/09) in triage categories 1-5.

Fast Track Zones

Over the period January 2006 to the present fast track zones have been implemented across NSW to improve access to treatment within the emergency department. Minor illness and injury patients are streamed from triage to a designated treatment area with skilled staff such as nurse practitioners, clinical initiatives nurses, doctors and allied health professionals. Patients are generally ambulatory and non complex with the potential to have their emergency care initiated by using clinical treatment protocols. In Fast Track zones the emphasis is on a clinical team commencing care, rather than... ‘waiting to see a doctor’. This in turn reduces the amount of time these types of patients spend in an ED, thus reducing the overall patient workload for nurses, especially with the use of clinical treatment protocols 9.0

8.0 7.0

Admitted patient waiting times have deceased by 8%, whilst non-admitted waiting times have remained steady

6.0 5.0 4.0

3.0 2.0 1.0 0.0




Avg time (Hrs) Admitted to Ward



Avg time (Hrs) Not Admitted

Figure 14: NSW Health Information Exchange (HIE) system extraction on the 19th February 2010. Average time in ED (2004/05 to 2008/09) for admitted and non admitted patients


Emergency Short Stay Units Over the period January 2006 to the present Short Stay Units (SSU) have been developed to provide a short period of specialist assessment and diagnosis, short term high level management and observation for a group of patients who no longer require active emergency care. Emergency short stay units are run by emergency physicians and staffed by ED doctors, nurses and allied health staff. They are designed as an alternative model of care for patients requiring short term observation and treatment in the ED for a maximum of 24 hours . Examples of Short Stay units are; Emergency Medical Units (EMUs) and Early Pregnancy Units (EPUs), supported by midwifery.

The proportion of patients admitted to a ward from ED has declined by 7%, despite a 21% increase in demand .

35% 30% 25% 20% 15% 10% 5% 0%

Figure 15: AIHW, Australian Hospital Statistics: % patients admitted to hospital from ED by year 2001-02 to 2008-09

Clinical Initiative Nurse Role in Emergency Departments Expansion of the Clinical Initiatives Nurse (CIN) role into a greater number of EDs in NSW is part of Stage One of the governments response (Caring Together: The Action Plan for NSWâ‚…) to the Special Commission of Inquiry into Acute Services in NSW Public Hospitals (2008). The role has been reviewed in a Redesign project in 2010. The CIN role was funded in 16 NSW EDs in 2002 to provide communication, re-assessment and initiate care as a priority for patients in the waiting rooms of EDs. A review of the position statewide found that the role lacked a standard structure and in many cases was being reallocated from the waiting room to other roles and was not achieving the roles intended objectives. As part of the CIN Redesign project a solutions design forum was conducted and resulted in ED clinicians defining the state wide role description, which included role priorities, a recommendation for equipment and dedicated CIN space as well as an outline of the key communication and referral pathways for the CIN. The state wide role description prioritises care and communication for patients and carers in ED waiting rooms. The CIN role can contribute to improvements in the patient experience for non admitted patients in EDs.


Out of Hospital Services The Department of Health is committed to the delivery of “the right care, to the right person, at the right time and in the right place�. This commitment is demonstrated through the increasing number of services that are delivered out of the hospital environment . There has been a reduction in hospital admissions and length of stay of patients in hospital as a result of the increasing amount of out of hospital services. These services can now provide patients with care out of the hospital environment and also allow them to be transferred home sooner to receive care in their home environment.















Data unavailable


Out of hospital services are continuing to increase

9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

Healthy At Home

Respiratory Rehab Clients Commenced

TACP cumulative

Cardiac Rehab Clients Commenced



Figure 16: NSW Health Information Exchange (HIE) system extraction by year (2004/05 to 2008/09) on the 19th February 2010. Provision of Out of hospital services 8.10 8.00 7.90

The average length of stay for the over 75yrs has decreased by 5%

7.80 7.70 7.60 7.50 7.40 2004/05





Figure 17: NSW Health Information Exchange (HIE) system extraction on the 25th January 2010. Average Length of Stay over 75yrs

Providing the right care, to the right person, at the right time and in the right place 15

Hospital in the Home/Community Acute Post Acute Care Hospital in the Home/ Community Acute Post Acute Care (CAPAC) refers to the range of clinical services that can be delivered to patients to provide substitution for in-patient hospital care or reduce the length of stay by providing care in the patients home environment. Services are able to deliver care in the home environment as they are staffed by or have access to experienced multidisciplinary teams. Services provided include: medical, nursing and allied health care. There are varying models of care included under the general term Hospital in the Home/CAPAC operating across NSW

The 2009-10 Health Budget included $11.9M in funding to provide more than 7,900 Hospital in the Home episodes for patients. This significant boost in funding has enabled a refocus from a state level and a very much needed increase in services across the area health services. In 2008/09 40,495 patients were treated by Hospital in the Home /CAPAC services program. This increased to over 54,000 In 2009/10 60,000. 54,165


Hospital in the Home services have continually increased over the past 3 years


40,495 30,000


20,000 10,000

0 Total 07/08

Total 08/09

Total 09/10

10 9 8 7 6 5 4 3 2 1 0

140,000 120,000 100,000 80,000 60,000 40,000 20,000

Total Bed Days

Length of Stay (Days)

Figure 18: Health System Performance Monthly Report July 2007 – June 2010. Out of Hospital treatment result for Hospital in the Home services.

The over 75yr + patients are increasingly coming to hospital as day only admissions


2005/06 2006/07 Median Length of Stay


2008/09 Bed Days

Figure 19: NSW Health Information Exchange (HIE) data base extraction on the 25th January 2010. Same day acute hospital admissions for patients over 75yrs


Advance Care Planning NSW Health is committed to respecting an individual’s values, preferences and expressed needs through patient and family centred care. Advance Care Planning describes the process in which a person plans ahead for health care related decisions in the event they do not have the capacity to make those decisions or communicate for themselves. This process involves the person talking to family, friends and health care professionals about their values and concerns relating to health care. A state-wide redesign project has established project officers in each Area Health Service. The work of the project officers has contributed to the development of skills and knowledge of clinicians regarding the benefits for patients in undertaking Advance Care Planning. Advance Care Training has been completed by in excess of 3,000 people from NSW Health facilities, Residential Aged Care, General Practitioners and the community. Resources, tools and more information is available at: Advance Care Planning outcomes have been measured through the audit of medical records for people transferred to EDs from Residential Aged Care Facilities. Transfer documentation was examined for the documentation of key Advance Care Planning elements – the “Person Responsible” i.e. the substitute decision maker and the presence of an Advance Care Plan. 100% 90% 80%

The presence of Advance Care Plans is increasing


60% 50% 40% 30% 20% 10%


23% 16%


0% Is the term “person responsible” specifically identified in the transfer documents as the substitute decision-maker? 2009 (n=249)

Is there an ACD / ACP / other documentation in the file?‡

2010 (n=292)

Figure 20: NSW Health File audit results for Advance Care Plans 2009 & 2010. NSCCH AHS data not available at time of print. ‡ This is a combination of 3 questions 1. Is there an advance care directive that has been completed by the patient? 2. Is there an advance care planning document that has been developed in collaboration with the patient’s substitute decision-maker? 3. Are the patient's preferences for treatment recorded in some other way in the transfer documents?


ComPacks Community Packages (ComPacks) provide patients returning home from hospital with case management and access to community services for a period of up to 6 weeks. The services range from house cleaning and assistance with bathing to assistance with shopping, meal preparation and transport. The case manager is a non-clinical person (i.e. not a nurse, doctor or allied health professional) who helps organise non-clinical community services.

ComPacks first commenced in 2004/05 and 5,036 patients utilised Community Packages. In 2009/10, 15,425 patients have utilised the packages. Implementation of the “ComPacks for the Future” project commenced in 2009 . This was a significant undertaking for a program that had grown considerably since its introduction in 2003 with 10 referral hospitals. There are now 110 referral hospitals and 49 Community Options service providers. The “ComPacks for the Future” project had input from over 130 people, through meetings surveys and workshops to aid in a “Redesign” of the ComPacks program. The results from this enabled robust procedural changes that helped improve access to services for patients, as well as a consistent approach to patient care. 18000 16000

The provision of ComPacks has significantly increased since 2004

14000 12000

10000 8000 6000

4000 2000














Figure 21: NSW Department of Health . Community Package referrals: July 2004 to June 2010. 1,600,000

Bed days for the over 75yr + patients show a 10% reduction on the predicted rise

1,500,000 1,400,000 1,300,000 1,200,000 1,100,000 1,000,000 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Actual Bed Days Projected Bed Days

Figure 22: NSW Health Information Exchange (HIE) data base extraction. NSW bed days for the over 75yrs


Patient Flow Redesign The Patient Flow Systems program is a whole of hospital approach to managing patient flow. This approach enables hospitals to identify and resolve delays within their current environment to create capacity. Hospital supported implementation; Area Health Service workshops and predictive tools have been developed and are currently being implemented across NSW. The main focus of this program is ensuring patients have access to the right care, at the right time, and in the right place, with minimum waiting times. The predictable planning tool allows each hospital to see 10 days in advance how many patients are coming into the hospital (admissions) and how many patients will be exiting (discharges) the hospital. This program was first introduced in 2008 and is now in 23 hospitals in NSW and 6 Area Health Services ( NSCCAHS, SESIAHS, SSWAHS, GWAHS, GSAHS, NCAHS) . The program allowes each hospital to align staffing to patient demand, ultimately resulting in a predictable workload for all staff and reducing the requirements of extended hours and overtime. To further Patient Flow Systems, the Health Service Performance Improvement Branch (HSPIB) and the Business Information Program are developing a suite of tools to assist staff with decision making and provide a more transparent view of current capacity. The Patient Flow Portal provides staff with a single point of access to: 1. Bed Board (new version) 2. Capacity and Demand Predictive Tool (new version) 3. Ward Activity Nursing Display WAND (new version) 4. Length of Stay Monitor The Patient Flow Portal will support Patient Flow Systems and will be implemented in all large district and metropolitan hospitals across NSW by June 2011. The Patient Flow Portal will provide staff with live information to make informed decisions on a day to day basis. The improved Predictive tool will allow staff to plan resources 14 days ahead of time to ensure patients receive the best care in a timely fashion. Furthermore, through the tracking of ‘waiting for what’ or delay reasons, staff can understand what the biggest constraints to patients receiving timely access to quality care is within a ward, across a facility, Area or the state. This information will inform resource allocation and longer term resource planning. The Patient Flow Portal will also improve the state bed reporting process by making the data easier to capture with a standard state-wide process. This will reduce data entry and ensure accurate data for reporting.


Patient and Carer Experience Redesign NSW Health through Redesign is changing the way we do things to improve patient and carer experiences within the health system.

A person's experience of using the health system is called a patient and carer journey. Usually many different clinical teams are part of each step, but patients and carers see their journey as one experience delivered by the "health system". They are the only witnesses to their whole journey through the health system. NSW Health is using Redesign to help us understand and improve patients' and carers' overall experiences. Hearing real experiences from patients and carers helps us deliver better patient journeys. An understanding of the patients and carers experience is gained through collecting detailed patient and carer stories and the State-wide patient survey. Over 700 in-depth interviews with patients and carers have been conducted, capturing their stories on video thus documenting their experience.

NSW Health Patient Survey We have also carried out the Patient Survey since 2007 with over 240,000 patients responding. This is one of the largest patient experience data collection programs in the world. After an external evaluation in 2009, the NSW Patient Survey has made the following changes in 2010:  Patient sampling methodology is based at hospital level not State level.  Patients receive surveys throughout the year  Many hospitals will receive quarterly reports, starting from November 2010  Annual reports will be available for all hospitals  A new reporting website provides easily accessible data for all health services to use Managers and health leaders will now have timely access to patient experience data with the ability to explore this data to improve services in line with identified patient need. 91.0%






89.0% 88.0%



64.0% 63.7%












Fig 23: 2009 Patient Survey data: overall 90% of patients rated their care very positively (good, very good or excellent).




Fig 24: 2009 Patient Survey data: over 66% said they would definitely recommend the service to others.


Experience Based Co-design Program In 2009 4 hospitals worked collaboratively with staff, patients and carers to identify positive and negative themes and to design strategies to improve the experience. NSW Health and the Premiers Department jointly funded this Experienced-Based Co-design Program. It was noted that patients and carers within the Emergency Departments in the 4 hospitals often attached strong emotions in both positive or negative ways to the following areas;

 Arrival & Accessing ED  Communicate Plan of Care  Quality of Wait  Pain Management & Physical Comfort

Interaction with Staff  Environment  Resources  Coordination/Continuity of Care

In the external evaluation by University of Technology Sydney : (see link below for reports)

A patient said: “...It was quite exciting because for once our opinions counted and we were able to develop the solutions ourselves. (Piper 2010) A staff member said: “…… communication was a big issue ...the staff attitude. With all that has changed the staff have been able to see over the past eight months that the number of complaints have decreased. There are more compliments than complaints. Adverse events have come down drastically.” (Piper 2010)

Studer Pilot Program and Customer Feedback System This program supported frontline staff and managers by delivering coaching and evidence-based tools for improving patient/carer experience, staff experience, communication, leadership, accountability, clinical safety and overall business excellence. Tools used included: Accountability framework  Aligning Behaviors  AIDET (communication framework)  Key words at Key Times

A staff member said: (ED) “works better now.. Not as frantic..”decreased complaints, increased compliments with the member specifically being named, increased retention and “ a better place to work.”

HSPIB, with funding from MTEC (Ministerial Taskforce on Emergency Care), will fund a project in 2011 which builds from the pilot called Improving Patient and Staff Experience. The Patient Experience Tracker System (PETS) was introduced in all Studer pilot sites. The touch pads provide real-time implementation data, and allowing managers to take proactive action where necessary. Since April 2010 the PETS have been available to clinical wards/ units across NSW Health for patients to provide real-time feedback, identifying where improvements would benefit patient experience. For further information on the Patient and Carer Experience please follow the link to the NSW Health website: - 21

Performance Management Redesign A new Performance Management Framework (PMF) has been developed as part of NSW Health's continuing efforts to improve system performance.

The PMF optimises performance on identified priorities through: Integrated aims and processes • Incorporates activity and budget priorities, including episode funding; • Integrates annual performance agreement and review and budget cycles; • Robust governing processes for escalation/de-escalation of interventions. Promotion of accountability and a high performance culture through: • Clear roles and responsibilities for Department of Health and Health Services; • Applies across all the Area Health Services, Justice Health, the Ambulance Service of NSW and The Children's Hospital, Westmead; • Sustained and/or superior performance is appropriately recognised; • Early identification and response to performance issues; • Recovery is the focus, with clear and practical steps to recovery. Transparency, predictability and consistency • Provides clear understanding of outcomes expected, monitoring and reporting processes, targets and triggers for intervention, levels of response and processes to achieve and maintain satisfactory performance; • Specific targets and tolerance ranges mean that Health Services know when intervention will be triggered; and • Responses are proportionate to the issue being addressed.

Levels of Intervention and Response

LEVEL 1: “Under review” - Assessment and advice LEVEL 2: “Underperforming” - Recovery Plan required. LEVEL 3: “Serious underperformance risk” - Requires external intervention. LEVEL 4: “Health Service challenged and failing” - Requires independent management


References 1. Australian Institute of Health and Welfare (AIHW) (2008) Population Projections Year Book, Australia 2. Begg S, Vos T, Barker B, Stevenson C, Stanley L and Lopez AD (2007) Burden of Disease and Injury in Australia 2003, Australian Institute of Health and Welfare (AIHW), Canberra 3. Le May M, et al (2003) “Hospitalisation costs of Primary stenting versus thrombolysis in acute myocardial infarction”, Circulation Journal,108:2624 – 2630 4. Carstensen S, et al (2007) “Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays associated with improved outcome”, European Heart Journal, 28:2313 -2319 5. NSW Department of Health (2009) Caring Together: The Action Plan for NSW, available at: 6. Australasian College for Emergency Physicians (2006) Policy on the Australasian Triage Scale available at:


Redesign Achievements 2009_10