FINAL Last Revised January 21, 2013

WRHA PATIENT FLOW STRATEGIC PLAN 2012 - 2015

The WRHA Patient Flow Strategic Plan will enable all care sectors in the Winnipeg Health Region to work toward the common

goal of providing care to patients, in the right setting of care, with the right resources, for the right amount of time.

The WRHA Patient Flow Strategic Plan will be built on four pillars:

1) Governance and Leadership –Leadership within the WRHA must have the will for Flow to be embedded as part of

everyday core business processes. Strong leadership support is well documented in the literature as being an

enabler and facilitator of flow change practices. An Executive Sponsor for Patient Flow will be assigned.

Accountability for flow performance is required through the development of a flow action plan that is measured at

regular reporting intervals. The action plan will detail the actions required to support the achievement of performance

targets. A Patient Flow Steering Committee will oversee the implementation of the action plan. The Executive

Sponsor and the Steering Committee will create the culture change needed in the organization, anchored by a desire

to approach flow from a dignity based perspective.

2) Flow Resources – A regional Patient Flow and Transition Support team exists to support interdisciplinary,

cross-program teams to improve patient flow and in turn build knowledge capacity in the organization. Unified quality

improvement methods, such as LEAN/DMAIC will guide teams as they develop integrated care pathways for patient

flow. A central repository of transition best practices will promote knowledge translation and exchange and prevent

duplication of effort. This work with teams will with efforts to establish Collaborative Care Practices wherever possible

and specifically with those flow measures whose outcomes are linked in evidence with an improved flow target.

3) Performance Monitoring and Reporting- Performance measures related to flow exist in many different repositories.

Indicators need to be matched with specific components of the flow action plan. Various flow targets will be developed

in order to promote accountability. A set of comprehensive flow indicators will capture change at both macro and

micro levels of the organization. Reporting and sharing of information is needed to track change, engage

participation, and provide transparency. Dashboards, monthly, quarterly, and annual reports specific to flow will be

refined and or developed.

4) Research and Evaluation – Patient Flow and Integrated Services are priorities in most health care organizations

nationally and internationally. Collaboration with partners will serve to exchange knowledge and compare

performance. The WRHA will participate in the Western Canadian Patient Flow Collaborative. Demand-capacity

issues which impact flow and transitions are important to understand via predictive modeling science. Innovative

practices such as Virtual wards will be connected to the Flow Action plan.

2012/15 Flow Action Plan – Structural Components

PILLAR

INITIATIVE

ACTION

LEAD

TARGET/TIMELINE

Governance and Leadership

Executive Sponsor Flow

WRHA CEO; WRHA VP Clinical

Services/CMO; WRHA VP Interprofessional Practice/CNO

n/a Completed

Flow Steering

Committee

RISC to serve as Flow Steering Committee

 Modify RISC T of R

 Modify Agenda to include Flow Items

Trish Bergal Trish Bergal November 2012 October 2012 Create Integration Councils by each Community Paired Area

 Identify Hospital COO and CAD as Co-Chairs in each Community Area

 Circulate draft terms of reference for Integration Council

 Meet with each Integration Council to review the Regional Flow Action Plan

Arlene Wilgosh/Brock Wright Trish Bergal/Dan Skwarchuk Trish Bergal October 2012 RISC November 2012 RISC November 2012 – March 2013 Flow Resources Re-Structure

Regional Utilization Program

Re-name unit to Patient Flow and Transition Support

 Reflect change on Regional Org Charts/InSite, etc

 Memo communicating change

 Revise Job Descriptions

 Assign Patient Flow and Transition Coordinator to each Integration Council Arlene Wilgosh/Brock Wright Trish Bergal/Jonathon Hildebrand Arlene Wilgosh/Brock Wright Brock Wright/Trish Bergal Trish Bergal December 2012 December 2012 December 2012 November 2012 – January 2012 Completed but continue to communicate and facilitate November 2012 – February 2013 3

PILLAR

INITIATIVE

ACTION

LEAD

TARGET/TIMELINE

Create a Regional Flow Collaborative Team to support the Integration Councils and Regional Program Teams in the implementation of the Flow Action Plan

Identify key members of the Collaborative. Members are Michel Tetreault (LEAN); Frank Krupka (PMO); Sandra Fedirchuk (Quality and Patient Safety); Decision Support (Michael Zhang, Ann Hakansson, Evelyn Fondse); Research and Evaluation (Mike Moffat, Colleen Metge); e-Health (Liz Loewen); Chronic Disease Collaborative (Jeanette Edwards); Patient Access (Luis Oppenheimer); Clinical Services and Integration (Dan Skwarchuk); Regional Program Teams; WRHA Allied Health Directors

Trish Bergal Ongoing

Facilitate the Flow Collaborative Team to assist the Community Integration Councils in the implementation of the Regional Flow Action Plan

Trish Bergal November 2012 –

March 2013

Support the Collaborative Practice Strategic Action Plan for teams that directly impact Patient Flow

Any new innovative patient flow practice will be reviewed by WRHA PAC to ensure strategies to address collaborative practice are indoctrinated into the practice proposal

PILLAR

INITIATIVE

ACTION

LEAD

TARGET/TIMELINE

Determine reporting method and frequency Trish Bergal December 2012

Create a Data

Warehouse for linking of flow data from various repositories

Define which data sets need linking Evelyn Fondse March 2014

Assist Integration Councils in

developing granular flow targets which pertain to the

acute/community/long term care sectors

Define sub-components of Flow targets by sector and by community area

Trish Bergal/Evelyn Fondse March 2014 RESEARCH AND EVALUATION Review of Patient Flow Initiatives in the WRHA

Inventory of current and past patient-flow initiatives

Colleen Metge January 2012

In-depth analysis to identify promising practices in Flow

Colleen Metge February 2012 - ??

Participate in the Western Patient Flow Collaborative

Compare flow performance and processes to Western Regions

Trish Bergal Ongoing

2012-2015 Flow Targets and Action Plans

At the request of the WRHA CEO, an economic analysis was prepared to show potential “savings” if the region’s hospitals were to

achieve the average performance of the Western Regions in 3 length of stay indicators. Using the CMG assignment, per diem

weights from CIHI’s ELOS-RIW tables and hospital specific cost per weighted case (adjusted to include only direct nursing

services and food costs), a site level estimate of conservable acute and ALC days and dollars was calculated for typical and long

stay outlier cases.

The resulting fiscal “savings” at best Western performance was estimated at roughly $46 million.

The resulting fiscal “savings” at 100% performance (ELOS) was estimated to be in the excess of $70 million dollars.

To initialize the planning for significant patient flow improvement, targets for ALOS: ELOS, Long Stay Outliers; ALC Days as

percent of total in-patient days have been established. The targets have been set to achieve the Median of current Western

performance.

The WRHA CEO has also identified that areas of focus for enhanced patient flow should address: 1) Ambulance Off-Load Delays;

2) ED LOS improvements in alignment with Western Regions; 3) A reduction in ALC days in acute care hospitals.

TARGET

STRATEGIES

LEAD

Reduce CTAS 4 and 5 visits as a percent of total ED visits by 6-7% percent per year.

(20% reduction by 2015)

 Advocate for legislative changes to enable the creation of a Community Paramedic role to reduce pre-hospital arrivals of non-urgent patients who can be safely cared for in a setting other than an ED

 Develop algorithms to enable safe referral from ED to Quick Care Clinics or the Crisis Response Center or Primary Care Clinics without first requiring a physician assessment

 In keeping with the development of Primary Care Networks, improve access to

diagnostics for primary care providers to reduce tendency to refer patients to ED for DI access

 Educate the public on options for accessing patient care information and care options including self care, access to primary care, Quick Care Clinics and emergency

departments

 Provincial Health Call Centre to review and revise protocols to offer alternatives to the ED

 Promote use of Nurse Practitioners in Long Term Care to avoid use of acute care systems

Helen Clark/Arlene Wilgosh

Alecs Chochinov/Karen Dunlop/Sheldon Permack/Murray Enns

Primary Care Program/DSM/Integration Councils

Jonathan Hildebrand/Heidi Graham/Primary Care Program/WRHA ED Program Team/Integration Councils

Real Cloutier and Rosie Jacuzzi as co-chairs of the Provincial Health Call Centre Working Group/Primary Care

Lori Lamont

Reduce Utilization of ED by High Users

 Provide detailed profiling of this population with a goal to develop alternate supports in the community to reduce the use of ED by this group

Joanne Warkentin

Meet Ambulance Off-Load Target of 30 – 60 minutes

 Monitor and reinforce need to offload patients to hospital stretchers or to the waiting room, per Regional Off-load Delay policy

Hospital COO’s and CEO’s/WRHA ED Program Team/Helen Clark

TARGET

STRATEGIES

LEAD

 90% of non-admitted patients treated and released within 4 hours

 90% of admitted patients treated and moved to an in-patient area within 8 hours

 Review ED Site Human Resource Needs in relation to ED activity and trends

 Implement ED Surge Plans to increase efficiency within EDs

 Establish a Minor Treatment Area at all EDs with a Nurse Practioner

 Introduce Physician Assistants in EDs to improve patient safety and flow

 Improve ED access to diagnostics and lab services

 24x7 access to Consultants with response time within 2 hours

 Standardize models of care for specialty patient groups across the Province, including the role of the ED in accessing specialty care

 Implement Regional Escort pool to enable ED staff to remain on-site to care for patients

Lori Lamont/Brock Wright WRHA ED Program Team Karen Dunlop

Alecs Chochinov

WRHA DI Program/WRHA ED Program/Brock Wright

Alecs Chochinov/Brock Wright/WRHA Medical Directors/Hospital CMO’s

Brock Wright via Provincial Medical Leadership Council

Helen Clark/Milton Good

 No patient to remain in ED longer than 24 hours

 All acute care sites to review their existing peak demand plan to clearly include this expectation

 Enable Emergency Department Physicians to admit, in consultation with either Admitting Physician or “Most Responsible Physician”  Ensure medical model of care allows for

movement from the ED for those individuals who do not meet formal admission criteria

 Review and adjust Home Care processes and assessments to facilitate expedient discharge planning from the ED

 Review and adjust the “Urgent Respite” process

 Provide Programs by Site information related

Hospital COO’s and CEO’s/Trish Bergal

Alecs Chochinov/Brock Wright/WRHA Medical Directors/Hospital CMO’s

Alecs Chochinov/Brock Wright/WRHA Medical Directors/Hospital CMO’s

Eliette Alec/Integration Councils

Linda Norton/Integration Councils Trish Bergal

9

TARGET

STRATEGIES

LEAD

ALOS: ELOS Ratio 1.0  Decline in ratio by 0.02

per year

 Review existing Care Maps and ensure maps are being adhered to

 Identification of ELOS on admission and use of ELOS flag in UMS

 Review Repatriation practices with Rural RHA’s

 Use of whiteboards in patient rooms with agreed upon Dates of Discharge with Patient and Family

WRHA Program Teams/WRHA Quality and Patient Safety Program

Trish Bergal/Evelyn Fondse

Brock Wright/Trish Bergal (via Provincial Medical Leadership Council)

Hospital COO’s/CEO’s

Reduction in Long Stay Outliers

 5% reduction over 3 years or 1.5% per year

 Goals of admission documented on admission and updated as needed in UMS/Patient record

 Interdisciplinary rounds conducted in keeping with ABC Project recommendations

 90 % Compliance with UMS use

 Continue to work on predictors of over-stay

 Develop processes and action plans for patients whose transition plan will be complex due to gaps in system resources

Trish Bergal

Hospital COO’s/CEO’s with support from Trish Bergal and Regional Allied Health Directors Hospital COO’s/CEO’s with support from Trish Bergal

WRHA Medicine Program Team/Trish Bergal/Research and Evaluation Trish Bergal

Reduction in ALC Days

 3% reduction over 3 years or 1.0 % per year

 Continue with work of Panel Process Improvement Action Council

 Develop new forms of service delivery in the Home Care Program which support PCH placement from home

 Continue with implementation of EFT project in Home Care

 Expansion of Virtual Ward concept

 Increase PCH capacity including spaces fro specialized services

Linda Norton/Trish Bergal Eliette Alec/Integration Councils

Eliette Alec/Integration Councils Integration Councils