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The Redesign of General Medicine Services Across The Sydney Children’s Hospitals Network

Sydney Children's Hospital Network
Project Added:
12 August 2016
Last updated:
19 August 2016

The Redesign of General Medicine Services Across The Sydney Children’s Hospitals Network

Summary

This project reviewed the admission pathway and model of care for admitted general medicine patients, and optimised the workforce structure to improve the delivery of safe, efficient and high-quality care.

View a poster from the Centre for Healthcare Redesign graduation, August 2016.

Redesign GMS poster

Aim

To reduce length of stay (LoS) by 10% and improve Emergency Treatment Performance (ETP) by 10%, for admitted patients in the Sydney Children’s Hospital Network (SCHN) general medicine department, within 12 months.

Benefits

  • Improves communication between the emergency department (ED), sub-specialty teams and the general medicine department, with clear expectations for admission.
  • Improves ETP for general medicine admissions.
  • Provides patients and families with consistent care, regardless of where they are treated.
  • Provides children who have chronic and complex healthcare needs with coordinated, timely care from medical teams who are familiar with their condition.
  • Improves referral pathways, transfer of care and communication processes with other local health districts, leading to stronger relationships and collaboration.
  • Increases the number of patients presenting to and managed by other local health districts.

Background

General medicine is a key priority for the SCHN and responsible for approximately 20% of all admitted patient activity. Staff in the general medicine department are responsible for an average of 30 separations and 85 occupied beds each day.

A preliminary diagnostic report conducted in February 2015 found the scope of practice for general medicine within The SCHN was unclear, with no agreed definition of a general medicine patient. The pathways for patients admitted to the general medicine department were inconsistent, uncoordinated and fragmented, with staff often using general medicine as a default admission team. An analysis of patients admitted to the general medicine department at the Children’s Hospital at Westmead found that 40-50% of inpatients had chronic and complex care needs, while the other 50-60% had an acute illness that required admission for less than 72 hours.

General medicine clinicians highlighted the fact that as there is no maximum number of admissions, it is normal to have 20 patients across multiple wards with complex care needs. As a result, there were increased risks associated with handover and rounding. Research suggests that a patient’s mortality rate can significantly increase if there are more than nine new admissions per team on a single day, with each new admission potentially increasing LoS, costs and risk of mortality1.

A patient survey conducted with 36 families found that 75% were satisfied with the care they received and 90% said felt their care was coordinated. However, 10% of families at Sydney Children’s Hospital, Randwick and 25% of families at the Children’s Hospital at Westmead reported challenges with the care team, particularly with regard to communication. Feedback included:

“It is frustrating that if you see more than one doctor, there seems to be no swapping of notes, you have to start again each time you meet someone new.” 

“…we saw a different doctor every couple of days and the plan kept changing.”

Implementation

Solution 1: A definition of the general medicine patient

As part of the diagnostic process, focus groups and surveys were undertaken with general medicine staff, to identify how they would define a general medicine patient. These responses were themed and combined with diagnostic data, resulting in the definition of two patient cohorts that are cared for by the general medicine department.

  • Chronic and complex patients: a child or young person with complex healthcare needs, who requires treatment by multiple teams with further holistic care coordination.
  • Acute patients: a child or young person presenting with an acute or undifferentiated medical condition.

Consultations and approval processes were undertaken to include these definitions in the general medicine admission process.

Solution 2: A decision-making algorithm for ED admission

A decision-making algorithm, called the ‘ED Decision Tree’, was developed based on the themes identified during the diagnostic phase and the approved definition of the general medicine patient. Feedback and consultation with general medicine clinicians was undertaken, with sub-specialty teams identified as the most appropriate admitting team, where the patient does not fall under the definition of a general medicine patient. All ED staff were trained in the use of the tool.

Solution 3: Redesign of the medical workforce

The redesign of the medical workforce is currently in the design phase. Data analysis, observations on medical ward rounding and real-time mapping was conducted for one month, to measure baseline data. A ‘Task Load Index’ tool will be used to identify the impact of workload on a clinician’s ability to safely perform their role, highlighting any negative impact on physical and personal wellbeing. Virtual modelling of possible workforce structures will be developed based on the data collected. Staff consultation about possible workforce solutions will take place, with implementation planning and solution testing conducted.

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • July 2015 – December 2016

Implementation sites

  • The Children’s Hospital at Westmead
  • Sydney Children’s Hospital, Randwick

Partnerships

  • Centre for Healthcare Redesign
  • Paediatricians representing the Metro Paediatric Hospital Network (MP4 Network), including Sutherland, Liverpool and Blacktown-Mt Druitt Hospitals.

Results

Process evaluation

  • An 80% response rate was achieved for patient satisfaction surveys prior to the project.
  • 55 multidisciplinary staff from the SCHN attended the solution design workshop in the diagnostic phase of the project.

The ED Decision Tree

  • The ED Decision Tree was tested for one month at both sites. Data was collected at baseline, during the test phase and following the test phase.
  • Results showed that 1-2% of all general medicine admissions should have been admitted under a sub-speciality team.
  • Due to the low numbers of inappropriate admissions, evaluation of the ED Decision Tree will take place over a longer period of time.
  • Data revealed poor uptake of the tool by staff, with further modification and testing required to improve outcomes.
  • The ED Decision Tree will be modified for use for other areas, including neonatal services.

Redesign of the medical workforce

  • One month of diagnostic data was collected, including new admissions, total patient load and chronic versus complex case mix.
  • The maximum number of total patients for one team was 29 and the maximum number of new admissions for one team was 18. Both numbers are significantly greater than is considered a safe inpatient load.
  • Data is being collected on ward rounding and workload, using the Task Load Index tool. Initial results showed that one medical team took more than seven hours to round on a ward.

Full evaluation

  • A full evaluation will take place in December 2016, with measurement of the following outcomes:
    • staff satisfaction with the new workforce structure
    • family and carer satisfaction with the service
    • LoS and ETP
    • workforce costs and efficiencies based on the Task Load Index tool results.

Lessons learnt

  • Sustained, consistent and timely communication is required within the project team and with other specialty teams.
  • It’s important to consider both the process and outcome measures within the testing phase, to understand the impact of any solution.

References

  1. Ong M, Bostrom A, Vidyarthi A et al. House Staff Team Workload and Organization Effects on Patient Outcomes in an Academic General Internal Medicine Inpatient Service. Archive of Internal Medicine 2007; 167(1): 47-52.

Contact

Joanne Ging
Department Head, General Medicine
The Children’s Hospital at Westmead
Sydney Children’s Hospitals Network
Phone: 02 9845 0678
joanne.ging@health.nsw.gov.au

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