CANTERBURY DISTRICT HEALTH BOARD A3 REPORT

Team 1: 80% of triage two chest pain patients should be seen within ten minutes CURRENT SITUATION PLAN Aim: Improve percentage of triage two chest Short term: 1. Patient direct to bed with registration at patient bedside pain patients seen within ten minutes to 80% 2. Call to doctor ("triage 2 in R5") over tannoy. Long term: 1. Pull from Cardiology Current: 38% seen within 10 minutes 2. Telemetry admission and discharge guidelines. 3. Clinical pathway for categories of chest pain patients. Discrepancy: 42%. Recurrence Prevention: 1. Embed clinical pathways Extent: Approximately 20 triage 2 chest pain patients per day. 2. Education. Rationale: Currently not meeting recommended Australasian standard 3. Audit. Why Recommended: To comply with Australasian guidelines and to PROPOSAL Increase the percentage of triage two chest pain patients seen within 10 improve the patient journey. minutes to 80% by 1st July, 2007 IMPLEMENTATION Formed a committee of stakeholders. Lean team. March 07 Liaison with reception; registration at bedside. ED subgroup. April 07 Introduction of tannoy alert. Senior ED staff. April 07. Redesign waiting room to improve flow. Lean team + Rob. May 07. Liaison with cardiology re pathways. Lean team. Ongoing. FOLLOW-UP COST AND TIME ANALYSIS
90 80

Percentage of Triage 2 Patients Seen Within 10 Minutes

Percentage of Patients

Medical Records

Sorting Nurse

Nurse Aid

X-Ray

Bed Manager

Cardiology Registrar

70 60
50 40

ED Reg/ SHO

Orderly

Cardiology Ward

30 20
10

Primary Nurse

Pathology Lab

Transfer Nurse

W Triage No. Staff No. shifts Reception No. Staff No. shifts

W TFA No. Staff No. shifts

Initial RN assessment observations Call Sorting Nurse to arrange transfer to Resus Transfer to Resus

W Sorting No. Staff No. shifts

W Resus Bay No. Staff No. shifts

Primary Nurse assessment monitoring,ECG IV access, bloods, Medical Assessment Treatment initiated

W X-Ray No. Staff No. shifts

W Resus/Back No. Staff No. shifts

W Cardiology Ward No. Staff No. shifts

No. Staff No. shifts

No. Staff No. shifts

% Triage 2 patients seen within 10 minutes Lower Limit Target 80% Mean
Mean

Mean Upper Limit % Triage 2 following "Stopping the Clock Initiative " % Triage 2 patients post Flashing T2 & ED Reconfiguration

RN Triage

Registration/ Computer entry Paperwork labels, order notes

Sorting Nurse clears Resus Bay Sorting Nurse assigns Primary Nurse

Chest X Ray

Sorting Nurse clears area

Put on Telemetry

Initial computer entry Call Bed Manager (alert) Call Sorting Nurse to arrange transfer to Resus

Dr reviews results - decision to refer Referral Cardiology assessment Decision made re telemetry Bed Manager orders bed

Bed Ordered Writing notes

? 12

3 6

2 9

0 5

0 58

10 10

1 49

190

Lead Time Processing Time

355 149

FUTURE Ensure sustainability through audit and elimination of variation. Improve access to telemetry beds through future projects Eliminate waste and bottlenecks in whole chest pain patient journey.

Plan-Do-Check-Act Process
Title

Grasp Situation

Background (Existing Value, Expectations, Policy, Goal, or Plan) Current Situation (Analysis of Needs and Contributing Conditions)

Plan

Recommendations (Cost/Benefits) Implementation (Detail of the Plan) Follow Up (Expected results - When/How They Will Be Checked)

Do

Check and Act

Sourse: The Toyota Way Jeffrey Liker

Problem Solving Process

1. Initial Problem Perception (Large, vague, complicated problem)

2. Clarify the Problem

The Real Problem

Grasp the Situation 3. Locate Area/ Point of Cause

POC

Why? Direct Cause Why? Cause Investigation Cause Why? Cause Why? Cause Why? Cause Cause Root Cause

Basic Cause and Effect Investigation

4. 5 Why? Investigation of Root Cause

5. Countermeasure

6. Evaluate

7. Standardise

Source: The Toyota Way, Jeffrey Liker

Efficient Meetings
1. Clear objectives prior to the meeting 2. The right people at the meeting 3. Prepared participants 4. Effective use of visual aids (eg the A3 format) 5. Separate information sharing form problem solving 6. The meeting starts and finishes on time

Source: The Toyota Way, Jeffrey Liker