CapPlan is being relied on to match occupancy and nursing resource at Waikato Hospital in New Zealand. In February 2009, after a rigorous pilot, the Inpatient module went live in all inpatient areas of the hospital.
Introduction
Poor patient flow is a hospital wide issue. Hospitals are having to review and improve the whole ‘patient journey’ from admission through to discharge to not only improve patient safety and quality of care, but also the work lives of the hospital staff, and the hospital’s ability to recruit and retain physicians and nurses.
While poor bed management often gets blamed for capacity problems in hospitals, the issues are deep rooted. New monitoring and forecasting tools like CapPlan are showing that extended length of stay (LOS) caused by the mismatch between the time when patients come into hospital and the time when they leave, is one of the biggest causes of blockages in hospitals today.
However, after decades of triage processes, the challenge of changing ingrained habits and introducing new systems is a formidable task for hospital operation managers. Particularly in an already strained environment faced with on-going pressures of staff shortages, increasing patients, and limited funding.
Waikato Hospital in New Zealand understands these challenges well. Since 2008, Nurse Manager Operations, Leigh Singers, has focussed significantly on capacity planning and patient flow. This has included the pilot and implementation of CapPlan, development of a capacity and bed plan which reflects facility and nursing resource requirements to meet demand, and development of tools to support these processes.
Waikato District Health Board (DHB)
Waikato DHB is responsible for planning, funding and providing quality health and disability support services for the 360,270 people living in the Waikato DHB region and tertiary/trauma hospital services to a regional population of more than 860,000. It has an annual turnover of $1.1 billion and employs more than 5800 people.
Health Waikato is the DHB’s main provider of hospital and health services with an annual budget of more than $606 million and 4740 staff. It has six divisions across five hospital sites, two maternity and continuing care hospitals and 21 community bases offering a comprehensive range of primary, secondary and tertiary health services.
A wide range of independent providers delivers other Waikato DHB-funded health services - including primary health, pharmacies and community laboratories.
Waikato Hospital is a 600-bed teaching hospital based in the city of Hamilton New Zealand.
Health Waikato also manages the 100-bed acute mental health facility Henry Rongomau Bennett Centre in Hamilton, a secondary hospital in Thames and rural hospitals in Taumarunui, Te Kuiti, and Tokoroa.
From 1 July 2008-30 June 2009, Health Waikato:
The DHB is committed to patient care and has a number of patient flow improvement projects underway, including the Patient Safety First programme that aims to improve timeliness of healthcare delivery to patients as they move through community and hospital services.
www.waikatodhb.govt.nz/healthwaikato
Operational Challenges
Prior to implementing CapPlan, Waikato Hospital’s operational issues were not extraordinary. Like most hospitals there were occasions where wards experience bottlenecks, particularly over the winter period resulting in delayed stays in ED, cancelled procedures, high numbers of outlier and poor visibility.
Leigh Singers, Waikato Hospital Nurse Manager Operations, explained, “Every winter year on year we’d experience ED overloads with more patients that we can cope with. Patients would be put into wards that are not adequately resourced and everyone would be working over capacity. This did not provide optimal care or service to our patients.”
“Winter 2007 and 2008 was particularly difficult. We were at a point of change and we knew the status quo wasn’t an option. We had to do something. From the pilot we knew CapPlan could provide the information we needed to make improvements, but it wasn’t fully implemented.”
CapPlan Pilot
“We first knew of CapPlan when our CIO saw it being demonstrated at a conference. He suggested it was worth considering for helping us to match occupancy and nursing resource, which has been a key problem area for us. After meeting with Emendo, we agreed to pilot the software in a small part of the hospital in 2007,” said Leigh.
CapPlan, developed by Emendo, is a capacity planning and forecasting solution for healthcare organisations. It provides the ability to accurately predict inpatient demands from surgery and medical ward requirements to recurring peaks such as influenza outbreaks, Christmas and Easter holidays, or responding to pandemics and staff strikes.
The Inpatient module, which is now implemented at Waikato Hospital, assists to plan beds and staffing to meet workload variation throughout the year including efficient staff schedules; annual leave planning; inpatient status visibility; and, removing avoidable costs.
Objectives
The aim of the CapPlan pilot at Waikato Hospital was to introduce the inpatient tool to the DHB and demonstrate how good capacity planning would help to improve resource management, patient flow and operational efficiency.
The objectives of the pilot were to demonstrate how CapPlan could help:
At the start of the pilot data extracts from the Waikato Hospital’s patient management system (iPM) over the previous four years were loaded into the CapPlan Inpatients tool. All ward configuration and historic changes were then applied to reflect the actual context over time. Nurse and patient ratios per ward were also entered.
Once all the data was entered Emendo then showed the team how they could use CapPlan to drill down into patient occupancy data to highlight patterns and trends and allow them to target areas to improve patient flow and capacity planning. This level of visibility was a first for the Hospital.
Pilot Results
“The results of the pilot were impressive,” said Nick Burns, Founder and Director Sales & Marketing at Emendo.
“Emendo had supported Waikato DHB management in achieving their project goals by supplying relevant information and subsequent recommendations for change. The CapPlan methodology had helped to successfully identify capacity planning and patient flow opportunities for Waikato DHB, and also created a Christmas bed plan.”
“Our analysis of the results revealed opportunities for improvement and potential cost savings, for instance if the Hospital were to better match resources to demand during the summer (and in particular the Christmas holiday), a saving of NZ$565,000 could be made by closing beds and reducing staffing accordingly,” he said.
The results also showed that between April and October 2007 there were 14,195 admissions to inpatient wards at Waikato Hospital, with an average length of stay of 4.8 days. This totalled 68,136 bed days over the six months. Based on CapPlan’s calculations, Emendo calculated that if LOS was reduced to 4.5 days, the number of bed days over the six months would reduce by 4,259 bed days and provide a saving of $1.06m, or an opportunity to increase turnover and see an additional 890 inpatients with a corresponding revenue increase.
Rostering resources based on forecasted patient activity, reducing the gap between peak and trough occupancy each day, and improving weekend discharge rates would also create efficiencies and provide cost savings.
Leigh explained, “During the pilot, CapPlan gave us visibility in terms of how we allocate patients to difference specialities, be it medical, surgeries, physical wards, etc. For example, we found that medicine is often over-occupied with up to 40 medical patients staying in the surgical wards. While this is not a unique problem in healthcare, there’s a lot of evidence that these patients don’t get specialised medical and nursing care because doctors have to go to 10 or 12 different wards to find their patients. They call this the ‘safari round’.”
“We now have daily reports and models of our normal patterns by six speciality clusters, which allow us to look out across the week, and plan any required variability in management accordingly. If we plan it right, we usually hit target most of the time.”
“We had a lot of data to sort out patient flow, and during the pilot CapPlan automated that for us. As well as all iPM data, we now have our staffing resource in there. This not only gives us clear visibility of expected occupancy by patients, we can also see the expected resource capacity by patients. It allows us to be proactive in our management.”
“While it was hard to validate any specific impact that CapPlan has made, certainly for me it has been the visibility that CapPlan provides which has created the catalyst to change the way we work. We’re now more confident with the data and with the planning process, which means we can put more nurses on leave when we don’t need them and bring them in when we need them.”
“At the time of going live, we didn’t have any concrete financial evidence, but it did fit with the philosophy and direction we were trying to head. While we certainly felt it had made a difference, at the time it was difficult to attribute any tangible results directly to CapPlan. We know it’s there, but it’s hard to pin point it specifically.”
During the pilot we really started to take that next step with patient flow.
CapPlan Goes Live
In February 2009 the full CapPlan Inpatient system went live. The system is now enabling users within Waikato DHB to create their own models based on growth and Length of Stay (LOS) assumptions within the application, and the impacts of these are now being overlaid with staffing requirements to produce a nursing plan.
Leigh Singers and other staff at Waikato Hospital now regularly refer to the CapPlan Viewer to access real-time updates with a dashboard view of the actual occupancy tracking against projection.
“The Viewer enables a quick response should any variable change significantly. It also allows for close monitoring of actions set within the bed meeting process – for instance, if a gridlock situation occurs and each ward is asked to ensure their discharges happen as early as possible, the actual number of discharges made can be tracked against admissions for the day as they happen, enabling further action to be taken promptly if required,” said Nick.
“They can also use CapPlan to review planned staffing and annual leave plans to produce a plan on additional leave opportunities, and agency staff requirements. With the agreed nursing hour ratios, the Hospital’s required staffing levels can also be reported to enable rosters to be set against forecast occupancy.”
Leigh recalled, “In last 18 months we’ve been using CapPlan to model our production plan based on predicted workload and demand which we can phase across the year. There is variability – particularly seasonal variability – which allows us to match supply with demand, and translate the data into bed days and staffing FTE resource.”
“We’re now linking in capacity planning to help us determine if we can meet the demand, and if not, what are our options? Can we shift it? Do we reduce what we are going to deliver? Can we outsource? And so on. This is crucial information that CapPlan can assist with.”
“The next step is to plan the resource to meet demand. Historically, we had a fairly siloed roster. Now, we can use CapPlan to better meet the demand based on what we are planning to do. It allows us to bring our nurses to work when we need them. Ultimately we will phase this part out to other areas of the Hospital.”
For special events planning Waikato Hospital tended traditionally to be quite conservative in their approach to how many nurses they had on leave. As CapPlan provides them with hard data, they now run with the same set of rules.
“Allocating leave used to be an adhoc and siloed approach. We realised two weeks before Christmas 2008 that we didn’t have enough nurses and we were under staffed and under resourced to get through. We had to crisis manage to get patients out of ED and into beds and get care that they needed. Otherwise we would get ED backlog and extended waits are not good for patients.
Leigh explained, “We used CapPlan to plan Christmas in 2008/2009 and 2010 for the first time and it was a spot on. We had hit the nail on the head. It was a vast improvement to how the Hospital had run the year before, and CapPlan definitely supported us. The difficulty in 2008 was that people weren’t confident with data, so we put in a healthy buffer, this time we were a lot more confident with the data, as it gave us a very good picture of what was going on.”
“In 2010, for the first time, we had a vastly improved year thanks to CapPlan. Even though we had treated more patients , we were better prepared with more beds open and more nurses working when we needed them. Admittedly the economic climate has also helped, as we have been able to recruit more fully than we have in the past. Without a doubt CapPlan definitely supported us.”
Adjusting to Change
Getting staff to trust and rely on the data presented by CapPlan for production and capacity planning purposes is the initial challenge that hospitals often encounter. But once they start relying on the data, they usually don’t want to go back. They recognise that CapPlan is a vital element of the patient flow improvement process, and it can help make major differences in the patient journey.
Leigh said, “It wasn’t easy to get staff buy-in. It’s not just the physical implementation; it’s the cultural change that’s the barrier. While I’m quite persistent, and will keep going and going, others need pushing. We work in organisations where we have had the same people in same roles for years, and asking them to operate in a different way was hard. It’s about educating people. Our key people are all very comfortable with it now.”
“It also took us a long time to get staffing data and other data to the point where we would feel confident enough to use it. Data integrity is an on-going challenge common with all hospitals. There was a lot of trial and error work, and it was about a 12-15 month journey to get people on board, but I could see we were getting there.”
Benefits
While CapPlan is one of several initiatives at Waikato DHB, it has fitted in well with the directions taken with production planning.
“The advantages are that it allows us to see if we are having a day below normal. If the projections show that we’re going to be below the optimum line, we can make adjustments. We can change the patterns and see the staffing and occupancies data refresh in real time. We can also see what patients we have where and at what time. CapPlan also provides visibility of our rural and small community hospitals,” said Leigh.
“However, the key benefit of CapPlan is that it gives us high level visibility of all inpatient areas, as opposed to looking at them in a silo. For the first time we can now see the full picture - from what beds are open to which nurses are rostered. By putting all the pieces together both on a planning and operational function, CapPlan provides us with high level overviews and an ability to drill down to ward and service cluster level.”
“It’s been an interesting exercise to go through, and it is quite incredible that it has taken us 15 months of saying ‘Saturday looks bad what are we going to do about it’ for the change to sink in.”
“In past we would have had to cancel a lot of elective surgeries, whereas now we see the projection, recognise that orthopaedics is light and discuss how we will manage. We can concentrate on next 24-48 hours and see that, for example we may only have 40 paediatric beds open , but 44-46 patients projected in next 48 hours. To cope, the agency will put in an extra nurse and more beds. CapPlan allows us to make decisions more proactively and to put plans in place.”
“While we can’t attribute all the improvements to CapPlan, we have noticed a number of improvements in the last year since CapPlan went live. ‘Bed block’ from ED has improved and cancellations have dropped significantly. CapPlan has been part of that and a catalyst in a change of culture and the way we do things.”
Going Forward
Looking ahead, Waikato DHB plans to extend CapPlan to the four community hospitals and also to the Henry Rongomau Bennet mental health centre. The Hospital is also looking at other CapPlan modules: Theatre and ED.
“CapPlan is currently accessible on our intranet, so anyone can link into the live feed. Within that there is a key group where the daily report feeds out to. At our daily operational meetings we use CapPlan on the AV screen, which has helped initiate people to use it. Our aim is to get more people using it throughout the DHB,” said Leigh.
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