Incentivising Hospital Medicine. Dr Ian Lawrence, Clinical Director, Emergency and Specialty Medicine

Transcription

1 Incentivising Hospital Medicine Dr Ian Lawrence, Clinical Director, Emergency and Specialty Medicine

2 What is your perception of Hospital Medicine?

3 Ward 38 LRI??

4 Hospital Medicine over recent years in the UK Wards full of patients later in life Not enough beds Medical patients outlyed to non medical beds Patients and relatives with increased, maybe unrealistic expectations Constant pressure to discharge / write TTO letters

5 What incentive to discharge?? Wards discharging patients immediately acquire an unwell patient from AMU / AFU Nursing and medical staff work harder More TTO letters More patient investigations to follow up or patients to see in clinic Perverse disincentives to not discharge patients

6 Were there incentives in the past? Large medical takes undertaken by the firm once every few days Discharged patients were not replaced by unwell patients from other firms Small number of patients prior to the next medical take Empty beds on the medical wards, particularly through the Summer

7 Is it possible to incentivise Hospital Medicine?

8 Resetting the equilibrium in Hospital Medicine Medicine retracts to its medical bed base Outlying of patients becomes the exception, rather than the norm Patients go from AMU to the appropriate specialty ward Patient discharges from the base wards occur in the morning Inter-ward transfers occur between 8am & 9pm Patients sleep at night on base wards!!

9 Recent changes in LRI Hospital Medicine Increased discharges from medical wards Closure of LGH Ward 2, and no outlying patients at LRI Empty beds on medical base wards and the assessment units ED freed up by improved bed availability, and no exit block No ambulances queuing on Infirmary Close

10 Are there immediate incentives for Hospital Medicine? No patients on outlying wards to review No early evening trek to meet dissatisfied patients and relatives No loss of base ward staff, with medical and nursing staff not being re-deployed to non medical wards No constant hassle to review Improved patient safety

11 Other potential incentives Opportunity to practice more holistic medicine with time freed up Teaching and training, particularly during afternoons Empty beds are good for morale Potential to use ward space differently (Doctors Office, Staff Room, Day Room) Healthy competition between wards Improved patient safety

12 Sustaining improvements: Mending the shed roof while the sun shines Employing processes which have been demonstrated to work Early assertive MDT Board Rounds One stop Consultant-led Ward Rounds Planning a day ahead (blood investigations / TTO letters pre-prepared) Discharge destination the same as preadmission Transport arranged early

13 Incentivisation of Hospital Medicine A new equilibrium with less beds in total A clear structure to the day MDT working Potential for teaching and training Better work life balance Improved patient safety

14 But what about the work environment?

15 Work environment issues Rotas at all grades Sick leave Training opportunities Respect of time (meal breaks) Professional courtesy Restoring camaraderie

16 Review and Revision of Rotas Suggestions re Medical SpR Rota Ensuring appropriate medical staffing out of hours (nights / weekends) Review of the LGH SpR overnight Remove specialty clashes on the SpR rota Sharing 2 SpRs 9am to 5pm between the assessment units In the longer term, inclusion of SpR level Trust Grade Doctors

17 Improving out of hours working Clinical Aides (phlebotomy, cannulae and ECGs) Trust Grade Doctors Advanced Nurse / Clinical Practitioners (ANPs / ACBs) Physician Assistants Closer links with ED through Gold Command (active and pro-active bed management)

18 Medical trainees Bottom up approach to rota revisions Feedback re problems and solutions Many solutions are within our gift Work group involvement of Working Parties of the UHL EQSG Monthly Junior Doctor Forum Potential for Focus Groups

19 Incentivisation of Hospital Medicine Smaller medical bed base Optimism, rather than hopelessness Structured day with early discharges and early flow Closer working and support of ED Teaching and training opportunities Leaving work on time Improved patient safety and outcomes

20 Victoria Wing, The Leicester Royal Infirmary, UK