Future Hospital Programme: - a Partner perspective Dr Roger Duckitt Royal College of Physicians Loughborough February 2017
Future hospital timeline Launch of Future Hospital Commission March 2012 Sept 2012 Sept 2013 June 2014 Sept 2014 : Most important statement about the future of British medicine for a generation
Why establish the Commission? Hospitals on the edge? Rising clinical demands Changing needs Fragmented care Out-of-hours care breakdown Medical workforce crisis
Average daily hospital beds, England 1987-1988 to 2009-2010 Source: Department of Health, Hospital Activity Statistics 33% fewer medical beds (25 years) Decade to 2012 37% increase in admissions
How old are NHS in-patients? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2004 2005 2006 2007 2008 2009 2010 2011 2012 85+ 75-84 65-74 <65
150% 140% 130% 120% 110% 100% 90% 80% 70% 60% 50% 40% 2000-1 2001-2 2002-3 2003-4 2004-5 2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 Acute beds Emergency admissions Length of stay How have we achieved increased in-patient activity? Reduced LOS But reduction in LOS flattening (tending to rise age > 85) Discontinuity of care
New principles of care Eleven principles of patient care, including: Patient experience valued as much as clinical effectiveness Clear responsibility for each patient s care No wards moves unless necessary for clinical care Robust arrangements for transferring of care Self-care and health promotion facilitated. Care plans that reflects individual needs for all 7-day working
Development sites Working in partnership with clinical teams implementing a project aligned with the future hospital vision Local patient involvement supported by RCP patient and carer network Evaluation and promotion of the sites Develop recommendations and messages for government/national bodies
Future Hospital development sites Phase 1 Phase 2 The first four sites all focus on improving care for people who are frail and elderly. The second phase sites are focussed on providing person-centred care across integrated healthcare services.
Development sites 4 sites in UK selected for Phase 1: Betsi Cadwaladr Mid-Yorkshire Hospitals Royal Blackburn Hospital Worthing Hospital
Worthing Hospital Budget : 220 million Catchment : 275000 A&E attendances : 230-250/day Medical Beds : 450 Average Medical take : 35-50 Elderly Care (separate) : 12-18 Average Surgical take : 12-15
Western Sussex NHS Foundation Trust
» Improve experience of care for all patients» Co-location of admission streams» Reduce non-elective admissions» Increase use of ambulatory Care» Improve flow» Reduce length of stay» Enhance multi-disciplinary input» Develop high-quality learning environment CLINICAL CONCEPT
Building Started - July 2013
Phase 1 - March 2014
Emergency Floor Acute Frailty Unit Major Incident Room Ambulatory Care High Care Area Radiology Clinical Site Team Accident & Emergency
Worthing Emergency Floor & FHC Launch of Future Hospital Commission March 2010 March 2012 Sept 2012 July 2013 Sept 2013 March 2014 June 2014 Sept 2014 Dec 2014 Initial EF concept meetings Planning and design Phase 1 building starts Phase 2 building starts FHC partner site Phase 2 complete GO LIVE
How does it work? Floor Layout and Staffing
30 Bay Allocation
One-Call -single point of access e-whiteboard Ambulatory Care
Early Consultant Input Acute Frailty Unit
A new model of hospital care Clinical Coordination Centre Medical Division Acute Care Hub
Development sites RCP Support Independent Site visit Patient-Carer Network link Performance and Quality metrics Data interpretation SharePoint Information sharing Patient Survey and Staff Surveys Organisational Readiness Survey Partner Site Promotional videos Newsletters
Performance & Quality Metrics
Reporting & Sharing
Is it working and what have we learned?
Network, share and learn!!!
MEDICAL FUN with DATA! Frailty non-elective Admission <72 hours- Worthing Does nurse do Obs before going to DOME? VARIATION: VARIATION: If there's a PAT long wait presents to for TRIAGE A&E via the nurse family. takes PAT Obs in the PAT PAT arrives PAT presents to at front of conveyed A&E hospital in to A&E and themselves ambulance awaits TRIAGE PAT presents to A&E via ambulance (approx. What proportion of the 25% go direct to PAT the Em Floor? presents to A&E via ambulance GP referral. Approx. VARIATION: Nurse checks Whiteboard to see if expected DOME referral- IF YES PAT goes direct to ward Amb crew Hand Over PAT to A&E nurse (24/7) A&E clerk adds PAT details to SEMA 1 who prints the casualty card? FUTURE STEP: Use Rockwood assessment at this point. can we use Rockwood score Who does Do PAT get seen data to see bloods at by Nurse what the spread Worthing? Practitioner? of PAT who are PAT is A&E nurse PAT seen Bloods X-ray moved to takes PAT by A&E Taken organised bed space obs and doctor in A&E by records on consultant Amb crew notes Registrar SHO Amb crew leave Information taken regarding Sometimes not enough condition and information is taken history and causes delays later FRAILTY DECISION VARIATION: PAT case sometimes discussed with senior RAT not available 24/7 Bed availability discussion missed at this point VARIATION: Decision already made if PAT Boundary issues is GP for referral based referral on condition causes re-work Decision to Decision as ADMIT to who to OR ADMIT DISCHARGE under VARIATION: Rapid Assessment team assess (WTG only) Discharge Letter Written Decision to Transport ADMIT if no Arranged transport available or RAT needed PAT leaves Hospital If a lack of or missing INFO taken in A&E this step takes longer Bleep / Phone DOME referral SURGERY / T&O acceptor in TRAGET specialty PAT sometimes stays longer than 24 hours VARIATION: PAT admitted to CDU or PAT goes to DOME if no DOME if no deb in CDU bed in CDU Frailty discussion with TARGET specialty acceptor Decision on Frailty YES / NO Decision to accept onto DOME - 1st then Med, Surg, T&O 2nd Future Step Delay caused at this point if A&E have not already added PAT info to the 'whiteboard' PAT details added to 'Whiteboard' by accepting specialty Decision A&E Triage nurse contacts site teamto arrange bed in TARGET ward 1 How many PAT go to CDU who are waiting for a bed in DOME? Danger of 4 hour A&E target breach at this point VARIATION: PAT may have to wait if no beds available and be admitted to CDU Issue Direct PAT may wait longer because they have missed the bed availability step PAT is taken to EF reception area (Days) Zone C (out of hours) VARIATION: PAT can come direct to this area if directly referred by GP via 'back door' Process Step System EF ward clerk checks Whiteboard for PAT admission details PAT is allocated a bed by nurse coordinator Question Process Variation Step PAT Admitted to ward
DATA Analysis for improvement, not analysis for judgment Statistical Process Control Charts SPC In-house analysis software from the RCP RCP FHC analyst support RCP FHC software support 17665 patients since December 4 th 2014 =53.3 patients / day
EF Opens Rota Changed
Time to First Review Surgery 140 mins =>76mins
Time to First Review Surgery 140 mins =>76mins
Metrics: January 2017 SURGERY 30%
Metrics: January 2017 SURGERY 1.1 days
Metrics: July 2015 Elderly Care 7% 4% 5%
Impact of rota modifications Twilights Consultant review documented Arrivals from 08:00 19:00 - MEDICINE 20%
Impact of rota modifications Weekends 60% 20%
Impact of rota modifications 14-hr reviews
4-hr breach reductions A&E 11% 9% 8% 1.4%
Performance A&E
DATA DRIVING QUALITY IMPROVEMENT & EFFICIENCY BROAD-BASED GENERALIST TRAINING EXPERIENCE NETWORKING AND SHARED LEARNING OPPORTUNITY TO EXPLORE AMPLIFICATION OF BENEFITS
QUALITY IMPROVEMENT CULTURE
ACUTE CARE FOUNDATION PROGRAM ALL F1 s rotate through Emergency Floor Exposure to Surgery, Medicine, DOME Solid understanding of MDT working Survey x 2 to assess benefits and learning I feel it is essential as the learning opportunities on the EF are great. I managed to complete almost 80% of all my CbDs, CEXs and core-procedures during the 4month rotation on the EF. Very useful and improved my knowledge immensely, whilst the job was busy, would happily do it again. Highly paced and tough job, but excellent training in learning to manage patients efficiently and effectively.
So what?
10 Worthing
So what next? Right person, right place, right time? National effect Amplification? Nuffield Trust NHI AMM Program Surgical admissions vs operations data Involvement of RCS Flow analytics
Effect Amplification St. Richards EF Average Length of Stay Surgery Period 1 mean = 7.2 Period 2 mean = 4.2 Period 3 mean = 35.00 30.00 A A 3 days 25.00 20.00 15.00 10.00 B B B B 5.00 B B BB B 0.00 12/01/14 02/02/14 23/02/14 16/03/14 06/04/14 27/04/14 18/05/14 08/06/14 29/06/14 20/07/14 10/08/14 31/08/14 21/09/14 12/10/14 02/11/14 23/11/14 14/12/14 04/01/15 25/01/15 15/02/15 08/03/15 29/03/15 19/04/15 10/05/15 31/05/15 21/06/15 12/07/15 02/08/15 23/08/15 13/09/15 04/10/15 25/10/15 15/11/15 06/12/15 27/12/15 17/01/16 07/02/16 28/02/16 20/03/16 10/04/16 A beyond 3 σ B 7 points on one side of mean C 7 points moving in same direction Mean Control Limits (+/- 3s) +/- 1s +/- 2s
??
Challenges Stake-holder engagement Surgical pathway?critical impact factors Change-management support Staffing all sectors Social care, downstream capacity Financial impact
Patient Experience Patient Representative involvement FHC + EFOG Patient Carer Network visit Focus Groups planned Friends and Family Door to doctor time e.g. DOME : 81minutes 67 minutes 58 minutes
Patient Experience
Looking forward for Future Hospital Where is the programme in 2017? Further 4 development sites in progress An active partnership network of key supporters of the future hospital Evolution of the RCP Quality Improvement Hub A full evaluation of the programme
Get in touch Sign up to the FHC Partners Network futurehospital@rcplondon.ac.uk Future Hospital Journal http://futurehospital.rcpjournal.org/ @RCPLondon / #FutureHospital